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

Live Webinar | Laura A. Dixon | From: Nov 25, 2020 - To: Dec 31, 2020

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Recorded Session     $249
DVD     $259
Recorded Session & DVD     $399
Transcript (Pdf)     $249
Recorded & Transcript (Pdf)     $389
DVD & Transcript (Pdf)     $399

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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 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 one on 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.


  • 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.


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 not required
  • CMS privacy and confidentiality memo

Who Will Benefit?

  • 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