CMS Hospital Conditions of Participation 2022: Surgery, PACU, and Anesthesia Standards

Introduction

• Presenter: Darling Evans, MSN, RNC, PHQ
• Role: Nurse Consultant, Nash Healthcare Consulting
• Experience: 25 years in healthcare specializing in clinical/regulatory operation management and accreditation

Key Points

CMS Hospital's Conditions of Participation (CoP)

• Federal and state mandates from CMS
• Initial focus started in 1986
• Divided into tag numbers or sections for hospitals
• Manual A or Appendix A for the Medicare State Operations Manual
• Critical access hospitals have separate guidelines
• Important to stay updated with state-specific regulations effective from January 2023

Focus Areas: Surgery, PACU, Anesthesia Standards

• CMS Manuals and Memos: Provide expectations for practices, based on tag numbers
• Safe Injection Practices: Focus on safe injection, single-use practices, and infection control
  • Follow CDC guidelines for waste disposal: red waste, white general waste, yellow for hazardous materials

Institute for Safe Medication Practices (ISMP)

• Guidelines for IV push medication
• Additional safety tips and practice expectations available at ismp.org
• Numerous best practice worksheets and resources

Safe Opioid Use

• Emphasis on preventing opioid misuse and safe administration practices

Deficiency Data

• Tags and calculations from CMS, Joint Commission, HVAP
• Identifying areas with high citations to improve practices

Surgical Services Standards

• Utilization of evidence-based resources in surgery, PACU, and procedural areas
• Regulations for circulating RNs, APRNs, Pas, and medical staff privileges
• Toolkits provided for safe environments and preventing OR fires

Record Keeping and Documentation

• Important to have complete documentation according to the scope of practice
• Maintain detailed records for devices and implantables

Anesthesia Services

• Must be administered by qualified physicians (MD/DO)
• Roles of medical staff providers and advanced providers
• Credentialing and privileging review every two years

Critical Access Hospitals

• Specific considerations and standards for critical access hospitals
• Resources provided to meet compliance requirements

American Society of Anesthesiologists (ASA) Guidelines

• Use of ASA physical status classification system to determine patient care
• Discussion points and case studies provided for staff review

Conclusion

• Emphasis on accurate, compliant practices in surgery, PACU, and anesthesia
• Importance of continual education and resource utilization
• Availability of education services and on-site visits for further support