I'd like to introduce our speaker to get us started this morning. Ms. Laura Dixon most recently served as a Director of Risk Management and Patient Safety for the Colorado region of Kaiser Permanente. Prior to joining Kaiser, she served as a Director of Facility, Patient Safety, and Risk Management and Operations for COSAC 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, preoperative services, and pain management. Prior to joining COPIC, she served as a Director of Western Region, Patient Safety, and Risk Management for the Doctors' Company in Napa, California. In this capacity, she provided patient safety and risk management consultation to the physicians and staff for the Western United States. Ms. Dixon is a registered nurse and attorney. Laura holds a Bachelor of Science from Regis University, a Doctor of Juvenile from Drake University College of Law, and a registered nurse diploma from St. Luke's School of Professional Nursing. And she is licensed to practice law in Colorado and in California. We thank you for being here with us today. Laura, we invite you to go ahead and get us started this morning. Okay. Thank you. We're talking today about a subject that really can cause some, I don't want to say headaches, but some consternation for some of the hospital. And that's patient rights. Patient rights section is the largest section within the conditions of participation. And that's acute. That's Appendix A for the conditions of participation. CMS has multiple ones where they're very concerned with patients, that we are treating them fairly, treating them correctly, in addition to providing good care. And so that's why they've really expanded that section within the manual. I have on slide number two, email addresses for CMS. You can reach out to them directly and ask a question, especially if it maybe pertains to your facility, like what would you, would we be in compliance with this situation? And so you might want to reach out to them in addition to Georgia Hospital Association, because then you'll get it right from that source on would we be in compliance with this if we do that. I always include my disclaimer where the information I'm providing today is that it's informational only. It is not meant to serve as providing legal advice nor establishing an attorney-client relationship. Please consult with your own in-house counsel or legal representative on advice, because there may be a specific state law that is in addition to what the conditions of participation are as a federal level. So as a quick introduction, the reason we're here today is so you don't get one of these, where you have that statement of deficiency after they've come through and done their survey, where you have to develop that plan of correction. And no facility, no provider wants to have noticed that they have been involuntarily terminated from the Medicare and Medicaid agreement. And that can be for a host of reasons, whether it's noncompliance with various areas, or that there has been no plan of correction, or the plan of correction was inadequate, or you just simply didn't allow them access into your facility, because that could lead to an involuntary termination. How does this all work? The regulations start in the Federal Register, and then CMS has the responsibility to, first off, of course, they have to publish it, send it out, hey, here, this is the new regulation. But they also have to develop interpretive guidelines and survey procedures. What is the rationale behind that regulation, and what are they going to look at? Who are they going to talk to during their survey? And then, of course, update the manual. Three types of survey, certification, validation, if they're coming back to see how you did, or if you happen to have deemed status, they may come along and do a validation survey, and then a complaint, where nobody wants to really get one of those. So this is where we're looking at, the State Operations Manual for Appendix A. It was last updated in 24. Hopefully they will start doing some of the updates, some of the items they have still out there have not been updated, and one of those we'll talk about happens to be with release of reproductive health information. And I have the arrow pointed to transmittals for Appendix A. That's where the new manual, if you want to go find those quickly, you click on that blue lettering to take you to it and list out what has been changed. Now, I want to talk about, briefly, critical access hospitals. You do not have, in your manual, a similar section within your manual. Now, you still have to do something to protect those rights, but you just don't have that. And so that's why I'm hoping criticals are listening to this, so that you'll have an idea about what is just minimally expected from a hospital, whether in acute or critical access. I mentioned the deficiency reports. There are some very specific, often cited deficiencies in this area. For example, one, they didn't make sure complaints and grievances were appropriately identified. They didn't provide that agency phone number for a patient, so they can lodge a grievance. They didn't give each patient or their representative information on how they do that with the state. They didn't follow their own policy. And then there wasn't prompt resolution of a patient's grievance. And by the way, CMS won't pinpoint a direct time to respond. They say seven days. That's a pretty good time to respond to that grievance. Now, whether it takes longer, that could be determined on a couple factors. But at least seven days, follow up with that patient and or their representative and let them know what happened. They didn't make sure there was a prompt resolution, especially when it happened to involve abuse by a staff. There was wrong information given on how to file that complaint. The governing body, they didn't make sure that there was effective oversight of the process and a grievance process. They didn't make sure staff were in staff settings on falls, code blues, rapid response. They didn't make sure that the staff were, you know, do we know what our processes are here? A safe environment where a confused patient ended up falling and having some significant injuries. Ligature-free environment in a behavioral health unit. Now, we're talking about all of these areas as we go through. They didn't make sure that a physically restrained patient happened to be restrained when there was criminal assault on a staff member. Also that they didn't provide supervision to prevent elopement. And then a person who was on a 72-hour hold, they were allowed to elope and they were found dead two weeks later near the hospital in a hospital gown. They didn't follow processes to follow up on that patient to do a search to try and locate them. So these are just some of the common deficiencies that keep cropping up when you look at those. All right. Let's go ahead and start in these. Now, what you see in your, what you might have been provided, I'm just going to say this right at the beginning. I updated these slides because what I wanted to add was the A letter, that's your appendix, and then the four-digit number. And so as you go through here, you'll see them in the upper right-hand corner where it says A, zero, whatever the three numbers are. Those are the tag numbers that we're talking about. And so just understand that that will be different than what you see on your slides. Otherwise, the information is the same. There's no change. So basically, you have to provide notice that we're going to have minimum protections and also rights for these patients. Again, these are minimum. Your state may have more advanced ones. This applies to any hospital that participates in Medicare and Medicaid. The rules themselves don't apply to a critical access hospital, but you have to do something to make sure those patient rights are still protected. And this doesn't matter what location within your hospital, inpatient, outpatient, maybe you have a provider-based entity that's under your CCM. That applies to them too. So just be aware, if you participate, these apply to you. We have to ensure that the requirements for notice are met, and this is to the patients and or their representative. And I say and or representative because not every patient may have a representative. We have to do this before we provide or we discontinue care, and we have to do it in a way they can understand it, whether it's limited English proficiency or low health literacy. In short, we have to put it in wording that someone who has a sixth grade education can understand. And rights to be in the notice, multiple rights, confidentiality and privacy. And privacy, what they're talking about here is in your daily care, that we're closing the curtain, that we're making sure that as an individual, I have some privacy when I'm in that room. Access to records, unnecessary restraints and or seclusion, care in a safe setting, freedom from abuse and harassment, and the right to determine who gets to come visit me. And equal treatment. In other words, if I don't speak English or it's not my primary language, I can get an interpreter at no charge. Other ones, mentioned those right at the beginning, grievances and complaints seem to be really hit hard in these last couple years. How did we address them? How did we resolve them? Also that we're sending notice to what's called the beneficiary and family patient care setting. Every state has one. The quality improvement organization. And so that this is who you can contact also if you have a complaint. Participate in decisions of care. Refuse treatment. And to give consent for treatment. Advanced directives, if I have them, then they should be abided by. And notice of admission. You also want to have policies to make sure patients have information on those rights. And again, inpatients and outpatients. So maybe you want to put this on your general admission form, your notice of privacy practice, however you want to do it so we can get them notice of those rights. You might want to add, this is not required, by the way, you might want to add a notice or somewhere that the patient can initial, I have received a copy of these rights. So if you can get them to initial it, or at least a representative, when you hand it to them, you've done your duty. And your compliance has been accomplished. What we do have to do is take reasonable steps also to determine if that person has a representative. You can ask them on admission. That's easy. Admission clerk can do that. If the person's not incapacitated, in other words, they're alert, oriented, take care of their own business, and they still have a representative, well, we still have to provide that person with those notice of rights. Along with the patient. Of course, the patient can tell you orally, or they can do it in writing. We know writing is always best, but it's not required. However, if they are incapacitated, well, then that's the person who maybe presents with a durable power of attorney or advanced directive. It doesn't have to be. But if you have that person, that's great. If you don't have that luxury of an advanced directive, then whoever shows up and says, I'm their representative, that could be a spouse or a best partner. Of course, with a minor, it's usually the parent or their guardian. It could be another family member. What you can't do is you cannot ask