CMS SOM App. W, Tag C-1058

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. A CAH must meet the following requirements:

(3) Not restrict, limit, or otherwise deny visitation privileges on the basis of

race, color, national origin, religion, sex, gender identity, sexual orientation, or

disability.

(4) Ensure that all visitors enjoy full and equal visitation privileges

consistent with patient preferences.

Interpretive Guidelines §485.635(f)(3)&(4)

The CAH’s visitation policies and procedures may not use the race, color, national origin,

religion, sex, gender identity, sexual orientation, or disability of either the patient (or the

patient’s support person, where appropriate) or the patient’s visitors (including

individuals seeking to visit the patient) as a basis for limiting, restricting, or otherwise

denying visitation privileges.

The CAH’s policies and procedures must ensure that all visitors (including individuals

seeking to visit the patient) enjoy full and equal visitation privileges, consistent with the

preferences the patient (or, where appropriate, the patient’s support person) has expressed

concerning visitors. In other words, it is permissible for the patient (or the patient’s

support person, where appropriate) to limit the visiting privileges of his/her visitors,

including providing for more limited visiting privileges for some visitors than those for

others. But it is not permissible for the CAH, on its own, to differentiate among visitors

without any clinically necessary or reasonable basis. This includes visitors designated by

the patient who have characteristics not addressed specifically in §485.635(f)(3), when

those characteristics do not reasonably relate to a clinically reasonable basis for limiting

or denying visitation. For example, it would not be appropriate to prohibit a designated

visitor based on that individual’s style of dress, unless there was a clinically reasonable

basis for doing so.

The CAH is responsible for ensuring that CAH staff treat all individuals seeking to visit

patients equally, consistent with the preferences of the patient (or, where appropriate, the

patient’s support person) and do not use the race, color, national origin, religion, sex,

gender identity, sexual orientation, or disability of either the patient (or the patient’s

support person, where appropriate) or the patient’s visitors (including individuals seeking

to visit the patient)as a basis for limiting, restricting, or otherwise denying visitation

privileges. CAHs are expected to educate all staff who play a role in facilitating or

controlling visitors on the CAH’s visitation policies and procedures, and are responsible

for ensuring that staff implement the CAH’s policies correctly. CAHs are urged to

develop culturally competent training programs designed to address the range of patients

served by the CAH.

Survey Procedures §485.635(f)(3)&(4)

• Review the CAH’s visitation policies and procedures to determine whether they

restrict, limit, or otherwise deny visitation to individuals on a prohibited basis.

• Ask the CAH how it educates staff to assure that visitation policies are implemented

in a non-discriminatory manner.

• Ask CAH staff who play a role in facilitating or controlling visitors to discuss their

understanding of the circumstances under which visitors may be subject to

restrictions/limitations. Are the restrictions/limitations appropriately based on the

CAH’s clinically-based policies?

• Ask CAH patients (or patients’ support persons, where appropriate) whether the CAH

has limited visitors against their wishes? If yes, verify whether the

restriction/limitation on visitors was addressed in the CAH’s visitation policies and in

the patient notice, and whether it was appropriately based on a clinical rationale rather

than impermissible discrimination.