Description
Any hospital that accepts Medicare reimbursement must comply with the CMS Conditions of Participation (CoPs). The Patient rights section of the CMS Condition of Participation manual has the highest number of deficiencies for hospitals. The highest number is in restraint and seclusion, followed by care in a safe setting, grievances, privacy, advance directives, confidentiality, admission status notification, and visitation and consent.
This program will cover in detail the Conditions of Participation Appendix A section on patient rights. Critical Access Hospital Appendix W does not have a similar section. However, CAHs must provide a safe environment for patients, which includes those to be discussed during this webinar.
Topics covered include grievances, right to receive notice of patient rights, the exercise of rights, informed consent, privacy, confidentially of medical records, safety, advance directives, interpreters, abuse and neglect, plan of care, visitation rules, support person rights, and staffing levels.
Learning Objectives:-
- Identify that the CMS regulations regarding grievances include the requirement to have a grievance committee.
- Recall that CMS has requirements for advance directives.
- Discuss CMS requirements for providing patients and/or their representatives with information on patient rights.
- Recall the various requirements for when a patient is placed into restraints and/or seclusion.
Agenda:-
- Background on CMS CoPs
- How to find the current copy
- How to find changes in the hospital CoPs
- Federal Register, interpretive guidelines, survey procedure
- Deficiency reports of patient rights
- OCR and patient access to medical records
- P&P requires to ensure patients have information on rights
- Notice of patient rights
- Interpreters
- Grievances and required procedures and processes
- Exercise of patient rights
- Right to make informed decisions
- Advance directive
- Privacy and safety requirements
- What constitutes physical privacy
- Protected health information and disclosures
- Care in a safe setting and suicide risks
- Ligature risks
- Components for abuse protection
- Restraints and seclusion and changes in 2019
- Appropriate and not appropriate use of restraints
- Medication as a restraint
- What is and is not seclusion
- Time limit on orders for restraint and seclusion
- Order for restraints – requirements
- Documentation and staff training with restraints and seclusion
- Visitation
- Board’s responsibility in a grievance process
- Restraints are not discussed in detail as there is a separate program that covers this topic
Who Should Attend:-
- Chief Executive Officer (CEO)
- Chief Operating Officer (COO)
- Chief Nursing Officer (CNO)
- Chief Medical Officer (CMO)
- Board Members
- Quality Improvement Coordinator
- Risk Managers
- Patient Safety Officer
- Inhouse Legal Counsel
- Nurse Educator
- Emergency Department Manager
- Nurse Managers/Supervisors
- Compliance Officer
- Consumer Advocates
- Staff Nurses
- Policy and procedure committee
- Ethicist
- Anyone involved in the implementation of the CMS grievance or Joint Commission compliant standards
- Anyone responsible for implementing restraints and/or seclusion
- Ethics committee members
