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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 V of the series will cover the Infection Control, Discharge Planning, Organ, Tissue & Eye Procurement, Surgery & Anesthesia, Outpatient, Emergency, Rehabilitation & Respiratory sections in the interpretive guidelines.
Infection Control & 2018 Proposed Changes
|- Final Infection Control Worksheet||- Required policies & procedures||- Medical equipment & supplies|
|- Infection preventionist||- IP responsibilities||- Logging incidents|
|- IC revised worksheet||- Safe injection practices||- Mandatory training|
|- 2017 & 2018 proposed changes||- Final discharge planning worksheet||- Discharge planning & evaluation|
|- Timely discharge evaluation||- Identifying patient needs||- Providing a written copy|
|- Patient identification||- Referrals & transfers||- Self-care evaluation|
Organ, Tissue & Eye Procurement
|- Policy requirements||- Organ donation training||- Family notification|
|- CMS OPO memo||- OPO One-Call Notification||- Board|
Surgical & Anesthesia Services
|- Following standards of care||- Pre & Post-anesthesia requirements||- Anesthesia & analgesia standards|
|- Preventing OR fires||- Intra-operative anesthesia record||- Documentation & operative report|
|- Anesthesia policies||- OR register||- Supervision requirement|
|- Policies & procedures||- PACU||- Required equipment|
Outpatient Services & 2018 Proposed Changes
|- Outpatient orders||- Meeting patient needs||- Policies & procedures|
|- EMTALA||- Standards of practice||- Qualified medical director|
|- Integrating into hospital PI||- Length of time for transportation||- Required policies|
Rehabilitation & Respiratory Services
|- Integrated into QAPI||- Qualified director||- Scope of services|
|- Standards of care||- Required policies & orders||- Plan of care|
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.