Patient Rights (CMS CoPs) 2023

Product Id : HLT96
Instructor : Darlene Evans, MSN, RN, CPHQ
Jun 15, 2023 1:00 PM ET | 12:00 PM CT | 10:00 AM PT | 90 Minutes


The Conditions of Participations (CoPs) related to promoting and protecting patient rights are among those most frequently cited by the Centers for Medicare and Medicaid Services (CMS) and are the ones that most often result in a condition-level deficiency.

Every hospital must be committed to promoting and protecting patient rights. To do this, staff must be educated about patient rights, and patients must be informed of their rights in a manner they understand.

What Attendees Will Learn:

Any hospital that accepts Medicare reimbursement must comply with the CMS Conditions of Participation (CoPs).  The patient rights section of the CMS Conditions 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 webinar outlines the CMS expectations for achieving compliance with these critical Conditions of Participations (CoPs), as well as the use of restraint and seclusion. These regulations cover notifying patients and their representatives of their rights, including the right to;

  • Have visitors;
  • Make informed decisions;
  • File grievances about their care;
  • Formulate Advance Directives and have these honored;
  • Be treated with respect and dignity with their confidential information and privacy protected; and,
  • Be free from abuse and neglect

Area Covered in this session:

  • Identify that the CMS regulations regarding grievances includes the requirement to have a grievance committee.
  • Recall that CMS has requirements for advance directives.
  • Discuss CMS requirement for providing patients and/or their representatives information on patient rights.
  • Recall the various requirements for when a patient is placed into restraints and/or seclusion.

Who Should Attend?

  • Chief Executive Officer (CEO)
  • Chief Operating Officer (COO)
  • Chief Nursing Officer (CNO)
  • Chief Medical Officer (CMO)
  • Joint Commission Coordinator
  • Quality Improvement Coordinator
  • Risk Managers
  • Nurse Educator, Staff Nurses, Nurse Managers
  • Patient Safety Officer
  • Emergency Department Manager
  • Compliance Officer
  • Consumer Advocates
  • Clinic Managers
  • OR Nurse Director
  • Lab director
  • Policy and procedure committee
  • Ethicist
Speaker Profile:

Darlene Evans is a healthcare quality leader with more than 25 years of experience, specializing in clinical and regulatory operations management, accreditation readiness and response, staff training, and business development. With her expertise in Centers for Medicare and Medicaid Services, Joint Commission, and Healthcare Facilities Accreditation Program standards and her commitment to education and collaboration, Darlene has a proven track record of helping clients identify opportunities for improvement and achieve sustainable, long-term results. She has also helped lead organizations through projects in areas such as operational effectiveness, infrastructure, staffing and productivity, fiscal stewardship, leadership development, and care delivery.

Darlene was Senior Manager of Clinical Operations, Quality, Safety, and Performance Improvement with Quorum Health Resources. In this role, she provided consultative services to 150 client hospitals, including accreditation, quality, and life safety and environment of care assessments, and the implementation of operational process improvement tools and best practices, as well as other specialty patient quality and safety initiatives. Previously, Darlene worked with the Joint Commission International as a hospital and  ambulatory care accreditation surveyor for healthcare organizations in Turkey, India, Ireland, Saudi Arabia, UAE, and China. In addition to her consulting and surveyor experience, Darlene has served in full-time leadership roles including Chief Nursing Officer, Vice President of Patient Care Services, Assistant Vice President of Nursing Services, and Director of Quality Management and Education.

Darlene earned her Master’s Degree and Bachelor's Degree in Nursing from Troy State University in Troy, AL. She has also taken courses in business and management and is Lean Six Sigma certified. Darlene is a Registered Nurse, a Certified Professional in Healthcare Quality, and a member of the American College of Healthcare Executives and the National Association for Healthcare Quality

Available Options

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