CMS 15.00.00 482.13 Condition of Participation: Patient Rights 15.01.00 Not Applicable Patient Rights 15.01.02 15.01.01 Not Applicable 15.01.02 482.13(a) 482.13(a)(1) Notice of Patient Rights 15.01.03 482.13(a)(2) Patient Grievances 15.01.04 482.13(a)(2) Governing Body Responsibility for the Grievance Process 15.01.05 482.13(a)(2) Timely Referrals 15.01.06 482.13(a)(2)(i) Grievance Process 15.01.07 482.13(a)(2)(ii) Grievance Process Response Timeframes 15.01.08 482.13(a)(2)(iii) Patient Notification of the Grievance Process Chapter 15 Patient Rights and Discharge Planning Page 1
CMS 15.01.09 482.13(b)(1) 482.13(b)(3) 482.13(b)(3) 482.13(b)(4) 482.13(c)(1) 482.13(c)(2) 482.13(c)(3) 482.13(d)(1) 482.13(d)(2) 482.13(e)(1) 482.13(b)(2) 482.13(h)(1)(2)(3)(4) Exercise of Patient s Rights 15.01.10 482.13(b)(1) Participation in the Plan of Care 15.01.11 482.12(b)(2) Participation in Decision Making 15.01.12 482.13(b)(3) Advance Directives 15.01.13 Not Applicable Patient Self- Determination (Advance Directives) 15.01.12 15.01.14 482.13(b)(4) Admission Notification 15.01.15 Not Applicable 15.01.16 482.13(c) 482.13(c)(1) Privacy & Safety: Personal Privacy 15.01.17 482.13(c)(2) Privacy & Safety: Safe Setting 15.01.18 482.13(c)(3) Privacy & Safety: Free From Abuse Chapter 15 Patient Rights and Discharge Planning Page 2
CMS 15.01.19 Not Applicable Suspected Abuse / Neglect 15.01.18 Patients 15.01.20 Not Applicable 15.01.21 482.13(d) 482.13(d)(1) Confidentiality of Patient Records changed from "Confidentiality of Patient Records: Confidentiality of Medical Records" 15.01.22 482.13(d)(2) 15.01.23 482.13(e) Access to Medical Records Restraint or Seclusion Re-numbered 15.02.00 15.01.24 Not Applicable 15.01.25 482.13(h) Visitation Rights 15.01.26 482.13(h)(1) 482.13(h)(2) Patient Visitation Rights Visitation Rights - Clinical Restrictions 15.01.27 482.13(h)(2) Visitation Rights - Patient Determination Incorporate into 15.01.26 15.01.28 482.13(h)(3) 482.13(h)(4) Visitation Rights - Discrimination 15.01.29 482.13(h)(4) Visitation Rights - Fair Application of Process Incorporate into 15.01.28 15.02.00 482.13(e) Restraint or Seclusion 15.01.23 Chapter 15 Patient Rights and Discharge Planning Page 3
CMS 15.02.01 482.13(e)(1)(i)(A) 15.02.02 482.13(e)(1)(i)(B) Restraint Definitions Medication as a Restraint 15.02.03 482.13(e)(1)(i)(C) Non-Restraints 15.02.04 482.13(e)(1)(ii) 15.02.05 482.13(e)(2) Definition of Seclusion Least Restrictive Interventions 15.02.06 Not Applicable 15.02.07 482.13(e)(3) Effective Restraints 15.02.08 482.13(e)(4) 482.13(e)(4)(i) Modification of the Plan of Care - Restraint or Seclusion 15.02.09 482.13(e)(4)(ii) Safe Application 15.02.10 482.13(e)(5) Orders for Restraint or Seclusion 15.02.11 482.13(e)(6) Use of Standing or PRN Orders 15.02.12 482.13(e)(7) Physician Notification of Restraint Use 15.02.13 482.13(e)(8)(i) Restraint Orders for Management of Violent Behavior 15.02.14 482.13(e)(8)(ii) Physician Assessment 15.02.15 482.13(e)(8)(iii) Renewal of Restraint Orders 15.02.16 482.13(e)(9) Discontinuation of Restraints Chapter 15 Patient Rights and Discharge Planning Page 4
