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All facilities accredited by TJC, AOA, CIHQ, and DNV Healthcare must adhere to the CMS CoPs. This 525-page manual contains interpretive guidelines, policies, procedures, and standards that must be followed for all providers treating patients hospitals or any hospital-owned departments.
Part IV of the series will cover the Medical Staff, Board, QAPI, Radiological Services, Laboratory Services, Food and Dietary Services, Utilization Review, and Physical Environment sections in the interpretive guidelines.
Medical Staff, Board & CEO
|- Shared medical staff||- MS by-laws||- Changes & appraisal of MS|
|- Credentialing & privileging||- Accountability of MS for quality of care||- CEO requirements|
|- History & physicals||- Autopsy requirements||- Board consults|
|- 2018 changes & revised tag numbers||- Tracking medical errors & adverse events||- Identifying opportunities for improvement|
|- PI program requirements||- QAPI worksheet||- Patient safety|
|- Radiation exposure||- Adverse reaction to agents||- Safety precautions|
|- Staff supervision||- Shielding patients||- Secure area for films|
|- Signing radiology reports||- Required orders||- Recent revision|
Laboratory Services & Look Back Program
|- Lab services||- Tissue specimens||- Blood bank|
|- Look back program||- Fully funded plan||And more!|
Food & Dietary Services
|- Mandatory orders||- Nutritional assessment||- Therapeutic diets & nutritional needs|
|- Diet manual||- Required dietary policies||- Infection control|
|- Qualified directors||- Patient nutritional needs||- Therapeutic menus|
|- UR committee composition||- Admission or continuous stays||- Patient discharge appeal rights|
|- Notice Law & MOON form||- Scope of reviews||- UR plans|
|- Buildings & equipment||- Emergency preparedness changes||- Life safety code|
|- Emergency power & lighting||- Emergency gas & water||- Ventilation, light & temperature|
|- Compliance with PI||- Trash||And more!|
Anyone involved with or interested in compliance regulations and standards, including but not limited to: CEOs, CFOs, COOs, CMOs, CNOs, CE Directors, Quality Improvement Staff, Physicians, Nurses (all levels), Board Members, Clinic Managers, Outpatient Directors, Lab Directors, Compliance Officers, CMS Liaisons, TJC Liaisons, Registration Staff, Safety Officers and Staff, Pharmacy Staff, Ethics Committee Members, Consumer Advocates, Risk Managers, Legal Counsel, Behavioral Health Staff, Psychiatry Staff, Social Workers, Discharge Planners, Case Managers, Hospice Staff and Regulatory Affairs Staff.