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Hospitals: Are Your Visitation Policies in Shape?

Health Law Update Sarah E. Coyne, Kevin J. Eldridge

We know all of you dashed to your computers to update your hospital visitation policies in January when you read our Health Law Update outlining the Centers for Medicare and Medicaid Services' ("CMS") new Conditions of Participation on patient visitation rights in hospitals and critical access hospitals. But just in case some evil force deleted your policy right off your system, The Joint Commission ("TJC") is giving you another reason to update your policies. TJC has updated its accreditation standards to mirror the CMS Conditions of Participation for hospitals and critical access hospitals that use TJC accreditation for deemed status.

As a reminder, the CMS Conditions of Participation require hospitals to have policies that prohibit visitation restrictions on the basis of race, color, national origin, religion, sex, gender identity, sexual orientation, and disability. The policies must ensure that full and equal visitation privileges are afforded to patients in accordance with their preference for visitors subject to any clinically necessary or reasonable restrictions or limitations, such as restrictions for infection control or disruptive visitors. Hospitals also must inform patients of their visitation rights. (For more detail on the new Conditions of Participation, see our January Health Law Update.)

TJC has followed suit by adding notes to two elements of performance to align its accreditation standards with the CMS requirements. TJC also added two elements of performance: (1) requiring hospitals to allow a support person to stay with a patient during the course of a hospital stay; and (2) prohibiting discrimination generally on the basis of age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, and gender identity or expression. The notes and the new elements of performance were effective as of July 1. (For more information, see the July 13 edition of The Joint Commission Online.)

For more details or if you have any questions, please contact Sarah Coyne at (608) 283-2435 / [email protected], Kevin Eldridge at (608) 283-2452 / [email protected] or your Quarles & Brady attorney.

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