May 31, 2012


We recently read the final regulations revising the Medicare Conditions of Participation and noticed several revisions dealing with patient care issues.  Does this mean that we will have to revise our Medical Staff rules and regulations?  If so, what changes will we need to make?


The final regulations revising the Medicare Conditions of Participation do indeed make changes to several patient care areas, including verbal orders, standing orders, self-administration of medications, and reporting of certain restraint-related deaths, that will require revisions to rules and regulations.  Some of the changes are “permissive” revisions, which simply means that they now allow, instead of require, hospitals to do certain patient care-related things that they were not permitted to do in the past.  For example, the Centers for Medicare & Medicaid Services are now permitting hospitals to have an optional program for patients, or their support persons, on the self-administration of hospital-issued medications or medications the patient brings into the hospital.  However, if a hospital wishes to pursue such a program, medical staff rules and regulations must comply with the revised Conditions of Participation and address when and how self-administration may occur, including the performance of an assessment of the patient’s capacity, or the caregiver’s capacity, to self-administer the specific medication.

Similarly, hospitals may continue to use standing orders and evidence-based protocols under the revised Conditions of Participation, but must now meet certain conditions, including review and approval by the medical staff and the hospital’s nursing and pharmacy leadership and periodic review for the safety and usefulness of the standing orders and protocols.  These conditions should be outlined in a section on standing orders in the rules and regulations, or a policy that is cross-referenced in the rules and regulations, to ensure that the medical staff is complying with the Conditions of Participation in the implementation and use of such orders.

For more information on this topic, please join Ian Donaldson and Charlie Chulack on Thursday, June 21, 2012 from 1:00 p.m. to 2:30 p.m. ET for the audio conference “The New Medicare CoPs and Patient Care:  Can High Quality Care & Low Administrative Burdens Coexist?”  Ian and Charlie will discuss in detail the patient care issues addressed in the revised Medicare Conditions of Participation and the changes the medical staff will have to make to its rules and regulations as a result.