Are You Ready for the New CMS Patient Visitation Policies?

Published: January 12, 2011

OAKBROOK TERRACE, Ill. – The Joint Commission announced it will align its visitation standards with the Centers for Medicare and Medicaid Services’ (CMS) recently updated Conditions of Participation (CoPs) for hospitals and critical access hospitals that require equal visitation rights for all patients.

The organization is providing advance notice of its standards changes, which will go into effect July 1. As of that date, hospitals will be surveyed under new EPs 28 and 29, as well as existing EPs. Originally, the date of implementation was Jan. 1, 2012. The announcement was published in the Joint Commission’s Jan. 12 newsletter.

The new standard and EPs are:

  • RI.01.01.01: “The hospital/critical access hospital respects, protects and promotes patient rights.”
  • EP 28: “The hospital/critical access hospital allows a family member, friend, or other individual to be present with the patient for emotional support during the course of stay. Note 1: The hospital/critical access hospital allows for the presence of a support individual of the patient’s choice, unless the individual’s presence infringes on others’ rights, safety, or is medically or therapeutically contraindicated. The individual may or may not be the patient’s surrogate decision-maker or legally authorized representative. (For more information on surrogate or family involvement in patient care, treatment, and services, refer to RI.01.02.01 EPs 6-8.)”
  • EP 29: “The hospital/critical access hospital prohibits discrimination based on age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, and gender identity or expression.”

Obici Hospital Security Manager and CS Editorial Advisor Linda Glasson recommends that security personnel become familiar with the new CMS policies.

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“There will be some people who will read that and see that patients have the right to have visitors but won’t see anything else in there,” she says. “The patient has a right, but there can be exceptions. Still, facilities can’t be discriminatory in applying the visitation policy, and that right has been added to CMS’ condition of participation for hospitals. Security has to understand that at certain times, visitation can be denied, and it is very clearly spelled out in the final rule.”

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