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Resident Right to Access and Visitation Policy

Resident Right to Access and Visitation
Date Implemented: 7/25/2022 Date Reviewed/Revised: 8/1/2022 Reviewed/Revised By: Angela McDaniel RN
VP Clinical Services

Policy:

It is the policy of this facility to support and facilitate the resident’s right to receive visitors of their choosing, at the time of their choosing, subject to the resident’s right to deny visitation when applicable, and in a manner that does not impose on the rights of other residents.  Visitation will be person-centered, consider the residents’ physical, mental, and psychosocial well-being, and support their quality of life.

Definition:

“Reasonable clinical and safety restrictions” include a facility’s policies, procedures or practices that protect the health and security of all residents and staff.

Policy Explanation and Compliance Guidelines:

  1. The facility will provide immediate access to any resident by:
    1. Any representative of the Secretary;
    2. Any representative of the State;
    3. Any representative of the Office of the State Long Term Care Ombudsman;
    4. The resident’s individual physician;
    5. Any representative of the agency responsible for the protection and advocacy system for the developmentally disabled individuals;
    6. Any representative of the agency responsible for the protection and advocacy system for individuals with mental disorder;
    7. The resident representative.
  2. The facility will provide immediate access to a resident by immediate family and other relatives of the resident, subject to the resident’s right to deny or withdraw consent at the time. Resident’s family members are not subject to visiting hour limitations or other restrictions not imposed by the resident, with the exception of reasonable clinical and safety restrictions, placed by the facility based on recommendations of CMS, CDC, or the local health department.
  3. If familial visits infringe upon the rights of other residents (e.g. family visits late at night when the resident’s roommate is already asleep), staff will find a location other than the resident’s room for visits.
  4. The facility will provide immediate access to a resident by others who are visiting with the consent of the resident, subject to reasonable clinical and safety restrictions and the resident’s right to deny or withdraw consent at any time.
  5. The facility will provide reasonable access to a resident by any entity or individual that provides health, social, legal, or other services to the resident, subject to the resident’s right to deny or withdraw consent at any time. Facility staff will provide space and privacy for these visits.
  6. The facility will inform each resident and/or resident representative of his or her visitation rights and related facility policies and procedures, including any clinical or safety restriction or limitation of such rights, in a manner he or she understands.
  7. The facility will inform each resident of the right, subject to his or her consent, to receive the visitors whom he or she designates as well as deny visitation, including but not limited to:
    1. A spouse, including a same-sex spouse
    2. A domestic partner, including a same-sex domestic partner
    3. Another family member
    4. Adoptive/foster family members
    5. A friend
  8. The facility will not restrict, limit, or otherwise deny visitation privileges based on race, color, national origin, religion, sex, gender identity, sexual orientation, or disability.
  9. Residents have the right to define their family. During the admissions process, facility staff will discuss this issue with the resident.  If the resident is unable to express or communicate whom they identify as family, facility staff will discuss this with the resident’s representative.
  10. The Office of the State Long-Term Care Ombudsman will be given access to examine a resident’s medical, social, and administrative records in accordance with State law.
  11. The facility will ensure all visitors enjoy full and equal visitation privileges consistent with resident preferences.
  12. Reasonable clinical and safety restrictions that protect the health and security of all residents and staff, which may include, but are not limited to:
    1. Placing visitation restrictions to prevent community-associated infection or communicable disease transmission to one or more residents. A residents risk factors for infection
      (e.g. immunocompromised) or current health state (e.g. end of life care) will be considered when restricting visitors. 
    2. Visitors with signs and symptoms of a transmissible infection (e.g., a visitor is febrile and exhibiting signs and symptoms of an influenza-like illness) will be asked to defer visitation until they are no longer potentially infectious (e.g., 24 hours after resolution outbreak of fever without antipyretic medication), or according to CMS or CDC guidelines, and/or local health department recommendations.
    3. Keeping the facility locked at night with a system in place for allowing visitors approved by the resident.
    4. Denying access or providing limited and supervised access to a visitor if that individual has been found to be abusing, exploiting, or coercing a resident until an investigation into the allegation has been completed or has been found to be abusing, exploiting, or coercing a resident.
    5. Denying access to a visitor who has been found to have been committing criminal acts such as theft.
    6. Denying access to visitors who are inebriated and disruptive.
    7. Denying access or providing supervised visitation to individuals who have a history of bringing illegal substances into the facility which places residents’ health and safety at risk.
      1. If the facility determines illegal substances have been brought into the facility by a visitor, the facility will not act as an arm of law enforcement. Rather, in accordance with state laws, these cases will be referred to local law enforcement.
      2. Facility staff will not conduct searches of a resident or their personal belongings, unless the resident or resident representative agrees to a voluntary search and understands the reason for the search.

 

References:

Centers for Medicare & Medicaid Services, Department of Health and Human Services. State Operations Manual (SOM): Appendix PP Guidance to Surveyors for Long Term Care Facilities. (October 2022 Revision)  F563 – Right to Receive/Deny Visitors. 42 C.F.R. §483.10(f).

Centers for Medicare & Medicaid Services, Department of Health and Human Services. State Operations Manual (SOM): Appendix PP Guidance to Surveyors for Long Term Care Facilities. (October 2022 Revision)  F564 – Inform of Visitation Rights/Equal Visitation priviledges. 42 C.F.R. §483.10(f).

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