Description

Any hospital that accepts Medicare reimbursement must comply with the CMS Conditions of Participation (CoPs). The Patient Rights section of the CMS Condition of Participation manual has the highest number of deficiencies for hospitals. Within the section, restraint and seclusion have the highest number, followed by care in a safe setting, grievances, privacy, advance directives, confidentiality, admission status notification, visitation, and consent.

The information to be presented applies to all hospitals, Acute or Critical Access. The Conditions of Participation for acute hospitals – Appendix A – will be covered in detail. The regulation and requirements for Critical Access Hospitals were added late in 2025 and are not yet part of Appendix W. There are no interpretive guidelines or survey procedures at this time – only the regulation. However, CAHs should listen to those for an acute hospital, as any pending guidelines and procedures may well follow what Appendix A requires.

Specific topics covered include grievances, right to receive notice of patient rights, exercise of rights, informed consent, privacy, confidentiality of medical records, safety, advance directives, interpreters, abuse and neglect, plan of care, visitation rules, and support person rights.

Learning Objectives:-

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

• Introduction to the CoPs and manual
• Deficiency reports of patient rights
• Notice of patient rights
• Grievances and required procedures and processes
• Exercise of patient rights
• Right to make informed decisions
• Advance directives
• Privacy and safety requirements
• What constitutes physical privacy
• Care in a safe setting and suicide risks
• Ligature risks
• Freedom from abuse and neglect
• Protected health information and disclosures
• OCR and patients’ access to medical records
• Appropriate and inappropriate use of restraints
• Medication as a restraint
• What is and is not a restraint
• What is and is not seclusion
• Time limit on orders for restraint and seclusion
• Order for restraints – requirements
• Documentation and staff training with restraints and seclusion
• Death reporting re: restraints
• Visitation

• Regulations

• Interpreters
• OCR Section 1557

• Chief Executive Officer (CEO)
• Chief Operating Officer (COO)
• Chief Nursing Officer (CNO)
• Chief Medical Officer (CMO)
• Quality Improvement Coordinator
• Risk Managers
• Patient Safety Officer
• Nurse Educator
• Emergency Department Manager
• Nurse Managers/Supervisors
• Compliance Officer
• Staff Nurses
• Policy and procedure committee
• Ethicist
• Anyone responsible for implementing restraints and/or seclusion
• Ethics committee members