for supporting documentation unless you've got two or more who show up and say, I'm the representative, and then you can ask for that documentation. By the way, if you refuse to recognize someone as the representative, document in the record and why. And you may want to check your state laws for information on how you do that. But you do have to, at a minimum, adopt your policy and procedures on that. Say you have a minor and you're very concerned about mistreatment of that minor. And you're wondering, hmm, this doesn't look right. Or you have parents that are going through a divorce or are divorced and there's an issue of custody. In those cases, you can. Or maybe you have an elder person and you're concerned about elder abuse. And the person who says, no, I'm their representative. And you're concerned that maybe they are the actual perpetrator. Then you don't have to recognize them. But you want to be on good, firm ground when you do do that. So that's why, if you have that option, check with your in-house counsel or your risk manager, unless you're the risk manager. Find out how you want to handle that. I just want to talk briefly about, it's called the IAM notice. All that stands for is important information. That's all it is. You have to give this to your Medicare patients. And that's within two days of admission or at least before discharge, if they're more than two days. And certain observation patients that you want to tell them, hey, this is the information from Medicare about your rights. But you do have to give that to them. The surveyor under this particular tag number, first up, they're going to look at your policy. Does that have in there how you notify all patients of their rights? How do you determine if this person has a representative? They're also going to look at medical records. And they're going to talk to your staff. And the records, they're going to want to see, is it in there that, yes, indeed, you have given them notice, here's your patient rights. They will also look at a sample of your Medicare patients' records for that IAM notice. They want to make sure that's in there. Talking to the staff, how do they inform patients of their rights? How do you determine if that patient has a representative? By the way, they may interview that representative. They may want to talk to them. And then they're just going to walk around. Some of the hospitals will post their notice of rights up in the hallway also. So you don't have to, but that's one way that you can give them notice of their rights. And they will look at those rights to make sure that they include what that notice, like to the QIO, to the BFCC, to the state, how do you notify them? How are grievances and complaints going to be handled within our hospital? So let's go ahead and start talking about grievances. You do have to have a way for prompt resolution of a grievance and show and inform each patient to whom do they file a grievance. Because the reason is patients have that expectation of care and services. And how are you going to address those expectations in a timely, reasonable, and consistent manner? So what is the definition of a grievance? By the way, you may want to add this language to your policy so you don't have to try and figure it out. It's a formal or informal written or verbal complaint made to the hospital by that person, whether it's a patient or their representative. And it's about their care. It can be about an abuse, about neglect. And this is when it cannot be resolved at the time by those people who are present, in other words, your staff. And it really is revolving around these conditions of participation. It also may involve billing, complaint related to those rights. So again, if it can't be resolved by, say, the nurse or the assistant, whoever's in there, your CNA, at that time, then it's considered a grievance. If by the way, if you happen to be joint commissioned, they call them complaints, but CMS refers to them as grievance. So let's say it's very minor. You don't have to do anything else. You have a way that your staff has the authority and the ability to deal with those minor requests rather than having to make the patient write out a written request, like change the bedding. Could you maybe exchange the food that I'm getting? Okay. Maybe not those mandatory dietary restrictions, but could I have more vegetables? Maybe I'm vegetarian. Those are things your staff can handle right at that time. You don't have to do a written response at that time. But if it is of such a substance that it cannot be resolved at the time, maybe it needs further action, maybe some investigation, then yes, it's a grievance. And all of the CMS requirements, if that's the case, have to be met. It is considered resolved when the patient's satisfied with those actions taken. It's generally a written complaint, can be outpatient, can be inpatient, can be emailed, can be faxed, can be actually mailed in to you. Can also be telephoned in after they're discharged. Now the exception, if you get something after the fact, and this is something that why didn't you tell us your room was cold? We could have taken care of it and our staff could have addressed it at that time. Then it's not. But be very careful with that. You want to make sure that you're not following up on what would be considered a valid grievance because, well, maybe we could have taken care of that, I wish you would have told us, where indeed, maybe it may not have been. So be very careful with that one. I'm just going to repeat it just for clarity. If after the hospital, the patient sends in a notice saying, you know, for the entire time I was there, this happened, and you look at it and you think, no, we could have changed those sheets. We could have warmed up the room. At that time, it's not a grievance, but be very careful with those. That's a very fine line of distinction. But we know if it involves abuse, neglect, any kind of harm, it's a complaint, it's a grievance, and it has to be addressed. What's not a grievance? Maybe the patient's great with what happened, but the family member's not. A billing issue, unless, of course, it resolves around the quality of care. What if you get a patient's satisfaction back, and the patient is unhappy about something? It's not a grievance unless the patient says, I want this addressed. This was terrible. I didn't like it. I need it addressed. Or if that's just your routine. You get anything coming back from those satisfaction surveys, and you have to take care of it. Now what if it's an anonymous? You can't resolve that if you don't know where it came from. But normally you will have an idea where those surveys are coming back from. But again, if it's anonymous, or if the patient's satisfied and doesn't want it handled as a complaint, then you don't have to. But follow your policy. You may decide, no matter what, we're going to address this and take care of it. So I mentioned that if the patient's cool with everything, it's not a grievance. Well, let's say someone else complains. First thing you want to do is, of course, contact the patient and ask, are they OK? Can we talk with them? Are they authorized representatives? It just may be someone coming out of the woodwork that has no bearing or no basis to act or act on the patient's behalf. Always get their permission to talk to them because that's more likely going to involve PHI. Document that you've got their permission to talk with the person and you may go to the extent of getting a HIPAA compliant form. That's totally your decision if you want to go to that extent. But if that person does not have the standing of a dental representative, the patient says, there's such a pain in my neck, just ignore them. You don't have to do anything. You don't have to, but you may decide to do so. That's up to your governing body and your policy. Again, the surveyors want to see your policy. They want to make sure it does also encourage staff to be aware of those grievances and report them up the chain of command. They may talk to patients and representatives who are inpatient at that time. Have you been told how to file a complaint or who to contact? And do you know that your quality improvement organization for your state can also help you with this? You want to make sure they will make sure your processes make sure grievances that put patients in immediate danger go to the top of the list. Those are the ones you want to handle right away. You don't want to put those on the back burner and wait five, seven days to handle them. On your process, you have to have something for prompt resolution. And that includes a way that you're informing patients who to contact within your hospital to file agreements. The governing body has to approve it because, again, they're responsible for the operation of the hospital. That includes the operation of this process. They have to review and resolve grievances unless they have delegated that in writing to a committee. So the board doesn't have to do that, but there must be documentation. They have done that to the committee. The committee has to be more than one person. There has to be enough qualified members that can review and resolve these. You may want medicine, nursing, pharmacy. You may want even housekeeping and dietary involved in this, depending on what are the issues that are coming up. And have a way that they're reviewed and analyzed through your QAPI. That's your quality assurance performance improvement processes. There has to be timely referrals that can go to the appropriate QIO. Each state has one. These are contractors with CMS, and they have the responsibility to look not only at the quality of care, but they also look at EMTALA issues and complaints. They will look at care issues and complaints by Medicare and Medicaid beneficiaries. So again, all states have them. They will show you here the areas and who happens to be involved. And Area 3 Georgia is also under Area 3, and that is Kepro. And that's also, by the way, for my state. Here's just some of the areas where you can have that information. This was the last one that I could find on the toll-free numbers and where they happen to be located. So as far, again, on what these QIOs do, they look at all complaints from the Medicare and Medicaid beneficiaries, quality care, EMTALA, because what they're trying to do is make sure there is a consistent review and a process. And they also take into account what's going on in your community. What is important in those localities for their beneficiaries. So again, some coordination, some mechanism for utilization review notice, referral to the QIOs. Now you're not mandated to automatically refer each grievance, but you have to tell the beneficiaries you have a right to have this reviewed outside of our hospital by this QIO. And if that's what the patient requests, then you have to send it on for that QIO review. There is also that updated notice of discharge. I've got the link in the appendix on what that looks like. You give that to all of your Medicare patients who are admitted. So they know they have special discharge appeal rights. Like if they feel they're being discharged home too soon, this is just an extra layer for them to get some protection if need be. So on your procedure, it has to be a clear procedure so that the patient can submit it, whether it's verbal or written. And the