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The compliance tip of the month for January is focused on Patient Rights specifically related to notification of hospitalization to either a family member or their own personal physician even if the admission is elective.

The challenge for organizations seems to center around the documentation. When asked, staff members will explain that the information is provided to the patient as part of the admission process. However, to provide evidence of compliance there needs to be clear documentation of not only the information being provided but the patient wishes regarding the notification and the attempts or success of the notification.

The medical record needs to indicate:

1. Whether or not the patient wishes to have a family member, or their own physician notified of their admission to the hospital.
2. If yes, then the steps used to assure that the notification was made or at least attempted.

The CMS regulation is included below. Additionally, the CMS interpretive Guidelines are included for further clarification.

§482.13(b)(4) - The patient has the right to have a family member or representative of his or her choice and his or her own physician notified promptly of his or her admission to the hospital.

For every inpatient admission, the hospital must ask the patient whether the hospital should notify a family member or representative about the admission. If the patient requests such notice and identifies the family member or representative to be notified, the hospital must provide such notice promptly to the designated individual. The explicit designation of a family member or representative by the patient takes precedence over any non-designated relationship.

The hospital must also ask the patient whether the hospital should notify his/her own physician. In the case of scheduled admissions, the patient’s own physician likely is already aware of the admission. However, if the patient requests notice to and identifies the physician, the hospital must provide such notice promptly to the designated physician, regardless of whether the admission was scheduled in advance or emergent.

When a patient is incapacitated or otherwise unable to communicate and to identify a family member or representative to be notified, the hospital must make reasonable efforts to identify and promptly notify a family member or patient’s representative. If an individual who has accompanied the patient to the hospital, or who comes to or contacts the hospital after the patient has been admitted, asserts that he or she is the patient’s spouse, domestic partner (whether or not formally established and including a same-sex domestic partner), parent (including someone who has stood in loco parentis for the patient who is a minor child), or other family member, the hospital is expected to accept this assertion, without demanding supporting documentation, and provide this individual information about the patient’s admission, unless:

• More than one individual claims to be the patient’s family member or representative. In such cases it would not be inappropriate for the hospital to ask each individual for documentation supporting his/her claim to be the patient’s family member or representative. The hospital should make its determination of who is the patient’s representative based upon the hospital’s determination of who the patient would most want to make decisions on his/her behalf. Examples of documentation a hospital might consider could include, but are not limited to, the following: proof of a legally recognized marriage, domestic partnership, or civil union; proof of a joint household; proof of shared or co-mingled finances; and any other documentation the hospital considers evidence of a special relationship that indicates familiarity with the patient’s preferences concerning medical treatment ;
• Treating the individual as the patient’s family member or representative without requesting supporting documentation would result in the hospital violating State law. State laws, including State regulations, may specify a procedure for determining who may be considered to be the incapacitated patient’s family member or representative, and may specify when documentation is or is not required; or
• The hospital has reasonable cause to believe that the individual is falsely claiming to be the patient’s spouse, domestic partner, parent or other family member.

Hospitals are expected to adopt policies and procedures that facilitate expeditious and non-discriminatory resolution of disputes about whether an individual should be notified as the patient’s family member or representative, given the critical role of the representative in exercising the patient’s rights. Hospitals may also choose to provide notice to more than one family member.

When a patient is incapacitated and the hospital is able through reasonable efforts to identify the patient’s own physician – e.g., through information obtained from a family member, or from review of prior admissions or outpatient encounters, or through access to the patient’s records in a regional system of electronic patient medical records in which the hospital participates – the hospital must promptly notify the patient’s physician of the admission.

The hospital must provide the required notice promptly. “Promptly” means as soon as possible after the physician’s or other qualified practitioner’s order to admit the patient has been given. Notice may be given orally in person, by telephone, by e-mail or other electronic means, or by other methods that achieve prompt notification. It is not acceptable for the hospital to send a letter by regular mail.

The hospital must document that the patient, unless incapacitated, was asked no later than the time of admission whether he or she wanted a family member/representative notified, the date, time and method of notification when the patient requested such, or whether the patient declined to have notice provided. If the patient was incapacitated at the time of admission, the medical record must indicate what steps were taken to identify and provide notice to a family member/representative and to the patient’s physician.

CIHQ encourages organization to evaluate the process used in order to identify a compliance issue and develop and implement a plan to eliminate the potential for a deficiency to be cited during survey.

The following resources are provided to CIHQ accredited organization as well as ARS member to assist with compliance to this regulation:

ARS Resource Library:
#1000 – Form Patient Notification of Admission Acknowledgment Form
#3015 – Patient Right to Notify Others of an Inpatient Admission
#2112 – Tool – Patient Rights & Responsibilities Information Pamphlet

ARS Staff Training Library:
#03 – Basic Patient Rights

CIHQ is on track for redesignation by CMS as an approved accrediting organizations for hospitals. We were approved and published in the Federal Register on December 19, 2022. Below is a link for your reference.

Federal Register :: Public Inspection: Medicare and Medicaid Programs: Application from the Center for Improvement in Healthcare Quality for Continued Approval of its Hospital Accreditation

The longest designation that CMS can award is for six years. CIHQ was awarded a five-year designation. This was determined based on budgetary issues at CMS. They were not able to shadow a survey which is a part of the application process which prohibited them from awarding the full six years.

CIHQ is expanding its accreditation programs to Critical Access Hospitals.

• Submission of the Application – Submitted on October 4, 2022.
• The application has been deemed complete by CMS and the review of the CIHQ standards crosswalk to CMS CoP for CAH has begun. We will keep you updated as we move through this process. We have completed the five pilot surveys and wish to thank them for allowing us to pilot our process in their hospital.
• Northeastern Vermont Regional Hospital
• Jackson County Hospital District
• Glen Medical Center
• Union County General Hospital
• Pawnee Valley Community Hospital
• Next steps will be a virtual office review, and shadow survey (dates to be determined)

CIHQ is expanding its accreditation programs to Critical Access Hospitals.

• Submission of the Application – Submission is scheduled for February 2023
• The application, standards and process review will occur. We will complete the five pilot surveys and wish to thank them for allowing us to pilot our process in their hospital.
  • Griffin Memorial Medical Center
  • SD Human Services Center
  • Adventist Health Vallejo
  • East End Behavioral Health Hospital
  • Glendora Hospital – A College Behavioral Health Hospital
• Next steps will be a virtual office review, and shadow survey (dates to be determined)