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The compliance tip of the month for May is focused on respiratory services provided to patients. There is a common area that is routinely cited by surveyors when reviewing documentation in medical records.

The most common deficiency is related to the orders for respiratory services which include supplemental oxygen therapy as well as bronchodilator medication administration. The orders should be clear and should guide nursing and respiratory therapists to deliver care in accordance with those orders.

Oxygen therapy and ventilator support are often found implemented or adjusted without a corresponding order from the provider responsible for the care of the patient. Also, patients should be assessed before and after bronchodilator treatments to determine the effectiveness of the medication. These items should be clearly documented in the medical record. It is important to remember “Not documented, not done.

The CMS regulations and interpretive guidance are provided below for reference.

§482.57(b)(3) - Services must only be provided under the orders of a qualified and licensed practitioner who is responsible for the care of the patient, acting within his or her scope of practice under State law, and who is authorized by the hospital’s medical staff to order the services in accordance with hospital policies and procedures and State laws.

Respiratory care services must be ordered by a qualified and licensed practitioner who is responsible for the care of the patient. The practitioner must have medical staff privileges to write orders for these services or, for outpatient services, if hospital policy permits acceptance of orders from outside practitioners, the practitioner’s order must meet the requirements at §482.54(c).

For practitioners who have medical staff privileges, such privileges must be granted in a manner consistent with the State’s scope of practice law, as well as with hospital policies and procedures governing respiratory care services developed by the medical staff.

Practitioners who may be granted privileges to order respiratory care services include physicians, and may also, in accordance with hospital policy, include Nurse Practitioners, Physicians’ Assistants, Clinical Nurse Specialists, Certified Registered Nurse Anesthetists, and Certified Nurse Midwives as long as they meet the parameters of this requirement. Although the following licensed professionals are also considered practitioners, in accordance with Section 1842(b)(18)(C) of the Social Security Act, they generally would not be considered responsible for the care of the patient with regard to respiratory care services or qualified to order respiratory care services: Clinical social worker (Section 1861(hh)(1) of the Act and as defined in 42 CFR 410.71); Clinical psychologist (for purposes of Section 1861(ii) of the Act); or registered dietician or nutrition professional.

CIHQ encourages organizations to evaluate their policies and documentation mechanisms to assure that they comply with the regulations in order to avoid a deficiency during survey.

ARS provides the following resources to assist organizations with their compliance. These can be found in the ARS Resource Library:

1. #3068 - Policy – Respiratory Services
2. #3184 - Tool – Competency Checklist for Basic Ventilator Management NIV and CPAP
3. #3186 - Tool – Competency Checklist for Nebulizer Breathing Treatments and MDI
4. #3187 - Tool – Competency Checklist for Providing Supplemental Oxygen

Each month we will publish fun facts about CIHQ and its history in our CIHQ Accreditation & Regulatory Journal. The facts will be in different locations within the Journal, but will all be housed in a box with a game-themed border. Search the Journal to learn interesting facts! At the Summit, teams will compete against each other for the level of knowledge and the team that knows the most will win a fun and exciting prize. In February, the bordered box began traveling to different pages of the Journal.

Stay tuned in to your journal for facts and fun about us! We can’t wait to see all of you at the Summit! This is the event that you won’t want to miss!

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CIHQ attended NALTH Spring 2024 Clinical Education Conference
Richard Curtis to be Featured Speaker Fall 2024

CIHQ Sponsors TORCH

CIHQ to Sponsor American Society of Addiction Medicine (ASAM)

CIHQ to Sponsor the Association of Children’s Residential & Community Services

Another first-time conference, CIHQ will also sponsor The Association of Children’s Residential & Community Services (ACRC) Annual Conference in Phoenix May 5-9. ACRC provides a network of learning, support, and advocacy for quality residential interventions for children. They are dedicated to being a powerful voice for best practices and innovation in the field. We are looking forward to this opportunity!

CIHQ to Attend COLA’s Laboratory Enrichment Forum

New! The brightest minds in the industry will gather at the 2024 COLA Forum in Destin/Fort Walton Beach, FL to share perspectives on the latest developments in laboratory science, essentials of CLIA compliance and accreditation. The theme is “Medical Laboratory Science: The Hidden Gem of Healthcare". Visit the CIHQ booth to learn more about our hospital accreditation programs that accept COLA accreditation.

CIHQ to Attend the Indiana Rural Health Association’s Annual Conference

CIHQ is able to accredit Critical Access Hospitals (CAH), and we look forward to attending Indiana RURAL Health Association’s Annual Conference in French Lick, IN on June 10- 12. A voice for rural residents of Indiana, the theme this year is, “Leveraging Opportunities for Change”.

CIHQ to Sponsor SIPS Scrub Ball

SIPS Consults has been a CIHQ partner since 2022. Each year, they celebrate and pay tribute to healthcare heroes at the ScrubBall in Dallas, June 20-22. Education, encouragement, and validation enhances job satisfaction and motivation. Ask for a tour of the SIPS training facility if you’re in the Dallas area; they are dedicated to training Sterile Processing Department staff.

CIHQ will present at the Mid-South Critical Access & Rural Hospital Conference

CIHQ will attend the Mid-South CAH & Rural Hospital Conference August 14-16 at Peabody Memphis where Rick will present on Inculcating a Culture of Quality & Regulatory Compliance, a favorite among audiences. The Mid-South Conference focuses on rural issues. Attendees hail from Alabama, Arkansas, Kentucky, Louisiana, Mississippi, and Tennessee.

CIHQ will Provide a Featured Speaker and ACRM’s Annual Conference

Rick Curtis will be speaking at the American Congress of Rehabilitation Medicine (ACRM) Annual Conference, “Progress in Rehabilitation Research: Translation to Clinical Practice” will be held October 31 – Nov 4 in Dallas, TX. Attendees will have the opportunity to hear Rick Curtis and other highly acclaimed professionals present on all things rehabilitation.

CIHQ to Provide Keynote Speaker for Louisiana Hospital Association’s Rural Healthcare Leadership Conference

Rick Curtis will be the keynote speaker for Louisiana Hospital Association's Rural Healthcare Leadership Conference, Nov 6-7 in Baton Rouge. Their mission is to support members through advocacy, education, and services. Its vision is to be recognized as the leader in fostering collaborative efforts that result in effective health policy and a vibrant provider system for Louisiana.