CMS SOM App. W, Tag C-1054

A CAH must have written policies

and procedures regarding the visitation rights of patients, including those setting

forth any clinically necessary or reasonable restriction or limitation that the CAH

may need to place on such rights and the reasons for the clinical restriction or

limitation….

Interpretive Guidelines §485.635(f)

Visitation plays an important role in the care of hospital patients, including CAHs. An

article published in 2004 in the Journal of the American Medical Association (Berwick,

D.M., and Kotagal, M.: “Restricted visiting hours in ICUs: time to change.”

JAMA. 2004; Vol. 292, pp. 736-737) discusses the health and safety benefits of open

visitation for patients, families, and intensive care unit (ICU) staff and debunks some of

the myths surrounding the issue (physiologic stress for the patient; barriers to provision

of care; exhaustion of family and friends). The article ultimately concluded that

“available evidence indicates that hazards and problems regarding open visitation are

generally overstated and manageable,” and that such visitation policies “do not harm

patients but rather may help them by providing a support system and shaping a more

familiar environment” as they “engender trust in families, creating a better working

relationship between hospital staff and family members.” CAHs that unnecessarily

restrict patient visitation often miss an opportunity to gain valuable patient information

from those who may know the patient best with respect to the patient’s medical history,

conditions, medications, and allergies, particularly if the patient has difficulties with

recall or articulation, or is totally unable to recall or articulate this vital personal

information. Many times visitors who may know the patient best act as an intermediary

for the patient, helping to communicate the patient’s needs to CAH staff.

Although visitation policies are generally considered to relate to visitors of inpatients,

“visitors” also play a role for outpatients who wish to have a support person present

during their outpatient visit. For example, a same-day surgery patient may wish to have a

support person present during the pre-operative patient preparation or post-operative

recovery. Or an outpatient clinic patient may wish to have a support person present

during their examination by a physician. Accordingly, CAH visitation policies must

address both the inpatient and outpatient settings.

CAHs are required to develop and implement written policies and procedures that address

the patient’s right to have visitors. If the CAH’s policy establishes restrictions or

limitations on visitation, such restrictions/limitations must be clinically necessary.

Furthermore, the CAH’s policy must include the reasons for any restrictions/limitations.

The right of a patient to have visitors may be limited or restricted when visitation would

interfere with the care of the patient and/or the care of other patients. The regulation

permits CAHs some flexibility, so that health care professionals may exercise their best

clinical judgment when determining when visitation is, and is not, appropriate. Best

clinical judgment takes into account all aspects of patient health and safety, including the

benefits of visitation on a patient’s care as well as potential negative impacts that visitors

may have on other patients in the CAH.

Broad examples of clinically reasonable bases for a CAH to impose restrictions or

limitations on visitors might include (but are not limited to) when:

• there may be infection control issues;

• visitation may interfere with the care of other patients;

• the CAH is aware that there is an existing court order restricting contact;

• visitors engage in disruptive, threatening, or violent behavior of any kind;

• the patient or patient’s roommate needs rest or privacy;

• in the case of an inpatient substance abuse treatment program, there are protocols

limiting visitation; and

• the patient is undergoing care interventions. However, while there may be valid

reasons for limiting visitation during a care intervention, we encourage CAHs to

try to accommodate the needs of any patient who requests that at least one visitor

be allowed to remain in the room to provide support and comfort at such times.

It may also be reasonable to limit the number of visitors for any one patient during a

specific period of time, as well as to establish minimum age requirements for child

visitors. However, when a CAH adopts policies that limit or restrict patients’ visitation

rights, the burden of proof is upon the CAH to demonstrate that the visitation restriction

is reasonably necessary to provide safe care.

CAHs are expected to provide a clear explanation in their written policy of the clinical

rationale for any visitation restrictions or limitations reflected in that policy. CAHs are

not required, however, to delineate each specific clinical reason for policies limiting or

restricting visitation, given that it is not possible to anticipate every instance that may

give rise to a clinically appropriate rationale for a restriction or limitation. If visitation

policies differ by type of unit, e.g., separate policies for intensive care units, or for

newborn nurseries, the CAH policy must address the clinical rationale for this

differentiation explicitly.

The CAH’s policies and procedures are expected to address how CAH staff who play a

role in facilitating or controlling visitor access to patients will be trained so as to assure

appropriate implementation of the visitation policies and procedures and avoidance of

unnecessary restrictions or limitations on patients’ visitation rights.

Survey Procedures §485.635(f)

• Verify that the CAH has written policies and procedures that address the right of

patients to have visitors.

• Review the policy to determine if there are limitations or restrictions on visitation. If

there are, does the policy explain the clinical rationale for the restrictions or

limitations? Is the rationale clear and reasonably related to clinical concerns?

• Is there documentation of how the CAH identifies and trains staff who play a role in

facilitating or limiting/restricting access of visitors to patients?

• Are CAH staff aware of the visitation policies and procedures? Can staff on a given

unit correctly describe the CAH’s visitation policies for that unit?