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Hospital Accreditation

Patient Rights - Part Two
Posted by
on 1/7/2020 10:00:00 AM
In September of 2011, CMS revised the Conditions of Participation regarding patient rights. In Part 2 of this series, we'll discuss a patient's right to visitation.
CMS requires hospitals to develop and implement policies regarding patient visitation, including any restrictions to visitation that it intends to invoke.
Hospitals must also provide patients with a written notice regarding their right to visitation - including the right to appoint a support person to be with them throughout their stay and to make visitation decisions on his or her behalf. The notice must also address any clinically necessary or reasonable limitations or restrictions imposed by hospital policy on visitation rights, providing the clinical reasons for such limitations/restrictions, including how they are aimed at protecting the health and safety of all patients. This information must be sufficiently detailed to allow a patient (or the patient's support person) to determine what the visitation hours are and what restrictions, if any, apply to that patient's visitation rights.
Hospitals can meet this requirement by including this information in a "patient rights document" (e.g. a brochure, handbook, or as part of the conditions of admission form). Because of the way the regulation is written, there is no need to demonstrate that the patient was asked if they wish to exercise this right. The patient simply must be informed. Should the patient wish to exercise his/her right to designate a support person, then that individual should be identified.
CMS has delineated very specific requirements around the designation of a support person: "A support person may be any individual including spouse, family member or friend. Not only may the support person visit the patient, but he or she may also exercise a patient's visitation rights on behalf of the patient with respect to other visitors when the patient is unable to do so. Hospitals must accept a patient's designation, orally or in writing, of an individual as the patient's support person." The support person would also need to be provided with the patient rights information - including any restrictions to visitation.
If a patient is incapacitated or otherwise unable to communicate his or her wishes, and there is no evidence to the contrary, then someone who asserts themselves as the patient's support person is considered to be so. The hospital is expected to accept this assertion, without demanding supporting documentation, provide the required notice of the patient's visitation rights, and allow the individual to exercise the patient's visitation rights on the patient's behalf.
Stay tuned next week for Part 3 of this series where we discuss a patient's right to be protected from abuse and neglect.
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About the Author

Traci Curtis RCP, HACP

Traci Curtis is the Executive Director of Survey Operations for CIHQ. Traci has more than 15 years of experience in hospital survey preparation.
Traci's past positions include Chief Quality Officer for a multi-hospital community based health system where she was responsible for accreditation and regulatory compliance. Prior to joining CIHQ, Traci served as the Executive Director of Quality for a large regional medical center, providing executive management oversight in the areas of quality, risk, medical staff credentialing, and patient relations.
Traci received her degree in education from Pima in Tucson Arizona. She is nationally certified in healthcare accreditation, and serves on the Board of Examiners for the Healthcare Accreditation Certification Program.
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