And now, I would like to introduce our speaker to get us started this morning. Ms. Laura Dixon most recently served as the Director of Risk Management and Patient Safety for the Colorado region of Kaiser Permanente. Prior to joining Kaiser, Laura served as the Director of Facility Patient Safety and Risk Management and Operations for COPIC from 2014 to 2020. In her role, Ms. Dixon provided patient safety and risk management consultation and training to facilities, practitioners, and staff in multiple states. Ms. Dixon has more than 20 years of clinical experience in acute care facilities, including critical care, coronary care, perioperative services, and pain management. Prior to joining COPIC, she served as the Director of Western Region Patient Safety and Risk Management for the Doctors' Company in Napa, California. In this capacity, Laura provided patient safety and risk management consultation to the physicians and staff for the Western United States. As a registered nurse and attorney, Laura holds a Bachelor of Science from Regis University, a Doctor of Jurisprudence from Drake University College of Law, and a registered nurse diploma from St. Luke's School of Professional Nursing. She is licensed to practice law in Colorado and in California. Thank you for being here with us this morning, Laura. We invite you to go ahead and get us started with today's presentation. Okay. Thank you very much, Lindsay, and welcome, everyone. What we're talking about today is a very large section within the Appendix A for the CMS Conditions of Participation State Operation Manual. In fact, one section of it alone takes almost 50 pages. So CMS is very serious about protecting the rights of patients when they're under our care and essentially under our control. So that's why it's so large. Well, I do want to point out my disclaimer that this information is just that. It is informational only. It is not meant to serve as legal advice nor to establish an attorney-client relationship. So please consult with your own in-house counsel, professional legal representative, your attorney, whoever that happens to be, for advice, and especially as it might relate to specific state law. For example, one of the areas we touch on today talks about restraint and seclusion. And some states have a little bit tougher requirements than what CMS does when we do put a patient in restraint or keep them in seclusion. Well, let's talk briefly about why we are here today, and that's, of course, so we don't get one of these. When CMS comes around and does their survey, if they find a lot of the condition levels are not meeting the requirements, you will get this statement of deficiencies. And then you have to do plan a correction. And no facility ever wants to be given notice of involuntary termination from the CMS agreement. The reason is because that is such a huge component of their financial support. That's why losing that is a very huge hit for a hospital. Well, how does this work? The regulation, what we're talking about today, starts in the Federal Register. From then, CMS has a couple responsibilities. One, they have to put that regulation into a transmittal. A transmittal tells their surveyors, hey, this is new. Be aware. Look out for this. They also have the responsibility to develop interpretive guidelines and survey procedures. Interpretive guidelines are geared to their surveyors, and it is tell them, hey, look at this, and this is why. This is what we expect. A lot more information in the interpretive guidelines than what's in the actual regulation. We still have to meet it all, though. And the survey procedures, just that. Now, these are not all-inclusive survey procedures. You may see they ask a lot more questions, but it will give you a good idea about the topics and where they're headed. And then, of course, they have to update the manual itself. Three types of survey. Certification when you're starting out. Complaint. Nobody wants to get a complaint. Now, with a complaint, if they do find some other issues, they might look further, but the idea with that complaint survey is to look at that section. And then a validation survey. They do these a lot, especially if you happen to have deemed status. Say, I'm just going to use joint commission, because that's one of the more common ones. They will sometimes follow them around. Don't be surprised if joint commission and CMS are at your door at the same time. So, how do we keep up with all of these changes? Subscribe to the Federal Register. I have the links on everything I'm talking about here. And then, you want to make sure you, of course, have the most current manual. A big, big change just came back in 2020. Well, in July of last year, CMS updated the acute manual, which is where we're focusing on today. It first came out, by the way, in 1986, then with multiple updates. If there is a new manual, check for the transmittal page, because that is a quick way to find out what did they change. And then, for you folks, check the survey and certification site at least monthly. That will keep you up to speed on what's going on, what's changed. If there is, heaven forbid, another COVID or another pandemic, you'd want to check that more often, because they do tend to put them out quicker when there's a public health emergency. A manual we're talking about today is Appendix A. Again, I have the link on all my slides. You'll have to copy-paste to your surfers, surf engines, in order to get. Then we may touch on W, but very, very briefly, but there's one I want you to keep an eye on, and that's Immediate Jeopardy. Look at that and keep it handy, because especially in restraint and seclusion, if they find that there is an issue that poses an immediate threat to the health, safety, and welfare of patients, they will go to Immediate Jeopardy. And then it gets a little bit more dicey there, very, very rigid in that interpretation. So the manual that we're talking about today, State Operations Manual A, you'll see again it came out July of 23, and the transmittals are right on that initial page where you can actually click the link when you're in the manual. And that just happens to be for Appendix W as a reference, but that's what the transmittal page link will take you to. Likewise, you will check our acrylic where it says that R200 or whatever happens to be the number, and that takes you right to the transmittal page. Again, quick, good way to find out what did they change. So when a new manual comes out, go to that transmittal page. Go to the 560-plus pages with the acute manual or the 380-plus pages with the critical access because this will save you much more time. By the way, that's what that memo site looks like. It does now go from most recent to oldest. So they did update their website in that respect, and that's just an example of what one looks like. We're touching on this memo, by the way, briefly today as we go through. I mentioned deficiencies where no one wants to get that. We can access it. It is updated quarterly now. It has a tag number, brief description of what they found, not always, but sometimes. And it will have the hospital name, address, date of survey, et cetera. So if you're trying to find out, okay, where are we falling and you're new to your role, that's one good way to find out quickly. And to get there, you will go to the Medicare provider enrollment, the certification site. Scroll to the bottom of the page, and that's where you will see the link for full-text statements. These go up until 23, December 23. I just checked the other day. They haven't gotten the first quarter of 24 out yet. I was hoping they would, but they don't. And this happens to be what it looks like when you pop it up, the huge Excel. Again, you can filter and sort with what you are looking for. Just make sure you add the letter and the four-digit number. If you don't, you will not get the right information. You'll be in the wrong section. The deficiencies we're talking about today, all the tag numbers we're going to cover, some a little bit more depth than others, but you see patient rights very, very often cited by CMS and what was missing. And then follow closely by care in a safe setting. Now, care in a safe setting is very broad. That can be everything from hand-washing to patient assaults. So it's a very broad topic. And then, again, restraints and seclusion, 50-some-odd pages alone, and the majority of the citation. So it does go 15,000. This is probably the highest cited area within the entire manual. Now, I've broken these down further. They are in the appendix for you if you want to find, okay, what does each and every one, especially where you see those ranges, 215 to, I'm sorry, 154 to 214. I have a further breakdown of what those particular deficiency numbers were. Well, I want to just talk about now moving on to the conditions of participation. This is what you have to do. And you have to do it for everybody, not just Medicare and Medicaid patients. Every patient, Blue Cross, Cigna, doesn't matter. You have to meet them for each and every patient. First off, we have to give them notice of what their rights are. And these are the minimum protections. And again, it requires and applies to all of those participating hospitals. One thing these regulations, these tag numbers do not apply to are critical access hospitals. And in fact, there's not really any same section in Appendix W. But we still have to do something to make sure they're protected. They do have some rights that they list, but that's in the swing bed section of Appendix W. But just keep in mind, they're still looking. When you come out for critical access, they will still evaluate. How are you making sure patient care is provided and patient rights are being met? It applies to every part of your hospital, every location, outpatient, inpatient. If you have provider-based entities within your hospital system, then it applies to them. We have to give them notice. And you have to make sure that requirement is actually met. We have to tell each patient and their representative, if they have one, these are your rights. And that's in advance of even touching them or, of course, sending them home. And usually that's in the ER where we let them know that. We have to give it in a way that the patients understand. So keep in mind low health literacy, limited English proficiency, or don't speak English. We've got huge numbers still. Ninety million are low health literacy and those who don't speak English. Twenty percent rated a fifth grade level. And, in fact, it's probably dropping at this point. There are certain rights we need to include in this notice. And a lot of you will probably have it up on a big poster board somewhere in your hospital. Or you may put it, in addition, on the back of your admission form. Hey, these are your rights as a patient. Confidentiality, access to their records, unnecessary restraint and seclusion, that you will be treated and given care in a safe setting, freedom from abuse and harassment. You get to determine who your visitors are. An equal treatment, in other words, doesn't matter who you are. You have the right to an interpreter at no charge if you so need it or want one. You have a right to have your grievances addressed and resolved. You have a right to contact state agency if you have any problems. Now, these refer to Medicare and Medicaid patients. You have a right to participate in your decision care, in other words, informed consent, which means you can refuse treatment or you can say, yeah, I'm going to consent to that. You have a right to make and have recognized and followed your advanced directives. And then, finally, notice of admission. You have a right to have someone know that you are admitted to the hospital or in the emergency department. You don't have to do that, but you have a right to let that happen. So what do you want to do here? Of course, policy and procedures. Make sure patients have that information. You may, as I mentioned, want to add it to your general consent to treat, notice of privacy practices, and you might want to also have a little sense at the bottom that the patient can initial if they will or could. I have received a copy of my patient rights. You don't have to agree to them, but at least they've gotten a copy. If the patient is a representative, DPOA, whoever it is, they can, of course, initial in that person's shoes. We have to take steps, reasonable steps, to know what are the patient's wishes on who can be their representative or who will be their representative. And this is for those folks who are not incapacitated. And especially those who happen to have a representative. If such a person shows up, we have to give that person the notice of patient rights in addition to the patient. Patient can tell you who that is orally. They can have it written out. They may have a, you know, like an advance directive that says so and so is my personal representative. If they are incapacitated, then give it to the person who shows up with an advance directive, like a DPOA or an actual advance directive. A patient representative, who are they? Well, if they're incapacitated and they don't have an advance directive, we don't have that luxury. They just show up in the emergency room. It helps if it is their spouse, a family member, partner, whoever that happens to be. That's the, you know, that's really the easiest for us. If such a person shows up and say, yes, I'm their partner, we can't say, okay, great. I need you to prove that. We can't have them or can't require them to provide supporting documentation unless more than one person shows up and makes that same claim. Now, if you have someone who says, I'm their representative, patient doesn't object or anything, and you've got this bad feeling, if you refuse to see that person as their representative, someone has to document that in the medical record. And why? You know, it could be an issue. I'm not too sure about this. This child's got some suspicious marks on them. Okay, you know, then you've got to take