CMS SOM App. L, Tag Q-0219

The ASC must inform the patient or the patient’s representative or surrogate of the

patient’s rights and must protect and promote the exercise of these rights, as set

forth in this section. The ASC must also post the written notice of patient rights in a

place or places within the ASC likely to be noticed by patients waiting for treatment

or by the patient’s representative or surrogate, if applicable.

Interpretive Guidelines: §416.50

The ASC must inform each of its patients, or the patient’s representative or surrogate in

the case of minor patients or other situations where there is a designated representative

for the patient, of their rights as an ASC patient. Further, all of the ASC’s policies,

procedures and actions must be consistent with the protection of the patients’ rights

articulated in this Condition. Further, the ASC must actively promote the patient’s

exercise of their rights.

In addition, the ASC must ensure that the written notice of patient rights is posted in one

or more places where it is likely to be seen by patients waiting for treatment, or the

patient’s representative or surrogate, if applicable. Such areas include, but are not limited

to, waiting rooms or pre-operative preparation areas where patients are awaiting care.

Notices must be posted in at least one area. Whether the ASC must post more than one

notice depends on the size and physical layout of the areas where notices are posted. The

determining factor is whether the notice(s) are posted in a manner that all patients (or

their representatives or surrogates, as applicable) are likely to see the notice.

The patient’s representative or surrogate is an individual designated by the patient, in

accordance with applicable State law, to make health care decisions on behalf of the

individual or to otherwise assist the patient during his/her stay in the ASC. Designation

may be in writing, as in an advance directive or medical power of attorney, or may be

oral (verbal). Written designation may occur before the patient presents to the ASC, or

during the ASC registration process. Oral designation may take place at any time during

the patient’s visit in the ASC. The patient’s representative or surrogate includes, but is

not limited to, an individual who could be a family member or friend who accompanies

the patient. Depending on the designation the patient has made, the patient’s

representative or surrogate may make all health care decisions for the patient during

his/her ASC visit, or may act in a more limited role, for example, as a liaison between the

patient and the ASC to help the patient communicate, understand, remember, and cope

with the interactions that take place during the visit, and explain any instructions to the

patient that are delivered by the ASC staff. If a patient is unable to fully communicate

directly with the ASC staff, then the ASC may give patient rights information to the

patient’s representative or surrogate.

Survey Procedures: §416.50

When there is a team surveying the ASC, survey of the Patients’ Rights Condition should

be coordinated by one surveyor. However, each surveyor, as he or she conducts his/her

survey assignments, should assess the ASC’s compliance with the Patient’s Rights

regulatory requirements. It is particularly important for the surveyor who will be

following one or more patients from the start of their case to discharge to be observing

how the ASC’s actions protect and promote those patients’ exercise of their rights.

• Determine whether the ASC provides patients (or their representatives or

surrogates, as applicable), with notice of their rights, consistent with the standards

under this condition.

• Determine whether the ASC promotes the patients’ exercise of their rights (or

their representatives or surrogates, as applicable), consistent with the standards

under this condition.

Review posted notices to determine if they contain the same information as the individual

written notice provided to patients or their representatives/surrogates, as required under

§416.50(a). Deficiencies related to posting of the notice are to be cited using tag -Q0219.