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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