Inpatient Facility Coding & Compliance Alert

Can’t-miss tips on CoPs for hospitals: standing orders, biologicals and more.

CMS continues to lay down new requirements of minimum health and safety standards that could affect your facility’s protocols known as conditions of participation (CoPs).  Find out how the latest rules, published in the July 11, 2014 Federal Register will affect your hospital’s compliance. .

The big picture: The State Operation Manual publication 100-107, Appendix-A, contains sections on nursing and Medical record services worth viewing. One big change is that CMS has proposed revisions at section 482.23 that will permit hospitals to create policies and procedures for the patient and his caregiver for self administration of specific medications. Other proposals of interest relate to standing orders and biologicals. 

Clearly Document Your Work Procedures With standing orders being the mainstay of the revised CoPs, CMS lays out the policies and procedures for them in TAGs A-0405, A-0406.  

The agency requires hospitals to have a process in place for development, approval, and periodic review of standing orders. This is consistent with the national guidelines, which require documentation and authentication by the responsible physician or another practitioner. The order should also be compliant with the state laws and hospital policies.

What this means: You now would need to “translate this into what you really need to be doing back at the hospital,” says Duane C. Abbey, Ph.D., president of Abbey and Abbey Consultants Inc., in Ames, IA. You would need to work on specific criteria, clinical situations, patient conditions, and diagnoses while developing the standing orders. 

“For example, in the ED provision of heparin IV for an MI … do we have to have a specific order for that or is this something we’re going to do as a standing order and then have the ER physician authenticated,” asks Abbey.

Train Your Staff On Standing Orders 

CMS now requires you to have in place a policy for the education and training of the medical, nursing and other staff so that they all know the standing orders and are able to apply them in unison. 

The individual responsibilities within the team should be well defined, documented, understood, synchronized, and implemented.  For instance, an ED nurse and other staff would know the expected role they are required to fulfill in a particular ED procedure for which the hospital has a standing order in place.

Tactic: The standing order should be fastidiously included in the patient’s chart, preferably at the time it is initiated for the patient. Do not forget to document the physician/ practitioner responsibility, sign off, and authenticate the patient chart.

The standing orders need to be continuously monitored to ensure they are actually being implemented at the ground level, as well as evaluated for their propriety and usefulness for the patient. Review them at regular intervals and document any updates and modifications your team might want to make. 

Both clinical and administrative concerns should be addressed. Having these records will be helpful in an audit, since auditors will probably ask questions about how your facility handles standing orders and how well the staff follows them. “Protocols, if they are there, should be used,” Abbey says. “If they’re not being used they shouldn’t be there. If they need to be changed, then change them.”

Ensure Pre-printed Order Sets Meet Guidelines 

As per the new guidelines, CMS permits the use of pre-printed electronic standing orders, order sets, and protocols for patients, provided the hospital adheres to the CMS guidelines. The hospital shall let a competent team develop and maintain these, and a medical staff representative must coordinate to check that the orders adhere to the Joint Commission, CMS policies, state laws, and regulations. 

“If you’re meeting the Medicare requirements, you’re probably meeting the others, but you have to be careful,” cautions Abbey.

Remember that the practitioner authenticates and documents such orders as well. Also, for order sets with pre-checked items, make sure the providers cross out and initial the items or service that they would not recommend for the patient.

Tread Carefully with Your Drugs and Biologicals

Appendix A, Tag A-0405, § 482.23(c), details the policy for the preparation and administration of drugs. It also has reference to non-physician practitioners and their role in preparation and administration, which has gained importance lately due to increasing utilization of non-physician practitioners.

As per the new guidelines, CMS also requires that the drugs and biologicals be prepared and developed in adherence with the federal and state laws, accepted standards of practice, and the orders of the practitioner responsible as classified under § 482.12(c). They may be prepared by other practitioners provided they act in accordance with the state laws including the scope of practice laws.

“These areas can become a little bit touchy because we may have a specially trained nursing staff preparing chemotherapy drugs,” Abbey points out. “Then we have a whole bunch of rules about where they’re prepared, do we have a hood… just make sure that they fall within the rules and regulations.” 

Document every detail: Every facility needs to have a system in place for medical staff approval of policy and procedures regarding personnel practices, timing of drug administration, frequency of administration, and whether the dosage was missed or was given late.

Example: “For drug X we give 100 milligrams at the beginning and then we cut it down to 50 milligrams two hours later, then whatever the protocol happens to be,” Abbey explains. “We just need to have policies and procedures about frequency, and missed or late administration of a drug particularly where timing is critical.” 

Practitioner order: In accordance with the standards of practice, verify that the practitioner order for drugs and biological includes: name of the patient, age and weight for dosage calculation as applicable, date and time, the name of the drug, its frequency and dosage, precise strength, quantity, instructions for use and, lastly, the name of the prescriber.

Editor’s Note:  Watch for analysis of CMS’ guidelines for hospital surveyors in the next issue of Inpatient Coding and Compliance Alert.