surveyor wants to see that information. Is it clearly telling the patient how to do that? In other words, in wording they can understand. They will talk to patients and maybe their representatives also. Did you get information on how to do that? On the time frames, again, the process has to spell that out. First off, for review of the grievance and then how soon you're going to get that response back to the patient. That means you have to review, investigate, and resolve each and every grievance within a time frame. Those of you who do this, you may get these grievances that spell out anywhere from one to multiple, five or six of them. You have to respond to each one of those and the substance of each grievance. That means you investigate and maybe do a deep dive and to find out what's going on. Is it a systematic problem that we're having or is it just something that's a one-off? Seven days. You know, CMS does consider seven days to be appropriate. What they don't say is it business or calendar days. You get to decide that. Maybe you want to go shorter or longer, depending on what staffing you have, but just make sure your policy spells that out. Document also if it is so involved that it's going to take longer. Maybe people are on vacation. Maybe they're out because of illness. CMS understands that. They do recognize that, and that could affect those time frames. But they do want to see, the surveyor wants to look at those time frames that your policy has established. We have to give patients also written notice of what came out of this decision. What do we find in our review? It could just be, and we looked at your agreements, we talked to those folks who were involved, and we found that the care that was provided was appropriate, and therefore, we are going to close your file. But you also have to give them additional information. That means the name of the contact person at your hospital, what you did to investigate it, the results, and data completion. It has to be, again, in a manner and a language they understand, so you may need to have these things translated into their primary language. These are minimum standards, by the way. You can use other tools to maybe resolve it. Have a sit-down meeting with the patient and or their family to resolve this issue. What's going on? Tell us why we didn't meet your expectations. The written response has to include all of the segments and the elements in that section. You don't have to have anything that might come back to bite you in a legal action, like, I'm sorry we didn't meet the standard of care. That's a legal statement. You want to avoid it. Maybe we didn't meet your expectations, okay? But have enough information so that we know you met the requirements. You don't have to go into great detail on what you found or what you did to resolve the actions. It's just, you know, we looked at your complaint, we reviewed your medical record, we talked to your providers, and we feel that we had met the expectations for your care. Here is who you contact if you have additional questions or want to take this further. By the way, if they emailed the complaint, you can email back if your communications policy allows that. You may prohibit communications by email with a patient. Keep copies of what you've done on this grievance and your complaint. And again, it's considered resolved when the patient's good with the action, or if you've done enough to meet those reasonable actions. Now, the patient may not be happy with it, and that's okay, because they can go further if they want. I want this to go to the board of directors, and I want a response from the board of directors, okay? Or it's like, I want this sent off to the state. That's fine. Then you do that. You send it on to the state. But as long as you've taken those reasonable steps, then it's considered closed on your part of it. This is section 1557. This is not in the conditions, but I did want to bring it up because this is the Office of Civil Rights. The person has 180 days from the date they became aware of a certain action that occurred under your care in order to file a complaint. So let's say they felt they were being discriminated based upon a religious status. They have 180 days, or six months, to file a complaint with the Office of Civil Rights due to that action, and it must be in writing. They can't call it, and they have to do it in writing. Then the coordinator, whoever's at your hospital to handle these things, have to investigate that grievance, and they have to then issue that written decision. So just be aware that this may also happen. On the OCR, that's the Office of Civil Rights again, and I have an example on the next slide of what this policy looks like. You have to keep records and files of what you investigated, and your coordinator has to investigate the complaint. Those who are involved in this care, anyone who has an interest, you know, is involved in this issue, has to be given the chance to give evidence in response to that grievance. And of course, we have to advise the patient of their right to go further, maybe file a lawsuit if that's their choice. And again, here is a sample. This is from the Office of Civil Rights. I have the link here if you want to go look that up on how to, again, just a sample from the Office of Civil Rights. I've got to hand it to them. They're trying to help you out in this respect on giving you a sample policy. Now I'm going to cover three areas, exercise of rights, informed consent or consent, and advanced directives. So on the exercise of rights, patients have a right to participate in their care. Hopefully they are. You know, in other words, what's the plan of care? What are you going to do? And how are you going to get me back to my level of care? But it's also outpatients. You can include, let's say you have an observation unit, include them in that development. Or maybe you have an infusion outpatient infusion service that you're providing. This also includes not only plan of care while they're there, but discharge planning and pain management. You have to actively include the patient in this, in the development, putting into place any revisions to their plan. The patient rep, they have a right to participate in the same development and implementation. And you really want to have them involved, especially in discharge planning, because they may be actually where that patient's going or responsible to make sure the patient gets to those appointments or that things, you know, they get their medication filled. Take steps to determine who that is on that representative. And this is a repeat. They put it in a couple sections. I guess they want to get their point across. But if the patient's not incapacitated and has that representative, include both of them. If they are incapacitated and someone shows up on that advanced directive, that person's involved. If they're incapacitated and no advanced directive, naming them, same thing. Whoever shows up and claims to be the representative, and you can't ask for documentation unless two or more show up and claim to be such. Lindsey mentioned we have a couple questions. And so let's go ahead and get started. Lindsey. Okay, let's get this one up here on your screen. Okay, hopefully y'all can all see this questionnaire that says that patient Z admitted via EMS 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, prior admission records show two sons in the area. Both are contacted and both arrive and state that they have DPOA. What should the hospital do in this scenario? Accept the first one who arrives, accept the older of the two, accept neither until one produces documented proof, seek a court order, or possibly another suggestion here. We'll give you a couple of seconds here to put in your responses. And if you have another suggestion, you can type that into the chat. And for those of you who missed the initial introduction this morning, and I had a couple of technical difficulties, but if you do have any questions for Laura throughout the presentation today, you can type those questions into the Q&A option found there at the bottom of your Zoom window. So you should see that little box that says Q&A. You can click on that and just type in your questions as you think of them throughout the presentation. And we'll use this time during the polling questions to address those questions as well. Okay, we've gotten some good responses here. I'll go ahead and share those results. Okay. I think that's your best approach. Now, some of this may also depend on what's the criticality of this patient's status too. You may not have the option of waiting until the other one shows up, and you would act in good faith in that situation. That's the best you can do. So yeah, if you have the luxury of time, yeah, you definitely want to have, you know, you stated you have DPOA, great. Go get me proof that this is what you have. Usually that's a quick document that the patient can write. Otherwise, you know, you may need to go out and get a court order saying, okay, especially if there's a conflict between the two sons on what's to be done for the patient. We, of course, want to act in the patient's best interest until we can get that information, because one may say, hey, pull the plug. The other may say, do everything. So when you have two or more, if you're going to say, no, we're not going to accept anybody, document it. Follow any specific state laws that you may have, and that's why you have to teach your staff what do they have to do, what is expected of them, and your policy needs to help them so that it's an expeditious, non-discriminatory resolution on who is actually the responsibility. One other thing you might want to do, I mentioned that patients have a right to participate in care, but what if they say, don't want to do it? Document when they're not participating, and include if you have an incompetent patient, if it's a minor, also when they have a legal representative, make sure that that's documented. This also talks about pain management and discharge planning. They have a right to choose where they end up going at discharge planning, and again, participation in pain management in their care, and they can say, no, just document it. Otherwise, they have a right to make informed decisions, be informed of their diagnosis, right to sign out AMA if they so choose to do so. Now, this does imply that both the patient and representative have been given information to make those informed decisions. In other words, you know, I've waited here long enough, I'm going to leave. We just have to give them information. If you leave, this is what could happen. It's totally your choice if you so to do so. The patient, this is what I also found interesting, patients can also delegate others to make these decisions for them. If state law does allow that, and who is going to be that individual, that could be a person who is just so overwhelmed, maybe has acute depression, even though they're still considered competent, and they say, I can't make these decisions, I'm going to give that to someone else. It could also be a cultural issue. So document if that's the case, that the patient has made that conscious, informed decision for someone else to make those decisions. Otherwise, we definitely want to take steps to find out who is that person, who is the designation, the designee of the representative. We