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

Product Id : HE176
Instructor : Sue Dill Calloway
Dec 03, 2019 1:00 PM ET | 12:00 PM CT | 10:00 AM PT | 90 Minutes

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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 or 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 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, 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 November 29, 2019.

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 one on confidentiality and privacy for hospitals. Privacy and confidentiality is important especially as the revised HIPAA and the increased penalties being levied against hospitals in the past year.

Session Highlights:

  • 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 includes the requirement to have a grievance committee.
  • Recall that CMS has requirements for advance directives.

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:

Sue Dill Calloway, RN, MSN, JD, is the president of Patient Safety and Healthcare Consulting and Education company with a focus on medical-legal education especially Joint Commission and the CMS hospital CoPs regulatory compliance. She also lectures on legal, risk management and patient safety issues. She was a director for risk management and patient safety for five years for the Doctors Company. She was the past VP of legal services at a community hospital in addition to being the privacy officer and the compliance officer. She was a medical malpractice defense attorney for ten years. She has 3 nursing degrees in addition to a law degree.

She is a well-known lecturer and the first one in the country to be a certified professional in CMS. She also teaches the course for the CMS certification program. She has written 102 books and thousands of articles.

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