Subject: The Joint Commission Announces Standards Alignment with CMS Patient Visitation Rights CoPs
Category: Centers for Medicare and Medicaid Services (CMS)
The Joint Commission (TJC)
Published: 01/13/2011 04:00 pm
On November 18, 2010 the StayAlert! Administrator reviewed CMS Conditions of Participation for hospitals [482.13(h)] and critical access hospitals [485.635(f)] that address the protection of patients' right to choose their own visitors during a hospital stay, including a visitor who is a same-sex domestic partner.
The Joint Commission has announced that they are aligning its standards to the CMS requirements for patient visitation rights.
Beginning February 18, 2011, deemed hospitals and all critical access hospitals will be surveyed for the CoPs regarding visitation rights under existing standards RI.01.01.01 Elements of Performance 1, 2, 5, 6 and LD.04.01.01 EP 2.
Effective July 1, 2011, all hospitals (deemed and non-deemed) and critical access hospitals will be surveyed under the existing EPs listed above and new EPs 28 and 29 under RI.01.01.01. TJC originally scheduled the implementation of these requirements on January 1, 2012 for hospitals. The changes for critical access hospitals are pending acceptance by The Joint Commission Board of Commissioners.
Please follow the link under References to review the new EPs 28 and 29 in the Joint Commission Online.
To review, the CMS Conditions of Participation for Hospitals Section 482.13 has added paragraph (h) as follows:
A hospital must have written policies and procedures regarding the visitation rights of patients, including those setting forth any clinically necessary or reasonable restriction or limitation that the hospital may need to place on such rights and the reasons for the clinical restriction or limitation. A hospital must meet the following requirements:
Inform each patient (or support person, where appropriate) of his or her visitation rights, including any clinical restriction or limitation on such rights, when he or she is informed of his or her other rights under this section.
Inform each patient (or support person, where appropriate) of the right, subject to his or her consent, to receive the visitors whom he or she designates, including, but not limited to, a spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend, and his or her right to withdraw or deny such consent at any time.
Not restrict, limit, or otherwise deny visitation privileges on the basis of race, color, national origin, religion, sex, gender identity, sexual orientation, or disability.
Ensure that all visitors enjoy full and equal visitation privileges consistent with patient preferences.
Policies / Forms / Additional Resources:
MCN EXAMPLE POLICY: Patient Visitation Rights (01-12-11)
StayAlert! Log-in Required to Access Policies
Medicare Finalizes New Rules to Require Equal Visitation Rights for all Hospital Patients
Joint Commission Online January 12, 2011
Additional Tools Related to This Topic:
MCNs Individual Rights and Responsibilities Manual