more steps. Or maybe it's an older person and someone comes in with them. And same thing, you're worried about misuse or mistreatment of the elderly person. Or it just doesn't sit right. You've got to have a really good reason for not recognizing them as it. But check the state law because there may be a specific statute or information giving you some more clout and some more support if that is the case. Make sure you have policy and procedures on that because you need to be able to guide your staff when these situations occur. And for those of you who work in risk, you probably know this happens about 2 in the morning and patient comes in through ER. That's when it usually occurs. When you have that policy, it will help get them through this until you can be there. I'm going to talk briefly about the I-am notice. And that only stands for important message. It goes to Medicare patients. We have to give this to them within two days of admission and before they're discharged home. And that's, of course, if they're there more than two days. We want to give it to certain observation patients. And essentially what this is saying to you is that, you know, you have certain rights to receive covered services. And so that's why we need to give them this notice, the I-am notice. Survey procedures for this tag number. Well, first off, they want to see your policy. Does it provide that you're giving notice to all patients of their rights and a way to determine if the patient has a representative? They want to look at medical records also because they're trying to find out how did you get that information to that patient? How did you determine if they have a representative? By the way, if there is a representative there, they'll talk to the patient and the representative, both. They'll talk to your staff. How do you tell a patient about their rights? Now, that could be the nurses or it could be admission personnel. Then they will look at the sample of Medicare patients. They're looking for that I-am notice. Was it given? When was it given to that particular patient? Well, I want to spend some time on grievances. There's been some chatter lately on the Ashram website. I don't know if anybody listens or looks at their lists on grievances and complaints. What constitutes a grievance and complaint to which you have to respond under CMS? Well, you have to have a way to do it, and you have to have that process for a prompt resolution of a patient grievance. You have to tell the patient where or to whom do they file that grievance because really patients have this rationale or an expectation for, you know, this is reasonable care and services, and we should address those expectations. It should be timely, reasonably, and consistently. Here's the definition of a grievance. It's pretty much anything. It can be verbal. It can be written. Written's, of course, best. It's made to the hospital by the patient and or their representative, and it talks about their care. Maybe it's about I wasn't treated nicely. I wasn't treated fairly. Abuse or neglect. And these are ones where your staff can't take care of it at that moment, and it also talks about your compliance with the conditions of participation. So, for example, you've got a patient who's complaining because they were not given an interpreter. Well, that's part of the conditions of participation. It can also be a beneficiary billing complaint related to rights. I don't talk about that because it does address billing, so consider adding language to your policy that's here on this particular slide. If it is a minor grievance or it needs further action, first off, have a way to take care of those little minor requests timely so that they don't have to sit down, write out a letter, and make that complaint because then you've got to go through your whole process. For example, a patient says, this food is terrible, it's cold, there's absolutely no flavor to it. Can I have something else? Yeah, they can take care of that at that time. You don't have to do anything more at that point. You don't need a written response. But if the staff can't take care of it at that moment, or it requires more action, more investigation, then it is a grievance. And if so, you have to meet all of the requirements for that grievance. And you take it to the level where it's considered resolved when the patient is satisfied with those actions. Not always, but usually it's when the patient's good with those actions. So it'd be written. Doesn't matter if they're inpatient, outpatient. If you get it by email, if it's faxed into you, it's still considered written. If they telephone you after the fact and say, you know, I really got a complaint about, you know, the care I received, then it's a grievance, unless afterwards, if you could have said, you know, my food was cold, why didn't you tell us? We could have popped it in the microwave and warmed it up. Then it's not a complaint. Be very careful, because that is a very fine distinction, a very fine line on getting those resolved. But anyway, if it is a complaint about abuse, neglect, any patient harm, then you have to treat that as a grievance and you really need to jump on those. And we're gonna talk about, you know, when you have patient harm and how you have to respond, how quickly you need to respond. Again, it's not a grievance, the patient's good with everything. Maybe a family member isn't, even if the representative isn't happy with it, but the patient is and the patient's competent. It's not a grievance. Billing, unless a quality of care. If you get something on a patient's satisfaction questionnaire and it comes back, it's not, unless the patient says, you know, I was really unhappy with my care. I had asked three times to be moved to a different room because it was cold. Nobody would listen to me. I felt I was being discriminated against. Then you need to address those, especially when the patient wants a resolution. If you do treat this, your policy within your hospital says no matter what, we get a patient satisfaction questionnaire, we didn't meet something, we treat it as complaint, then it's a grievance, period. Now, what if someone else, other than the patient, complains? Well, first you wanna contact the patient, if that's possible. In other words, they're competent, they're not in stage dementia. Contact that person and say, you know, so-and-so is complaining about your care. Are they your authorized representative? Can we speak with them and work with them to get this resolved? Because we're talking HIPAA here and that doesn't go away. Yes, you can do that if the patient consents. Now, if the patient says, oh, for crying out loud, I wish you would stop complaining about it, I'm fine, you're done, just document that. If they say yes, work with them, then you document their agreement that you can do so. You may wanna get a HIPAA compliant form signed just as another coverage measure, so to speak. The surveyor here, first of course, they wanna see your policy. They wanna make sure the process does, first off, encourage your staff, all personnel, to alert those who are responsible about this issue. They will interview patient, probably their representatives too. Who do you file a complaint with? You know how to do this. By the way, did you know you can reach out for Medicare, your QIO, if there's a question or concern that you have? And they wanna make sure the process, make sure that those who place patients in immediate danger, you're all over those. You're on those in a really quick and timely manner because we can't let those go by. Next tag talks about prompt resolution. You have to have a way to do that, a process. You have to tell each patient, okay, who do I contact if you wanna file agreements? And we have to give them the name and their title. Now, a couple months ago, I'd done this program and one person asked, you know, with all of the issues with violence, threats, we're very hesitant to provide the name because then they can go look them up. So I reached out to CMS and they said, yes, you do have to provide the person's name. And we hope that your security processes will be in place. I was a little disappointed with that response, but that is it. We do have to provide the name. By the way, your governing body, your board, they have to approve that process. They have to be responsible for the effective operation of your grievance process. They have to review, make sure they're resolved unless they delegate that process to the grievance committee and that must be delegated in writing. And they still have to know what's going on. They don't get to lose it, but they can delegate the responsibility and making sure this is all done to that grievance committee. That committee has to be more than one, more than one person, enough qualified persons to review and resolve them. And that includes giving that written response. You may wanna think about other departments. You just don't have to always be clinically based. It doesn't. You can even rotate some of the members or have ad hoc members to help. Maybe it is an issue with laundry. Maybe you want the head of your laundry to be brought in on an ad hoc, even food services. Why is this happening? You have to have a way that your process is reviewed and then analyzed going through your QAPI process. That never goes away. We also have to have a way for timely referrals, the patient concerns to the appropriate QIO. We know every state has one. These are contractors with CMS and they are there to help Medicare beneficiaries with quality of care issues while they're in the hospital setting. They are tasked with also utilization review decisions and discontinuation of stay determinations. I have the link there to find out which one is yours. Area three, you're probably in area three. And then as far as finding, okay, where do these folks belong? There is the list. Now you want to check on this because sometimes they like to change around every now and then, just to make sure that your area beneficiary is still that correct number. The beneficiaries, the BFCCs, again, they handle all complaints. They do utilization review on premature discharge. They may do quality of care, EMTALA for your Medicare and Medicaid beneficiaries and other types of reviews. And they usually will come in at the same time the state would come in. So if the patient says, you know, I want this handled or I want this sent on to my BFCC or whoever it happens to be in our state, you have to do that, by the way. You have to coordinate, have a way to coordinate for utilization review and referral to the QIO concerns. I see you have a typo on that slide. Now, you're not required to automatically send it off, the grievance, to the QIO. You have to tell the beneficiary, hey, this is your right to do this. Now, if the patient and or the representative says, send this off to the QIO for my state, you must, you have to do that. Unfortunately, if they request it, if they don't, you are not required, we just tell them you have a right to have this reviewed by Kepro or Libtana. Then real quick, they updated that notice, detailed notice of discharge, the form and instructions. This is one we have to give to, again, all Medicare patients. This is one of their rights. So they know what are their discharge appeal rights? Do you have a patient in, and really they're ready to go home or move to that next stage of care and they don't want to leave. And they think, no, I'm not ready to go home. I don't want to go home. They have a right to appeal that discharge. And so we have to give them this notice how they can do that. I have the link and more information in the appendix. That's a form that they can fill electronically. And then as far as your procedures, it must be a clear procedure for submission of that patient's complaint, whether written or verbal. The surveyor wants to look at that information. Does it clearly tell the patient how they do this? Again, think simple language so they all understand it. And they've been, of course, talking to patients and their representative. Did you, were you told how you can file agreements if you so want to do that? Not that every patient might remember, but as long as you have something that shows, yes, they were given that, their notice of rights, it's going to help you. But don't be surprised if they still talk to patients. You have to include in there in your process, timeframes for review and providing a response back to that patient. You must review, you must investigate, and you must resolve each and every grievance within a reasonable time. Now, they could have a couple of grievances that could go into one letter, but you still have to look at each and every one. Respond to the substance, investigate and resolve any deeper or systematic problem that you can kind of start to pick up with this grievance, say it's discharge planning. And all of a sudden you're seeing these grievances, these complaints coming across. It's like, you know, I was sent home early and they wouldn't help me set up my home health or there was no one there to help me. I couldn't get anybody into maybe Meals on Wheels or anything like that. Well, then you want to start looking, okay, why didn't that occur? Is that a recurrent grievance that we're getting? Where are we in our process that we need to go back and visit and perhaps fix it? As far as the timeframe, a seven days, that's considered appropriate. If you don't resolve it within seven days, then you have to tell the patient and representative, we're working on it and we'll follow up. But usually, you know, if it is so complicated that it takes more time, same thing, tell the patient. They do recognize staffing issues, vacations, complexity of agreements might take and affect longer timeframes. And the surveyor will look, what timeframes did you establish? Now, I do want to put one thing. CMS doesn't say if it's calendar days or business days, but it might be best to have it a shorter days, calendar days, so we don't forget about it. Now, some of the other