have to get written consent for the patients who are not incapacitated, and the representative, and this stays throughout the hospital. These are the same provisions, if it's incapacitated patient, no events directed, the representative steps into the shoes of that patient. Informed decisions, we give them information, so they know what's going to happen, what are the risks for that surgery or that treatment. Also informed of their health status, informed on discharge planning, maybe they have to go somewhere else besides home, and what's going to happen when that does occur. You can write to request or refuse treatment, now this doesn't mean that they can request and they will receive inappropriate or unnecessary care. That's just, that's above and beyond what that informed decision and informed rights includes. That's why you have to make sure your policy and procedures, make sure this is completed. Now there was a recent memo on informed consent, and it talks about your training situations. And it talks about those exams that occurred outside of medically required procedures. And some of you may have heard about this, where the patient was a nurse, and she was having some abdominal surgery in a teaching hospital. And she told them, I don't want any med students involved doing anything other than this surgery. And she wakes up and the resident said, you're having your period. And the only way they would have known that is if they had done a pelvic exam. And so that's why this new memo came out in the new requirements. Otherwise, we have two disclosures that you must put in writing. One, is this a physician-owned hospital. And two, if a physician is not available or ED physician is not available 24 hours a day on site to help with emergencies. So you may want to put that up in your ED. And also make sure that's part of your patient rights or notices that you're giving them that it is signed. That's if these two are occurring. Give them at the beginning of your stay. And also if physicians refer patients to the hospital where they have that ownership interest. And that this is a requirement for privileges. So I'm coming into ED. My physician happens to be a part owner of this hospital. You have to put that in writing. Your physician is a part owner of this hospital. And we require that this as a condition for them to have privileges. In other words, this notice has to be given to you for them to come and take care of you here. Again, that's if these two events occur. Advanced directive, they can make and have them followed. That's when they're incapacitated. We provide care consistent with those directives. Policies have to include delegation of rights to the representative when that patient's incompetent and the person can designate a support person to make decisions on visitation. That they can do, they don't, if they can't or they're just too tired and don't want that happening, then the support person can do that. Your policies, you have to provide written notice on them on implementation of advanced directive. Are there any limitations like conscious objections? Clarify when that objection is facility-wide or if it's the providers or the staff, where does that delineation, if any, lie? We can't refuse to honor that DPOA or support person or patient representative. We can't refuse to honor that designation. We may not like them, but we can't refuse to honor it. How soon do we give this at admission? Maybe outpatients also. Like emergency department, that's outpatient. Observation, same-day surgery. And document whether or not they have an advanced directive. You can put this on your registration form. Do you have advanced directives? If so, could you provide us with a copy of them so that we're prepared? Overall, you can't condition treatment on whether or not they have advanced directives. Again, it's not a way that they can get inappropriate or unnecessary care. Make sure that you're in compliance with state law and inform when they can file a complaint. If they do have one, they had an advanced directive, it wasn't followed, it wasn't honored. How do they do that? Have education to your staff on your advanced directives policy and procedures. And either way, this is in the requirements. You have to provide community education on advanced directive. What your hospital does, put it in your website if you want to, if that's an option for you. You can put it along with your notice of patient rights if that's what you wanna do, but you have to do that. We have to provide community education. There is something called a psychiatric advanced directive. It's very similar to your normal or your traditional one. And that's for those who are really concerned about involuntary commitment or involuntary treatment. And really covers quite a bit, medications and therapies. Who do you notify if they're admitted? Hospitalizations. Now, there may be times you have to do this for patient safety, but it's just the same thing. Patients admitted for a psychiatric event, if they have that advanced directive, we have to look at it and honor it to the extent that the patient is being taken care of under psychiatric care. The next area we have to do is called notification of admission. And this is where patients have that right to have their loved ones, their family members, whoever, notified of their admission promptly, but also their own physician. It's the same provisions, even if there's more than one person who claims to be their representative. Yes, you have to notify everybody that I'm admitted. If they're incapacitated, get someone as soon as you can to find out this person's been admitted. Can you come in and help us with notifying who this patient is? So that's the other thing we have to do is let the physician know I've been admitted and then some family members. Now, you may have that patient who said, don't tell anybody. You don't. You don't tell anybody. If like a family member, don't tell them I'm here. Now, here's one area that is very involved and it's very encompassing. Privacy, safety, ligature risk, and confidentiality. So just basic with privacy and safety. This is personal privacy. In other words, shutting the curtain while you're doing an exam. We have a right to respect, dignity, and of course, comfort. Personal privacy, those while we're giving them a bath or helping them with hygiene. Those who are not involved in care should not be present during an exam or treatment unless you get consent from the patient, otherwise limited. Privacy, when the physician and staff are discussing care issues to the extent you can. So if you have a semi-private room and that other patient can't leave, you do the best you can. They also talk and include video and audio monitoring under privacy and confidentiality. So you have to have some reason that this is going to occur. And you have to tell the patient and the representative, hey, by the way, we use audio and video monitoring for patient safety. The screens cannot be readily visible to people walking past. So you might wanna just put this in a separate room if you have that option. Video recording does require consent. And you might wanna add a reference to your general admission form. Hey, this is what we do for patient safety. But privacy can be limited when a patient does have to have continual observation. Violent self-destructive behavior, suicidal precautions, falls. You can, that privacy right can be limited when you have those requirements for patient care. Add wording to your general admission form. By the way, this is what we do, audio and or video monitoring and or recording. And here's just some straight wording you can use. I agree to medical imaging, photographs, audio recording, blah, blah, blah, may be made while I'm receiving care at my hospital. I would have them initial that. So you know they saw it and that they're aware of it. Check your state laws. Maybe there's specific wording that you have to add in and can have them initial it so they're aware of it. Privacy includes limiting disclosure of a PHI. So we have to make sure that we tell the patient prior to disclosure so they can object. Permitted disclosures where you don't need to get their consent, payment, healthcare operations. And your policy procedures, they are required here. And it covers who can access and what categories a PHI can be accessed. Now there may be times of incidental disclosure where you just can't help it and it's gonna occur. Like names on the back of a chart or outside the room. If you have something that says fall risk, whiteboards like in the OR. And then also in your directory. Now in your directory, the patient can restrict that. They can say, no, I don't want my name posted in the directory for people to know I'm here. They can restrict it. So we know those incidental disclosures, they're going to happen no matter what. We just take reasonable safeguards to the best you can. And these are reasonable ones. Asking patients, visitors, stand back from the counter. Dividers or curtains when you can. Quietly if they're in a semi-private room. Limit access to those whiteboards where they are posted. What information is going to be up there? I worked in a hospital intermittently where out in the open in the nurse's area, nurse's station area. It had the patient's full name, the doctor's name, what their diagnosis was, who their nurse was, and if they needed anything special. And this was pre-HIPAA. So now that HIPAA came along, that pretty much went away. And all they had were initials and the doctor's name and the room number. That was it. Nothing else. Surveyor is going to observe. They're going to talk to patients about privacy. Was there privacy during exams? Where were patients' names posted in plain view? Audio-visual monitoring. Did they want to find out were the speakers readily audible to someone passing in the hallway? They want to see your policy also. They're going to talk to your staff. Do they have, does staff understand the use of information in that directory? How about the policy? Does it talk about restricted access and use? And then what about reasonable safeguards so that we can try and reduce incidental disclosures to the best you can? Our next area talks about care in a safe setting. And this is everything, whether it's preventing falls, medication errors, infection control, environment. So it's really covering a host of areas on patient care. So first off, you have to identify those persons who are at risk for intentional harm to themselves or others like staff and visitors. That means we also then provide education and training to staff. But don't forget your volunteers because they have to be aware of those areas and steps to keep themselves safe too. Whether it's hand-washing, prohibiting unwanted visitors, contraband material coming in, background checks on staff, that's included in here. How do you mitigate or remove those risks to ligature, self-ligature? And that's why they talk about ligature risk where we want to have that safe environment. So not only do they not hang themselves, but they could harm others. What they're trying to do here, identify those patients and that environment care area where a reasonable person similarly situated would consider safe. By the way, no waivers for your ligature deficiencies. You have to be, you have to get progress reports on what you've done to eliminate