Catalog Number : ngd1573
Title : CMS Patient Rights Standards
Speaker : Sue Dill

Webplay Recording Date : 9-11-2017
Webplay Price : $ 125 for two weeks viewing

Webinar Description:

Any hospital in the U.S. that accepts Medicare and Medicaid reimbursement must be in compliance with the CMS Conditions of Participation (CoPs). This webinar will cover the final regulations to the patient rights standards on visitation. This webinar will cover in detail the CMS patient rights requirements which are a frequent source of investigation and represent problematic areas for hospitals. This section includes grievances, right to get notice of patient rights, exercise of rights, visitation, informed consent, privacy, confidentially of medical records, safety, advance directives, interpreters, abuse and neglect, infant security, staffing levels, and over 50 pages of restraint standards. This webinar will also discuss the crosswalk to the Joint Commission standard. Many hospitals are surprised at the number of regulations and the detail required complying with these problematic standards.

Target Audience:

• 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 complaint standards, Anyone responsible for implementing restraints, Policy and procedure committee, Ethics committee members, Person who will be responsible for implementing visitation policy

Webinar 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, AOA, DNV Healthcare or not)
• Identify that the CMS regulations under grievances includes the requirement to have a grievance committee
• Recall that CMS has requirements for advance directives
• Describe the restraint and seclusion requirements including the requirement that all staff must be trained
• Recall that CMS issued 34 pages of interpretive guidelines on visitations

A few of the topics to be discussed:

• Background on CMS CoPs
• How to find 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
• 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
• Requirement to inform each patient on how to file grievances
• Board’s responsibility in grievance process
• Grievance committee required
• P&P on grievances
• Written notice to patient requirements
• Time frame for responding to grievances
• Privacy and safety
• Confidentiality and memo issued March 2, 2012
• Infant security
• Staffing levels
• Abuse and neglect
• Criminal background checks
• Restraint and seclusion
• R&S death reporting requirements
• 21 rules to understanding the 50 pages of regulations on R&S
• Soft wrist restraint and internal log changes July 16, 2012
• Mandated restraint training
• Restraint policy requirements
• One hour face to face
• Orders, alternatives, and debriefing not required
• CMS privacy and confidentiality memo

**Note: That Critical Access Hospitals (CAH) have a separate set of hospital CoPs and there is no corresponding patient rights chapter except for the visitation and Proposed QIO/state agency notification. CAH hospitals that are in systems should know the differences in the two sets of CoPs and may find the program of interest for that reason. CAH should have a policy and process for restraint and seclusion and many follow many of these regulations. The visitation standards and the proposed telemedicine standards will apply to CAH.

Full tuition is refunded immediately on request if the participant has not been sent the program materials and instructions. Once the instructions (including access codes) have been sent, a full refund will be issued only after the program runs and it is verified that the participant did not access the program.