CMS Pharmacy and Medication: Complying with the Hospital CoPs
Recorded Webinar | Laura A. Dixon | From: May 23, 2022 - To: Dec 31, 2022
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Just about every hospital in America accepts Medicare and Medicaid reimbursement and, as such, must follow the Center for Medicare and Medicaid Services (CMS) hospital regulations and interpretive guidelines. These regulations and guidelines must be followed for all patients in the hospital, not just Medicare/Medicaid patients. In 2020, CMS made changes to 3 of the 18 pharmacy tag numbers. However, interpretive guidelines and survey procedures are still pending from CMS.
There has been increased scrutiny of the standards and an increase in the number of deficiencies for hospitals. This includes changes regarding the compounding of sterile medication and the beyond-use date (BUD). The goal of the changes is to align them with the acceptable standards of practice. The language was included to allow the surveyor to cite the hospitals at either the standard or condition level.
There have been many recent changes in the nursing section that address medication usage also. This includes changes to the timing of medication, self-administered medication, compounding, blood, and safe opioid use. There are three-time frames during which medications must be administered along with the QAPI requirements.
The OIG recommended surveyor training and the evaluation of 55 things in addition to revising the pharmacy standards which was done. More educated surveyors can increase the chances of finding a deficiency. The surveyor may ask for the contract if the hospital outsources compounding.
Medication errors are a common medical error in hospitals today. CMS said that drug-related adverse outcomes occur in 1.9 million inpatient stays which is almost 5% of all admissions. There are also 838,000 patients a year who are treated as an outpatient who have a drug-related adverse event. Hospitals that spend more resources on medication issues generally have lower rates.
Information will be provided on the top problematic pharmacy standards by CMS. CMS is now issuing a deficiency report showing when the pharmacy is cited for being out of compliance. This program is a must to help ensure compliance with the hospital CoPs.
It is important for nursing to understand the medication and pharmacy standards since many of them apply to nursing. For the first time, CMS mentions that nursing needs to be aware of some of the pharmacy standards and vice versa. This includes medication errors, adverse events, drug incompatibilities, self-administered medication, and required medication policies. If a medication error or ADE occurs there must be a notification from the physician, documentation in the medical record and it must be included in the PI data.
The timing of medication requires policies and procedures and training by hospitals. This section requires notification of the physicians and discusses when medications are administered outside of the timeframes. Hospitals should have a non-punitive approach and the definition of medication error should be broad enough to include near misses.
The CMS interpretive guidelines address medication management and pharmacy-related standards. These can be looked at when CMS conducts a complaint or validation survey. Medication management is not only a big issue with CMS but also with the Joint Commission. Medication errors are the largest number of medical errors in healthcare today. They are also the most common reason for unnecessary readmissions to the hospital.
Hospitals must work together to implement and follow these regulations. Problematic standards include verbal orders for medication, orders for medications, and standing orders.
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