CMS Hospital CoPs on Patient Rights Standards (W4010)
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Credit Offered
1 HLT Credit
This is a recording of a live webinar delivered on April 23, 2024.

Any hospital that accepts Medicare reimbursement must comply with the Centers for Medicare & Medicaid Services (CMS) Conditions of Participation (CoPs). The patient rights section of the CMS CoPs manual has the highest number of deficiencies for hospitals.  

This webinar will cover the CoPs Appendix A section on patient rights, which applies to all hospitals. Critical Access Hospital (CAH) Appendix W does not have a similar section. However, CAHs must provide a safe environment for patients. 

Topics to be covered in this session include grievances, right to receive notice of patient rights, exercise of rights, informed consent, privacy, confidentially of medical records, safety, advance directives, interpreters, abuse and neglect, plan of care, visitation rules, and support person rights. 

Laura A. Dixon, BS, JD, RN, CPHRM 

Laura A. Dixon served as the director of risk management and patient safety for the Colorado Region of Kaiser Permanente. Prior to joining Kaiser, she served as the director, facility patient safety and risk management and operations for COPIC from 2014 to 2020. In her role, she provided patient safety and risk management consultation and training to facilities, practitioners, and staff in multiple states. 

Dixon has more than 20 years of clinical experience in acute care facilities, including critical care, coronary care, peri-operative services, and pain management. Prior to joining COPIC, she served as the director, 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  

As a registered nurse and attorney, Dixon holds a Bachelor of Science degree from Regis University, RECEP of Denver, a Doctor of Jurisprudence degree from Drake University College of Law, Des Moines, Iowa, and a Registered Nurse Diploma from Saint Luke’s School Professional Nursing, Cedar Rapids, Iowa.  She is licensed to practice law in Colorado and California.

The speaker has no real or perceived conflicts of interest that relate to this presentation.

At the conclusion of this session, participants should be able to: 


    1. Identify that the CMS regulations regarding grievances require hospitals to have a grievance committee. 

    2. Recall that CMS has requirements for advance directives. 

    3. Discuss the CMS requirement for providing patients and/or their representatives information on patient rights.  

    4. Recall the various requirements for when a patient is placed into restraints and/or seclusion.

The Georgia Hospital Association Research & Education Foundation is an approved provider of nursing home administrator credits as a professional trade association in long term care under Ga. Comp. R. & Regs. 393-13-.02, (1) (a). Approved for 2 contact hours.   

 By attending CMS Hospital CoPs on Patient Rights Standards offered by Georgia Hospital Association, participants may earn up to 2 ACHE Qualifying Education Hours toward initial certification or recertification of the Fellow of the American College of Healthcare Executives (FACHE) designation. Attendees who wish to have the hours applied toward ACHE Qualifying Education credit must self-report their participation by logging into their MyACHE account and selecting ACHE Qualifying Education Credit. 

Please complete the course evaluation to earn your certificate of participation.
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