CMS Updates: Respiratory/Rehab, Blood/IV, Error Reporting
On May 13, CMS released a 14 page memo outlining updates due to Appendix A of the State Operations Manual (SOM) related to:
• Orders for rehabilitation and respiratory services due to regulatory changes
• Clarifications for blood and IV medication administration requirements for nursing
• Reporting of medication errors guidance.
These revisions were immediately effective so it’s a good chance to review what CMS expects in these areas.
Rehabilitation Services [§482.56 (b)]
Medical Staff policies and procedures should address the types of practitioners that can order rehab services in accordance with your State law. Ensure that they are privileged by you to do so. CMS emphasized that all services received by the patient should have an order by the responsible provider, be provided by qualified individuals and be reflective in the patient’s care plan. [§482.56 (b)(2)]. Once again, make sure staff competencies are current and appropriate, even if rehab is a contracted provider for you.
Respiratory Services [§482.57 (b)(3)]
The responsible practitioner who orders respiratory care services must be privileged to do so as well. These privileges must be granted in a manner consistent with your State’s scope of practice law, hospital policies and procedures, developed by the medical staff and approved by the governing body. The staff qualification criteria should be clearly defined. Of course, the medical record must demonstrate evidence of the respiratory services received.
Blood Transfusion and IV Medications
Under its Nursing Service regulation [42 CFR 482.23 (c)(3)], CMS clarified its Interpretive Guidelines for staff that administer blood transfusions or IV medications related to the documentation of training received. (This excludes physicians). Each employee’s record should contain evidence of these competencies. Aside from State practice, surveyors will expect to see that staff training is based on recognized practices which minimally include:
• Fluid and electrolyte balance
• Venipuncture techniques (demonstration and supervised practice)
• Blood components
• Blood administration procedures based on hospital policy, State law, and nationally recognized standards of practice
• Requirements for patient monitoring, including frequency and documentation of monitoring
• The process for verification of the right blood product for the right patient;
• Identification and treatment of transfusion reactions.
Consider reviewing your policies’ expectations, training received and documentation requirements in these areas to see if you pass muster. Too often, the link between all three aspects is broken. Specifically monitor patients who have had transfusions to see if the documentation meets your expectations including completed blood slips, vital sign monitoring, patients’ reactions and staff competencies. Don’t forget any staff that performs admixing of IVs.
Medication Error Reporting
CMS requires that hospitals define the circumstances for reporting drug administration errors, adverse drug reactions and incompatibilities including the circumstances and process for physician notification under its Pharmaceutical Services Conditions of Participation. Surveyors have been instructed to look at your policies and procedures, patient records and to conduct staff interviews about your process. The tricky part will be the use of staff clinical judgment about when not to notify the attending or covering physician such as a missed night time medication dose. Consider what resources are available for staff to make this determination especially if you don’t have 24 hour onsite pharmacy coverage. Ensure that all these circumstances are covered under your quality program for reporting and evaluation in consideration of State requirements, even for those circumstances that didn’t cause problems for the patients.
Since this memo reflects an early-release version of the CMS updates, there may be changes whenever the updated Appendix A of the SOM is eventually released. Since your State surveyors have recently received these details, they may be on their radar screens for additional scrutiny. This link provides additional details if needed. http://www.cms.gov/Surveycertificationgeninfo/downloads/SCLetter11_28.pdf