good day everyone I'm John modern for this webinar and welcome everyone for today's webinar CMS Hospital conditions of participation 2022 surgery p a c u and anesthesia standard I would now like to introduce our presenter for today darling Evans darling Evans Amazon RNC phq is a nurse consultant for Nash Healthcare Consulting darling brings 25 years of experience in the healthcare industry specializing in clinical and Regulatory operation management and accreditation Readiness and response I would now like to hand over the one of the best speaker of Nash darling events over Theodore hi everybody and thank you for joining us um we'll start moving through this again uh focuses on CMS Hospital's condition of participation and ending 2022 the new standards for all of the accreditation and Regulatory processes will go into effect 2023 so we always like to say that depending on your hospital little tight where you're located certainly the state you're within you want to be mindful of any pending changes that might be reflected for your state become effective January 2023. so this particular focus is on surgery pack you and anesthesia standards and we'll go ahead and get started just for those on the call that might be new to your role one of the things we like to point out is these particular requirements are federal and state mandates from CMS one of the things we always remind you of too how do you keep up with the CMS standards uh conditions for participation they're quite voluminous so the initial point of focus was in 1986 and they're divided if you're also duly accredited by Joint Commission CMS uses the term tag or tag numbers so predominantly on your screen you see a for hospitals we call that manual a or appendix a the for the Medicare State operations manual if your critical access then of course we'll show you those in that CMS success regardless it gives you other types of resources again for your support for your care treatment service within your organization so in this particular Focus the CMS manual survey memos issue the other thing they do is quite often put I'm going to say tips at the trade they they it's an open book they give you the expectation for practice and so a lot of times based on the tags and what they expect in your delivery of care improving safe quality care so our focus is looking at the CMS memo that was released on safe injection practices single dose and infection control breaches relative to that quite an extensive topic the national standards are imperative and again anything that's coming out of CMS I.E remember those are federal and state guidelines so it is imperative that those be followed um and then discarding them appropriately so again your state may have regulations around this but appropriately in this country following under the CDC guidelines for discard 30 whether it's red waste considered white trash or white General waste and or then it's if it's hazardous materials or hazardous medications quite often are in yellow don't let the color spool you want to follow those guidelines appropriately so then we transition to The Institute for safe medication practices and guidelines the ismp for IB push medication and this is the similar to the same medication practice expectations but there are some specific care and safety aspects about this information you can again find it on the website at isnp.org we've provided that information for you and it does um add the additional practice expectations and safety tips for you um there are many worksheets that some of the best practice organizations use or guide there certainly are for CMS so now you get CDC on safe injection practices same thing um and again more specific um in regards to getting down to the granularity while we have these practices so lots of again resources there those we've just talked about safe opioid use big topic again I want to talk a little bit about deficiency data you see again from those deficiencies where based on each tag they're calculated Joint Commission HVAC and all the organizations do this to know where the highest citations are so looking at the cop section for surgery Pacquiao and anesthesia for surgery proper surgical Services procedural areas perioperative Arenas you want to again utilize as many evidence-based resources as possible so circulating REM surgical privileges a lot of times we're talking about your Advance providers so aprns Pas and dork anybody on the medical staff with Surgical and clinical privileges as Dean um designated by the organization in medical executive team so we've given you again and some tool kits here for keeping your environment in the procedure and perioperative and operative Suites safe what's expected preventing or fires this is actually still tragic when it happens but it still does happen which means we have to continue to be vigilant to prevent them all right and a lot of these now if you'll see so again even if you're only CMS accredited or or surveyed if you will again use these resources that are available to you so you don't have to necessarily be duly accredited by Joint Commission or DMV but their their information and packets and resources are available to you as well documented appropriately in the record as according to scope of practice and roles and responsibilities making sure that it's complete again what's appropriate in a full hmp versus an assessment the or register this is imperative whether still manual or electronic there are requirements and the reason for this is quite often for the devices we use or implantables they have to be tracked accordingly right and again with an encounter uh with anesthesia so within separate from so anesthesia itself must be provided in a well-organized manner under qualified Physicians and MD or a do only who can administer and again we've said this your medical staff provider or Advanced provider under the design of the scope of practice and then based on those Provisions if they're approved or not so we've talked about this and that they're reevaluated so we said at minimum every two years in that credentialing and privileging process so critical access I've reference critical access hospitals so I'm going to move very quickly through this and this is actually where up until we've now finished talking all of these are now available just as resources to you but whether you're acute care hospital critical access hospital or less then you want to be mindful again of what we've talked about so this just summarizes again so the American Society of anesthesiologists just as much as all the other service guidelines are there as we've said we will say this is most important because no matter who's doing that anesthesia review whether it's that surgeon or CRNA under the surgeon or an anesthesiologist they do use the ASA physical status classification system for identifying the appropriate care process for that patient what level of risk they are what needs to be determined that we've talked about but this gives you more specifics and then these are discussions that again are case studies it gives you I'm going to say points of challenge for you and that you want to look at and discuss with your staff because it is important I thank you for your time today it's always our pleasure to help you in any capacity be it my education services or on-site visitation all right thank you so much