accrediting organizations do specify calendar days. CMS did not. Either way, we have to give written notice back to the patient of, hey, this is what we found out. This was our decision in the investigation of your complaint. In there, the name of the person, hospital contact person, what you did to investigate the agreements, what was the result, and when did you shut it down? When did you close out that file? And you may not always resolve their issues. That's understandable. We just have to say, you know, if you disagree, then you have a right to appeal in how you do it. But again, put it in a language they can understand. Very basic. And I'm not being mean to patients, but we in healthcare use a lot of big words sometimes, and that's why we need to make it very clear and understandable. This is what we found out. You don't want to put in there anything that could cause a problem. You know, like, I'm sorry, we fell below the standard of care. Please do not include that. It'll make your hospital attorney, your defense counsel, head spin around. Just make sure this is what we looked into, and we did take appropriate steps to resolve this. If you can, try to meet with the family, if that's at all possible. It doesn't have to be in person. Do a Zoom call, a phone call at their convenience. So maybe you can really ferret out some information, and they'll come back and say, you know what, after I thought about it, okay, you guys did do a good job, and I'm okay with it. Just document it and close the file. Just make sure all of the elements are in that section, that you looked into it, you worked to resolve the process, and that as of this date, we're closing out the file. Again, you're not required to put in statements that could be used against you in court, but enough to tell that you met those requirements. You are not required to give a very long explanation of each and every action you did to investigate, to resolve, to do anything different. We developed our policy and procedure. You don't have to do that. Just make sure it's enough that, you know, we took your complaint very seriously, and we have investigated it with those staff members who were involved, and now we have put processes in place so that we can do better the next time around. Other considerations you might wanna keep just in the back of your mind, if the patient emails it, you can email it back as long as your internal communications allows that. Keep evidence that you met and did what you were supposed to, because the surveyors are probably gonna wanna see it. It is considered done and resolved when the patient is satisfied when they're over it, or appropriate and reasonable steps. Do that, you know, they may say, hey, listen, I didn't like the way I was treated. I want that person fired. Yeah, you're not gonna do that, probably. It's just, you know, we've taken action to address this so that, again, it will not happen in the future. Now, section 1557, that's under the ACA. They have a grievance procedure, and this is one where the patient's complaining about the way they were treated, maybe discriminatory treatment. They have 180 days from the date they became aware of that alleged action to file a complaint, and it must be in writing. This goes, by the way, to the OCR, Office of Civil Rights. Your coordinator, your designee, they have to investigate any such grievance where you are not complying with that section 1557. They have to issue, that coordinator has to issue a written decision. So that's why your OCR policy and procedures are very important here. You must maintain records and files of these investigations, and I'm just going to use discrimination based upon, say, age. You've got a patient who was maybe younger, but had dementia, and so you put them into a special care area so that it was easier to keep track of them, staff was better equipped to handle them, but the family was really upset, and maybe the patient was, why was I in with all those old people when it wasn't necessary? So that's why you have to make sure you have this person. Interested persons, those who are involved in the care, they have to give a chance to give evidence in response to that grievance, and then tell the patient, this is what you can do if you want to pursue further legal remedies. So we do have to tell them, I have an example of what that policy looks like. That is the link, if you want to look it up, that's right off of the OCR website, so if you want to look at that. All right, I want to go in now to an area called exercise of rights, and we're going to cover a couple areas in particular, consent and advanced directives, and then we'll discuss these next couple tag numbers. So now we know, okay, these are your rights. Now they can exercise those rights, participate in working with their plan of care, inpatient and outpatient, and that includes discharge planning and pain management. You must actively include the patient when they develop, implement, and any revisions to this plan of care. Now there may be certain parts of the plan of care that they don't agree with, but they can participate and get it going. The patient representative also has a right to participate in planning their care, and that includes, again, inpatient, outpatient, discharge planning, pain management. They're pretty much stepping into the shoes of the patient with them. You are expected to take steps to determine who is that patient's wishes on designation of that representative. If you're in a large family, have a large family, try and pinpoint one representative. We'll save you some headache and back and forth. That one representative, that the others can communicate with them because the patient may say, oh, whatever they want to do is fine, but it'll help make it easier for you. If they're not incapacitated and they have a representative, we have to include both in the development of their plan of care. If they are incapacitated, person comes with an advanced directive, they're there. If there is no advanced directive, same thing. Who comes in and claims to be the representative? No supporting document can be required unless you have two or more who are claiming to be the representative. Now, Lindsay did mention we have a few polling questions, and here's our first one. I'll have her put it up and take it from there. Perfect, thank you so much, Laura. Give you a little break there. I know you've been having to speak for quite a long time now. So I'll read this first question, and then I will put up the response options here for you. So it says, patient Z has been admitted via EMS and found unresponsive in an alley, victim of an assault. Patient known to the hospital for frequent admissions for wound care due to poor DM control. Power admission records show that two sons are in the area and both have been contacted and both arrive and state that they have DPOA. What should the hospital do? And then I'll put up your options here. Okay, so you should see that now on your screen that says, accept the first one who arrived, accept the order of the two, accept neither until one produces documented proof, seek a court order, or possibly another suggestion. And if you have another suggestion, you can go ahead and type that into the chat box as well. And then as I mentioned at the beginning, we will also address any questions that you have for Laura up to this point in the presentation during the time of these polling questions. And it looks like we do have one question that has come in, Laura. Okay, so while you all are still putting in your responses here, we'll address this one that says, in the grievance letter, what type of details do you give about the follow-up? Is it a summary or do you have to include exact specifics? You don't have to include exact specifics. You just have to be able to say, we looked at each and every one of your response, every one of your grievances. On grievance one, we talked to the staff and we have resolved this with some, we've resolved it. You can do it that amount. Don't discount any of those complaints. So you might want to go step-by-step on how many grievances, if it is an overall. And I've seen some pretty bad ones that said, okay, we got your grievance, we shut the file. That's not sufficient. What they're looking for is, did you look into it? What steps did you do to resolve it? That could be, we talked to staff, we reviewed your medical records. We had one of your doctors look at the record and they believe that what we did was appropriate. You're done. Or it says, and we've identified one or two areas that we can resolve and we've taken those steps to get that in process. You're done. That's it. Again, you don't want to put anything in there. We fell below the standard of care. You can say, I'm sorry, we didn't meet your expectations. That's fine. But just make sure we've addressed all of your issues and this is how we investigate it. That's the big thing. How did you investigate it? We talked to staff, we looked at your record. And then this is what we did to resolve it, the very general language. We've addressed it with our staff to make sure they're more aware of what are the expectations and then close it out. That's where you really want to work with your legal counsel. You may also want to check with your professional carrier. Sometimes your professional carrier, their claims people, or they may have attorneys that they know of that can work with you on doing a good response so that you're not, so to speak, shooting yourself in the foot with that response, that it's a good response and you're not putting anything that can be used against you in a legal action if it does progress to that level. Great. Okay, and then I'm gonna share these responses here. And while I do that, there's a comment here in the chat as well that says, first seek consensus of the two. And then if that cannot be reached, wait on the DPOA to be provided. Yep, absolutely. Yeah, you don't have to accept neither, correct. I think those are great responses. And the person who put that in the chat, absolutely correct. Because you may find a DPOA that's older than the other one and the newer one would supersede it in that situation. Good responses. Thank you everyone for those of you who did participate. Again, two or more representatives. Document, if you're not gonna recognize someone, follow your state law. There may be a state law that's out there that does address it. My state does not. They follow what CMS says. Have a policy so staff know what to do in these circumstances. And make sure it's quick and non-discriminatory in who you identify as that representative. Now that doesn't mean a patient can't have more than one. It makes your life miserable, but it doesn't mean they can't have it. It's just, there has to be an agreement between those two. You know, one says, take them off the vent. The other one says, leave them on. That's when you're going to need to get other individuals involved to make that determination. That's where, again, the court would come into play. Another thing you wanna do, if the patient doesn't want to participate in care, then we have to document it. Include their representative because the representative may help if it is life-saving care, whatever it is, may help the patient understand and then consent. We don't wanna pressure the patient, but they can be a big help too. Of course, if you've got a minor, you've got an incompetent, a guardian, whoever that is. And pain management, care issues, discharge planning, that is included in what we need to make sure the patient is precipitating or declining. This does mention in here that there is a free choice of long-term care or home health. Of course, they would have that right to do so. I'm gonna move on to consent now. This is a very broad topic. They have a right to make informed decisions, be informed of their diagnosis, but they can also refuse care, which means they can sign out AMA if they so wish to, with the exception, unless they do pose an imminent or harm to themselves or others under, say, psychiatric. Of course, the, does imply we give the representative the same information to help with that informed decision. Now, the patient can delegate that decision-making to another, but follow your state law in that. And of course, if they do so, I would get that in writing. So, you know, it's like, I'm not gonna make these decisions. My daughter, my son, whoever it is, is going to make all of those informed decisions regarding my care. In other words, they're relinquishing that right. But take steps to determine who that is, unless, of course, it's prohibited by state law. Have that written consent of the representative, patient who is not incapacitated, that does continue throughout their hospitalization, and if they are incapacitated and no events are active, who is going to be that representative? We have to give them enough information to make these decisions, surgery, treatment, be informed of their health status involved in their care, in their treatment, discharge planning. Let's say they're going to a post-acute care provider, a nursing home, long-term care, and they can request or refuse treatment. Now, that doesn't mean that they can request unnecessary or inappropriate care. Well, they can request it, they just won't get it. That doesn't, that's not a blanket open area for them in order to receive it. And again, we have to have a process, a policy, a procedure to make sure all of this is completed. Now, there's something I do want to bring up on especially surgery, and it will go into the surgical section, and that talks about informed consent for surgery. And when you, say, have a teaching situation, you've got residents, whoever it happens to be, there was a recent memo that came out earlier this month, I think it came out around the 10th, and it talked about including in the surgical consent form when you will have training and education persons within there and exams outside of that medically required procedure. Now, like pelvic exams, breast