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Advance Directives: Ensuring Compliance with CMS and TJC

Recorded Session | Sue Dill Calloway | From: Oct 26, 2020 - To: Dec 31, 2020
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Course Description

If CMS or The Joint Commission showed up tomorrow at your door would you be in compliance with the advance directive requirements? Did you know there was a federal law that addresses advance directives that all hospitals must be in compliance with? Did you know that CMS reimburses some physicians for advance care planning? Did you know better end-of-life care can reduce readmissions? Hospitals need to do this right or they can face a wrongful death or medical malpractice case.

Advance care planning is making decisions about the care a patient wants to receive if they become unable to speak for themselves. It was a big step for CMS to allow physicians to be compensated for advanced care planning. Providers are spending time discussing advance directives and end of life care and they deserve to be paid for it. It is essential that practitioners have an understanding of the CMS advance directive requirements when doing advanced care planning. Advance care planning reduced the cost of end-of-life care without increasing mortality.

Better end-of-life care can result in reduced readmissions. There were 2,573 hospitals that were penalized 564 million dollars for having a higher readmission rate. It is important to engage with the patient on what matters to them at end-of-life care and to respect their wishes for care.

Have you heard of the $16.5 million dollar case in which the plaintiff won because of the failure of the physician and hospital to follow a patient’s advance directives? Many experts are advocating that he is a new wave of lawsuits if a hospital fails to honor the advance directive. Another recent case involved a brain dead girl who is moved from a California hospital and a pregnant woman that was brain dead who had been life support until the husband obtained a court order. Do you ask every inpatient if they have any advance directives and do you discuss the end of life wishes?

This webinar will discuss the CMS hospital Cops on advance directives along with the Joint Commission standards to help hospitals ensure compliance with the standards. Hospitals have received a high number of deficiencies in this area. This program will cover in detail advance directives such as the living will, durable power of attorney, organ donation, mental health declaration, organ donor cards, patient advocates and do not resuscitate orders. It will discuss the rights of patient representatives such as DPOA, support persons, parents, or guardians. It will discuss the IHI conversation starter kit regarding discussions about end of life care since it has been downloaded over 100,000 times. Also discussed will be asking patients about end of life wishes, resources on advance care planning and a toolkit CriSTAL to identify dying patients. The checklist has 29 predictors.

The program will discuss case law, organization position statements on DNR (do not resuscitate), and other federal laws on advance directives. CMS made revisions to the hospital visitation CoP regulation which included changes to advance directives and visitation advance directives. CMS has issued a memo that will be discussed outlining the number of deficiencies received by hospitals regarding advance directives. The program will discuss the Joint Commission visitation standard which is found in the patient-centered care standard.

The CMS hospital CoP standards require that the information about the hospital’s advance directive policy be provided to inpatients, and three categories of outpatients; observation, emergency department patients, and same-day surgery patients. Staff will have to determine if there are any patient representatives including support person or patient advocates and those with visitation advance directives. Do you know the four rights provided to patient representatives? The standard changed with regard to what a hospital must do if a patient who has no advance directives on file and a support person shows up. These are very interesting changes to the CMS hospital CoP manual.


  • Recall  that the CMS Conditions of Participation has requirements for advance directives for hospitals
  • Discuss that CMS will now pay physicians to do advance care planning
  • 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 the CMS has now issued a deficiency report that shows the number of hospitals out of compliance with the advance directive standards
  • Discuss that information on the hospital’s advance directive policies must be given to inpatients, ED, observation, and same-day surgery patients under the CMS CoP hospital manual


  • Introduction
  • One-third of patients have advance directives
  • CMS Pays for advance care planning
  • CMS CoP on advance directives
    • Tag 132
    • Must be given to inpatients, ED, observation, and same-day surgery patients
    • Visitation advance directive
    • Patient representative and new patient rights
    • Number of deficiencies
  •  Joint Commission standards on advance directives
  • Federal law on the Patient Self Determination Act
  • Community education requirement
  • Documenting advance directives under the Record of Care chapter
  • Case law update
  • Asking patients about end of life wishes
  • Resources from advance care planning
  • Toolkit CriSTAL to identify dying patients
    • Checklist with 29 predictors
  • Requirements of the Patient Self Determination Act federal law
  • Informed consent requirements
  • Living wills, DPOA, DNR orders, mental health declarations, organ donor
  • Assisted suicide
  • Professional organization position statements on DNR (AORN, ACS, ASA, ASPAN, ACEP, ENA, etc.)
  • Joint Commission Tracer
  • Joint Commission standard under RI and RC chapters
  • Visitation Advance Directive under CMS and TJC visitation standard
  • Resources

Who Will Benefit?

  • Chief Nursing Officer (CNO)
  • Compliance Officers
  • Ethics Committee
  • Social Workers
  • Discharge Planners
  • Consumer Advocate
  • Nurse Educator
  • Chief Financial Officer
  • All nurses with direct patient care
  • Registration Staff
  • Ethicist
  • Ethics Committee Members
  • Physicians
  • Chief Medical Officer (CMO)
  • Nurse Educators
  • Nurse Managers
  • Nurse Supervisors
  • Risk Managers
  • Quality Improvement Director
  • Joint Commission Coordinator
  • Hospital Legal Counsel
  • Director of  Registration
  • Palliative Care Physicians
  • Behavioral Health Staff
  • Psychiatrist
  • Patient Safety Officer
  • Outpatient and Emergency Department Managers
  • OR director
  • Hospice Unit Staff
  • Patient Safety Officer
  • Physicians including any physician who does advanced care planning