Medication Safety & Compliance: Tackling ISMP Top Hazards, CMS CoPs, and Restraint Protocols

Session 1: Safe Medication – ISMP's Top 10 Errors and Hazards: Opioid Use, IV Infusion Pump Hazards, IV Medication, Mixtures Outside Pharmacy and More

Pre-recorded Webinar (Instant Access)

Speaker: Laura A. Dixon

Webinar Description

ISMP published their annual “Top 10” issues on medication errors and hazards. There are many requirements that must be met when the patient is provided their first opioid. This webinar will discuss common errors and hazards related to medication administration. 

Also covered will be CDC opioid guidelines, Joint Commission final pain management guidelines, federal guidelines for opioid programs, opioid epidemic, and required hospital policies and training. The CMS standards on the care of the patient receiving opioids will be addresses, which also apply to critical access hospitals. 

This session by our expert speaker Laura Dixon will also cover the ISMP IV Push guidelines for adults and the National Action Plan for ADR prevention related to the opioid recommendations. The CMS final worksheet on QAPI will be covered regarding the tracking of medication administration errors and adverse drug reactions. The CDC final opioid guidelines are also discussed.

Staff education on the safe opioid use policy is required by CMS and includes an assessment of the patient to determine who will be at risk for an adverse event from the use of IV opioids including PCA. This webinar includes education on the side effects and how to recognize them.

Webinar Objectives

• Recall ISMP Top 10 Medication Errors and hazards
• Describe error-prone abbreviations, symbols or dose designations
• Discuss CMS 32-page memo on medication administration and safe opioid use
• Describe that all medications must be administered within three different time frames
• Recall that CMS has required policies and education requirements on medication administration and safe opioid use
• Recall that the CDC issued opioid prescribing guidelines

Webinar Agenda

• ISMP 2020 Top 10 medication errors and hazards
• ISMP 26 pages of guidelines on IV Push medication
• CDC Opioid Guidelines 
• Federal guidelines for opioid programs
• TJC pain management guidelines 
• Changes: medication administration, IV, blood, and opioid safe use and immediate post-op care
• National Action Plan for ADE prevention
• Incidence of medication errors and ADEs
• Assessment and safe use of opioids
• CMS Conditions of Participation related to medication administration including “nine rights” and timing of medications.

Session 2: Discharge Planning: Compliance with CMS Hospital & CAH CoPs in 2024

Live Date: October 24, 2024

Time: 1 PM ET

Speaker: Laura A. Dixon

Duration: 90  minutes

Webinar Description

Every hospital that accepts Medicare and Medicaid must adhere to the CMS discharge planning guidelines. These standards apply to all patients, not just those covered by Medicare or Medicaid. CMS mandates specific discharge planning policies and procedures, and this webinar will outline which ones are required and the reasons behind CMS's updates to these standards.

This session by industry expert Laura A. Dixon, will cover the Impact Act and its influence on hospital discharge planning, including standardized assessment, quality data, and resource data requirements. Hospitals are required to assist patients with post-discharge care options such as home health services, skilled nursing facilities, long-term care hospitals, and inpatient rehabilitation facilities, providing information on all four except for Critical Access Hospitals (CAHs).

Patients are entitled to timely access to their medical records, which must include details of the discharge planning process, discharge instructions, and discharge planning requirements. This webinar will also address the following topics:

• Transfers to other facilities
• Assessment of readmission within 30 days
• Caregiver rights and recommendations
• Reduction of factors leading to preventable readmissions
• Timely discharge planning

Additionally, the discharge planning conditions of participation for Critical Access Hospitals will be briefly discussed, highlighting their alignment with the requirements for acute care hospitals.

Webinar Objectives

• Discuss the revised discharge planning requirements by CMS for all hospitals and critical access hospitals.
• Recall how patients and physicians can request a discharge planning evaluation.
• Discuss the importance of providing hospitalization information to the physician or provider before the first post-hospital visit.
• Describe the patient’s right to timely access their medical records, including a copy of their discharge plan.

