CMS Hospital CoPs on Patient Rights Standards; Keys to Ensuring Compliance

Webinar Details

Speaker

Laura A Dixon

Industry

Healthcare

Speciality

Nursing

Available

All Days

Duration

120 Minutes


Registration Options

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Description

This is a must-attend for every nurse, physician, or healthcare provider who has direct patient care. Did you know the highest number of deficiencies for hospitals being out of compliance with the hospital CoP manual is in the area of patient rights? Patient rights should be on the radar screen for every hospital in 2020! The highest number was in the area of restraint and seclusion, followed by care in a safe setting, grievances, privacy, advance directives, confidentiality, admission status notification, and visitation and consent. There are over 9,000 deficiencies in patient rights.

This program will cover in detail the CMS patient rights requirements which include grievances, right to get notice of patient rights, the exercise of rights, visitation, informed consent, privacy, confidentially of medical records, safety, advance directives, interpreters, abuse, and neglect, infant security, plan of care, visitation rules, support person rights, consent, and staffing levels. CMS added a detailed section on ligature risks and the requirements for caring for suicidal patients to prevent strangulation and this will be discussed. A change was made to the restraint and seclusion section that went into effect on November 29, 2019, and interpretive guidelines in 2020.

Most every hospital in the U.S. accepts Medicare reimbursement and as such must be in compliance with the CMS Conditions of Participation (CoPs). This program will also discuss important CMS memos which include confidentiality and privacy for hospitals. Privacy and confidentiality are important, especially as the revised HIPAA and the increased penalties being levied against hospitals in the past year.

Learning Objectives

  • Discuss that any hospital that receives reimbursement for Medicare patients must follow the CMS Conditions of Participation on patient rights.   (This is true whether the hospital is accredited by Joint Commission, HFAP, CIHQ, DNV Healthcare or not). 
  • Identify that the CMS regulations under grievances include the requirement to have a grievance committee,
  • Recall that CMS has requirements for advance directives.

Agenda

This program will cover the following:

  • Background on CMS CoPs
  • Deficiency reports of CMS show patient rights top problematic standard
  • How to find a current copy
  • How to find changes in the hospital CoPs
  • Standing order memo
  • Preprinted order sheet changes
  • Federal Register, interpretive guidelines, survey procedure
  • P&P requires to ensure patients have information on rights
  • Notice of patient rights
  • Exercise of patient rights
  • Interpreters
  • Ligature risks
  • Low health literacy and teach-back
  • Visitation
  • Advance Directives
  • Notice of Non Coverage
  • Community Education of advance directives
  • Prompt resolution of grievances
  • CMS definition of grievance
  • TJC definition and six elements of performance on complaints
  • P&P with all the required elements on grievances
  • The requirement to inform each patient on how to file grievances
  • Board’s responsibility in the grievance process
  • Grievance committee required
  • P&P on grievances
  • Written notice to patient requirements
  • The time frame for responding to grievances
  • Privacy and safety
  • Confidentiality and memo issued
  • Infant security
  • Staffing levels
  • Abuse and neglect
  • Criminal background checks
  • Mandated restraint training
  • One hour face to face
  • Orders, alternatives, and debriefing are not required
  • CMS privacy and confidentiality memo

Who Should Attend

  • Chief Executive Officer (CEO)
  • Chief Operating Officer (COO)
  • Chief Nursing Officer (CNO)
  • Chief Medical Officer (CMO)
  • Board Members
  • Joint Commission Coordinator
  • Quality Improvement Coordinator
  • Risk Managers
  • Nurse Educator
  • Patient Safety Officer
  • Emergency Department Manager
  • Nurse Managers/Supervisors
  • Compliance Officer
  • Consumer Advocates
  • Staff Nurses
  • Clinic Managers
  • Medical Department Nurse Manager
  • Surgery Department Nurse Manager
  • OR Nurse Director
  • ICU Nurse Director
  • CCU Nurse Director
  • Outpatient Director
  • Lab director
  • Policy and procedure committee
  • Ethicist
  • Anyone involved in the implementation of the CMS grievance or Joint Commission compliant standards
  • Anyone responsible for implementing restraints
  • Policy and procedure committee
  • Ethics committee members
  • The Person who will be responsible for implementing visitation policy
Laura A Dixon
Laura A Dixon

(BS, JD, RN, CPHRM)

Laura A. Dixon recently served as the Regional Director of Risk Management and Patient Safety for Kaiser Permanente Colorado where she provided 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 the creation of presentations on risk management topics, assessment of healthcare facilities; and development of programs and compilation of reference materials that complement physician-oriented products.

Prior to 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 more than 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.

Registration Options

Choose Your Options

Error Conference Exists In Wish-list.

Congrats Conference Added In Wish-list.


Need Corporate Discount ?


  • * For more than 6 attendee call us at +1-800-803-7592 or mail us at cs@conferencepanel.com
  • * For Check and ACH payment call us at +1-800-803-7592 or mail us at cs@conferencepanel.com
  • * Click to download the Order Form
Laura A Dixon
Laura A Dixon

(BS, JD, RN, CPHRM)

Laura A. Dixon recently served as the Regional Director of Risk Management and Patient Safety for Kaiser Permanente Colorado where she provided 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 the creation of presentations on risk management topics, assessment of healthcare facilities; and development of programs and compilation of reference materials that complement physician-oriented products.

Prior to 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 more than 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.