CMS 15.02.17 482.13(e)(10) Monitoring of the Patient 15.02.18 482.13(e)(11) Physician 15.02.19 482.13(e)(12)(i) One Hour Face-to- Face 15.02.20 482.13(e)(12)(ii) Physician Assessment Requirements 15.02.21 482.13(e)(13) State Requirements 15.02.22 482.13(e)(14) Physician Notification 15.02.23 482.13(e)(15) Simultaneous Use of Restraint and Seclusion 15.02.24 482.13(e)(16)(i) Requirements for 15.02.25 482.13(e)(16)(ii) Requirements for 15.02.26 482.13(e)(16)(iii) Requirements for 15.02.27 482.13(e)(16)(iv) Requirements for 15.02.28 482.13(e)(16)(v) Requirements for Clarification 15.02.29 482.13(f) Staff Requirements - Use of Restraints or Seclusion 15.02.30 482.13(f)(1)(i) 482.13(f)(1)(ii) 482.13(f)(1)(iii) Intervals 15.02.31 482.13(f)(2)(i) Content Chapter 15 Patient Rights and Discharge Planning Page 5
CMS 15.02.32 482.13(f)(2)(ii) Requirements: Nonphysical Intervention 15.02.33 482.13(f)(2)(iii) Requirements: Least Restrictive Intervention 15.02.34 482.13(f)(2)(iv) 15.02.35 482.13(f)(2)(v) Requirements: Safe Application Requirements: Restraint Removal 15.02.36 482.13(f)(2)(vi) Requirements: Patient Monitoring 15.02.37 482.13(f)(2)(vii) 15.02.38 482.13(f)(3) 15.02.39 482.13(f)(4) Requirements: CPR Trainer Requirements 15.02.40 Not Applicable Restraint Data 15.02.41 482.13(g)(1) 482.13(g)(1)(i)(ii)(iii) 482.13(g)(2) 482.13(g)(2)(i)(ii) 482.13(g)(3) 482.13(g)(4) 482.13(g)(4)(i)(ii)(iii) Death Related to Restraint or Seclusion - Reporting Requirements 15.03.00 482.43 Condition of Participation: Discharge Planning 15.06.00 Chapter 15 Patient Rights and Discharge Planning Page 6
CMS 15.03.01 482.43(a) Discharge Planning - Identification of Patients in Need 15.06.01 15.03.02 482.43(b) 482.43(b)(1) 482.43(b)(3) 482.43(b)(4) Discharge Planning Evaluation 15.06.02 15.03.03 482.43(b)(2) Discharge Planning - Staff Qualifications 15.06.03 15.03.04 Not Applicable 15.03.05 Not Applicable 15.03.06 482.43(b)(5) Timeliness of Assessment Incorporate into 15.03.02 Incorporate into 15.03.02 15.06.06 15.03.07 482.43(b)(6) Patient Involvement & Requirements 15.06.07 15.03.08 Not Applicable 15.03.09 482.43(c) 482.43(c)(1) Discharge Planning: Required Supervision 15.06.09 15.03.10 482.43(c)(2) Discharge Plan - Physician Request 15.06.10 15.03.11 482.43(c)(3) 482.43(c)(5) Implementation of the Discharge Plan 15.06.11 15.03.12 482.43(c)(4) Plan Reassessment 15.06.12 15.03.13 Not Applicable Incorporate into 15.03.11 Chapter 15 Patient Rights and Discharge Planning Page 7
