PATIENT RIGHTS - MHA
PATIENT RIGHTSSelf-Assessment QuestionsYESNON/ADate/InitialsCommentsNote: Additional information is also found in Survey and Cert Letter 07-28, Survey and Cert Letter 08-07 and Surveyand Cert Letter 11-36.If your facility is a physician-owned hospital, doyou have a policy and provide written notice to allpatients at the earliest possible encounter for aninpatient stay or outpatient visit that the hospitalis physician-owned and that a list of the physicianowners or investors is available upon request?A-0131 COP §482.13(b)(2) If there is not physician coverage 24/7 at aminimum of one location or campus, do youprovide written notice of this to all patients at theearliest possible encounter for an inpatient stay oroutpatient visit?A-0131 COP §482.13(b)(2) Does the notice indicate how you will meet themedical needs of a patient who develops anemergency medical condition when there is nophysician on-site?A-0131 COP §482.13(b)(2) Does the hospital's policy for notifying all patientsof their rights include both inpatients andoutpatients?A-0117 COP §482.13(a)(1) Does your facility inform each patient, or patient'srepresentative, of the patient's rights in advanceof furnishing or discontinuing patient carewhenever possible?19 CSR 30-20.84(1)(E)A-0117 COP §482.13(a)(1) Does your hospital have an alternative means,such as written materials, signs or interpreters tocommunicate patient rights to all patientsincluding individuals who need assistive devices ortranslation services?A-0117 COP §482.13(a)(1) Are all Medicare inpatients given the notice “AnImportant Message (IM) from Medicare” within 2days of admission?a. are all IMs signed and dated by thepatient/representative?b. for inpatients whose discharge occurred morethan 2 days after the initial IM was given, is asecond IM given within 2 days of discharge?NOTE: See also SAQs for Discharge Planning andSocial work.A-0117 COP §482.13(a)(1) 18/20
PATIENT RIGHTSSelf-Assessment QuestionsDoes the hospital provide a hospital-issued noticeof non-coverage to any fee-for-service Medicarebeneficiary that expresses dissatisfaction with animpending discharge?A-0120 COP §482.13(a)(2)Does the patient rights’ policy include the patientand patient’s representative’s right to:a. participate in the development andimplementation of his/her plan of care?b. make informed decisions regarding his/hercare?c. be informed of his/her health status,including diagnosis and prognosis?d. be involved in care planning and treatment?e. request or refuse treatment?(Note: This right must not be construed as amechanism to demand treatment or servicesdeemed medically unnecessary orinappropriate.)f. formulate advance directives and havehospital staff and practitioners comply withthese directives including:- providing information on ADs toinpatients?- documenting in the patient recordwhether or not the patient has an AD?- placing in the medical record a copy ofthe AD?- complying with state laws? See RSMo459.010 to 459.055.- informing patients of right to file acomplaint in regard to AD with stateagency?- providing community education on ADs?- having a process for patients to updateAD?g. be informed about any aspects of anadvanced directive that the hospital will notimplement due to institution-wide orindividual physician conscientious objection(s)including:- the authority that permits suchobjections?- the range of medical conditions orprocedures affected by the conscientiousobjection?h. have a family member or representative ofhis/her choice and his/her own physicianpromptly notified of his/her admission to thehospital?i. personal privacy including:YESNON/ADate/InitialsComments 28/20
PATIENT RIGHTSSelf-Assessment Questions-privacy during personal hygieneactivities, medical/nursing treatments?release or disclosure of patientinformation?confidentiality of his/her clinical records?Note: Review A-0143 and A-014 for specificexamples and acceptable incidental use anddisclosure.j. care in a safe setting?k. assurance that staff will follow currentstandards of practice for patientenvironmental safety, infection control andsecurity?l. be free from all forms of abuse orharassment?n. be free from restraints of any form that arenot medically necessary?o. participate in the patient's discharge planning,including being informed of service optionsthat are available to the patient and a choiceof agencies which provide the service?YESNON/ADate/InitialsComments A-0130 COP 482.13(b)(1)A-0131 COP 482.13(b)(2)A-0132 COP 482.13(b)(3)A-0133 COP 482.13(b)(4)A-0143 COP 482.13(c)(1)A-0144 COP 482.13(c)(2)A-0145 COP 482.13(c)(3)A-0147 COP 482.13(d)A-0154 COP 482.13(e)Are there policies and procedures regardingvisitation rights of patients?a. are all restrictions on visitation clinicallynecessary?b. does the policy ensure that there are norestrictions or limitations regarding visitationprivileges based on race, color, nationalorigin, religion, sex, gender identity, sexualorientation, or disability?c. does the policy ensure that all visitors havefull and equal visitation privileges?d. are patients or their support person (whereappropriate) informed of their visitation rightsincluding restrictions?e. are patients or their support person (whereappropriate) given a notice of their ability toconsent to receive designated visitors?f. does the notice allow for same visitationrights for anyone the patient designatesincluding but not limited to, a spouse, adomestic partner (including a same-sex 38/20