exam, prostate, rectal, and they are focusing this right now. They're reinforcing those consent obligations in the surgical consent form area. They will amend Appendix A, they will update it. How soon, we don't know, but it is going to be updated that we have to include that in our consent forms for surgery or procedure because the patients have a right to say, nope, I don't want that done. There was a case where, in fact, involved a nurse, back a couple of years ago, she was having surgery, and she had said, you know, I don't want, just do the surgery, don't do any other exams, because she was smart, she knew what was going on. And after surgery, sure enough, one of the residents came in post-op and said, oh, by the way, you're having your period. And the only way they would have known that was if they had done the pelvic exam. So that was quite a shock. You can imagine how that patient felt knowing that, first off, she said, don't do it, and then they turned around and did it when she was under anesthesia. So that is going, right now, only in to the surgical component with the surgical consent. They may go ahead, and once they do the manual, they go back to the medical records and to patient rights. Otherwise, you've got two disclosures you are required to make. Now, this is different from the notice of rights. This is two disclosures. You have to put them in writing. One, if your hospital is owned by physicians, and two, if a physician is not available 24-7 to assist in emergencies. Include that, though, in your notice of rights. You may want to just put up a sign in ED, also. It must be a signed acknowledgment from the patient that, yes, indeed, they have this. Give it at the beginning of stay, whether it's an ER visit or they're actually admitted. As far as the first one, physicians who refer patients to the hospital where they have an ownership, they have to disclose this also, and that you require, excuse me, that they disclose this as a condition for credentialing and privileging. So if that is the case with your hospital, make sure that the patient has signed off on that. Advanced directives. We have to make sure that patients know they can make and have those directives followed when they can't make their decisions. And staff, they have to make sure that care is consistent with what's in those directives. Policies, procedures include delegation to that representative when the patient is incapacitated, and they can choose a support person. They can even make decisions on visitation. So it doesn't have to always be end-of-life care. It can be visitation that's in an advanced directive. Your policies have to be written and how you're going to implement those advanced directives. Clear statement of any limitations. Excuse me. Are there conscious objections to what happens to be within that advanced directives? At a minimum, include in your policy when there's a difference in the facility objections, conscious objections, and those that are raised by the individual provider. And we can't refuse to honor that designation of a support person, a representative, a DPOA. We cannot refuse to honor the designation of that person. We have to, of course, give it timely. We give them written notice at a time when they're admitted. There could be three other times, emergency department, observation, same day. Just document whether or not they have an advanced directive. We always know and we always ask them, hey, can we get a copy of it, especially when we know they're going to be inpatient for a while? But don't expect to get it too often, especially if it's outpatient. Of course, we can't condition treatment on whether or not they have one. Like before, it's not a way that they can demand inappropriate or unnecessary care. Just make sure they're following your state laws on advanced directive. Most of them have, states mostly have, it's called a MOST, whether it's, it talks about end of life care or this are my advanced directives. It's a very simple form, makes it easy for the patient. We want to make sure we provide a document that we gave them education to the staff on policy and procedures. They have to know, okay, we've got this advanced directive. What am I supposed to do with it? And then they also are required to provide community education. Well, CMS won't tell you how to do that, but one example, and this is just my example, put it on your website, that by the way, you have a right to make and have recognized and followed your advanced directives. There's another little animal called a psychiatric advanced directive, very similar to traditional advanced directives. And that usually comes up if you've got someone who's very concerned with involuntary commitment or treatment and very, very wide range of subjects, everything from medications and therapies to use of restraints and seclusion. I have never seen a psychiatric advanced directive. I know they're out there and one of my colleagues has seen it, but they also have that right to make a psychiatric advanced directive. And then we have a right to have family members, someone notified that they are in the hospital. And there, we also want to make sure that we give them the option to have their physician notified of admission. And if they're incapacitated family members, get them notified promptly so that they know they're here. Now, the physician can make that determination if it's not clear. It's nice if you have their family doctor because sometimes a family doc knows, hey, they always showed up with them, they know more about them than their family knows. Now, maybe that's the person you want to reach out to first in order to get ahold of them. All right, the next topic I'm talking about is ligature, risk, and confidentiality. So privacy, safety included in there. First off, let's start with privacy and safety. Patient has a right to personal privacy and it's really quite a basic principle, dignity, respect, and comfort, those very basic rights. On physical privacy, well, that's when we're giving them care. Close the curtain when they're getting a bath, close the curtain when they're on the commode, maybe when they want it. Could we just kind of close the curtain? I need a little private time here. Patients, people who are not involved in patient care don't need to be there when care is being provided. Privacy, staff, physician, especially when they're talking care issues. Now, that can be tough when you've got a two-bed unit. That was somewhat always of a challenge, pulling that curtain while it's a nice thought, but we do the best we can, recognizing we're not gonna protect everything. It's like in the ED when you have those hot bays, you do the best you can to protect the confidentiality. Video and audio monitoring is within this section. So of course you have to have a reason, a clinical need, and we have to tell the patient and their representative, by the way, we do audio and video monitoring for patients, especially when they're at full risk so that we can make sure that they are providing care because we can't be in here 24 seven. Screens, you can of course have them easily visible by somebody walking by. If you're doing recording, video recording, you must have a consent for that. Make sure you wanna add that to your general consent form. I've seen a lot of hospitals starting to do that. Now for patient safety and wellbeing, we have now instituted audio and or video recording or monitoring, whichever one it happens to be. But privacy, make sure that you have a patient who requires continual observation, your violence, obstructive behavior, those who have suicide precautions, make sure that we're still maintaining their privacy when others happen to be around. So again, you might wanna add that consent form statement. I agree to images, photographs, see this quite a bit. Check your state law, any wording requirements, or if it's permitted without a separate consent and others don't have done that piece of paper and that they acknowledge that they have been given this notice and consent. Moving on to just protecting their PHI. It includes limiting disclosure and we have to notify those, the patient prior to disclosure so that they can restrict or agree to it. They do talk in this section about permitted disclosures like payment, healthcare operations where you don't have to have consent. And of course you have to have policy and procedures. First off, what categories can people access and who can access it? Physicians taking care of a patient or you'd have residents who might be involved in the care. So if you do have residents, make sure that they're aware of their duty to maintain that privacy. They just can't go snooping or other care providers can't go snooping. We do have permitted disclosures. We can do a facility directory. Just make sure your patients have a right to say, no, don't list me on there. I don't want anybody to know I'm here. Incidental uses. If it's on the side of a chart, you've got a patient care sign that says fall risk. Whiteboards where it's very limited information and restricted access to those areas. Those are okay. But again, that's like OR and PACU where you just don't have everybody walking in and out. We always have to take reasonable steps for safeguard. Look at what you're doing. Walk around and see how things are being handled. Do we need those curtains or is that enough to protect privacy? When you have patients who are hard of hearing, that can be a challenge. I totally understand that. Speak quietly if it's semi-private. Limit access where you do have those whiteboards. I worked in a unit where you walked up and the first thing on this big whiteboard on the wall was the patient name, doctor, diagnosis, room number, everything. Then HIPAA came around and that whiteboard all of a sudden got really clear and it was just simply first initial, the room number and that was about it because that's all we needed to know. That really pretty much went away. The surveyor will watch and they will interview patients. Did we protect their privacy? Are doors closed? Are curtains closed? How are the names? Are they in plain view? Is it limited information that is disclosed? If you're using audio-visual monitoring, are they easily visible to the public or do you have them in a separate room, which is of course best? They'll look at your policies. They want to interview staff. Do they understand the information that goes up on the whiteboard? How much is going to go up there? Does the policy talk about restricting use or access? Are there reasonable safeguards so they're incidental disclosures? We couldn't help it. It did happen. Let me move on to care in a safe setting. Now, this is very broad. It doesn't necessarily mean protection from abduction, abuse, it can be infection control, environmental safeties, medication errors, that's also included. We have to, of course, identify those patients at risk who want to hurt themselves or others and then that there is education and training to staff and even volunteers so that they're aware of it. So here's just in some safe setting. Start with the general stuff, hand-washing, managing unwanted visitors or contraband material, background checks on staff, removing or mitigating ligature risk. On ligature risk, we want that safe environment so they don't hang themselves, don't strangulate anyone else. Now, the intention of this requirement is that each patient receive care in an area that's reasonable person similarly situated as the patient would consider safe because you may have that behavioral health patient who's had an incomplete suicide attempt who's on your medical floor. Well, you then have to take an account. Let's say you have another patient. How are you going to protect them? We know there's no waivers for these deficiencies. You will be cited and you have to give monthly progress reports if they are observed. So as far as the risk of suicide, ligature-free, ligature-resistant, these are for your units, your psych units, your hospitals, your psychiatric hospitals. You may not want to think about your non-psych, your ED, ICU, med-surg, who is going to be at risk. That may mean one-to-one monitoring of them, removing things from the room so they don't hurt them. Again, if you've got a person who's on med-surg, stepped down from ICU, that may need to clean out the room or do a one-to-one monitoring. There were some guideline updates last July. They mentioned, and they changed it from must to should. So you should identify those patients who are at risk for intentional harm. There's three or four steps. One, a patient assessment, an environmental risk assessment, and added non-compliance to include when the risks don't necessarily pose an immediate jeopardy, but you really need to get on them as soon as possible within that timeframe. Usually it's the regional office that makes that determination. So they talk about in that memo, what's the definition of a ligature? Well, it's pretty much anything that you can tie a cord or anything around for hanging or strangulation. And that can be a doorknob to a shower rail. They also talked about keeping an eye on your housekeeping carts, your utility carts, because there could be some good stuff in there. Cleaning agents, disinfectant. Now that's not necessarily a ligature, but they could still harm themselves. Other safety risks, something that can be thrown, sharp objects that they can use, plastic bags, oxygen tubing, even breakaway windows. That picture happens to be, that's the picture of a window insulation that the patient pulled out and used as a ligature. We have to identify the risk. They don't, CMS doesn't specify any particular tool that you're going to use. So of course you want to look at your patient population. Where are they being taken care of? How good is staff on recognizing and assessing these individuals? You are expected to put into place appropriate assessment strategy based upon that patient assessment. We're talking OB versus an ED patient. Next one is your environmental assessment. You should do this