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Description
Advance directives play a critical role in ensuring that patient preferences are respected when they are unable to communicate their healthcare decisions. Healthcare organizations must comply with strict regulatory requirements set by the Centers for Medicare & Medicaid Services (CMS) and The Joint Commission (TJC), along with federal laws such as the Patient Self-Determination Act.
Failure to properly implement and document advance directives can lead to compliance violations, legal risks, and patient safety concerns. Hospitals are increasingly being cited for deficiencies in this area, making it essential to understand and follow regulatory expectations.
This guide explains CMS and TJC requirements, common compliance gaps, and best practices for managing advance directives effectively.
What Are Advance Directives?
Advance directives are legal documents that allow patients to outline their medical care preferences if they become unable to communicate.
Common Types:
- Living wills
- Durable Power of Attorney (DPOA)
- Do Not Resuscitate (DNR) orders
- Organ donation directives
CMS Requirements for Advance Directives
CMS requires hospitals to comply with Conditions of Participation (CoPs) related to patient rights and advance directives.
Key Requirements:
- Inform patients of their rights
- Document advance directives in records
- Provide information to:
- Inpatients
- Emergency patients
- Observation patients
- Same-day surgery patients
Joint Commission (TJC) Standards
The Joint Commission requires healthcare organizations to:
- Respect patient preferences
- Ensure proper documentation
- Educate staff on advance directives
- Maintain compliance with patient-centered care standards
Patient Self-Determination Act (PSDA)
This federal law requires healthcare providers to:
- Inform patients about advance directives
- Document whether a patient has one
- Ensure policies are in place
Common Deficiencies Found by CMS
Hospitals frequently face issues such as:
- Not asking patients about advance directives
- Missing documentation
- Failure to inform patients of their rights
- Poor staff training
Risks of Non-Compliance
- Legal cases and malpractice claims
- Financial penalties
- Increased regulatory scrutiny
- Patient dissatisfaction
Best Practices for Compliance
- Standardize admission procedures
- Train staff regularly
- Maintain accurate documentation
- Conduct internal audits
- Use compliance checklists
Advance Directive Compliance Checklist
- Ask every patient about advance directives
- Document in medical records
- Inform patient representatives
- Ensure accessibility of documents
- Train staff on policies
- Audit compliance regularly
Learning Objectives
- Describe the CMS Conditions of Participation requirements for advance directives for hospitals
- Describe that the Joint Commission has standards on advance directives
- Explain what is required of hospitals under the federal law called the Patient Self-Determination Act
- Discuss which patients must and should be provided information on the hospital’s advance directive policies in the CMS CoP hospital manual.
Agenda
- Introduction
- Types of advance directives
- Case law related to Advance directives
- CMS payment for advance care planning
- Federal Laws on Advance Directives – Patient Self Determination Act
- Deficiency reports on advance directives
- CMS CoP on advance directives
- Required notice to patients
- Patient Representative
- Incompetent patients
- Patient rights and advance directives
- Hospital Policies
- Conscience objectors
- Informing the patient
- DNR and Surgery
- Transfer of a patient
- CAH and advance directives
- Joint Commission standards on advance directives
- Documenting advance directives under the Record of Care chapter
- Professional organization position statements on DNR (AORN, ACS, ASA, ASPAN, ACEP, ENA, etc.)
Appendix: Resources and links
Who Should Attend
- Compliance Officers
- Ethics Committee
- Social Workers
- Discharge Planners
- Consumer advocate
- Nurse Educator
- All nurses with direct patient care
- Director of Registration
- Registration staff
- Physicians
- Chief Medical Officer (CMO)
- Chief Nursing Officer (CNO)
- Nurse Managers/Supervisors
- Risk Managers
- Quality Improvement Director
- Joint Commission Coordinator
- Behavioral Health Staff
- Patient Safety Officer
- Outpatient and Emergency Department managers
- OR director
- Hospice director and unit staff.
Faqs
1. What are advance directives in healthcare?
They are legal documents that specify a patient’s medical care preferences.
2. Are advance directives required by CMS?
Yes, hospitals must comply with CMS Conditions of Participation.
3. What is the Patient Self-Determination Act?
A federal law requires hospitals to inform patients of their rights regarding medical decisions.
4. What are common CMS deficiencies?
Lack of documentation, failure to inform patients, and poor staff training.
5. How can hospitals ensure compliance?
By implementing policies, training staff, and conducting regular audits.
Speaker
Laura A. Dixon recently served as the Regional Director of Risk Management and Patient Safety for Kaiser Permanente Colorado, providing consultation and resources to clinical staff. Prior to joining Kaiser, she served as the Director of Facility Patient Safety and Risk Management and Operations for COPIC from 2014 to 2020. In her role, Ms. Dixon provided patient safety and risk management consultation and training to facilities, practitioners, and staff in multiple states. Such services included creating presentations on risk management topics, assessing healthcare facilities, developing programs, and compiling reference materials that complement physician-oriented products.
Before joining COPIC, she served as the Director, of the Western Region, Patient Safety and Risk Management for The Doctors Company, Napa, California. In this capacity, she provided patient safety and risk management consultation to the physicians and staff in the western United States. Ms. Dixon’s legal experience includes medical malpractice insurance defense and representation of nurses before the Colorado Board of Nursing.
Ms. Dixon has over twenty years of clinical experience in acute care facilities, including critical care, coronary care, peri-operative services, and pain management.
As a registered nurse and attorney, Laura holds a Bachelor of Science degree from Regis University, RECEP of Denver, a Doctor of Jurisprudence degree from Drake University College of Law, Des Moines, Iowa, and a Registered Nurse Diploma from Saint Luke’s School Professional Nursing, Cedar Rapids, Iowa. She is licensed to practice law in Colorado and California.