PATIENT RIGHTSSelf-Assessment Questionsdomestic partner), another family member, orfriend.g. does the notice to the patient regarding theirvisitation rights include the right to withdrawor deny his/her consent to receive specificvisitors?h. is there documented training demonstratingthat staff know and understand the visitationpolicy and how to facilitate access forpatients?A-0215 COP 482.13(h)A-0216 COP 482.13(h)(1)&(2)A-0217 COP 482.13(h)(3)&(4)Are there hospital policies addressing:a. the patient’s right to make informed decisionsand how the hospital assures the patient’sability to exercise this right?b. delegation of the patient’s rights to arepresentative?c. the patient’s right to have information ontheir medical status, diagnosis and prognosis?d. how the patient will be involved in their careplanning and treatment?e. how patient requests for treatment will behandled, in particular, the circumstancesunder which a patient request for treatmentcan be denied?A-0131 COP 482.13(b)(2)To protect patient rights, does the hospital:a. maintain adequate staff on duty at all times?b. provide appropriate security protections toprevent abduction of infants and children?c. curtail unwanted visitors?d. ensure hospital security policies/proceduresare being followed?e. provide employees during orientation andongoing training on information on abuse andneglect, reporting requirements, prevention,intervention and detection?f. conduct criminal background checks of newhires?g. check the Employee Disqualification list uponhire and quarterly so that disqualified personsare not employed?h. check the Family Care Safety Registry to see ifhome health, in-home service or LTC unitemployees are registered?i. take a proactive approach to identifyingevents and occurrences that may contributeto abuse and neglect?j. notify appropriate agencies regardingincidences of abuse and neglect?k. protect patients from abuse duringYESNON/ADate/InitialsComments 48/20
PATIENT RIGHTSSelf-Assessment Questionsinvestigation of any allegations of abuse,neglect or harassment?l. investigate allegations in a timely andthorough manner?m. promptly report and analyze incidents ofabuse, neglect or harassment in accordancewith applicable laws?n. protect personal possessions that have beenbrought to the hospital?o. limit access to all information regardingpatients to those individuals designated bylaw, regulation and policy?p. apply the hospital's confidentiality process toboth central records and clinical recordinformation that may be kept at otherlocations in the hospital such as radiology,data system, etc.?q. prevent unauthorized persons from readingor removing information from the patient’smedical record?r. ensure the patient's right to access his/herclinical record information within areasonable time frame and to receive copiesof the record at a reasonable photocopy fee?A-0144 COP 482.13(c)(3)A-0145 COP 482.13(c)(3)A-0147 COP 482.13(d)(1)A-0148 COP 482.13(d)(2)A-0441 COP 482.24(b)(3)YESNON/ADate/InitialsComments GRIEVANCESDo hospital's policies identify those circumstancesas stated in federal HIPAA privacy standards, wheninformation may be withheld from the patient?A-0148 482.13(d)(2)Does the hospital have a process for promptresolution of patient grievances?19 CSR 30-20.84(1)(L)A-0118 COP 482.13(a)(2)Do hospital's policies and procedures assure itsgrievance process encourages all personnel toalert appropriate staff concerning any patientgrievance?A-0118 COP 482.13(a)(2)Does your hospital define a grievance as thefollowing: a written or verbal complaint (when theverbal complaint about patientcare is not resolved at the time of the complaintby staff present) by a patient, or the patient’srepresentative, regarding the patient’s care, abuseor neglect, issues related to the hospital’scompliance with the CMS HospitalCoP, or aMedicare beneficiary billing complaint related to 58/20