those risks or any deficiencies that you have been cited on. On the risk of suicide, ligature resistant or free. This is for those behavioral health units and hospitals. Non-psych health settings like ICU, maybe med-surg, you have a patient who might want to do some self-harm. That's why we have to identify who that is. Mitigate to the best you can. That may mean one-to-one monitoring, that's continual visual monitoring. Taking things out to the extent you can, like equipment, if you can take it out. Now, I understand it could be hard, patients on oxygen the cord can be used as a ligature. That person may require one-to-one monitoring so that they don't harm themselves. Because in July of 23, they did come out with some updated guidelines. Now I put in here should, previously it's you must. Now they're saying should identify those who are at risk to harm not only themselves, but others. That means put together and do a risk assessment. Look at your environment. What strategies can you take and put into place? Like identifying those handrails that can be used as a point, a securing point for a ligature. They added non-compliance, which don't pose an immediate jeopardy, but take care of them as soon as possible. And the timeframe is what CMS or the state agency may identify as that timeframe. Because they'll look at your position, your situation. What's a good timeframe to get this thing fixed? Anything that can be used to tie something around to hang or strangulate themselves. That's a ligature risk. Whether it's a handrail, doorknob, whatever it is. They will also, surprisingly, added housekeeping cards and utility cards to this. Like with the mops, maybe taking off some of that to use as a ligature. Cleaning agents and disinfectant just for harm to themselves overall. Other risk furniture that can be thrown, sharp objects. Oxygen tubing, I already mentioned that. Windows. What you're looking at here is the insulation of a window where a patient took the window out and pulled it out of there and was able to make a ligature from it. So again, do a risk assessment on your patients. Is this person at risk to harm themselves? Now they won't say what tool you use, but look at your population. Where are they being taken care of and your staff competency to identify these individuals? And then you are expected to have appropriate strategy to address them. Whether they're an ED, an OB, med surge, whoever it is. What is an appropriate assessment strategy for that patient? Then look at your environment. What is the appropriate care environment in your patient population? What is the possibility that they could harm themselves or others? Again, they won't require use of an assessment tool. They do mention the VA Environment Risk Assessment Tool. Yes, it's in the appendix for you, along with what's called the Behavioral Health Guide Design. Now this is from 2022 and they're telling us that there's a new one coming out. It hasn't come out yet. So just be aware that there may be a new one for that Behavioral Health Design Guide. Otherwise, look to the VA Risk Assessment for your environment and then correct them. You have 60 days from once you get that report to do that. And then they'll come back and do another survey to find out how did you do. They are not eligible for any life safety code waivers. If it's not, again, an immediate jeopardy, the remedy that's in the specific timeframe that CMS will spell out, whether it's a regional office, your accrediting organization, they spell out how soon you have to make that remedy. If you need more time, you might, because getting supplies, getting bids, et cetera, because if it's somewhat of a big construction project, you will have to have a mitigation plan in place and you must provide updates, but it still has to be corrected. Give education and training according to the level for those staff taking care of them. Patients, what are the environment risk mitigation strategies? And that includes everybody, whether it's contracted, employed, volunteers if they're involved, and on orientation, anytime you make a change. And CMS also says regardless every two years. So that July memo, they reiterated the guidelines. Do your patient risk assessment, have environmental risk assessment also, and education to your staff with appropriate monitoring. So that's just a culmination of what that memo said. It is in the appendix for you. Next area they talk about is freedom from abuse and harassment. It is somewhat discouraging that they had to put this in there, but it's there. That patient has a right to be free from all forms of abuse or harassment. And that's what we're trying to prohibit. Neglect is a form of abuse. And it doesn't matter who it's coming from, whether it's staff, other patients, or visitors. We still have to provide that safe environment and a way to make sure that occurs. So they give us some definitions. Again, you might want to consider adding these to your policies. Abuse, that's willful infliction of this injury. It could also be unreasonable confinement, intimidations, punishment that end up causing harm, whether it's pain or mental anguish. And that includes neglect or indifference to injury or intimidation by one patient to another. You may have a patient who's just simply had some behavioral health issues or it's just maybe not nice and goes in and bullies or harasses other patients. We have to make sure that we stop that, that that does not occur. And so that's included in here. Neglect, we're not giving them services, goods to avoid any harm or mental anguish. So here's just some items for prevention. You don't have to do this, just they give you some examples, have enough staff who are qualified and trained, experienced. We don't want to hire anyone with that record of abuse or neglect. And then look at those events. Is there an event that was from the abuse or neglect? Train your employees to report this. That's huge. Make sure that they feel comfortable and safe in reporting when they have a concern, whether it's a staff member or another patient. Also, how do they prevent, what interventions can they use? Now, getting that other patient out of the room, maybe providing some quiet time for the patient to decompress. Investigate all allegations. Don't poo-poo them away. And especially with it's abuse, just because the patient has some behavioral health issues doesn't mean it didn't occur. And then report and respond. Take those corrective actions. That may mean discipline of that person and reporting to their licensing board. So we do have to do certain things when it talks about abuse and neglect. I'm gonna move now over to medical records, whether it's confidentiality, access and copies. And there's our second question, Lindsay. Okay, let's get this one up here on your screen. Hopefully you all can see this one that says that Hospital X is a multi-specialty hospital that transitioned to a new electronic medical record. To access their medical records, patients must complete a hospital prepared release. And 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 the arrangement for the bill to be paid is made. Is this permissible? Yes or no? And I see lots of you immediately putting in your responses here. Good. Again, if you have any questions for Laura, I don't see any pending at this time, but please feel free to type in those questions into the Q&A option. Or if you don't see that, you can of course type in your questions into the chat as well. Okay, pretty unanimous here. I'll go ahead and share the results. All right. Is that permissible? No, very good. No way can you do that. Well, let's start with confidentiality. Yes, they have a right to have their records confidential. In other words, we have to make sure we've got safeguards in place. And it doesn't matter where it's located, where are the patients located? So that's why you have to have those policy and procedures on disclosure. First off, minimum necessary. We're all familiar with that. Who can have access to what? Now, let's say you get a request from social services or child protective services, and they want information on a patient who was admitted for a suspected child mistreatment, child abuse. Well, this child's record could be somewhat involved. Like maybe they were in for their appendix or tonsillitis or whatever it happened to be. You can abstract out information that doesn't have to be disclosed. So that's the minimum necessary. We had one where the child protective service, no, we want everything on the patient. It's like, I'm sorry, this patient is 16 years old. When they were four, they had their tonsils out. We're not disclosing that. If you need this on their current status, fine, we'll give it to you. There was a little back and forth, but they did finally recognize they were overstepping their bounds for that request. Again, please work with your counsel if you have any questions on that or your risk manager. Otherwise, we have to get their authorization. When it's not for treatment, payment, or healthcare operations, again, those you don't have to have their permission. Otherwise, yes, for disclosure. Access to records. This is when the patients have a right to get that information. They don't have to have that written requirement. You can, you can do it, but it's not required. That can be verbal or written in whatever format that they choose to put it in. We can't frustrate their efforts to get access to that information. They get to inspect or a copy within that 30-day rules. Now, your state law may be shorter, so check on that. There are limited exceptions, of course. And that talks about psychotherapy notes. And when you have prisoners, they are a ward of the state. And so then it's usually up to the state to determine, can that prisoner have access to their own medical records? And psychotherapy notes, that has not changed. There is still that protection in place for psychotherapy notes. Now, a copy of their records, they still get them timely, 30 days, if it's stored off-site or whatever, 60 days. Now, CMS says timely, but check again your state law. They may be shorter. And it's the entire record, or of course, a portion of it. And make sure your discharge planning documents are in there. I'm gonna just talk really briefly on some medical record issues. Where CMS and OCR work together, and there is some overlap. The conditions of participation, they updated them to include right of access from a patient to their records. OCR has requirements, and that's on the difference between a request for access and when you have to have an authorization. And a lot of the hospitals weren't aware of this a couple of years ago. Now, we know HIPAA's been around forever and a day, and that you probably already have a policy on a copy of their medical records or release of it. So under patient rights and the Office of Civil Rights, CMS is now saying, you know what? With our technology today, it shouldn't take you 30 days to get them that information that they want. We know we can't frustrate that. And this section, this really overlaps with what OCR is saying. There is a very lengthy memo on access to records. I'm not going to go into that, but it's very lengthy. Really shortly, patients have a right to access that information, inspect their records. And now you can allow email so they can make that request or fax it over if that's what your