4 CMS Nursing Memos Hospitals Should Know About!

Over fifteen memos of particular importance to nursing and hospital administration have been issued in the past two years by CMS. Here are four of the most important among them:

Hospital Patient Privacy and Medical Record Confidentiality (12-18-Hospitals)

This memo clarifies HIPAA. It lays out the idea of an “incidental” use or disclosure of patient information that cannot reasonably be prevented, and occurs as a result of a permitted use or disclosure. This is designed to clarify that HIPAA is not meant to “impede customary and essential communications and practices within a hospital. ” Beyond this the memo gives guidance for exactly how to maintain patient privacy, especially considering how to maintain those customary/essential communications while still considering patients’ needs for privacy and confidentiality.

Requirements for Hospital Medication Administration, Particularly Intravenous (IV) Medications and Post-Operative Care of Patients Receiving IV Opioids (14-15-Hospital)

Here, the CMS is updating their guidance for IV medications and blood transfusions in general, stressing risk assessment and monitoring during and after administration of medication, particularly for post-operative patients receiving opioids intravenously. Opioids are one of the most common medications that result in adverse drug events (ADEs) in hospitals, and these ADEs are among the most preventable. Opioid-induced respiratory depression has led to patient deaths which could have been prevented with appropriate risk assessment and monitoring of respiration, and patients on IV opioids are often placed in units where vital signs monitoring is not performed as frequently as in post-anesthesia units or ICUs. New guidelines lay out particulars of developing a process for patient risk assessment in any IV situation, including blood transfusions and IV medications.


In particular, considering the particulars and duration of IV opioid therapy, the memo explains, hospitals must determine what is to be monitored, its frequency and methods, and then explain the risk assessment and monitoring process to the patient or their representative, including the rationale for frequent monitoring and how to alert staff to breathing problems or other possible ADEs. Staff are to be trained in early detection and intervention for IV opioid-induced over-sedation and respiratory depression.

Potential Adverse Impact of Lower Relative Humidity (RH) in Operating Rooms (ORs) (15-27-Hospital, CAH & ASC)

The National Fire Protection Association (NFPA) requires that mechanical ventilation systems in hospital anesthetizing locations can keep RH above 35% to ensure correct functioning of equipment. CMS previously allowed hospitals to use the lower minimum RH of 20% via a categorical waiver, intending to alleviate unreasonable hardship on facilities. It was discovered that an RH below 30% was not compatible with the instructions for use (IFU) of some supplies and equipment used in operating rooms. Following a convention coordinated by AAMI, a joint communication was released stating that manufacturers of supplies and equipment would be expanding the RH range of their products to encompass a lower level of 20%, but in the meanwhile, the RH listed in equipment’s IFU must be followed. The Joint Communication outlines useful questions and ways forward for hospital leadership on assessing risk related to low RH and equipment’s IFUs.

Use of Insulin Pens in Health Care Facilities (12-30-ALL)

Though insulin pens are meant to be used by the same person multiple times, and use a new, clean needle each time, the possibility that blood may be pulled into the insulin cartridge after injection means there is a risk of bloodborne pathogen infection if they are used by more than one person. CMS issued guidances in 2007 and 2009, but an incident in 2011 requiring the notification of more than 2000 patients caused them to issue this binding memorandum. Besides the obvious, this memo lays out two duties for healthcare providers: actively training their staff in safe use of insulin pens, and clearly identifying insulin pens’ owners by labeling the pens.


Are you concerned about compliance with CMS nursing CoP standards? Do you work with nursing codes? Fortunately, the broad web of continuing education in nursing is on your side with convenient live conferences on sorting out exactly these issues. View Sue Dill Calloway, RN, MSN, JD’s clear, helpful webinar live for a level-headed review of the most important information these CMS memos contain.

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