Webinar Agenda

• Introduction
• Deficiency data for discharge planning
• Discharge planning process and the IMPACT Act
• Identification of patients needing discharge planning
• Role of support person
• Incapacitated patient
• Discharge planning process
• RN, social worker, or qualified person to develop evaluation
• Timely evaluation
• Discussion of evaluation with patient or individual acting on their behalf
• Discharge evaluation in the medical record
• Documentation of the discharge process
• Discharge plan
• Physician request for discharge planning
• Implementation of the patient’s discharge plan
• Reassessment of the discharge plan
• Freedom of choice for post-acute care providers
• Transfer or referral
• Critical Access Hospital Discharge planning requirements
• Discharge planning metrics
• Appendix and Resources

Session 3: CMS Hospital Restraint and Seclusion: Navigating the Most Problematic CMS Standards

Live Date: November 14, 2024

Time: 1 PM ET

Speaker: Laura A. Dixon

Duration: 90  minutes

Webinar Description

Restraint and Seclusion is a hot spot with both CMS and the Joint Commission and an area where hospitals are frequently cited non-compliance. This webinar will discuss this most problematic standard.

CMS has fifty pages of interpretive guidelines on restraint and seclusions for hospitals. Every hospital that accepts Medicare patients will have to comply with the regulations even if accredited by Joint Commission, HFAP, CIHQ, or DNV Healthcare.

Any physician or provider who orders restraint must be trained in the hospital’s policy. Both CMS and Joint Commission require hospital staff to be educated on restraint and seclusion interpretive guidelines on an annual basis. CMS also says that restraint training must occur before a staff member/provider can apply or remove restraints and must be on-going so it cannot occur at orientation only. There are ten pages of training requirements.

Finally, this webinar will briefly cover The Joint Commission standards on restraint and seclusion, many which fall closely with the CMS Conditions of Participation.

Webinar Objectives

• Recall that CMS requires that all physicians and others who order restraints be educated on the hospital policy.
• Describe that CMS has restraint education requirements for staff.
• Discuss that CMS has specific things that need to be documented in the medical record for the one-hour face to face evaluation on patients who are violent and or self-destructive.
• Define the CMS restraint requirement of what a hospital must document in the internal log if a patient dies within 24 hours with having two soft wrist restraints on.

Webinar Agenda

• Restraints in the news
• Introduction to CoP Manual
• Deficiencies – restraints and seclusion
• Complaint manual and process
• Conditions of Participation
• Seclusion – what it is and is not
• Medical restraints
• Behavioral health restraints
• Definition of restraint and seclusion
• Reasons to restrain
• Leadership responsibilities
• Falls and use of restraints
• Drugs used as a restraint
• What restraints do not include
• Side rails, forensic restraints, freedom splints, immobilizers
• Patient assessment
• Need order ASAP
• Order from LP and notification to attending physician
• Documentation requirements
• Least restrictive requirements
• RNs and One-hour face to face assessment
• Training for RN doing one-hour face to face assessment
• Training requirements
• Ending at earliest time
• Revisions to the plan of care
• Time limited orders
• Renewing orders
• Provider training
• Staff education
• First aid training required
• Monitoring of patient in R/S
• Death reporting requirements
• Joint Commission standards

Who Should Attend

• All nurses with direct patient care
• Compliance officer
• Chief nursing officer
• Chief of medical staff
• COO
• Nurse Educator
• ED nurses
• ED physicians
• Medical staff coordinator
• Risk manager
• Patient safety officer
• Chief Risk Officer
• PI director
• Joint Commission coordinator
• Nurse managers
• Quality director
• Chief medical officer
• Security guards
• Accreditation and regulation staff and others responsible for compliance with hospital regulations
• Anyone involved in the restraint or seclusion of patients.
• Any staff that could remove/apply restraints as part of care