The recent CMS rule changes have emphasized the critical role of antibiotic stewardship programs in all hospitals. By including this requirement, CMS aims to encourage healthcare facilities to adopt evidence-based practices in antibiotic prescribing and administration, ultimately minimizing the emergence of antibiotic-resistant bacteria. The extensive nature of the CMS document underscores the agency's commitment to enhancing healthcare quality and patient safety. By consolidating multiple laws into a single document, CMS seeks to streamline compliance efforts and provide hospitals with a comprehensive framework to guide their operations. Healthcare professionals and administrators can benefit significantly from accessing the CMS webinar on the finalized rule changes. This webinar serves as an invaluable resource, offering detailed insights into the revised hospital conditions of participation and providing clarity on compliance requirements and expectations. Register Now, https://conferencepanel.com/conference/cms-hospital-improvement-final-rules-nursing-medical-records-infection-control-and-more

1. CMS Hospital
Improvement Rules

2. 2
Speaker
▪ Laura A. Dixon, Esq.
▪ BS, JD, RN, CPHRM
▪ President, Healthcare Risk
Education and Consulting, LLC
▪ 303-955-8104
▪ Email questions to CMS:
Critical Access Hospitals: qsog_CAH@cms.hhs.gov.
Acute hospitals: qsog_hospital@cms.hhs.gov.
2
2

3. Introduction
3

4. Introduction – Next Steps
▪ CMS published interpretive guidelines for Acute
Hospitals for Infection Prevention and Control and
ASP March 2023
▪ CMS will publish the rule in a transmittal
▪ Will update the CoP manual - eventually
▪ Hospitals will need to review and implement the
requirements
▪ Can do a gap analysis where they go through it line by line
and document how they meet compliance
4

5. CMS Hospital CoP Changes
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6. QAPI Program
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7. Psychiatric Hospitals
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8. Patient Rights and Non-
Discrimination
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9. PAs Ordering Restraint and
Seclusion

10. Emergency Preparedness
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11. H&P for Healthy Outpatients

12. LAB Look Back Program
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13. Nursing Services
13

14. Medical Staff: Autopsies
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15. 4 Swing Bed Changes

16. CDC Guide to Infection Prevention
for Outpatient Settings
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17. Infection Control and
Antibiotic Stewardship
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18. CAH
Infection Control and ASP,
Staffing and More
18

19. APPENDIX
Resources and Internet Links
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20. Patient Rights and
Medical Records
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