Hospital Condition of Participation Rule Impacts ANA Members

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Conditions of Participation (CoPs) are designed to protect patient health and safety and ensure quality of care, through specific requirements each hospital service or department must meet to participate in Medicare and Medicaid.  CoPs serve as compliance guidelines for State surveyors, and minimum standards for private accrediting programs like the Joint Commission.  CMS, the Centers for Medicare & Medicaid Services, are calling for changes in the CoPs for hospitals and critical access hospitals (CAHs) which will impact nursing practice and patient care within these hospitals – and potentially throughout health care.  These changes involve:  
  • Section 482.13, Patients’ Rights:  Use of restraints and seclusion
  • Section 482.22, Medical Staff:  Hospital privileging and APRN practice
  • Section 482,23, Nursing Services:  Nursing care plans; standing orders; who can order drugs; training for blood transfusions and IV medications
  • Section 482.24, Medical Record Services:  Verbal order review and authentication
  • Section 482.25, Pharmaceutical Services:  Reporting of drug errors
  • Section 482.42, Infection Control:  Infection tracking and surveillance; quality assessment and performance improvement (QAPI) programs
  • Section 485.604, Personnel Qualifications:  Definition of Clinical Nurse Specialist

Comments on the proposed rule are due Dec. 23, 2011. ANA's draft comments will be available in the coming weeks.  The Federal Register notice can be found at: