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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. Within the section, restraint and seclusion have the highest number, followed by care in a safe setting, grievances, privacy, advance directives, confidentiality, admission status notification, visitation, and consent.
The information to be presented applies to all hospitals, Acute or Critical Access. The Conditions of Participation for acute hospitals – Appendix A – will be covered in detail. The regulation and requirements for Critical Access Hospitals were added late in 2025 and are not yet part of Appendix W. There are no interpretive guidelines or survey procedures at this time – only the regulation. However, CAHs should listen to those for an acute hospital, as any pending guidelines and procedures may well follow what Appendix A requires.
Specific topics covered include grievances, right to receive notice of patient rights, exercise of rights, informed consent, privacy, confidentiality of medical records, safety, advance directives, interpreters, abuse and neglect, plan of care, visitation rules, and support person rights.
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 the CMS requirement 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
- Introduction to the CoPs and manual
- Deficiency reports of patient rights
- Notice of patient rights
- Grievances and required procedures and processes
- Exercise of patient rights
- Right to make informed decisions
- Advance directives
- Privacy and safety requirements
- What constitutes physical privacy
- Care in a safe setting and suicide risks
- Ligature risks
- Freedom from abuse and neglect
- Protected health information and disclosures
- OCR and patients’ access to medical records
- Appropriate and inappropriate use of restraints
- Medication as a restraint
- What is and is not 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
- Death reporting re: restraints
- Visitation
Critical Access Hospitals
- Regulations
Additional Information
- Interpreters
- OCR Section 1557
Who Should Attend
- Chief Executive Officer (CEO)
- Chief Operating Officer (COO)
- Chief Nursing Officer (CNO)
- Chief Medical Officer (CMO)
- Quality Improvement Coordinator
- Risk Managers
- Patient Safety Officer
- Nurse Educator
- Emergency Department Manager
- Nurse Managers/Supervisors
- Compliance Officer
- Staff Nurses
- Policy and procedure committee
- Ethicist
- Anyone responsible for implementing restraints and/or seclusion
- Ethics committee members
Speaker
Laura A. Dixon recently served as the Regional Director of Risk Management and Patient Safety for Kaiser Permanente Colorado, providing consultation and resources to clinical staff. Prior to joining Kaiser, she served as the Director of Facility Patient Safety and Risk Management and Operations for COPIC from 2014 to 2020. In her role, Ms. Dixon provided patient safety and risk management consultation and training to facilities, practitioners, and staff in multiple states. Such services included creating presentations on risk management topics, assessing healthcare facilities, developing programs, and compiling reference materials that complement physician-oriented products.
Before joining COPIC, she served as the Director, of the Western Region, Patient Safety and Risk Management for The Doctors Company, Napa, California. In this capacity, she provided patient safety and risk management consultation to the physicians and staff in the western United States. Ms. Dixon’s legal experience includes medical malpractice insurance defense and representation of nurses before the Colorado Board of Nursing.
Ms. Dixon has over twenty years of clinical experience in acute care facilities, including critical care, coronary care, peri-operative services, and pain management.
As a registered nurse and attorney, Laura holds a Bachelor of Science degree from Regis University, RECEP of Denver, a Doctor of Jurisprudence degree from Drake University College of Law, Des Moines, Iowa, and a Registered Nurse Diploma from Saint Luke’s School Professional Nursing, Cedar Rapids, Iowa. She is licensed to practice law in Colorado and California.