system permits. You just have to confirm who are they? What is their identity? What you cannot do is require someone to come in and request records in person. In short, of course, they can mail them. You cannot require them to mail the authorization as long as you have that authorization for release of records. They can request, of course, paper, electronic x-rays, then get a copy of their x-rays. And within 30 days of request, you can charge for the records, but no retrieval fee. You have to be clear when you deny that request and you can't refuse copy again because the bill isn't being paid. Now, in denying a request for records, it has to be very, very specific. CMS doesn't give us any explanation of when you can deny a copy. Usually it's your psychotherapy notes. That's what they're talking about. So here is the actual statement. This is how the requirement is on access. You may require them to make requests for access in writing as long as you tell the person of that requirement. I don't have any facility I've worked with that makes that requirement. This is access. So in short, if I'm a patient in your hospital and I wanna see my records, you can say, great, I need to have you make that request in writing to me. Otherwise, most of them say, okay, here's your record. Go take a look at it. Copies are different. Of course, they have a right to get them timely, 30 days, and it can be all apart. And again, include that documentation. However format what works for you and the patient, try to work with them, whether it's flash drive or paper, and make sure that that's the agreement between the patient and you. Now, this is the most recent one. Your slides may show a different graph at the bottom. This one I found just the other day. These are the penalties for violations when patients don't get them timely because OCR will find you, CMS will not, OCR will. And it doesn't matter. You can see they're kind of all over the board here for a while. It was high in 20, low in 21, high in 22. Now we're coming back up. These are the fines. Here was 80,000 because again, patient didn't get the HIPAA. They'd had their HIPAA request and they didn't get it done in time. Here were a Florida clinic worker, 22 years in jail because there was identity theft. They got into their medical record and took information and started running bills. So a patient can request again, a paper or copy, 30 days charge for them, no release, no retrieval fee and they get the copies. Here's the access again, access to their current record within a reasonable time. So look at your policy. Make sure nurses, physicians, other staff know this. That could be your HIM department. Maybe they want to look at them while they're inpatient. That's up to them. Just have a way they can do that. And again, have them sign that request. If you can, you don't have to. And it's not, if they say, no, I'm not doing, I want to look at my records, you're done. A right of access under OCR, allow to be faxed or emailed. And again, we can't require them to come in and request them. You cannot require them to mail the authorization. Again, access to their information. So here's one, this happened just late last year, 70,000. A dental office, wouldn't give them over, wouldn't allow access to it. So they find them 70,000. There were some updates in 23. I just put some of the more current ones or more relevant ones. They want to decrease the time from 30 to 15 days when individuals should be given the information without any charge. And they also expanded the wording. What they're trying to do is lower the bar so that when you have a patient that has threatened or made some statements that are concerning to harm to others, to lower the bar when you can notify law enforcement or others that this harm could be imminent. Right now, it is serious and imminent. They want to lower that to serious and reasonably foreseeable that the person could harm another individual. I have the full list in the appendix. Those haven't gone through, which I'm kind of surprised. Hopefully they'll get around to making those changes this year. There is a website for OCR on privacy to help you also. There's some for business associates and also for healthcare providers and professionals. All right, let's talk restraints and seclusion. Again, this is a very involved area. Critical access, you don't have this information. You don't have the patient rights section in your manual. But if you have your critical access, you have a dedicated behavioral health unit, you follow A. So you have to follow these requirements. Have policy and procedures that address restraints. Some hospitals, criticals have adopted A, especially if you're in a system with a regular hospital. And they use some except for the reporting requirements. But I am surprised they didn't include them because critical access hospitals have behavioral health patients just as much as perhaps an acute does, whether it's temporary time or regardless. So overall, patients have a right to be free from physical or mental abuse and corporal punishment and freedom from restraint and seclusion when it's used as a form of discipline, convenience, retaliation or coercion. We only use it when necessary for safety, patient, staff or others. And we stop them as soon as possible. And this applies to all hospital patients. So here's just some suggestions. You don't need to do this. It's just a suggestion. Add freed from your patient rights statement. Remember, we have to give them a copy. Remind staff to document. Have patients sign it if you can that they've gotten a copy of their rights. And maybe you give them an admission packet. You may wanna add it. Back to the regulations. The decision is based upon their behavior, their assessment, not their diagnosis. And that assessment should include a physical assessment. Is there something going on physically that's causing this behavior? Staff have to assess and monitor their condition once they're in restraint and or seclusion to continue to see how they're doing. Only employed when that unsafe condition exists. Leadership has a role here. This is your C-suite and your governing board because they're responsible to make sure that there's a culture to support their rights. They have to make sure there are systems and processes in place to eliminate inappropriate restraint and seclusion. Through your QAPI, assess and monitor the use of these restraints and seclusion. Why did that occur? Was it for physical safety? Are we complying with all of the requirements? Here's when it's not appropriate, when it's part of your routine fall prevention program because some of the studies show it might increase them. Just because a patient might fall, that's not enough. History of falling without a clinical basis for the use, again, just it's not okay. And a request from the patient or family to apply restraints, not okay. There has to be some reason, a clinical reason for that use of them. The documentation has to show that restraint was less restrictive and that's based on your assessment of that person. You assess them on an ongoing basis. Yes, I need to continue this. Once a day may not be enough to support the adequate use and simply may not meet the requirement for discontinuation as soon as possible. So weapons, they bring up weapons and that's in the application of restraints. And I added that emphasis. There's been some confusion. Wait a minute, are you telling me our security can't use a taser to protect us when a patient's becoming assaultive or going to assault? No, what they're talking here is the use of weapons and application of the restraint. Like pepper spray, taser, they specifically list those two. Used by security staff, they're considered law enforcement, but it cannot be a healthcare intervention because that could be, they can use them for breaking and entering, again, when they're assaulting or threatening charging staff where they need to stop them. It is permitted by law enforcement if they're under arrest. These are usually non-employed folks as state federal law enforcement. Again, they're authorized to use the weapons. And again, it's not a healthcare use. It is for law enforcement. Forensic restraints are not covered under this. That's when that's handcuffs and shackles. It's considered not appropriate for healthcare providers to use shackles and handcuffs as a form of restraint. Law enforcement, that's different. Surveyors look at your policies on restraint and seclusion. Who can discontinue it? When can they be discontinued? They will look at records. Those who had restraints and seclusion, like both violent and nonviolent patients, any patients currently in restraint and seclusion, they'll also look at those records. They want evidence that the staff identified the need for that. And there's evidence least restrictive didn't work. They were ineffective. They will talk to your staff. Tell us about the policy. What's your understanding of your restraint policy? And for those who are currently restrained, when did you last look at them? When did you last assess your patient? They want to look at your incident reports on patient injuries. Were they proximal or during that intervention? They will look at the records that indicates injuries. What'd you do to investigate? Were there any changes that were needed as a result of the injury caused by that use of the restraint? Then they want to look at the date on the use. Was there a pattern like a day of the week, a unit? That's what they're looking for. They give us definitions of restraint, any manual method, whether it's physical or mechanical that immobilizes or reduces the person's ability to freely move about. And again, all healthcare settings. There's examples that they have. I'm not going to go through all of these just in the interest of time. A freedom supplant that immobilizes a limb, that's considered a restraint. A cherry chair recliner, if they can't remove that to get up and move around. Physically holding for forced medication. Now that doesn't mean you can't hold the child to calm them while they're getting a shot, that's okay. But this is when you're holding the patient down and ordering that and giving that medication. Tucking in the sheets, a net bed where they cannot get themselves out. Medications can also be a restraint when it's used to manage their behavior or restrict their movement. And it's not a standard treatment or dose for that condition. You may have to give them that, I'm just going to say held all, to get them back to the level of functioning. That's okay, because that's the course of treatment. Getting them to be quiet so you have a quiet shift, that is not, that's considered a restraint. Again, if it's part of your standard psychiatric treatment, then it's not a restraint. PRN standing order is only prohibited if it's used to meet and meets that definition of restraint. For example, giving Ativan when they're going through alcohol withdrawal, that's okay. Phenergan when they get a little agitated, they're not happy, Phenergan, that's a restraint. The criteria they're looking at is standard use, like FDA and the manufacturer. Are you following national practice standards and are you treating that specific condition so that they can come back to that level of functioning? That is considered the standard of use. Then you have to do a comprehensive assessment. What type of