Policy Statement/Purpose:

St. Charles Health System (“SCHS”) embraces a philosophy of open and flexible visitation that welcomes and encourages the involvement of family members and significant others in the patient's care.

Definitions: (Definitions of acronyms or specialized terminology)


1. Patients may receive visitors of their choosing, including, but not limited to, spouses, domestic partners (including same-sex domestic partners), other family members, or friends.

2. Patients may refuse visitors, or may withdraw consent for one or more visitors at any time. SCHS will take reasonable measures to help patients enforce or implement their visitation preferences.

3. SCHS will ensure that all visitors enjoy full and equal visitation privileges consistent with patient preferences. SCHS will not restrict, limit, or otherwise deny visitation privileges on the basis of race, color, national origin, religion, sex, gender identity, sexual orientation, or disability, nor will it permit anyone else to do so. However, SCHS will not allow or restrict visitation where doing so would cause SCHS to violate applicable laws or regulations, such as parental custody laws.

4. Patients may designate personal representatives to exercise their visitation rights on their behalf. Patients may designate personal representatives in any manner, including orally, in writing, or through non-verbal communications (such as pointing).

5. SCHS may reasonably restrict patient visitation when necessary to promote patient health and safety or to maintain a healing environment. Such restrictions may be based upon, but are not limited solely to, any of the following:

  • (a) a court order limiting or restraining contact;
  • (b) a visitor's behavior presenting a direct risk or threat to the patient, hospital staff, or others in the immediate environment;
  • (c) visitor behavior or a number of visitor that is disruptive to the functioning of the patient care unit involved;
  • (d) the patient's risk of infection by the visitor;
  • (e) the visitor's risk of infection by the patient;
  • (f) a patient's need for privacy or rest, as agreed upon by the patient and his/her physician or caregiver;
  • (g) the need for privacy or rest by another patient in the patient's shared room;
  • (h) any special restriction rules that apply to special patient care units (mental health/behavioral health, drug and alcohol, etc.);
  • (i) when visitation would otherwise interfere with the care of the patient and/or the care of other patients; and
  • (j) applicable laws and regulations.

References: (Documents or Regulatory Requirements to which this document refers, is linked to within Document Library, or from which the document was created.)

Centers for Medicare and Medicaid Services, 42 CFR Parts 482 and 485, 482.13

Document #3422, version 1; Effective date: 07/08/2014