New CMS Rules for Hospitals Recognize Nurses & Allow Flexibility in Care
Recent changes to the “Conditions of Participation” (CoPs) for hospitals participating in Medicare and Medicaid will give nurses more flexibility in key areas — nursing care plans, standing orders, medication administration, infection control, and medical staff participation by advance practice registered nurses (APRNs). In the notice of final rule, the Centers for Medicare and Medicaid Services (CMS) recognized the contributions and leadership of registered and advance practice nurses, even quoting from ANA’s comments. CMS also decided to grant critical access hospitals (CAHs) more flexibility in how they operate. With the Joint Commission involved in ensuring hospitals comply with the CoPs, the guidelines can also have an effect beyond Medicare/Medicaid hospitals.
In addition to reflecting current practice, the revisions should reduce the administrative burden for participating hospitals, consistent with President Obama’s Executive Order 13563, “Improving Regulation and Regulatory Review.” CMS estimates hospitals will save a total of $940 million per year; almost $5 billion over the next 5 years. The final rule appeared in the Federal Register on May 16, 2012 and takes effect July 16, 2012
The complete hospital CoPs appear in parts 42 and 45 of the Code of Federal Regulations (CFR; citations below). ANA’s comments on the proposed rule. Here are the major changes affecting RNs & APRNs:
Nursing Care Plans: Hospitals will have the option of “having a stand-alone nursing care plan, or a single interdisciplinary care plan that addresses nursing and other disciplines” (42 CFR 482.23(b)). ANA comments emphasized the importance of the nursing care plan to nursing care, but also supported the interdisciplinary team approach.
Medication Administration: With appropriate safeguards, education, supervision and documentation, hospitals can allow patients and their caregivers to self-administer some medications (42 CFR 482.23(c)(6)). ANA sees this as an important part of patient-centered care. CMS agreed with our point that “self-administration can be an extraordinarily helpful tool for teaching self-care as a patient and his or her family begin the transition back home.” In addition, the CoPs will no longer require special training to administer blood transfusions and intravenous medications. But hospitals must follow State law and medical staff policies and procedures (42 CFR 482.23(c)(4)).
Medical Orders: (1) Standing orders can be used by hospitals. CMS “added a requirement for medical staff, nursing, and pharmacy to approve written and electronic standing orders, order sets, and protocols” (emphasis added) (42 CFR 482.24(c)(3)). ANA strongly supported this. (2) Verbal orders will need to be authenticated promptly, consistent with State law, but the rigid 48-hour rule is eliminated (42 CFR 482.24(c)(2)). ANA supported this change, as nurses are often charged with policing the rule and hunting down clinicians for signatures. (3) Orders by “other practitioners:” “We have allowed for drugs and biological to be prepared and administered on the orders of practitioners (other than a doctor), in accordance with hospital policy and State law, and have also allowed orders for drugs and biologicals to be documented and signed by practitioners (other than a doctor), in accordance with hospital policy and State law” (42 CFR 482.23(c)). This appears to simply reflect current practice.
Infection Control: Logs are no longer required. “Hospitals are already required to monitor infections and do so through various surveillance methods including electronic systems.” And “quality assurance program” was changed to “quality assessment and performance improvement program.” (42 CFR 482.42). ANA supported greater flexibility in this area, and CMS agreed with ANA’s comments that “the vast majority of the officers are registered nurses who take their roles very seriously and have a very high level of professionalism and vigilance.”
Restraint-Related Deaths: Deaths of patients with 2-point wrist restraints who have not been under seclusion must be included in an internal log, but do not have to be reported separately (as with other restraints) (42 CFR 482.13(g)). ANA comments supported continued separate reporting, to ensure that hospitals comply with standards to ensure ongoing patient safety.
Medical Staff Privileges for APRNs, etc: Hospitals can continue to include “other practitioners” (such as APRNs) within their medical staff, and grant them hospital privileges, in accordance with State law (42 CFR 482.22(a)). “This change will clearly permit hospitals to allow other practitioners (e.g., APRNs, PAs, pharmacists) to perform all functions within their scope of practice.” ANA supported requiring “due process” ensuring fair treatment for all applications for staff privileges by non-physicians, which unfortunately was not adopted.
CMS noted that “changes to the Medical staff CoP will allow hospitals to broaden the concept of ‘medical staff’ through the appointment of non-physician practitioners to the medical staff so that they may perform the duties for which they are qualified through training and education and as allowed within their State scope-of-practice laws. For hospitals that choose this option, significant savings might be achieved as non-physician practitioners will enable physicians to more effectively manage their time so that they may focus on the more medically complex patients.”
Critical Access Hospitals: Will no longer have to offer surgical services, and can provide many services under contract, rather than directly by CAH staff. (42 CFR 485.635 & 639). The definition of “clinical nurse specialist” in the CAH rules was aligned with that of the Social Security Act. (42 CFR 485.604(a)). ANA comments endorsed those of the National Association of Clinical Nurse Specialists on this issue, and supported greater flexibility for CAHs, which provide crucial access to health care for rural and underserved communities.
Transplant Procedures: Organ recovery teams will no longer have to conduct a “blood type and other vital data verification” before organ recovery when the recipient is known (42 CFR 482.92). This is already required at two stages of the transplant process.
Other Issues: Hospitals are no longer required to have a single “director of outpatient services.” (42 CFR 482.54(b)). Multi-hospital systems can have one, single governing body that includes at least one member of the medical staff (42 CFR 482.12). A podiatrist can be head of the medical staff (42 CFR 482.22(b)).
Eileen Shannon Carlson, RN, JD