assessment also. Appropriate to the environment and the patients. You know, they don't require the use of any specific tool. They do mention the VA risk assessment tool and the behavioral health design. The asterisk means there is a reference in the appendix for you. You can download that behavioral health design guide for free. And they usually update it pretty regularly. I'm expecting another update later this year. You have to correct those risks. You have 60 days to do so. That's 60 days after you get the report and then they come back to visit. They want to make sure everything was done. These are not eligible for waivers. Now if it's not an immediate jeopardy or it's not remedied, the regional office or your accrediting organization, they determine how quickly they will come back. If you need an extension of time, you have to give a mitigation plan and update. So let's say it happened to be you were cited because there were so many items within a particular room that you designated for behavioral health patients and you were in the process of redesigning it and remodeling it. You just have to give those updates. This is where we're at in getting an update. It could be a supply chain issue, but you have to do the mitigation. And you have to do education and training for your, you know, those folks who need to identify them. Who's going to do the assessment? How are you going to make those mitigation strategies? And that includes everybody. It includes agency staff. It includes contracted staff. It includes your volunteers if they are involved in patient care. And of course, during orientation, CMS does recommend doing education and training every two years for this assessment type. And the MEDEMO, they did reiterate the guidelines. They referenced the National Alliance for Suicide Prevention. That's a good resource on best practices. Look at your environmental risk assessment. Have someone who isn't normally on your floor maybe come around and just kind of walk around and see what's down there. Those clean eyes can sometimes pick it up. And of course, education to your staff on that monitoring. Well, then moving over to freedom from abuse and harassment. You wouldn't think you would have to make a note on this, but CMS has found, yes, it is necessary. And that's all forms. And the intent is that we just do that. We prohibit it. Neglect is a form of abuse. And that can be from anyone. That can be from staff. We don't want that. Other patients, they can walk into a room and abuse someone. It can be from visitors. That's why you have to have a mechanism and a way to make sure that that doesn't occur. They add definitions. So by the way, if you're looking to update your policy, just use their definitions. You don't have to go and do this great expounding. Use CMSs. It'll save you some headache. That's, of course, willful infliction. Unreasonable confinement can be considered abuse or intimidation that results in harm, whether it's physical or mental. And again, staff neglect or indifference. And especially if it's intimidation by one patient by another, we don't tolerate that. No. Neglect, that's a failure to provide services and to avoid any harm. And then there's several items for effective abuse prevention. I've listed them here. This is on slide number 98. Of course, we want to train our employees. How do you report? How do you prevent? Do you have enough staff on duty? Are they qualified? Screening folks. So we don't hire them. Identify those events. Make sure they're listed out. This is what constitutes abuse or neglect. And then how do they report them? You know, how do you take that corrective action? Investigate them all. We cannot poo-poo them just because a patient continually complains. Just because they're complaining doesn't mean it didn't happen. All right. I want to switch over to medical records now. Another big area. And that brings me to my second question, Lindsay. Okay. This question says, hospital X is a multi-specialty hospital which transitioned to a new electronic medical record. To access their medical records, patients must complete a hospital prepared release. Once the form is completed and reviewed by a medical record staff member, the patient is provided an access code. However, if the patient has an outstanding balance due, access is denied until arrangement for the bill to be paid is made. Is this permissible? And let's post those options there on the screen for you. Okay. Yes or no. And then we do have a couple of questions as well. This first one says, this organization was told by the Joint Commission that video monitoring cannot be done for suicidal or violent patients. Can you confirm if that is correct? Say that again. The Joint Commission told this organization that video monitoring cannot be done for suicidal or violent patients. Wow. I'm not familiar with that requirement. Yeah. Because what they're looking for is video. They have to be close by if they're going to, because it's sometimes not safe to be in the room. If you've got a video, I mean, I'm sorry, a violent patient, it's not safe to be in there. And, you know, it's just unreasonable to expect a staff member to go in and sit with them. So you can't do video. If you're going to be in restraint and seclusion, they have to have both audio and video monitoring of that person and the person, if they're not like right there. I've seen it where the staff member is sitting outside the door when the patient's in restraint and seclusion, and that's all they do. They just sit there and watch them and monitor them and make sure they don't harm themselves or get into physical trouble. So I'd be very surprised or curious to find out the circumstances behind Joint Commission's recommendation. Do they talk monitoring or are they talking taping, recording? Which, you know, that's a little different than just monitoring the patient. Because we do video monitoring and recording, like security does that for outside, et cetera. And that is okay, that you can do. Right. And then similarly here, but in the reverse format. So this question says, are patients allowed to video record staff? That is a long going question. The staff have a right to say, no, you cannot record me, you cannot take pictures. If they want to audio record, and I always think about it when you're in the doctor's office, and you're trying to just take in everything the doctor's saying, just ask, hey, you know, I'm not, I quit, I frequently forget things. And it helps if I can just record it so I can play it back and remember, ask them, why do you want to do that? You know, it could be because we're just, you know, trying to keep track of how he's doing. We can't say no, they cannot do that. It's the staff who have the right to say, you cannot photograph or video my likeness. You cannot do that. They have the right to say that. Audio recording is a little bit looser. Because if you're out in public, then yeah, they can record it. And that's where you want to check with your counsel on that. Again, your state law may be a little bit more rigid. But from some of the attorney, other attorneys I've worked with, if it is an audio, and you're talking to them, they can record it if they want. Some states, by the way, are only single consent states. My state is one of them. A lot of them are now, as opposed to two consent states, which require both the person you're recording and you to give that consent. So that's one thing you might also want to check into. Great. And the last question I see here is when we have students or vendors, should those also be listed in the patient's record? Students or vendors? Are you talking about when they're in working with the patient? I guess I need more information on that. Yeah. And this question came in anonymously. So if the person who typed that in, if you would maybe just give us a little bit more background, and then we'll make sure that we address that appropriately. I think what they're trying to do with notifying who's in the room, you know, and again, when you're in a teaching situation, and you're doing a very simple procedure, you've got 20 people in the room. No, only those who are involved in that care need to be in the room. Do they need to be listed in the patient records? Not unless they're doing something with the patient. Yeah, there was a clarification here that says yes, when they are working with the patient, such as in surgery. It would, usually that's recorded somewhere in the, um, like with the nurse. How do I want to describe it? When we were in nursing, we would observe. That's all. We never touched the patient, never did anything else. So if we weren't recorded, it's only those who are doing important tasks or something with that patient they should be. And that's usually listed on who's in the room working with the patient, like nurse so-and-so, nurse so-and-so, tech so-and-so. Those have to be listed. Observers, no, not so much. Okay. And then there's a comment here that just says in Georgia, our law allows recording in public as long as one gives consent. However, our hospital is privately owned and considered private property. Would this allow us to make our own guidelines regarding audio recording? You can try. Try your policy. Your state law is going to override that. Just be aware of it. So that's why, you know, okay, we understand you can do this. Give us the opportunity to know when you are recording us. And it's like, okay, we understand why you want to do this. Okay. I'm going to share the results here for that polling question. Okay. Yeah, I love it. Okay. Is that permissible? No. All right. Patients have a right, of course, confidentiality in the records. And that applies no matter where the record or the patient is located. So that's why we have to have policy and procedures on disclosure to the minimum necessary. So let's say you get a request, and we used to have this every once in a while from ER, where we'd get a concern for child mistreatment, and Child Protective Services would show up and they'd want the entire record. It's like, yeah, you don't need to know about their tonsillectomy when they were six. You don't need to know that. So you can redact it and make sure you don't have to give that. Just get the patient's authorization when you do have to have it, other than payment, treatment and operations. And we have to give patients access to their records. They can tell you verbally, or they can write it out, say, I want access to my record, and the way they want it, whether it's electronic or old school hard copy. We just can't frustrate those efforts to gain access. And I always keep saying access, because that's different than getting a copy of their record. They can inspect their record. They have a right to get a copy, a 30-day rule, most state laws, tighter, shorter, in other words, and there are limited exceptions. We know psychotherapy notes, they tend to be the most, but prisoners too. Prisoners are words of the state, and so the state makes that determination. They get them timely, 30 days, and again, your state law may be shorter. They get the entire record, and you have to include your discharge planning documents in those records. I want to talk CMS and OCR as it relates to medical record issues. That's the Office of Civil Rights. The conditions were amended to include patient rights access to their records. Now, OCR notes the difference between when a patient wants a copy of their records, and then you have to have an authorization for that. Now, many hospitals at that time weren't aware of the OCR rules. HIPAA, they've already had that requirement, so you're probably already doing this. It's not a big deal, but right now what's going on is CMS in particular says, you know, with our technology, in other words, our electronic records, you should have this stuff to them quicker than 30 days, and of course, we can't frustrate their efforts. So this example here where they're saying, hey, you got a balance too. We're not giving you until you pay it up. We can't do that. Whether or not they have a balance, they're not. It overlaps with the requirements of the Office of Civil Rights. There is a very lengthy memo, but, you know, essentially, we're going to be doing what we've been doing for so long. Most of your hospitals are really up to speed on this, so they know what the requirements are. So they have a right to their information when they, the patients, they can inspect their records. We can email it if your system allows it, just of course verify their identity. What we can't do is require the person to come in and request their records in person. They can mail in that consent if that's what they want to do. We can't require them to mail an authorization. They can drop it off. They can email it, whatever it is. Again, we don't want to frustrate those efforts. They can get copy. They can request copy of x-rays. You have 30 days to send it unless it's off-site. You can charge for the actual record, but you can't charge the retrieval fee because that's what your staff does. They said, no, we're not going to let you double bill it. You have to include when you deny the request, and you can deny it because, one, you don't have them. Number two, it could be because they just no longer exist because, you know, whatever the time frame was, that patient died 50 years ago. We just don't have them anymore. And, of course, we can't refuse it just because the bill is not paid. Now, I wanted to include in here, this is the 45. This is under HIPAA, and you may require them to make requests for access in writing just as long as you make sure the patient knows that requirement. This is access. You may require it. Otherwise, you can copy based upon an authorization form. And, again, all are part, and it has to include your discharge. As far as form and format, however it works for the patient. They just can't put so many requirements on you. Now, I want these four pages sent here. I want those four pages sent here. Send it to the patient and say, here's your records. If they are available in the form, great. Otherwise, give them hard copy. Form and format, just agree with the patient, whoever's making that request before you do that. Untimely, they can, if we don't get untimely, they can file a complaint with OCR. One in every 10 complaints because they didn't get their records either timely or at all. And this was the most recent one that I found from the OCR penalties for violations. You can see it spiked there back in 2022. But then OCR really started leveling fines, and we started to see a decrease. This was from August of last year. This was just United Health. 