interventions before the use of that medication, that is considered a restraint. What have you done? Detoxing and the Ativan can help them. Maybe sundown or syndrome where it's helped to sedate them, then that could be considered a restraint. By the way, if state law prohibits medication against their wishes without a court order, state law prevails. What's not included in a restraint? Those orthopedic devices, bandages, protective helmets for those who have seizures. Holding a patient, as I said, to do those routine tests, protecting them from falling out of bed if they can't lower the rail. Padded side rails, but that's when they're used as a seizure precaution. IV board, unless it's tied to the bed. Postural support for positioning, that's not a restraint. Excuse me, coming out of anesthesia, that you've got the side rails up, maybe have that band across their waist to keep them in place because the cart may be kind of narrow. A striker bed. All of those are not considered restraints. Mitts, unless again, they're tied or pinned down. Holding a child to give a shot, a stroller, a swing bed safety belt, as long as they're age or developmentally appropriate. Forensic restraints, we had talked about those handcuffed shackles. Those are under law enforcement. So here's, I believe, our next question. Would you see any of these as being a restraint? And you can check all that apply. Yep. And I just put those up there as options one, two, or three. So you can just select those there on your screen now. And I know we're getting closer to the end of the presentation. So I don't see any questions pending. So make sure that you are typing any questions that you have for Laura. And as we go along here, I may start to just kind of go through this a little bit more expeditiously so that we cover everything. No worries. Okay. And I'll make it easy for you. There's only one that's a restraint. Ah. No, only one of these would be considered a restraint. And I'll explain. All right. Go ahead and share those results there. Yeah, all right. So it's okay that you answered, because then you're thinking, oh, hey, wait, can they do anything? Number one is the only one that constitutes as a restraint. Because in number two, she can move her fingers. She can use her fingers. That's there to help keep the hand in one spot and protect her palm. The third one here, he can take that off. That's a Velcro. And so unless he couldn't, like whip it around and he can't get access to it, it is a restraint. But the way this is put on there, it's not a restraint. These are some of the very fine distinctions that CMS will look at when they come around. How is it used? And what is it used for? So number one is definitely the restraint. So that's what they're going to do. First off, do your policies talk about the description of what is a restraint? They're going to walk around. And what they're looking for, first off, is your side rails. Is it used as a restraint? They'll talk to staff. What's your definition of restraint? Especially side rails. Now, seclusion, believe it or not, has one tag number. That's it. That's where we involuntarily confine them alone in a room or area where they are physically prevented from leaving, only used for management of violent or self-destructive behavior, where there's an immediate jeopardy to safety of the staff and others. It is not seclusion if they're on a locked unit with others. They're put in time out. They're in a designated area for, say, you need to go into timeout for about 15 minutes to decompress. Now, they can leave the area. They're not physically prevented. May only be used when, again, less restrictive measures don't work, the type is the least restrictive intervention to prevent harm, and according to modifications in the written care plan. Used to implement safety and appropriate techniques. Used according to a physician order. Now, this can be a licensed practitioner, like a PA, nurse practitioner, as long as the policy, hospital policy, and state law permits it. And if you have to put them on right away, excuse me, get that order as soon as possible. Licensed practitioner, I already mentioned that, can be a resident if the state law permits it. A medical student, no, because they are not licensed. Protocols, previously CMS says no, you can't use them, but now they're okay, but you have to have a separate order. And there's enough information in that protocol so staff know when and how to apply them. Usually these are exceptional events where you're doing okay and something triggers this person and they just become violent and or self-destructive. Standing orders, no, you cannot have standing orders for a PRN Each episode has to have an order. If the patient's out of them, their behavior comes back, you have to have a new order. Trial release, that's considered a PRN and it's not permitted. A temporary release for care, you're okay. Now, there are three exceptions to that PRN order. A jerry chair, or in other words, they have to be out, they have to sit up to eat. Number two, side rails raised for seizure precautions or they have an air mattress and they're going to fall out. And then third, it's called the leishmania syndrome, that's self-mutilating behavior where the patient cannot control it. And here it's where they bitten off and rub their fingernails off to the point of bleeding. Otherwise, we notify the attending as soon as possible. Let them know if they did not order, the attending has to be notified if that order came from someone other than them, like they can't be contacted, they're on vacation. Policies determine who is the attending and what is considered ASPS as soon as possible. There are time limits on the orders and each order can only be renewed for these time limits for up to 24 hours. Four hours adults, two, nine to 17, one under the age of nine. But again, check your state law, it may be more restrictive. A violent self-destructive doesn't apply to the management of non-violent. This is what these time limits apply to, is the violent self-destructive. End at the earliest possible time. These are the maximum times. They can be shorter, of course. But what is required for the order, the length of the order when there's mandatory contact by that provider. The nurse can evaluate and share it, but then when does the physician need to reorder? The original order, you can renew up to 24 hours. You don't have to do that one hour face-to-face if it's renewed. But after the original order expires, then yes, the provider has to come in, see the patient, and assess them before they do a new order. So again, they have to come in and see the patient, put their eyes on them, evaluate them. And documentation has to include what they find on that re-evaluation. End at the earliest possible time. If there's time left over, great. You can just discontinue it, but if it comes back, then you have to get a new order. And it's based upon their behavior, like they're no longer a threat. And policies have to address, first off, what circumstances can they be discontinued, and who can discontinue it. And that's where training comes into play. The condition of the patient has to be monitored by the physician or trained staff, according to your policy. Assessment and monitoring individualized to the patient. Now they talk 15-minute checks or vitals every two hours, that may not be enough. But again, waking them up at 2 in the morning when they're sleeping, that may be overkill. Your policies have to address that. So physicians, practitioners have to have training on what are your hospital policies. They have to have a working knowledge of it. And when you use these violent self-destructive behavior, they have to know they have to come in and see them. They have to come in and see them eventually. Now, whether it's the physician or an RN with training to do that one-hour face-to-face, somebody has to do it. They have to evaluate their situation. How are they responding to this intervention? Their medical behavioral condition? And do we need to keep with the restraints and or seclusion, or can we stop them? If you're trained RN is doing this assessment, they have to consult with the provider as soon as possible. Use them at the same time only if that patient is continually monitoring, and they have to have a trained staff person do that. Now, you can do video and audio, but they have to be close to the patient. You have to have documentation of what the evaluation was. What was their behavior? What interventions have you used? Also, that you document alternatives didn't work. What's the patient's condition that warranted the use of restraint and seclusion? How are they responding to this, and why do we need to continue? Surveyors, again, going to look at records. Is there documentation of that behavior in your assessment? And that you tried least restrictive measures. They are going to look at staff competencies, not only in the assessment, but in the policies. In the policy review, they're going to make sure the one-hour face-to-face evaluation was put in there, the time frame, and who can do this. That's why staff training is so important. This is the one area in the entire manual where there has to be documented staff training and competency in application, monitoring, assessment, and also who can remove them. This has to occur before any action. It's part of your orientation, and then on a periodic basis, according to your policy. So, this is the one area where staff must be trained and competent before it can occur. You have to require appropriate staff to know this. They have to be educated and trained techniques to identify and what can trigger it, and then employee interventions. That includes non-physical interventions. De-escalation is not required by CMS, but it's always a good idea. What is the least restrictive intervention and safe application and use? And also, how do you respond to those emergencies? Maybe they're going into some physical distress, like asphyxiation. Clinical identification of behaviors that maybe indicate restrained seclusion, no longer necessary. That we continually monitor this person for any respiratory and circulatory status. Watch their skin, and if they're really agitated moving around, they could get some breakdown of the skin. Any special requirements associated with your one-to-one assessment, one-hour assessment, excuse me. First aid techniques, trainer requirements, they talk about that. Make sure it's in the personnel records that your staff are competent in the application. And by the way, security guards, if those respond to these, they're going to need your training also. So, death reporting. We have to report deaths associated with the use of restraints or seclusion no later than the close of business, the next business day. Once you become aware of the death. Each death, while they're in restraint or seclusion, unless it's those soft wrist restraints, and it wasn't related to, it was like person in ICU and they're intubated, then it goes to your internal log. You also have to do it within 24 hours after they've come out of restraint and seclusion, if it's reasonable to assume that the restraint and seclusion contributed to that death. And the same for the third one, where death occurred one week after restraint and seclusion were used, where it's reasonable to believe the use contributed to the death. Doesn't matter