CMS 15.03.14 482.43(c)(6) 482.43(c)(6)(i) 482.43(c)(6)(ii) 482.43(c)(6)(iii) 482.43(c)(7) 482.43(c)(8) Selection of Discharge Care Providers 15.06.14 15.03.15 Not Applicable 15.06.14 15.03.16 Not Applicable 15.06.14 15.03.17 Not Applicable 15.06.14 15.03.18 Not Applicable 15.06.14 15.03.19 Not Applicable 15.06.14 15.03.20 Not Applicable 15.06.14 15.03.21 Not Applicable 15.06.14 15.03.22 Not Applicable 15.06.14 15.03.23 482.43(d) 15.03.24 482.43(e) Transfer or Referral Discharge Plan Reassessment 15.06.23 15.06.24 15.03.25 Not Applicable Incorporate into 15.06.26 15.06.27 15.03.26 Discharge Instructions 15.06.26 15.03.27 Discharge Checklist 15.06.27 Chapter 15 Patient Rights and Discharge Planning Page 8
CMS 16.00.00 482.23 Condition of Participation: Nursing Services 16.00.02 16.00.01 Not Applicable 16.00.02 Not Applicable Plan for Nursing Care 16.00.04 Re-numbered 16.00.00 16.00.03 482.23(a) 16.00.04 482.23(b) Nursing Organization Staffing and Delivery of Care Staffing 16.00.05 482.23(b)(1) 24-Hour Provision of Services 16.00.06 482.23(b)(2) Licensure 16.00.07 Not Applicable 16.00.00 16.00.08 Not Applicable 16.00.00 16.00.09 482.23(b)(3) Supervision of Care 16.00.10 482.23(b)(4) Plan of Care 16.00.11 482.23(b)(5) Care Assignments 16.00.12 Not Applicable 16.00.04 16.00.05 16.00.13 482.23(b)(6) Supervision of Nonemployee Staff Format Chapter 16 Nursing Department Page 9
CMS 16.00.14 Not Applicable 16.00.04 04.00.12 16.00.15 Not Applicable 04.00.12 16.00.16 Not Applicable 04.00.12 16.01.01 482.23(c) 482.23(c)(1) 482.23(c)(1)(i) 482.23(c)(2) Preparation and Administration of Drugs Medication Administration 16.01.02 Not Applicable Incorporated into 16.01.01 16.01.03 482.23(c)(1)(ii) 482.23(c)(3) 482.23(c)(3)(iii) Medication Orders 16.01.04 482.23(c)(3)(i) Verbal Orders 16.01.05 482.23(c)(3)(ii) Accepting Verbal Orders 16.01.06 482.23(c)(4) Administration of Blood Products and IV Medications 16.01.07 482.23(c)(5) Adverse Drug Reactions, Transfusion Reaction, & Medical Error Reporting 16.01.08 Not Applicable Incorporated into 16.01.03 Chapter 16 Nursing Department Page 10
CMS 16.01.09 482.23(c)(6) 482.23(c)(6)(i) 482.23(c)(6)(i)(A) 482.23(c)(6)(i)(B) 482.23(c)(6)(i)(C) 482.23(c)(6)(i)(D) 482.23(c)(6)(i)(E) Self-Administration of Medications: Hospital Issued Medications Incorporated 16.01.10 16.01.10 482.23(c)(6)(ii) 482.23(c)(6)(ii)(A) 482.23(c)(6)(ii)(B) 482.23(c)(6)(ii)(C) 482.23(c)(6)(ii)(D) 482.23(c)(6)(ii)(E) Self-Administration of Hospital Issued Medications: Medications Brought into the Hospital Incorporated into 16.01.09 16.01.11 Not Applicable Re-numbered 16.01.10 16.02.00 Not Applicable 16.02.01 Assessment 16.00.04 16.00.10 16.02.02 Patients at Risk Relocated to the new Chapter 33 Patient Safety Patient Safety Initiative 16.02.03 List of Patient Problems 10.01.21 16.02.04 Not Applicable 16.02.05 Reassessements of Patients 10.01.25 10.01.28 15.01.10 16.00.10 16.03.00 Standards of Practice & Care 16.03.01 Standards of Practice Chapter 16 Nursing Department Page 11
CMS 16.03.02 Clinical Practice Standards 16.03.03 Standards Content 16.03.04 Standards of Care 16.03.05 Standards Availability 16.03.06 Standards Review 16.04.01 Nursing Quality Assessment Performance Improvement (QAPI) 12.00.04 16.04.02 Use of QAPI Data 12.00.04 Chapter 16 Nursing Department Page 12