80,000 because they didn't do it. And these lawsuits continue to come on, and they're getting very serious about these fines up to 100,000 if we don't give them. Otherwise, request a copy, send it within 30 days, can charge, can request a copy of x-rays, can't refuse again because the bill is not paid. So back to access. They have a right of access within a reasonable time. So that's why you want to check out that policy. This is when I can go online to the patient portal and look at my records. That's what they're taught, access. That's why we have to train our nurses, doctors, other staff who are involved. That could be your HIM department. Have a way so that if a patient wants to look at their record while they're still inpatient, they can do that. Most of us have electronic records. Oral written requests, you can. If you want the records in writing or it's printed out, you can ask them to sign so they can get a copy of those records. OCR, same thing, a right of access. That includes inspection, email or fax, just of course, verify their identity. And we cannot require them to come in and request or mail it. The Cures Act talked about open notes. That was way back in 2021. And again, we have to give them free access to their medical records. That's through open notes. I like it. It's been very helpful. Found it personally, it's a good communication tool between myself and my providers. And it's much more efficient. You know, I don't have to wait three weeks to get an appointment. Briefly, proposed updates. Proposed updates. These have not gone through. I just checked last week and they still have not gone through any or all of them. One, they can take notes or photograph their PHI. They want to reduce providing access, again, from 30 down to 15 days. Restricting that right of persons to transfer to a third party if it's only maintained in an EHR. Confirming the identity that they are permitted to direct you to send it off to another person if they so do so. We do it anyway. When they should be provided without charge. There are certain state laws. And I'm thinking Social Security, for example. There are certain laws that you must provide a copy at no charge, but they want to update these up to HIPAA. Entities inform individuals when they can get direct copies sent to a third person. Armed Forces, that's a little different. They've had definitions for electronic health records. And they changed the wording. And I want to point this one out because I think this is very important. That when you can disclose protected health information to avert a threat to the health or safety, they want to decrease that threshold from serious and reasonably foreseeable where right now it's at serious and imminent. So they want to decrease that threshold. That if it's serious and reasonably foreseeable, you can disclose it like to law enforcement to say, you know, I'm concerned about this person. They made some comments and threats about going out and harming people at a mall. If this goes through, they can allow that. You can disclose that to law enforcement. You don't have to have that serious and imminent. Otherwise, again, take photos. I think this might be a repeat, so I apologize for that. All right. I just want to point out there a couple of websites you might want to look into, especially if this is under your compliance. The OCR privacy, and it talks about HIPAA for professionals also. Okay. Now the fun part. Restraints and seclusion. Again, 50 pages right now alone on the requirements for restraints and seclusion. Briefly, if you have a critical access within your system, I do want to bring this up. They have their own manual, no patient rights section, but if you have your critical access as a dedicated behavioral health unit, you have to follow these requirements in A. Otherwise, have a policy to address restraints and or seclusion. Some of the critical access hospitals just say it's easier just to adopt these, and then it's done. You might want to use the same, especially for reporting requirements, which we get to soon. Otherwise, patients have a right from physical or mental abuse, corporal punishment, and that includes freedom from restraint or seclusion. This means coercion, discipline, convenience, or retaliation. Only used when necessary, and then discontinued as soon as possible. The guidelines apply to all hospital patients, not just those in behavioral health. You might want to add that reference to your patient rights section. Remind staff, document, have that patient sign that they've received a copy of those rights. And you may just, if you're still doing admission packets, add that to the admission packet. Now, as far as the decision to use them, it's of course, it's driven by their assessment and their behavior, not because I'm a paranoid schizophrenic. The assessment should include also a physical, is there a medical cause that's resulting in this behavior? Staff, they have to be able to assess and monitor the patient on an ongoing basis. And again, only use when that unsafe situation continues. Leadership has a very strong role. And when I mean leadership, I'm talking C-suite and the governing body, because they're responsible for this culture that supports patient rights. They have to make sure systems and processes are developed, they're put into place and evaluated so that we're not using restraint and seclusion inappropriately. This of course, will go through your QA because we want to monitor and assess the use, that it's only used for the physical safety of the patient or staff, and that we're complying with all of those requirements. There are certain times restraints are not appropriate. It should not be used as a part of your routine fall prevention. They have found that when it does, when you're using it as a fall prevention, they get more serious injuries, or because the patient might fall, or they have a history of falling, and there's no clinical basis for the use, such as your elderly patient. Or if the family says, you know, you might want to tie down Aunt Laura, because at night she gets up and wanders. I've got the reference there that talks about the Journal of American Geriatric Society, where it talks about, you know, this doesn't really, really help. We have to document it, that it was first off the least restrictive intervention, and it was based on that individual assessment. It has to be an ongoing assessment, so we know we need to continue it. Once a day documentation, probably not enough, and certainly won't require with any requirement to discontinue as soon as possible. I do talk about weapons. CMS doesn't consider this use of weapons by staff to apply restraints. In other words, think taser. That's not appropriate. It could also be pepper spray, stun guns. If you're using, you know, security staff, that's different. Use by security staff, that's law enforcement action. That's not health care. So they could use it if they need to. It's permitted if the patient is under law enforcement arrest, and they are using law enforcement, like police, state, federal law enforcement. So that's not included under here. They are permitted. Forensic restraints are not governed by this. That could be handcuffs or shackles. It is considered not safe, appropriate, again, for hospital staff to apply them. In other words, law enforcement comes in and says, here, you can go ahead and put these on when you need them. We don't do that. That's a law enforcement move. The surveyor will look at your policy. They want to determine, first off, who can discontinue it, and when, under what circumstances has restraint seclusion discontinued. They will look at a sample of records where we did use restraints, and anybody who's currently in restraints. They want to look for staff evidence that they've identified that reason, and it was the least restrictive method. They will talk to your staff. Do they understand the policies on this application? For those currently in, when did you last go check on that patient? They want to look at accident or incident reports for any injuries to the patient. Was that during or around the time of that intervention? In other words, we were putting them on, and whoops, we dislocated the risk. Does the record show any indication of injuries, and what did you do on that investigation to make sure it doesn't happen again? Data on the time, the patterns for use, was it a particular shift? Day of the week, maybe you were short staffed. They include definitions in the manual, and that's nice, because, again, if you're looking to revisit your policy, just look at their definitions. A restraint that's anything, whether it's manual or something else that immobilizes or reduces the ability of a person to freely move their arms, legs, body, head, and, again, that's in all healthcare settings. Here's an example of what's considered a restraint, those tucking in the sheets so the patient can't move, a net bed, unless it's age appropriate, so where you have a toddler that they, well, we want to keep them safe and that they're not rolling out. Freedom splint, where it immobilizes the limb. Side rails, so they can't get up voluntarily, get up now. A jerry chair, if, again, they can't remove that restraint, get up on their own. Physical holding for forced medicine. That's just some of the examples CMS provided. Now, there is times when a drug can be considered a restraint when it's used to manage their behavior or restrict their movement, and it is not a standard treatment or dose for that condition. This is not all your psychotropics. These are the ones where you're just trying to keep them quiet because you're busy and you want them to stay quiet. There are times when it is not a restraint, when it is part of their treatment program, and you're using the standard dosages. A PRN drug, standing order is only permitted if it meets the definition of a restraint. So, for example, you've got Ativan for withdrawal. That's not a restraint. You use that as part of their treatment to control that withdrawal. Phenergan for agitation, that's a restraint, and we can't use it. Criteria, they give us the criteria for standard use. That's pharmacy parameters from the FDA and the manufacturer. And we're following national practice standards to treat that condition. And the standard treatment, really, the idea is we're trying to help them be more, be able to function better, more appropriately, more effectively with their standard treatment. Of course, we have to do a comprehensive assessment and determine the need for what type of intervention, especially when you're using that medication as a restraint. Are they detoxing or are you using it to sedate a person with sundowners? And again, not necessarily appropriate. Look at your state law. Do they prohibit administration of any medication against the patient's wishes absent a court order? In that case, state law wins because it is more restrictive. Restraints don't include certain orthopedic devices, dressings, even a helmet for a protective helmet when you have a child who has seizures. Holding a patient to do a routine exam, protecting a patient from falling out of bed, padded rails for seizure precautions. Again, all four have to be up. That's not considered a restraint. IV board, unless, of course, it's tied to the bed. If you are using a device to help position a patient during x-ray or surgery, recovering from anesthesia, putting up the side rails when you're transferring them to and from recovery or surgery to recovery, that's not a restraint. Striker beds, again, those are not considered restraints. Now, if you have mitts, unless they are tied down or they're so bulky that they can't use or bend their hand in any way, they look like boxing gloves, that's a restraint. Giving a child a shot and holding them, that's not a restraint. A stroller or swing bed safety belts, again, not a restraint. I've already talked forensic restraints. They don't fall under this. That's under law enforcement, which brings me to my next question. Lindsay. Okay, let's get this one up here on the screen. The way this one is going to work, you see the options here on the screen, one, two, or three, which of the below would be a restraint? Your options here are just going to be to select one, two, or three. You should see that now on your screen. You can check all that apply here. Again, which one of those three would be a restraint? I don't see any pending questions at this time, so if you have any, you can go ahead and be tapping those in. Give it just another couple of seconds. I see some of you putting in your responses. Okay, there we go. Go ahead and share those results. Okay, so which would it be a restraint? Very good responses. Thank you, everyone, and I'm going to go through these. First off, they will determine if your policy and procedures employ a definition, a description of what a restraint is. During their walk around, first off, they're going to see are side rails up and are they done safely? Are they used as a restraint? Is there documentation in that particular record to support its use? You know, you may have those side rails where there's three total, I mean, sorry, four total, and there's, you know, the two main ones are split. You can have them up if the patient wants it to help them get them up as long as, again, the patient can safely exit the bed. They would talk to staff, what is a restraint, and are those side rails, are those considered a restraint, and