Changes to the Conditions of Participation for Hospitals ...
Changes to the Conditions of Participation for Hospitals -Section 482
(H&P, Verbal Order Authentication, Medication Storage, Anesthesia)
Effective January, 2007
|Condition of Participation Revision |Related Joint Commission Standard |Implications/Key Issues |
|History and Physical (H&P) examination |Standard PC.2.120 |Expands permissible LIPs allowed to perform H&P |
|(482.22) |Patient assessment/History and Physical |H&P may be up to 30 days old prior to inpatient admission |
|Major changes: |Elements of Performance 1. Written time frame for conducting |If up to 30 days old an update documenting changes must be |
|-H&P completed no more than 30 days before or|initial assessment |completed within 24 hours after inpatient admission (meaning|
|24 hours after admission for each patient |2. H&P completed no more than 30 days prior to or within no more |if the LIP saw the patient in the office the day before and |
|-By a physician, an oralmaxillofacial |than 24 hours after of inpatient admission |updated the H&P there would still need to be an update after|
|surgeon, or other qualified individual in |6. For an H&P completed within 30 days prior to inpatient |the inpatient admission |
|accordance with State law and hospital policy|admission, an update documenting any changes in the patient’s |There will need to be an update to the H&P for inpatient |
|-Must be placed into the record within 24 |condition is completed within 24 hours after inpatient admission |surgical patients prior to surgery after the patient is |
|hours of admission |or prior to surgery |admitted, if the surgeon is using an H&P that is up to 30 |
|-If completed prior to admission, an update |(June Perspectives, 2007) |days old. Again, an update in the office the day before will|
|note documenting an examination for any |7. Updates to the patient’s condition are recorded at the time of |not suffice. |
|changes in the patients condition is entered |admission. This update can be based on the patient’s response to a|While both TJC and CMS are unclear about the application of |
|within 24 hours of admission |simple question such as “have there been any changes in your |this for outpatients – it is advisable to make the process |
| |condition since you last saw your physician and were examined?” |consistent for both populations |
| |(FAQ 7-12-07) |The FAQ allows for the healthcare professional (i.e., nurse |
| | |as part of preop assessment) to query the patient about |
| | |changes in condition from the H&P with a simple question. |
| | |The LIP with privileges to perform the H&P can then |
| | |authenticate this with a signature. As a simplified process,|
| | |this can be done as part of the anesthesia provider’s |
| | |signature block in the pre-anesthesia evaluation. |
|Authentication of verbal orders (482.23 & |Standard IM.6.50 |CMS is requiring all record entries to be dated, timed and |
|482.24) |Acceptance and transcription of verbal orders |authenticated. |
|-Verbal orders are to be used infrequently |Elements of Performance |In effect until the year 2012 – this component of the |
|-Only authorized staff can receive verbal |1. Qualified individuals defined by hospital policy and state law |revision has a five year limit. Verbal/telephone orders may |
|orders consistent with Federal and State law |receive and record verbal orders |be authenticated by another practitioner responsible for the|
|-All medical record entries must be legible, |2. Verbal orders are dated and include the prescriber, receiver |care of the patient. This means another LIP that is |
|complete, dated, timed, and authenticated |and individual who implemented the order |responsible for the care of the patient (covering LIP, |
|(written or electronic) by the person |3. Verbal orders are authenticated within legally (state/federal) |surgeon on the case, etc.) may sign off on the verbal order |
|responsible for providing or evaluating the |time frames |of another LIP. This authentication is of the order, meaning|
|service provided (follow hospital policy) | |the person signing the order of another, is signing that |
|-For 5 years authentication may include |Standard IM.6.10 |they have reviewed the order. It does not mean that they are|
|another practitioner who is responsible for |Complete and accurate medical record |in agreement with the order. The signature is evidence of |
|the care of the patient and authorized to |Elements of Performance |review (acknowledgment) only not agreement. The LIP signing |
|write orders by the hospital and State law |1. Only individuals authorized to do so make entries into the |the order may well change elements or all of the order. |
|-Authentication is according to State law or |medical record |Authentication must occur within 48 hours or state law |
|48 hours |2. The hospital which entries made by non LIPs require |requirements (some states require 24 hours, some up to 72 |
| |countersignature |hours) policy should indicate the time frame. If your state |
| |3. Medical record entries are dated and the author identified and |is silent, you must comply with the CMS requirement. |
| |authenticated when required by law | |
|Security of Medications (482.25) |Standard MM.2.20 Medication Storage |Nonscheduled drugs do not have to be locked when in a secure|
|-All drugs and biologicals must be kept in a |Medications are stored properly and safely |area. ICU, L&D, OR Suites are considered secure areas. A |
|secure area and locked when appropriate |Elements of Performance: |secure area means there is someone present to consider the |
|-Schedule II, III, IV, and V drugs must be |5. Unauthorized persons cannot obtain access to medications (per |area secure. |
|kept locked within a secure area |hospital policy and law) |Scheduled drugs must be locked |
|-Only authorized individual may have access |6. Controlled substances are stored to prevent diversion in |Policy defines who has access to locked areas (i.e. |
|to locked areas |accordance with law |housekeeping, pharmacy) |
|Postanesthesia evaluation (482.52) |Standard PC.13.20 |Preanesthesia and Postanesthesia responsibilities must be |
|-Policies on anesthesia must include the |Administration of anesthesia/sedation |described in writing |
|delineation of preanesthesia and post |Elements of Performance |A post anesthesia inpatient evaluation must be documented by|
|anesthesia responsibilities |1. Sufficient staff present to manage the procedure from |a qualified (privileged) anesthesia provided within 48 hours|
|-With respect to inpatients, a post |evaluation to recovery |post procedure |
|anesthesia evaluation must be completed and |2. Qualified providers administer anesthesia/sedation | |
|documented by an individual qualified to |7. Needs of the patient are assessed | |
|administer anesthesia as specified in |10. Preanesthesia/sedation assessment performed | |
|paragraph (a) of this section within 48 hours|11. Prior to anesthesia/sedation LIP with privileges plans or | |
|after surgery |agrees with planned anesthesia/sedation | |
| |12. There is a reevaluation of the patient immediately before | |
| |anesthesia/sedation | |
| |Standard PC.13.30 | |
| |Monitoring during anesthesia/sedation | |
| |Elements of Performance: | |
| |1.Oxygenation, ventilation and circulation are monitored during | |
| |anesthesia/sedation | |
| |2. The anesthesia/sedation is documented in the record | |
| |Standard PC.13.40 | |
| |Post procedure anesthesia/sedation monitoring | |
| |Elements of Performance: | |
| |1. Assessment of patient condition immediately after the | |
| |administration of anesthesia/sedation | |
| |2. Patient’s clinical condition including pain is monitored | |
| |3. Monitoring performed at a level consistent with the | |
| |anesthesia/sedation | |
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