2013 CMS Jun 20 Enduring

Self Study Course Description

Patient Rights Standards

Course Faculty
Sue Dill Calloway, RN, MSN, JD, CPHRM, CCMSCP
President, Patient Safety Education and Consulting
Dublin, Ohio

Type of Activity: Enduring Event/Web-Based Training
Release Date: June 21, 2013
Expiration Date: May 30, 2014
Estimated Time to Complete Course: 2 hours

There is no fee associated with this educational activity.

Target Audience: Physicians, Nurses, Administrators, QM Staff, Risk Managers, and other interested Health Care Providers

Course Overview
Did you know the highest number of hospitals out of compliance is in the area or patient rights? CMS published the data March 22, 2013 which showed hospitals out of compliance for the past year had the highest number in the area of patient rights. In fact, there were 950 hospital found to be out of compliance. The highest number was in the area of restraint and seclusion, followed by care in a safe setting, personal privacy, grievances, advance directives, confidentiality, admission status notification and visitation.

This program will cover the final regulations to the patient rights standards on visitation which have had many changes. A final transmittal was issued by CMS on December 2, 2011 which has changes to visitation, advance directives, plan of care, and informed consent. CMS also issued a memo on confidentiality and privacy for hospitals on March 2, 2012 which amends this section. Privacy and confidentiality is important especially as the new HIPAA law goes into effect September 23, 2013. There are also new changes effective July 16, 2012 which contains one on restraints. CMS published the final interpretive guidelines on these March 15, 2013.

This program 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 will include the three types of PRN orders for restraints, standing orders, stamps, and protocols. It will discuss the restraint changes effective March 15, 2013 and the requirement for an internal log for patients who die with two soft wrist restraints. This program 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.

Learning Objectives
After completing this activity, the participants will be able to:
1. 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).
2. Identify that the CMS regulations under grievances includes the requirement to have a grievance committee.
3. Recall that CMS has requirements for advance directives.
4. Describe the restraint and seclusion requirements including the requirement that all staff must be trained.
5. Recall that CMS issued 34 pages of interpretive guidelines on visitations.

Criteria for Successful Completion
• Registration is required for verification of attendance.
• Attend the webinar in its entirety.
• Complete the web based Course Evaluation.
• Complete the online Post-Test with a passing score of 75%.
• CSC will send you a CE Certificate upon successful completion. Note: you will be notified to retake the post-test if your score is below 75%.
Accreditation: The Indian Health Service (IHS) Clinical Support Center is accredited by the Accreditation Council for Continuing Medical Education to sponsor continuing medical education for physicians. The IHS Clinical Support Center designates this enduring educational activity for 1 hour of AMA PRA Category 1 Credit™ for each hour of participation. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
The Indian Health Service Clinical Support Center is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

This activity is designated 2 contact hours for nurses.

Accreditation applies solely to this educational activity and does not imply approval or endorsement of any commercial product, services or processes by the CSC, IHS, the federal government, or the accrediting bodies

Faculty Disclosure Statement: As a provider accredited by ACCME, ANCC, and ACPE, the IHS Clinical Support Center must ensure balance, independence, objectivity, and scientific rigor in its educational activities. Course directors/coordinators, planning committee members, faculty, and all others who are in a position to control the content of this educational activity are required to disclose all relevant financial relationships with any commercial interest related to the subject matter of the educational activity. Safeguards against commercial bias have been put in place. Faculty will also disclose any off-label and/or investigational use of pharmaceuticals or instruments discussed in their presentation. The course directors/coordinators, planning committee members, and faculty for this activity have completed the disclosure process and have indicated that they do not have any significant financial relationships or affiliations with any manufacturers or commercial products to disclose. There is no commercial or non-commercial company financial support for this educational activity.

Email ihscsc@ihs.gov if you have any questions or need assistance.

You may review the IHS Privacy Policy at http://www.ihs.gov/privacy_policy.asp and the Survey Monkey Privacy Policy for details on how user information submitted in the evaluation is protected (http://www.surveymonkey.com/mp/policy/privacy-policy/). Your information will be kept confidential when you participate in a CE Internet based program. The information collected is necessary to provide you with the appropriate CE credits for your participation.
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