2013 CMS Sep 12 Enduring
Self Study Course Description
Hospital CoPs Medication & Pharmacy Standards
Sue Dill Calloway, RN, MSN, JD, CPHRM, CCMSCP
President, Patient Safety Education and Consulting
Type of Activity: Enduring Event/Web-Based Training
Release Date: September 13, 2013
Expiration Date: May 30, 2014
Estimated Time to Complete Course: 1.5 hours
There is no fee associated with this educational activity.
Target Audience: Physicians, Nurses, Pharmacists, Administrators, QM Staff, Risk Managers, and other interested Health Care Providers
Just about every hospital in America accepts Medicare and Medicaid reimbursement and as such must follow the Center for Medicare and Medicaid Services (CMS) hospital interpretive guidelines. These regulations and interpretive guidelines must be followed for all patients in the hospital. There have been many changes in the past few years. This includes changes to timing of medication and anesthesia issues. There are three time frames that medications must be administered along with the PI requirement. This program will include information on anesthesia and analgesia. It will discuss who can do moderate and deep sedation. It will include the July 16, 2012 standards on standing orders, protocols, order sets, and pre-printed orders.
CMS made significant changes to the hospital pharmacy conditions of participation, tag 508, on June 20, 2011 which is important for the nursing staff to follow. It includes medication errors, adverse events, and drug incompatibilities. If one occurs there must be notification of the physician, documentation in the medical record and it must be included in the PI data.
The timing of medication requires policies and procedures and training by hospitals. This section requires notification of the physicians and discusses when this must occur. Hospitals should have a non-punitive approach and the definition of medication error should be broad enough to include near misses.
The CMS interpretive guidelines address medication management and pharmacy related standards. These can be looked at when CMS conducts a complaint or validation survey. Medication management is not only a big issue with CMS but also with the Joint Commission. Medication errors are the largest number of medical errors in healthcare today. They are also the most common reason for unnecessary readmissions to the hospital.
It is essential that hospitals work together to implement and follow these regulations. Problematic standards include verbal orders for medication, order for medications, NS standing orders.
After completing this activity, the participants will be able to:
1. Recall that all hospitals that receive Medicare/Medicaid reimbursement must follow the medication guidelines even if the hospital has deemed status.
2. Discuss CMS requirements for standing orders and protocols.
3. Recall that all medications must be given within three different medication timing schedules.
4. Describe CMS policy for high risk drugs such as double checks or dose limits.
Criteria for Successful Completion
• Registration is required for verification of attendance.
• Attend the webinar in its entirety.
• Complete the web-based Course Evaluation.
• Complete the online Post-Test with a passing score of 75%.
• CSC will send you a CE Certificate upon successful completion. Note: you will be notified to retake the post-test if your score is below 75%.
Accreditation: The Indian Health Service (IHS) Clinical Support Center is accredited by the Accreditation Council for Continuing Medical Education to sponsor continuing medical education for physicians. The IHS Clinical Support Center designates this enduring educational activity for 1 hour of AMA PRA Category 1 Credit™ for each hour of participation. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
The Indian Health Service Clinical Support Center is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
This activity is designated 1.5 contact hours for nurses.
Accreditation applies solely to this educational activity and does not imply approval or endorsement of any commercial product, services or processes by the CSC, IHS, the federal government, or the accrediting bodies
Faculty Disclosure Statement: As a provider accredited by ACCME, ANCC, and ACPE, the IHS Clinical Support Center must ensure balance, independence, objectivity, and scientific rigor in its educational activities. Course directors/coordinators, planning committee members, faculty, and all others who are in a position to control the content of this educational activity are required to disclose all relevant financial relationships with any commercial interest related to the subject matter of the educational activity. Safeguards against commercial bias have been put in place. Faculty will also disclose any off-label and/or investigational use of pharmaceuticals or instruments discussed in their presentation. The course directors/coordinators, planning committee members, and faculty for this activity have completed the disclosure process and have indicated that they do not have any significant financial relationships or affiliations with any manufacturers or commercial products to disclose. There is no commercial or non-commercial company financial support for this educational activity.
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