what type of restraint or seclusion was used. And that means that deaths related to the restriction of movement, chest compression, restriction of breathing, asphyxiation. Staff have to document the date and time the death was reported to CMS. You send that to your regional office. Then they determine, do we need to come out and have a visit? The internal log, this is when you have no seclusion, it's those soft wrist restraints. If that does occur within 24 hours after it's come off, document the medical record, date and time of the death. And then your internal log, no later than seven days after death. And here, this slide has the information, patient's name, date of death, why are they there, tending, record, et cetera. Have it available for CMS. They may want to see it when they come around. You may need to look at your policies and retrain. Death reporting form, it's electronic. They don't take paper anymore. They updated it in November. I've got the link there for you. Don't forget Safe Medical Device Act. You also have to do reporting if it was a device that was used and sentinel event. If you are joint commission, it is voluntary, but you have to do that RCA within 45 days. So visitation very quickly, have policies regarding patient visitation. And when you're going to restrict it, they don't recommend restricting ICU patients. They don't recommend it. You can, but they just say you don't have to do that. Same day surgeries, they may want somebody there with them. Outpatient, same thing during an exam. Here's some reasonable restrictions. If the visitors are interfering with care, child visitors, you may want to restrict some of those young ones. And safety for abduction. If there's a court order in place, maybe it's an infection control issue also. And then you have your others, your disruptive visitor, maybe they're on a substance use program. Then simple, they're having a procedure. We need to have some privacy. You have to put notice of visitation rights and a policy on it. And any restrictions. You have to inform each patient. They get to determine who comes to visit them. And maybe they don't want to have anybody. Just honor their refusal document in the record. Otherwise, it's equal visitation privileges so that it's stress support. Doesn't matter if sex, gender, et cetera, and educate their staff. I want to talk briefly on interpreters. I'm going to pass on this question, Lindsay, in the interest of time. I know we're probably getting over, if not close. Interpreters. And make sure they are available. You need qualified interpreters. And document when you do use them. Office of Civil Rights, again, has a whole section on this, not only for patients, but for you as providers. You have to offer timely, qualified interpreters when you do oral. That's a reasonable step for access. Language services are free of charge. And you can't require them to bring their own. Don't use a child unless it's an emergency. And don't use that low-quality remote interpreting. Post a sign in several languages that it's available at no charge. Have a skills lab for your nurses so they know and understand. Look at your policy. If you own your physician offices, make sure interpreters are present. There are taglines. Office of Civil Rights have them. I have the link there for you. You don't have to use their list of numbers. You have your own as long as it's representative of who you have. Again, four states have 17 languages. On your interpreter, make sure, you don't have to have certification. They just have to be qualified. Whether you're going to use the qualified high-level one or your entry-level, like core certification. There's a national board for certification. And there's also qualified medical interpreters. They're the best. Office of Civil Rights, there is a section they added on prohibiting sex discrimination. So, again, this is still OCR. We can't segregate or deny services. We can't delay effective assistance to patients who don't have good English proficiency. Gender identity, this is another restriction. We treat them consistent with their identity. In other words, access to facilities. This is still undergoing a lot of changes. And that's why OCR has put up a website to try and help us with this. Now, I do want to mention, I think I mentioned this yesterday to you. On HIPAA and disclosure of protected health information, when you have, and you're in a state where you have a patient coming requesting birth control or some reproductive services, if your state permits it, there is certain requirements where you are protected from disclosure where another state comes in and wants that information from you. I thought it was covered here. I apologize. It's not. But you are not required to disclose reproductive healthcare that you are providing or that a patient has requested healthcare from you if it's legal in your state. If you get a patient where you know received services in another state that were not permitted, then you can disclose that if it is requested. It's a very limited disclosure. In fact, there was an article today where it happened in a state where extremely prohibited and the person was providing termination services and they weren't licensed. That is against the law, period, no matter where. And so, the physician, if that physician had gotten a request in another state to have that information disclosed, they have to disclose it because it was an illegal act in the state where it did occur. So, if they want more information on that, Lindsay, I'm happy to provide that. So, again, I thought we were going to cover it. And unfortunately, with our time, we're not going to. So, this is our final discussion. I'll do a real quick. We've got a 73-year-old, hypertension, remote smoking, alcohol abuse on a daily, came in for a colon resection, immediate post-op, unremarkable. He starts to have withdrawal symptoms. He's put in two soft wrist restraints and they give him Ativan. That's okay. The Ativan was okay. They took wrist restraints off on post-op day six. They reduced the Ativan. They sent him to swing bed until transferred home and he is ambulatory. He's now post-op day nine, swing bed day three. He's unresponsive. He uses a bathrobe as a ligature. They don't, they don't need to resuscitate him. So, is this a restraint-related death that they have to report? If no, do they have to report it at all? Any citations? What would you recommend? And so, that's just the final one. If they have time, they're willing to hang around, then great. Otherwise, I'll open it up for any questions. Perfect. Thank you so much, Laura. I did not put this in as a polling question, just because those were a little bit open-ended. So, if you would like to type in your responses here to the discussion question, you can, of course, utilize the chat to do so. And if you have, again, any questions for Laura, go ahead and type in those in as well. We'll give you just a couple of seconds here to do that. And in the meantime, Laura, I can go ahead and give my closing remarks if you'd like, or if you want to go over any resources or anything. Yeah. There are about 24 slides of resources, though. Not too many. If you have any questions on some of the... I just put in here how you can find those deficiency reports, otherwise a discharge notice, and that IM on what you do have to do. And then, I'm happy to go further into that release of information on reproductive health. It was covered in January. I don't know if that's still available for folks to listen to, but that was covered during that timeframe. Yep. Absolutely. And if you're a member of the Georgia Hospital Association and you'd like access to that session that Laura is referencing, you can reach out to us at education at gha.org. And I'm happy to give you access to that via the new GHA Learning Academy, which hopefully you've had a chance to look over. And if you'd like more information on the Learning Academy in general, again, I do encourage you to reach out to education at gha.org. And I'm happy to give you more information on that as well. And I did just go ahead and post some additional information there for you all in the chat, just as a reminder that you are going to receive an email tomorrow morning, but just note that it does come from educationnoreplyatzoom.us. And so, because it's coming to you from a Zoom email, it very well may get caught in your spam, your quarantine, your junk folders. So, if you don't see that in your inbox in the morning, I would just encourage you first to check those additional folders. And if it's still not there and you'd just like to access the recording of today's session, you can always use the same Zoom link that you used to join us for the live presentation today to go back and access that recording. And the recording is available via Zoom for 60 days from today's date. And once you click on that Zoom link, it will ask you to enter your information. That will prompt an email to come to us to approve that recording access request. We do typically approve those requests very quickly, but we just ask you to give us one business day to grant those approvals. And then also included in that email tomorrow morning will be a link to the slides that Laura did present for us today. But I did go ahead and provide that link there for you in the chat now as well. And again, if you have just any questions in general related to the material that Laura presented today, you can always send those over to us at educationatga.org. I'm happy to get those questions over to Laura. And thankfully, she is wonderful about being very timely and thorough in her responses to us. So, please don't hesitate to send those as well. Okay, I don't see any questions. Laura, did you want to go back and reference this discussion question here? Yeah, what they did was they did, they reported internally only because he had no history of any suicidal behavior or depression or anything. But they did decide to report it internally and just kept an eye on it. They weren't cited because they had no idea this would happen with this patient. Even though he did have a history of ETOH abuse, this was not in their radar. So, it was not considered. They weren't cited on it. Otherwise, that was a hard lesson for them to learn that now when they have a patient who maybe is going through alcohol withdrawal to keep an eye on him and help support him to get through it. So, thank you, Lindsay. I'm sorry we went over a bit. And again, open to questions if anyone has anything after the fact. I just would ask they go through you if they wouldn't mind. Yep, absolutely. And again, that email address is educationatga.org. So, please send those questions over and we'll be happy to get responses back to you as soon as we can. Thank you so much for joining us today. Thank you, Laura, as always, for your time and information that you presented to us. Just seeing lots of comments here saying very informative and thanking you so much as always. I hope y'all have a wonderful afternoon. We look forward to having you back with us for future sessions. Thank you, Laura. Thank you. Thank you, Lindsay. Bye-bye.

patient rights

regulatory requirements

patient safety

healthcare facilities

Laura Dixon

risk management

CMS conditions

Medicare Medicaid

patient privacy

grievance handling

interpreter services

restraints and seclusion

compliance documentation