if not, why not? By the way, on those mitts, the first one was a restraint because it was a boxing glove that couldn't move or bend or anything. The second one, they could move their wrist and even fiddle with their fingers a little bit, and so that's not. The belt, the patient could remove it and was able to get out, so that would not be a restraint. Seclusion, that's where we keep them in one spot, and they are physically prevented from leaving. Only used for management of violent or self-destructive behavior that jeopardizes physical safety of others, whether it's the patient, staff, visitors, other patients. Not, just because you're on a locked unit, that's not seclusion. Being put in timeout, it's in a designated area for an agreed-upon time frame. The patient can leave, so they, as long as they are not physically prevented from leaving, it is not seclusion. So, a patient's in a bad moment, they're starting to yell, it's like, maybe you need a timeout. Just go back to your room, take a few moments, get collected, and let me know when you're ready. That's not considered seclusion. It can only be used, again, when there's less restrictive measures, and the interpretive guidelines, there are resources on what are considered least restrictive interventions, and it's not just for seclusion, it's also for restraints. Overall, the type has to be least restrictive to prevent harm, and it must be according to, and put in to their plan of care. You just can't put them on without adding that to the plan of care. Has to be put in a safe manner, an appropriate manner, according to your policies, and must never act as a barrier of interventions to meet those patient needs. Has to be by order, by a physician or a licensed practitioner who is authorized, first off, by policy and state law to order that. And licensed practitioners, your nurse practitioners, your PAs, maybe it's a clinical nurse specialist. Again, as long as both the state law at a minimum, or your hospital policy allow it. If you do have to put them on right away, you need to get that order as soon as possible. I already talked about licensed practitioner. Resident can do it, as long as the state law allows them. And again, your residency program says, not a medical student, because they're not licensed. For protocols, they didn't previously recognize protocols for administration or, excuse me, application of restraints or implementation of seclusion. Now they are no longer prohibited. They're no longer banned. You just have to have a separate order to make sure that that's in place. There must be enough guidelines in that protocol, so staff know how and when they can use. And this is those exceptional circumstances. They have to document their assessment of the person, what were they showing, and that triggered the use of that protocol. Medical staff has to be involved in this. They have to develop them, review them, monitor when they are actually utilized. Standing orders are a little different, or PRN. Apply restraints PRN. No, that is not okay. In fact, they will cite you if they see restraints and seclusion PRN. Now, if the patient does come out of them, and the behavior returns, you have to get a new order. You cannot discontinue and then restart under the same order. A trial release, that's considered PRN, so no go. Temporary release for care, okay. Yes, it's a play on words, but I understand the difference. A trial release says, okay, we're going to see how you do here. That's not okay, but I'm going to let you out so you can go to the bathroom. That's okay. There are three exceptions to that PRN. A jerry chair, if the patient has to have it to be safely up and out of bed, like eating meals. You have a side rail, where they have to be up, like for seizure precautions, so they're on an air mattress, and you don't want the thing flying off. And then finally, it's called the repetitive self-mutilating behaviors. And I just put a picture of what one of them is. If you aren't familiar with that, it's a really interesting read on the psych unit on what that is, that where you do have to do it so they don't harm themselves. We have to give notice to the attending as soon as possible, especially if they didn't order restraints and seclusion. They can delegate that to another provider if they're not in town, but they don't have to have that face-to-face consultation. They can do it by phone. You'd still have to have notice and an order eventually. The policies with your hospital determine who that is and define what is as soon as possible. There are time limits on how renewing the time limits for up to 24 hours. Four hours for adults, two nine to 17, and one for under age of nine. These are the same as joint commission, by the way. State law can be more restrictive. For violent and self-destructive, we use that. The time limits don't apply for the management of those folks, so it may stay on longer. But overall, we do want to try and end them as soon as possible. It's the maximum time limits on the length of each order. They can be shorter for that length of time. What do you need? Length of the order has to identify when there's mandatory contact from the physician. Usually what happens is nurse puts them on, they contact the physician, they evaluate the patient, contact that assessment practitioner, and say, hey, it's time to renew the order. But you can renew the original order once for up to 24 hours. The one hour face-to-face is no longer required if for renewal only. But after that original order expires, then yes, the provider has to assess the patient before doing that original order. They want to see the patient. That's what they have to do. State law can be more restrictive, document it, what you found on your reevaluation, and then renew according to any policy. End at the earliest possible time. Regardless of if there's more time left on that order, the decision to discontinue, like with application, is based upon their behavior. They're no longer a threat. Policies include who can discontinue and the circumstances when restraint and seclusion can be discontinued. Now, this is one area in the entire manual where for putting on restraints and seclusion, the person must be trained before they do it. So starting with staff and provider training, the condition of the patient, of course, we have to monitor them. Someone who's trained, whether it's the physician or trained staff, do it according to what your intervals of your policies say. I'm going to talk training here in a minute. That assessment and monitoring individualized mentions that if you're waking them up every 15 minutes or vitals every two hours, that might not be sufficient. You really have to look at this patient. Waking up a patient every two hours, maybe not okay. They're sleeping and they're resting. It's two in the morning. Let them sleep. But the policies really need to address how you're doing that. Physicians, practitioners, they have to be trained on the hospital policy the same. They have to have a working knowledge of it. And if it's for violent self-destructive behavior, they have to go in and see the patient within one hour of application or an RN with training. What are they evaluating? What's the patient? What's their immediate situation? How are they reacting to this intervention? What are their medical, maybe behavioral conditions? Maybe there's something else going on with them. Do we need to continue or terminate? If you have a trained RN to do this, they have to consult with the provider as soon as possible. Simultaneous, it's only permitted if the patient is continually monitored. Now, this is where I think that question, hopefully this will address it. Train staff using both video and audio equipment. If that's the case, they must be in close proximity to the room. Otherwise, they have to be there in the room to really keep an eye on them. Documentation of the evaluation. What is the description of the patient's behavior and the interventions you use? How are they doing with this restraint? Alternatives, you tried it, they didn't work. Their symptoms, they warrant the use of it. And this is how the patient's responding and it's still not doing well. We have to continue them. The surveyor is going to look at records. They want to see is there documentation of behaviors and that you did try to use least restrictive. We tried that time out. And point things, especially at the staff. They'll talk to staff. Tell me how you learned about this restraint and seclusion. What's the policy say? Are you familiar with what you have to assess with the patient? And then they'll look at the policy, especially the one hour face-to-face evaluation. The policy needs to spell what are the time frame and who can do it, who can order it, who can apply it, and who can review it. So again, staff training. This is the one area where CMS requires staff training before, and they have to show competency by the way. Demonstrate competency before they can even apply them. And that includes seclusion. What does that include? Monitoring, assessment, and giving care to the patient. This must be part of their orientation. And then per basis on what your policy says. How often are you going to be doing this every year, especially if it's very, you know, not used very often, or every two years. If you're on a psych unit and you're using them, yeah, pretty consistently. A hospital has to require appropriate staff to have this knowledge. How can they identify behaviors? Maybe there's something going on. Is there something environmental that triggers these individuals and train them so they can employ interventions to keep the area and the patients safe? And that maybe non-physical intervention, those de-escalation. De-escalation isn't required by CMS or Joint Commission, but most of you are probably using it now. Maybe the least restrictive intervention based on their assessment, and then safe application of all types. And then how do you respond to signs of physical or psychological stress? Is it positional asphyxiation, or have they just completely gone non-communicative? Doesn't have to be something physical. Clinical identification of those behavior changes that maybe we can take them out of restraint and seclusion. Just continue to monitor their physical and psychological well-being. Not just, you know, respiratory and circulatory, but keep an eye on their skin. If they're really mobile and they're in restraint, four-point restraints, watch their backside. They could get a good de-cube going on. And then anything special requirements according to your policy. First aid, CPR certification, those are in restraint, seclusion, or higher risk. They talk about train the trainer, qualified through education, document, and the personnel records that they have done this, both for training and a competency, a teach-back. Security guards, those who respond, they really need to have that training also. And then we have death reporting. There are two segments here, two tag numbers. The first one, those deaths associated with use of restraint or seclusion, you have certain requirements. No later than the close of business, the next business day after you find out that this person has died. Each death while they're in restraint or seclusion, unless of course it's a too soft risk restraints and it is not associated with a psychological issue. In other words, they're on a ventilator and you have them in these restraints so they don't extubate themselves by reflex. Then you put it in a log. Within 24 hours after you took them out of restraint or seclusion and death occurred, or it recurred within one week after the use of them, where it is reasonable to assume that the use contributed either directly or indirectly to that death, regardless of the type of restraint used at that time. What does reasonable to assume mean? It was related to the restriction of movement for a long period of time or chest compression that resulted or restriction of breathing or again, asphyxiation. Staff have to document in the record the date and time death was reported to CMS. And that goes to your regional office. They determine if they're going to do an onsite investigation. Otherwise, the internal log, that's when you don't have any seclusion, only too soft risk restraints. They still record the death for the patient who was in restraints and they died at the time or within 24 hours after you took them off. That goes into the record date and time of death. The entry into that log has to include great information. This is no later than seven days after death. This is just the internal log. The name, date of death, diagnosis, date of birth, attending, and the medical record number. We have to make this available to CMS and that you may need to look at your policies and train staff on it. Now, there is a death reporting form. It's an electronic form. They no longer take paper forms, by the way. They updated December of 19 and completion instructions are included. Now, don't forget, if it was a piece of equipment, the Safe Medical Device Act also requires reporting. If you're using joint commission, sentinel event reporting, it's voluntary, but you still have to do that RCA within 45 days of the event. All right. Now, as we start to wind down, we'll talk visitation. Have to have policy on visitation rights and any restrictions, whether it's clinical or sometimes just reasonable. They don't recommend restricting ICU visitors. They find that sometimes having familiar voices and faces really helps a patient recover and get out of ICU quicker. Same day patients, they may want to have somebody there during pre and post-op. Again, this is outside of any restrictions that are necessary and someone who's present during an examination. So, here's just some reasonable restrictions. If they interview with care, either of the patient or another individual, so you've got a family of 20 who are in this room and you've got two people in that room, you can restrict the number of people who are in that room. For child visitors, of