Healthcare Facility Compliance 15 items
Patient Rights & Informed Consent Audit
Audit of patient and resident rights covering notification of rights, informed consent, advance directives, grievances, and privacy across acute and long-term care.
CMS 42 CFR 482.13TJC Rights & Responsibilities (RI)CMS 42 CFR 483.10
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Notification of Rights
- Is each patient/resident informed of their rights before or at the start of care? *
- Are rights information and consent materials provided in a language/manner the patient understands? *
- Is the patient informed of the identity/role of physicians and practitioners responsible for their care? *
Informed Consent & Decision-Making
- Is informed consent obtained and documented for procedures/treatments requiring it? *
- Does the consent form include risks, benefits, alternatives, and the practitioner performing the procedure? *
- Is the patient's right to refuse care/treatment honored and documented? *
- Are surrogate decision-makers identified and documented when the patient lacks capacity? *
Advance Directives
- Is the patient asked whether they have an advance directive, and is it documented in the record? *
- Is written information about advance directive rights provided at admission? *
Grievances & Complaints
- Is there a documented process to promptly resolve patient grievances? *
- Does the patient receive written notice of the grievance decision with steps, results, and completion date? *
- Are patients informed of the right to file a complaint with the state agency regardless of internal process? *
Privacy, Confidentiality & Freedom from Abuse
- Is personal privacy provided during examinations, treatments, and personal care? *
- Is the patient free from all forms of abuse, neglect, and harassment? *
- Are visitation rights honored without discrimination, with any clinical restrictions documented? *
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