CMS SOM App. PP, Tag F552

The resident has the right to be informed of, and participate in, his or her treatment,

including:

§483.10(c)(1) The right to be fully informed in language that he or she can understand of

his or her total health status, including but not limited to, his or her medical condition.

§483.10(c)(4) The right to be informed, in advance, of the care to be furnished and the type

of care giver or professional that will furnish care.

§483.10(c)(5) The right to be informed in advance, by the physician or other practitioner or

professional, of the risks and benefits of proposed care, of treatment and treatment

alternatives or treatment options and to choose the alternative or option he or she prefers.

DEFINITIONS §483.10(c)(1), (4)-(5)

“Total health status” includes functional status, nutritional status, rehabilitation and restorative

potential, ability to participate in activities, cognitive status, oral health status, psychosocial

status, and sensory and physical impairments.

“Treatment” refers to medical care, nursing care, and interventions provided to maintain or

restore health and well-being, improve functional level, or relieve symptoms.

GUIDANCE §483.10(c)(1), (4)-(5)

Health information and services must be provided in ways that are easy for the resident and/or

the resident’s representative to understand. This includes, but is not limited to, communicating

in plain language, explaining technical and medical terminology in a way that makes sense to the

resident, offering language assistance services to residents who have limited English proficiency,

and providing qualified sign language interpreters or auxiliary aids if hearing is impaired. This

does not mean that a facility is required to supply and pay for hearing aids.

The physician or other practitioner or professional must inform the resident or their

representative in advance of treatment risks and benefits, options, and alternatives. The

information should be communicated at times it would be most useful to them, such as when

they are expressing concerns, raising questions, or when a change in treatment is being proposed.

The resident or resident representative has the right to choose the option he or she prefers.

Discussion and documentation of the resident's choices regarding future health care may take

place during the development of the initial comprehensive assessment and care plan and

periodically thereafter.

NOTE: While surveyors must only cite F552 when deficient practice is found related to

applicable program requirements as reflected in the CFR, the following information may

inform surveyors about important considerations in making compliance decisions. The

Federal Patient Self - Determination Act contained in Public Law 101-508 is the authority on

an individual’s rights and facility responsibilities related to advance directives. This

includes, the right of an individual to direct his or her own medical treatment, including

withholding or withdrawing life-sustaining treatment. If there are concerns with advance

directives, refer to §483.10(g)(12), F578.

See §483.21(a), F655 (Baseline Care Plans), Comprehensive Person-Centered Care Planning, for

additional guidance.