CMS Hospital CoPs Made Easy - Patient Rights, Restraint and Seclusion: June 26

Time: 12:00 PM




IHA members: $195 per webinar connection
Non-IHA members: $250 per webinar connection

A 15 percent series registration discount is available. Click the registration link below for additional details.

Register Online

If a surveyor from the Centers for Medicare & Medicaid Services (CMS) showed up at your hospital tomorrow, would you be prepared?

Take part in a five-session webinar series focused on the current CMS hospital Conditions of Participation (CoP) manual, interpretative guidelines and compliance resources. In each session, nurse attorney Sue Dill Calloway will explore CMS survey processes and areas of focus, along with compliance strategies to help you prepare.

The CoPs require hospitals to protect and promote each patient’s rights. But what does this mean for day-to-day operations at your organization? In the second webinar, learn CoP compliance strategies for issues like health literacy, restraint and seclusion, informed consent, and grievance policies. Participants will also review recent CMS guidance on current issues, including ligature risks, weapons and visitation rights.

Take advantage of this opportunity to train your entire team for the cost of one registration. An unlimited number of staff may participate using one phone line and internet connection. Attend the webinar with your colleagues and use the program as a springboard to discuss your organization’s implementation strategies.


This second webinar in the series will focus on the Patient’s Rights chapter of the CoPs and will cover:

  • Common hospital deficiencies identified by the Centers for Medicare & Medicaid Services on Hospital Complaint Reports
  • Patient right to privacy, safety and confidentiality
    • Grievances and complaints
    • Prevention and reporting of abuse and neglect
    • Ligature risks
    • Patient access to medical records
  • Designation and role of patient advocate or support person
    • Connection to advance directives
    • Visitation rights
  • Addressing health literacy with effective communication
    • Interpreters
    • Informed consent
    • Requirements of the Office of Civil Rights and Section 1557 of the Affordable Care Act
    • Right to an Important Message from Medicare (IM Notice)
    • Plan of care
  • Restraint and seclusion (R&S)
    • CoP changes to restraint requirements
    • R&S policy, including  assessment, ordering, documentation, one-hour rule, and end at earliest time
    • Internal and external documentation and reporting requirements, including use of restraint worksheet
    • Physical, medical and soft limb restraints
    • Restraint alternatives
    • Hospital education requirements


Upon completion of this program, participants will be able to:

  • Restate the Centers for Medicare & Medicaid Services’ required restraint standards for hospitals.
  • Discuss the components of the mandated hospital grievance policy and procedure, and identify how it is triggered.
  • Understand that interpreters should be provided for patients with limited English proficiency and that this should be documented in the patient’s medical record.

Who this is for

This webinar series is designed for anyone involved with or interested in regulatory compliance, including leaders and professionals in:

  • Administration
  • Finance
  • Operations
  • Clinical care
  • Compliance
  • Quality improvement
  • Risk management
  • Legal affairs
  • Facilities management
  • Board members
  • Government relations


Sue Dill Calloway, RN, MSN, JD, President, Patient Safety and Healthcare Consulting and Education

Sue has been a medico-legal consultant for over 30 years and is a long-time educator for healthcare providers. A frequent speaker, she is a nationally recognized expert on Centers for Medicare & Medicaid Services hospital CoP issues and well-known in the areas of healthcare law, risk management and patient safety. She has authored over 100 books and hundreds of articles.

Sue earned her Associate Degree in Nursing from Central Ohio Technical College and her Bachelor of the Arts, Bachelors of Science in Nursing, Master of Science in Nursing (summa cum laude), and Juris Doctorate (with honors) from Capital University.