Patient Rights in 2025 for Hospitals

Overview:

During 2023 and 2024, non-compliances with the Condition of Patient Rights have made this Condition the #2 most frequently cited Condition in the hospitals in South Dakota. Hospitals, critical access hospitals and rural emergency hospitals must comply with the Centers for Medicare & Medicaid Services (CMS) Conditions of Participation. According to CMS and accrediting organizations such as DNV and Joint Commission, Patient Rights and Responsibilities Condition is consistently in the top Condition Level Deficiencies cited. Within that condition, most non-compliances come from the regulations governing care in a safe environment, abuse, restraints and seclusion.

Objectives:

• Describe the documentation requirements for restraints and seclusion
• Explain restraint death reporting requirements
• Explain the responsibilities of CAH under the 2023 Patient Rights Condition of Participation
• Describe the CMS requirements for providing care in a safe environment for all patients
• Explain what is require for a physical environmental risk assessment

Presenter: Nancy Ruzicka, BS, RPh, MBA, MJ, CHC, Ruzicka Consulting

Nancy Ruzicka has experience teaching and assisting hospitals and other healthcare facilities in understanding applicable Federal and State laws, rules, regulations and interpretative guidelines. Her experience also encompasses teaching all levels of healthcare staff in understanding compliance and HIPAA requirements. Nancy has been a frequent speaker for the Iowa Hospital Association on EMTALA and Conditions of Participation for hospitals and critical access hospitals.

Nancy’s previous experiences include Director of Integrity & Compliance and Privacy Official at Mercy Medical Center, Des Moines; Director of Regulatory Compliance at UnityPoint Health and over twenty years of experience with Iowa Department of Inspections and Appeals. Nancy received her MJ in Health Law, MBA and BS in Pharmacy from Drake University, Des Moines. She is certified in Healthcare Compliance (CHC) and maintains her Iowa pharmacy license.