CMS CoPs - Respiratory Care: More than Just Meeting Seasonal Demands

Providing respiratory care services can be a challenge for hospitals, especially during months when respiratory illnesses are at their peak throughout communities. Hospitals spend a great deal of time planning to meet the needs of patients during peak periods as they must prepare for the possibility of a large influx of patients. There are several additional strategies that hospitals must also follow in addition to managing respiratory illness and preventing the spread of respiratory illness.

Reporting responsibilities must also be considered. Failure to report the specified data related to COVID-19, influenza, and respiratory syncytial virus (RSV), including confirmed infections of respiratory illnesses among hospitalized patients, hospital bed census and capacity (both overall and by hospital setting and population group [adult or pediatric]), and limited patient demographic information, including age, may lead to the termination of a hospital’s participation from the Medicare and Medicaid programs.

Hospitals who participate in CMS should ensure that they are meeting reporting requirements for acute respiratory illness such as COVID-19, influenza and respiratory syncytial virus (RSV).

Additional data reporting requirements include patient population affected, demographic data and bed capacity. Participating hospitals should also ensure that respiratory care services are integrated into their respective Quality Assurance Performance Improvement Programs.

If you are uncertain if your organization provides services that quality as respiratory care, CMS provided the following list of examples: Respiratory Care Service

Respiratory Care Services Oversight

Identifying a qualified individual(s) to provide respiratory care services is a requirement for hospitals who participate in CMS, which is just one of the requirements. Respiratory professionals should meet qualifications as determined by the hospital’s medical staff and in accordance with state law. Moreover, hospitals must appoint a Doctor of Medicine or osteopathy to oversee respiratory care services. This individual must be appointed on no less than a part-time basis.

Delivery of Services

Being familiar with CMS requirements for delivery of respiratory care services is another important consideration for participating hospitals. A hospital’s medical staff must develop a written directive outlining how care will be delivered by respiratory professionals. Such directives should specify what supervision is required before respiratory care services can be delivered independently by a healthcare professional.

If lab work is being performed, the collection of such labs must be done in accordance with CMS laboratory service requirements. All respiratory treatments must be documented in the patient’s medical record.

Our experts understand the challenges that all healthcare facilities are facing today. Using a customizable approach, we will help you navigate through even the toughest of challenges.

Whether you are in need of a mock survey, leadership training, corrective action plans or ongoing support services, we can help!

We pride ourselves on helping our clients achieve and maintain a status of excellence in the healthcare industry.

Be sure to browse Our Website for a full list of services we provide.

Contact us today at (800) 813-7117 to schedule a free consultation.

References:

https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-482/subpart-D/section-482.57

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NSHN and OSHA Reporting: Prepared to Meet the Deadline?

February 10, 2025

It is that time of year again. At least for acute care hospitals, long-term acute care (LTAC) hospitals and inpatient rehabilitation facilities (IRF) who report to The National Healthcare Safety Network (NHSN). If annual surveys are not reported by March 1 st , then your organization will not be permitted to enter monthly reporting plans until the annual survey has been completed. Although there are just a few weeks to go, early planning is the key. It is important to consider that responses to the Annual Survey questions are a collaborative effort. Planning a meeting in advance with key stakeholders will help to ease the stress of completing what some may consider to be a daunting task. Be sure to coordinate with Facilities Managers, Pharmacists, Laboratory, Nursing, Infection Prevention and Quality leaders on annual survey responses. Although individuals who are responsible for report submission may find that some of the data has not changed significantly from the previous year, we have identified that some questions have been removed while additional questions have been added. If you are new to NHSN reporting and have not yet completed an annual survey, you will find an alert reminding you on your dashboard upon logging in. Keep in mind that the survey you are completing requires data from the previous calendar year. You will be submitting data for 2024 due March 1 st , 2025. There are a variety of questions that will require information about metrics, facility type, infection prevention practices, laboratory testing methods, water quality management, and antimicrobial stewardship practices for example. Instructions on completing your organization’s annual survey click on the link below that corresponds with your facility type: Instructions for Completing Annual Hospital Survey Instructions for Completing LTAC Annual Survey Instructions for Completing IRF Annual Survey OSHA requires the following facilities to complete an annual occupational injury and Illness Report: Ambulatory Health Care Servies General Medical and Surgical Hospitals Psychiatric and Substance Abuse Hospitals Specialty Hospitals Skilled Nursing Facilities For a complete list of facilities required to report annually via electronic submission and for additional information on Standard 1904 Subpart E Appendix B click on the following link: OSHA Injury and Illness Reporting Requirements . Much like NHSN annual surveys, this reporting is also for the prior calendar year. Your deadline for submission is March 2, 2025. If your organization has not previously been reporting, please note that you will need to set up an Injury Tracking Application (ITA) account. For complete instructions, click on the following link User Guide . Individuals who are responsible for report completion and submission should have a clear understanding of criteria that constitutes a work-related injury. They will also need to know if the employee missed days of work because of injury or illness. If an employee was restricted from usual work activities or reassigned to a new role as a result of the injury or illness this information must be documented. If an employee required care beyond basic first aid, this will also need to be reported. Reporters should not include Protected Health Information (PHI). For a brief tutorial on OSHA annual reporting requirements, click on the following link OSHA Injury and Illness Reporting . Our experts understand the challenges that all healthcare facilities are facing today. Using a customizable approach, we will help you navigate through even the toughest of challenges. Whether you are in need of mock surveys, leadership training, corrective action plans or ongoing support services, we can help! We pride ourselves on helping our clients achieve and maintain a status of excellence in the healthcare industry. Be sure to browse Our Website for a full list of services we provide. Contact us today at +1 (800) 813-7117 to schedule a free consultation. References: https://www.cdc.gov/nhsn/forms/instr/57_103-toi.pd https://www.osha.gov/laws-regs/regulations/standardnumber/1904/1904SubpartEAppB https://www.osha.gov/sites/default/files/ita_user_guide.pdf https://www.osha.gov/sites/default/files/osha_rktutorial.pdf

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