CMS Clarifies Order Requirements
By Marty Piepoli
In a Center for Medicare and Medicaid Services (CMS) Memorandum to State Survey Agency Directors (S & C -09-10, 10/24/08), a clarification has been issued related to use and implementation of standing orders. You may recall that CMS issued several changes to the Interpretive Guidelines related to multiple CoP’s in February 2008. The focus of these new guidelines addressed requirements for the History and Physical, Authentication of Verbal Orders, Securing Medications and Post –Anesthesia Evaluations.
At that time CMS stated that all orders for care, orders for medications and use of standing orders or protocols required a physician order to implement those orders or patient care. The only exception was for orders related to the use of influenza and pneumonia vaccines. The commentary from the field, communicated to CMS by the American Hospital Association (AHA), saw this stance as being counter-productive to efforts to initiate care through a pre-approved/standing order process, where an urgent/emergent need to initiate care had been identified.
CMS responded by removing the note that caused “confusion about the ability of rapid response teams and other health care professionals in hospitals to initiate effective responses to emergency situations and/or to implement best practices for providing necessary patient care in a timely fashion under the aegis of standing orders.” The 10/24/08 CMS Memorandum further states that:
- The use of standing orders must be documented as an order in the patient’s medical record and authenticated by the practitioner responsible for the care of the patient, as the regulations at 42 CFR §482.23(c)(2) and §482.24(c)(1) require.
- However, the timing of such documentation should not be a barrier to effective emergency response, timely and necessary care, or other patient safety advances.
- CMS would expect to see that the standing order had been entered into the order entry section of the patient's medical record as soon as possible after implementation of the order (much like a verbal order would be entered), with authentication by the patient's physician.
What does this mean for your organization… ?
- Organizations should review all standing orders/protocols to make sure the authentication process complies with the new language of the Interpretive Guidelines.
- Set the expectation that physicians and other LIP’s are dating, timing and authenticating based on the Interpretive Guidelines, State Law and hospital policy.
- Acknowledge the additional burden to manage the telephone and verbal order process, both from an authentication and reduction in use perspective.
In conjunction with this revision by CMS, the State Operations Manual A (SOM-A) has been re-released and contains this update in addition to revisions to Interpretive Guidelines for Conditions of Participation.
For more information or questions about this topic, please direct your inquiry to info@courtemanche-assocs.com.