PATIENT RIGHTSSelf-Assessment Questionsrights and limitations provided by 42 CFR §489?A-0118 COP 482.13(a)(2)Are all written, faxed and email complaintsconsidered grievances?A-0118 COP 482.13(a)(2)Are all verbal and written complaints regardingabuse, patient harm or compliance with CoPsconsidered grievances?19 CSR 30-20.84(1)(L)A-0118 COP 482.13(a)(2)Does the hospital provide the patient orrepresentative a phone number/address forlodging a grievance with the state hospitallicensure agency?A-0118 COP 482.13(a)(2)Do patients and /or representatives know thatthey have a right to file a complaint with a stateagency as well as or instead of utilizing thehospital’s grievance process?A-0118 COP 482.13(a)(2)Does the hospital have a procedure for clearlyexplaining to the patients the internal process forsubmitting written or verbal grievances includingwho to contact?A-0118 COP 482.13(a)(2)Is data collected R/T patient grievances as well asother complaints incorporated in the hospitalQAPI program?A-0118 COP 482.13(a)(2)Does the hospital's governing body, or acommittee (must be more than one individual)designated in writing by the governing body,review and assure resolutions of grievances?A-0119 COP 482.13(a)(2)Is the hospital’s grievance policy approved by thegoverning body?A-0119 COP 482.13(a)(2)Are beneficiaries aware of their right to seekreview by the Quality ImprovementOrganization (QIO) for quality of care issues,coverage decisions, and to appeal a prematuredischarge?A-0120 COP 482.13(a)(2)Does the grievance procedure assure that thereview of the grievance and the provision of awritten response usually is completed withinseven days of the filing of the grievance?A-0122 COP 482.13(a)(2)(ii)If the grievance cannot be resolved within sevendays, does the hospital notify the person filing thecomplaint that the hospital is still working toYESNON/ADate/InitialsComments 68/20
PATIENT RIGHTSSelf-Assessment QuestionsYESNON/Aresolve the complaint and provide a completiondate for the resolution?19 CSR 30-20.84(1)(L)A-0122 COP 482.13(a)(2)(ii)Does the written notice to the patient of thegrievance resolution include the name of thehospital contact person, the steps taken on behalfof the patient to investigate the grievance, theresults of the grievance process and the date ofcompletion? A-0123 COP 482.13(a)(2)(iii)Does the hospital maintain documentation ofgrievances’ resolutions?A-0123 COP 482.13(a)(2)(iii) Date/InitialsCommentsRESTRAINT AND SECLUSIONDoes the hospital have clear and concise policiesthat assure:a. a patient’s right to be free from physical ormental abuse and corporal punishment?b. a patient’s right to be free from restraint orseclusion, of any form, imposed as a means ofcoercion, discipline, convenience orretaliation?c. restraint or seclusion is only imposed toensure the immediate physical safety of thepatient, staff or others?d. restraint or seclusion is ended at the earliestpossible time?A-0154 COP 482.13(e)Do hospital policies:a. define a restraint as:1. any manual method, physical or mechanicaldevice, material or equipment thatimmobilizes or reduces the ability of a patientto move his or her arms, legs, body or headfreely?2. any drug when it is used as a restriction tomanage the patient’s behavior or restrict thepatient’s freedom of movement and is not astandard treatment or dosage for thepatient’s condition?b. define seclusion as the involuntaryconfinement of a patient alone in a room orarea from which the patient is physicallyprevented from leaving?A-0159 COP 482.13(e)(1)A-0160 COP 482.13(e)(1)(i)(B)A-0162 COP 482.13(e)(1)(ii)Note: A restraint does not include devices, such as orthopedically prescribed devices, surgical dressings or bandages,protective helmets, or other methods that involve the physical holding of a patient for the purpose of conducting 78/20
PATIENT RIGHTSSelf-Assessment QuestionsYESNON/ADate/InitialsCommentsroutine physical exams or tests. A restraint does not include devices that protect the patient from falling out of bed orpermit the patient to participate in activities without the risk of physical harm (this does not include a physicalescort).A-0161 COP 482.13(e)(1)(i)(C)CMS considers a drug to be a “standard treatment” for a patient’s condition and therefore not a restraint, if the drugorder:1.is within parameters approved by the FDA and manufacturer2.follows national professional practice standards3.treats a specific patient’s clinical conditionA-0160 COP 482.13(e)(1)(i)(B)Is a comprehensive assessment of the patientperformed addressing the following elements?a. the reason for restraint or seclusion, the typeof restraint, and the duration of restraint orseclusion?b. the severity of the behavior justify seclusionor restraint usage by identifying an immediateand serious danger to the physical safety ofthe patient or others?c. consideration of factors other than theindividual patient in determining causes forthe need for restraints or seclusion (i.e.,environmental factors)?d. whether the patient’s behavior placed thepatient or others at risk for harm? Was thepatient’s behavior violent or self-destructive?e. were other, less restrictive interventions triedand documented, or is