course you can restrict when you have an issue of safety, child abduction. If there's a court order restricting visitors for a particular patient, maybe you have infection control issues, and then there's a whole host of others, disruptive patient, substance abuse program, and you're worried about those environmental supplements working their way back to your patient, or maybe they're just having a procedure. So, you do have reasonable restrictions, but we do have to give them notice of their rights. That policy has to include reasonable restrictions. We have to inform the patient and their representative, hey, these are the restrictions. Document that you gave it. Inform the patient that they can receive visitors, or they can change their mind, and also if you're going to refuse to honor it, you have to document why, if they are not going along. Otherwise, patients have a right to full and equal visitation privileges. You can't discriminate based upon those protected classes, gender identity, orientation, race, disability. The surveyor will ask patients, did you have any restrictions? If so, was that restriction noted in your policy and procedure? And that's why you have to educate your staff. Just make sure it's culturally competent that if you are going to restrict them. So, really quick interpreters and also how this plays into patient rights under OCR. I think this is our last general question. Lindsay, would you put that up for me? Absolutely. This says when we need an interpreter, we, and then you can check all that apply here, and I will put up those options here for you. Okay. Have a company that we utilize and can call them when needed. Use present any staff member who speaks the language. Sometimes must resort to using a family member. Use a language line or possibly not sure. And if you have any other comments, you can, of course, utilize the chat as well. And then, Laura, were you going to reference that last polling question with the three options for the restraints to just clarify which ones are? Yes. Okay. Perfect. Yes. Number one, the boxing gloves. Those are restraint. Number two, the one where you can kind of see their fingers and they can move their wrist. No, that is not a restraint. The belt around the patient. No, that is not a restraint because it's Velcro and he or she can take it off. So, those were not restraints. Two and three were not restraints. Number one was a restraint. Usually, we see those again with that leash and I am where I think I had the picture where the patient was just devastating their fingers. If you use those, the boxing gloves types, you have to document why, and that would be okay when you can because that's a safety issue. You just have to document, yes, it's a restraint and this is why we're using it. Great. That was the only question that I saw pending. So, I'll go ahead and end this poll and show those results there. Okay. So, great. Language line. That's a very popular one. Okay. So, what do we have to use? We have to make sure they're available and that they meet the needs of the patient. Qualified interpreters, not certified, qualified. We have to comply with the civil rights law. If CMS sees an issue with interpreters and we didn't do it, they can notify OCR. So, just be aware that they can refer it over to them. You want to document when you did use an interpreter. Now, Joint Commission has patient-centered communication standards. If you're a member of Joint Commission, you could look up those because they have some really good standards on them. Office of Civil Rights will also give you information on an interpreter and there is even a section for your providers. What is considered? What are your obligations in respect to interpreters? But generally, you have to offer timely, qualified interpreter when you have oral interpretation as a reasonable step to help this patient. Now, just because this patient does speak some English doesn't mean they shouldn't have an interpreter. Healthcare is very specialized and that's why you need to really consider. I know you may not want it, but it's in your best interest to have an interpreter. Free of charge. We can't require that they bring their own and please don't rely upon a child with very few exceptions like when they're in the ER and they come in with mom or dad or whoever it is and all they can give is just basic information. And no low-quality video remote interpreting. A lot of the remote services, they're pretty good now. They've really hammered out a lot of those details and they're very synchronous. There's no delay and very clear. So a lot of them have quite improved. You want to post a sign in several languages that these services are available at no charge. Most states have 15, five total. D.C. and four states have 17 languages. Thank you, Colorado, you happen to be one of them. Include yearly skills lab so they know what they have to do. Review your policy so you're hitting all the buttons on it. If you have physician-owned practices, your hospital owns them, again, interpreters, make sure they're present during those appointments. There is a way to find the top 15 in your state. I've got the link there. When you get to the link, go to where it says appendix A. You don't have to use this list. If you have your own and it's reasonable to rely on that list, but this is what it happens to look for. Like when you pull it up, it goes by state and your top 15 in those states. Usually with those who have 17, it will have 15 through 17, and then there's a couple that are listed on that last line. You can require certification. That's up to you. There is an associate healthcare interpreter, two of them. Entry level is core. CHI, that's certified, that is the best. They have quite a few. Then there's, of course, the National Board of Certification for Medical Interpreters. Those are pretty good, but you can use others. OCR added a section also including on discrimination. Before I do that, I just want to go back and clarify. If you are using your hospital staff, think about who that staff is. When you are talking nurses, doctors, medically trained people, that's great, especially if they are very fluent in it. We used to use our ER nurses for some of it on the floor because they were so fluent in the language. It's their second language. Housekeeping, probably not the best idea. Use someone who has a basic knowledge of medical care so they can translate it appropriately, but yes, you can use your own hospital staff as long as you feel they are qualified. There is information on what makes them qualified that you know they're doing. What the patient is saying is being interpreted to the physician correctly and then backwards because some languages have certain dialects and it may not translate appropriately. So otherwise, as far as OCR, add a section regarding prohibiting that certain discrimination like sex discrimination. We can't delay or segregate based upon those protected classes. We can't deny or delay language assistance to patients. We have to get it as soon as possible. Taglines, they notify patients that they get this service free of charge. You want to put this up in prominent locations like in the ER or the lobby. As far as gender identity, treat them consistent with their identity. So facilities, bathrooms, and rooms. This is in recent area where they're really starting to get some litigation on it. OCR has that website for you on protecting their rights. So that brings me to my last discussion. I'll go ahead and read through this and I'll have Lindsay put it up. We have a 73-year-old, past medical history of high blood pressure, history of smoking in the past, daily alcohol abuse. He's scheduled for a colon resection. He's got grade two adenocarcinoma. Immediately post-op, pretty unremarkable. So on day four, he starts getting withdrawal symptoms. They put him in two soft wrist restraints. Ativan's ordered on a BID basis to help with the withdrawal. PO day six, they take him off the wrist restraints, they reduce the Ativan, and he's sent to a swing vet until arrangements so home health could be completed, and he is ambulatory. He's up and around. So now this is post-op day nine, swing vet day three. He's found unresponsive in the bathroom. He used his robe as a ligature. He's unable to be resuscitated. He is pronounced deceased. So here's the question. Is this a restraint-related death that we have to report to CMS? If no, where do they report it? If you get a survey, where should they expect citations, possible citations could exist, and any other advice for our hospital? And if you want me to back up, have them put it in the chat box for me, Lindsay, and I'll back up the slide. So I'll be curious to see how you folks feel about this particular patient. Yeah, I didn't put this in as a polling question, so I figured if you all just want to type your comments here in the chat as a response to these, then that would be great. And if you have any other final questions as we're starting to wrap up, you can go ahead and type in those questions into the Q&A option or the chat as well. Now there's about 16 pages of resources for you. I did want to put here the discharge appeal notices. That's the IM notice. They have detailed notice, what is necessary for when they are being discharged. That happens to be the revision. That's the new memo that just came out. Yeah, it was April 1 of this year, where they're going to be putting into the surgical component in absence of informed consent. So I won't make everybody dizzy by flipping through those, but there's just some additional resources if you're interested in using them. Perfect. I think we have one response here saying, yes, that this is a restraint-related death to report to CMS. Because, yeah, he was there. It was related to his condition. It wasn't intubated or anything, but we had to keep him safe so that he wouldn't harm himself. Actually, they were on longer than I expected. They were on for six days, which kind of found interesting. And another response here saying, no, yes, and yes. This hospital chose to, yeah, I'm sorry, go ahead. No, I was saying, so I guess that would be no to reporting to CMS and then yes, the citations could be issued. Yeah. Okay. They chose to treat it as a reportable death only because he was put in there going through withdrawal, and they were worried that he would harm himself. Yes, it was a two-restraint cloth, but they chose to report this just to be on the safe side. As far as any survey, they said, why in the world did he have a bathrobe tie? So what they did come out and visit, they felt that was unreasonable, that perhaps given his past history of alcohol abuse, that he should have, you know, somebody, they should have maybe kept a close eye on him so that he didn't harm himself with that withdrawal. But that's how they chose to do it. Otherwise, they did okay. They recognized, yeah, that was a mistake. They did update the policies. They were not cited. They actually were not cited on it because they took steps immediately to fix this, and it was resolved right away. Well, thank you, everyone. Thank you, Lindsay. If you have additional questions, get them to Lindsay. She's great about getting them to me, and I'll respond back to Lindsay with anything further. So I'll turn it back to you to close us out, Lindsay. Perfect. Thank you so much, Laura. I did just post some last comments there for you all in the chat. This is a quick reminder that you will receive an email tomorrow morning. Just note that it does come from educationnoreplyatzoom.us, and so because it will come from that Zoom email, it may get called in your spam quarantine junk folders. So if you don't see it in your inbox in the morning, go ahead and check those additional folders, and then if it's still not there and you'd like to access the recording, we do record these as on demand, meaning that you can use the same Zoom link to access both the recording and the live session, and then just remember that the link to the recording is available for 60 days, and we do have an additional security measure in place to protect Laura's intellectual property here, and so you will need to click on that Zoom link and then type in your information. That will prompt an email to come to us for approval, and then we approve those requests very quickly, typically within a few moments of receiving the request, but we ask that you give us one business day, and then once we have approved your recording access request, you will receive a follow-up response from Zoom just confirming that your request has been approved, and you will receive the final link to access the recording, and then again you will have full access to the recording for 60 days from today's date, and then also included in that email tomorrow morning will be a link to the slides that were presented today, but I did go ahead and provide the link to the slides there for you in the chat to have as a resource now as well, and then if you're joining us as a member of the Georgia Hospital Association, also pay special attention to the survey link that will be included in that email tomorrow. That is how you will obtain any continuing education credit as well, and then as Laura mentioned, if you have any follow-up questions, you can always reach us at education at gha.org. We'll be happy to get those questions over to Laura, and she is wonderful about being timely and very thorough in her responses, and we just so appreciate her for doing so, and we thank you so much for joining us all today, and thank you as always to Laura for your time and the information that you shared with us. We look forward to having you all back with us in the future. Hope you have a wonderful afternoon. Thank you so much, Laura. Thank you, everyone. Thanks, Lindsay. Bye-bye. Bye-bye.

patient rights

privacy

safety

informed consent

advanced directives

ligature risks

confidentiality

dignified care

compliance

quality healthcare

staff training

medical records management

visitation policies

interpreters

self-harm