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PIN CAH CMS Standards Review
Conference Call Notes
Call: January 13, 2015
Attendees: Community Hospital of Anaconda, Pioneer Medical Center, Cabinet Peaks Medical Center,
Prairie Community Hospital, Deer Lodge Medical Center, Central Montana Medical Center, Roosevelt
Memorial Hospital, Northern Rockies Medical Center, Crown/N. Cheyenne Indian Hospital, Fort Belknap
Service Unit, Sheridan Memorial Healthcare, Big Horn County Memorial Hospital, Livingston HealthCare,
Garfield County Health Center, Mountainview Medical Center
Tag 294
Nursing services must meet needs of patients
 CPMC – Educator keeps files on nursing education. Observe adequacy of staffing
through education through nurses. Have a ratio to maintain and keep reports to show
surveyors.
 Plentywood – nurse education trains on skills twice per year, keep skills checklist on all
staff. Track certifications and where nurses are at. Combination of duties from
education coordinator, HR, and trauma coordinator.
 Pioneer – HR tracks/trends ACLS and etc requirements. Beginning nurse competencies –
through education and education serivces documented.
 CMMC - Nursing orientation – Orientation schedule: New nurses assigned to initially
follow one-on-one with current nurses (same nurse entire period). New grad v.
experienced nurse determines amount of time to shadow.
 CHOFA – Orient with individual, ADON does P&P, have checklists to complete in
orientation.
 Prairie – Non-CAH staff: Travel staffs are a challenge. Have a checklist to run through but
traveler is fed so much info in a short period of time it is them to remember the info.
Implemented 1 page guide to where to go to find things.
 Big Horn- Have a packet of info for travelers including what they need from nurse.
Coordinating nurse comes in before shift to go through packet.
Tag 295
A registered nurse must provide (or assign to other personnel) the nursing care of
each patient, including patients at a SNF level of care in a swing-bed CAH. The care must be
provided in accordance with the patient's needs and the specialized qualifications and
competence of the staff available.
 CPMC – Assignment sheets provided each shift. Unit director goes over sheets.
Assignments are made by charge nurse. Nurses do acuity but it is not recorded.
 Big Horn – Anyone establish acuity and assign staffing to acuity? Is this what its asking?
 Plentywood – not meeting criteria in formal manner. One LPN, rest are RNs. RNs divvy
up patients themselves.
 CMMC – Internally assessed, but not formal.
PIN CAH CMS Standards Review
Conference Call Notes
Tag 296
A registered nurse or, where permitted by State law, a physician assistant, must
supervise and evaluate the nursing care for each patient, including patients at a SNF level of care
in a swing-bed CAH.
 DLMC - 2 Rn and 1 LPN. Open dialogue. Some RNs are more active than others.
 Functions essentially the same all over.
Tag 297
All drugs, biologicals, and intravenous medications must be administered by or
under the supervision of a registered nurse, a doctor of medicine or osteopathy, or, where
permitted by State law, a physician assistant, in accordance with written and signed orders,
accepted standards of practice, and Federal and State laws.
 DLMC – all IV drugs give through RNs. LPNs can place and evaluation but not administrator
drugs.
 Big Hardin/Plentywood: allow LPN according to scope of practice – BON information posted
in med room.
 CPMC/CMMC – RN only
 “in accordance with Fed and State Laws” piece of the tag addresses the ability to work
within their scope of practice.
 Verbal Orders – Verification of Provider orders
o DLMC – don’t take verbal orders outside of ED. All must be written through
providers. EPIC documentation signs off verbal orders when they open ED record.
In ED there is a read-back policy for confirmation.
o Big Horn – When nurses take verbal order in Healthland, they click in order area,
mark as verbal, and confirm they read back. Sign off on their size when they go back
to finish records.
o CPMC – 24 hours signed off of verification.
 Livingston – consequences? Current policy says 48 hours, CMS currently
says timely – but there is no definition to timely. No effective way to
enforce  Roosevelt – 48 hours
 Pioneer – physicians on floor daily, no problem – unsure of policy
 CMMC – covered w/I 24 hours. Not sure of policy. Physician or covering
physician always there.
 Plentywood – 24 or 48 – EHR covers it, some issues if they are off work 3-4
days. Provider on call may be able to co-sign for them.
Tag 298
A nursing care plan must be developed and kept current for each inpatient.
 Livingston - with EHR many admission orders generate POC at point of admission, all
elements including discharge planning maybe be addresses – POCs occur with risk/diagnosis
 Prairie – every 4 month care plan meeting; it is a challenge as they do paper charting.
Trying to put processes in place that take the question out of it.
PIN CAH CMS Standards Review
Conference Call Notes
C-1000
Standard: Patient visitation rights. A CAH must have written policies and
procedures regarding the visitation rights of patients, including those setting forth any clinically
necessary or reasonable restriction or limitation that the CAH may need to place on such rights
and the reasons for the clinical restriction or limitation.
 CMMC – rewrote visitation policy a couple years ago. Approached from the idea of
justified clinical restrictions. Changed wording of who visitors could be to “support
person”. Suggestion of word changes to alleviate questions.
 Visitation policy in every room. Indicates “not limited except for infection control,
communicable disease, threatening individuals.”
 Livingston – pretty open policy. Will look again.
 Big Horn – train/facility staff – anyone?
o CMMC – covered as competency’s when patient rights are covered. Address in
annual in-service.
Next Call:
February 17; 2:00 pm
We will cover :
C-1001– 1002 A CAH must have written policies and procedures regarding the visitation rights
of patients, including those setting forth any clinically necessary or reasonable restriction or
limitation that the CAH may need to place on such rights and the reasons for the clinical
restriction or limitation. A CAH must meet requirements noted in the SOM.
C-301
The CAH maintains a clinical records system in accordance with written policies
and procedures.
C-302
The records are legible, complete, accurately documented, readily accessible,
and systematically organized.
C-303
A designated member of the professional staff is responsible for maintaining the
records and for ensuring that they are completely and accurately documented, readily
accessible, and systematically organized.
Interpretive Guidelines
C-304
For each patient receiving health care services, the CAH maintains a record that
includes, as applicable: Identification and social data, evidence of properly executed informed
consent forms, pertinent medical history, assessment of the health status and health care
needs of the patient, and a brief summary of the episode, disposition, and instructions to the
patient;