there evidence thatalternatives were considered and determinedto be insufficient?A-0164 COP 482.13(e)(2) If restraints and seclusion are usedsimultaneously, is the patient either:a. continuously monitored face-to-face by anassigned, trained staff member?b. or continuously monitored by staff in closeproximity to the patient and using both videoand audio equipment?A-0183 COP 482.13(e)(15)Do the hospital’s policies ensure that restraints orseclusion are only used:a. to protect the immediate physical safety ofthe patient, a staff member or others?b. when less restrictive interventions have beendetermined to be ineffective to protect thepatient, a staff member or others from harm?c. in accordance with a written modification tothe patient’s plan of care?d. when it is the least restrictive interventionthat will be effective to protect the patient,staff member or others from harm?e. in accordance with safe and appropriate 88/20
PATIENT RIGHTSSelf-Assessment QuestionsYESNON/ADate/InitialsCommentsrestraint and seclusion techniques asdetermined by hospital policy in accordancewith state law?A-0154 COP 482.13(e)A-0164 COP 482.13(e)(2)A-0165 COP 482.13(e)(3)A-0166 COP 482.13(e0(4)(i)A-0167 COP 482.13(e)(4)(ii)Note: Seclusion may only be used for themanagement of violent or self-destructivebehavior.A-0162 COP 482.13(e)(1)(ii)The following questions only apply to non-violent and non-self-destructive patients in restraints.Are restraint orders:a. authorized by a physician or other licensedindependent practitioner who is responsiblefor the care of the patient and permitted bythe hospital to order restraints?b. authorized prior to the intervention wheneverpossible?c. never written as a standing order or on an asneeded basis?d. always followed by consultation with thepatient's attending physician as soon aspossible if the restraint was not ordered bythe patient's attending physician?e. written for time limits and renewed asspecified by hospital policy?A-0168 COP 482.13(e)(5)A-0169 COP 482.13(e)(6)A-0170 COP 482.13(e)(7)A-0171 COP 482.13(e)(8)(iii)The following questions only apply to violent and self-destructive patients in restraints and seclusion.1. Are restraint or seclusion orders:a. authorized by a physician who is responsiblefor the care of the patient and permitted bythe hospital to order restraints?b. authorized prior to the intervention ifpossible?c. never written as a standing order or on an asneeded basis?d. always followed by consultation with thepatient's attending physician as soon aspossible if the restraint was not ordered bythe patient’s attending physician?e. and renewals limited to 4 hours for adults, 2hours for ages 9-17 and 1 hour for under age9?f. only renewed for a maximum of 24 hours? 2.Within one hour after initiation of theintervention, does a physician or specially 98/20
PATIENT RIGHTSSelf-Assessment Questionstrained R.N., P.A. or other LIP perform a faceto-face assessment to evaluate the patient?3. Does this evaluation include an assessment ofthe patient’s:a.immediate situation?b.reaction to the intervention?c.medical and behavioral condition?d.the need to continue the intervention?4. If the assessment is conducted by a R.N. orP.A., is a physician responsible for thepatient’s care consulted ASAP after the 1-hourevaluation?5. After 24 hours, and before writing a neworder, does a physician or LIP who isresponsible for the care of the patient andauthorized by hospital policy see and assessthe patient?A-0168 COP 482.13(e)(5)A-0169 COP 482.13(e)(6)A-0170 COP 482.13(e)(7)A-0171 COP 482.13(e)(8)A-0172 COP 482.13(e)(8)(ii)A-0178 COP 482.13(e)(12)A-0179 COP 482.13(e)(12)(ii)A-0182 COP 482.13(e)(14)If a restraint or seclusion is discontinued (trialrelease) and then reapplied, is a new orderobtained?A-0169 COP 482.13(e)(6)Does the hospital and its policies and procedures:a. identify who can initiate the emergencyapplication of a restraint prior to obtaining anorder?b. determine the level of monitoring and theinterval at which the physician or othertrained staff must monitor the condition ofthe patient?c. include a requirement to end the restraint orseclusion as soon as is safely possible?d. address who can discontinue the restraint andunder what circumstances it can bediscontinued?e. determine what are considered to be safe andappropriate restraint and seclusiontechniques?f. reflect a culture that minimizes the use ofrestrictive interventions and ensures safe andquality care of patients in restraint orseclusion?g. incorporate restraint and seclusion usage inits QA/PI activities?h. differentiate between the use of restraints asYESNON/A Date/InitialsComments 108/20
PATIENT RIGHTSSelf-Assessment Questionsappropriate health care intervention and theuse of weapons/restraint devices by lawenforcement?i. assure that handcuffs
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