CMS SOM App. U, Tag R103

The patient has the right to:

(1) Be informed of his or her rights and to participate in the development and

implementation of his or her plan of care.

Interpretive Guidelines: §403.730(b)(1)

The patient has the right to make an informed decision regarding his/her care in the

RNHCI. The right to make informed decisions means that the patient or patient’s

representative is given the information needed in order to make "informed" decisions

regarding his/her care. The right to make informed decisions regarding care presumes

that the patient has been provided with information about his/her health status and has

chosen care to be provided by the RNHCI. A RNHCI does not provide medical treatment

or biologics. However, the patient will still have a plan of care provided by the RNHCI.

The patient's participation in the development of their plan of care should be encouraged.

The patient or the patient's representative should receive adequate information, provided

in a manner that the patient or the patient's representative can understand, to ensure that

the patient can effectively exercise the right to make informed decisions.

Survey Procedures:

• Interview a sample of patient(s). During the interview:

o Ask the patient to describe the services that he or she is receiving specific

to the plan of care.

o Ask the patient how he or she was told of any changes in the plan of care.

o Discuss the changes and see if the patient has received written information

and if the patient understands the information.

o Determine the extent to which the facility initiates activities that involve

the patient in his or her care.

• Interview a member of the care team and ask them to describe how patients are

informed of their plan of care and participate in the plan of care.

• Determine based on the interviews and record review, whether the RNHCI is

compliant with this requirement.