36C24218R0567-003.pdf

Network Memorandum 10N2-092-14 Department of Veterans Affairs VA Health Care Upstate New York April 10, 2014

D.21 NETWORK 2 PATIENT AND COMMUNITY LIVING CENTER

RESIDENT RIGHTS AND RESPONSIBILITIES

1. PURPOSE: The establishment of Network policy and procedure describing the rights and responsibilities of patients and residents.

2. POLICY: VISN 2 Medical Centers support and protect the fundamental human, civil, constitutional, and statutory rights of all patients. Basic rights involving freedom of expression, all medical center staff supports decision-making, and the maintenance of human dignity. The Department of Veterans Affairs (VA) Medical Centers recognize that it is the responsibility of each employee to promote patients rights. In the provision of medical care, in all care settings, relative to patient condition. VISN 2 Medical Centers have the right to expect reasonable and responsible behavior from patients, relatives, and friends. All employees are responsible for attending to and promoting patient rights.

3. RESPONSIBILITY:

A. The Network Director, Performance Management and facility managers have overall responsibility for assuring the continued development and implementation of Patient and Nursing Home Resident Rights and Responsibilities.

B. The Medical Center Directors will assure that there is an effective method of informing patients and residents of their rights and responsibilities.

C. The Chief of Staff will assure that clinical staff are informed and educated regarding a patient’s right to be involved in ethical decision-making, the right to accept or refuse treatment without retribution and the right to participate in all decision making aspects of their care.

D. The interdisciplinary team is responsible for assuring that patients are supplied with their rights and responsibilities and are educated on this information.

E. The patient advocate will be available for clarification of provided information and to handle complaints that cannot be resolved at the point of service/contact at each site.

F. The treatment team will take all necessary steps to inform the patient of his/her rights as well as responsibilities to participate in and to cooperate with his/her treatment plan.

G. It is the responsibility of all employees to observe a patient’s/resident’s rights and responsibilities, thus contributing to more effective care and greater satisfaction of the patient and employees.

Department of Veterans Affairs Network Memorandum 10N2-092-14 VA Health Care Upstate New York April 10, 2014

4. PROCEDURES: The Department of Veterans Affairs respects the rights of the patient/resident and informs them of any responsibilities incumbent upon him/her in the exercise of those rights. The patient’s/resident’s rights and responsibilities are located in all patient/resident care areas, the patient’s handbooks, and the patient’s binders.

Hospitals have many functions to perform, including the enhancement of health status, health promotion, and the prevention and treatment of injury and disease; the immediate and ongoing care and rehabilitation of patients; the education of health professionals, patients, and the community; and research.

All these activities must be conducted with an overriding concern for the values and dignity of patients/residents. For Patient and Nursing Home Resident Rights and Responsibilities, see Attachment A, for Rights and Responsibilities of Family Members of VA Patients and Residents, see Attachment B.

5. REFERENCES:

A. The Department of Veterans Affairs Veterans Mission and Vision Statement.

B. The Joint Commission Accreditation Manual for Hospitals.

C. VISN 2 Patient Advocate Program Policy.

D. The Patient Self-determination Act of 1990.

E. Department of Veterans Affairs Patient and Nursing Home Resident Rights and Responsibilities, September 2006.

F. VA regulations CFR 17.33.

G. VHA Support Service Center Data Use Agreement, http://vssc.med.va.gov/.

H. Veterans Health Administration, Patient Advocate Program, http://www.va.gov/health/patientadvocate/.

I. Rights and Responsibilities of VA Patients and Residents of Community Living Centers, http://www.va.gov/health/rights/patientrights.asp.

J. AHA Homepage, http://www.hospitalconnect.com/aha/about/pbillofrights.html.

6. RESCISSIONS: Network Memorandum 10N2-92-03, dated September 5, 2013.

7. FOLLOW-UP RESPONSIBILITY: Network Patient Advocate, VISN2PatientAdvocates@MED.VA.GOV.

8. AUTOMATIC RESCISSION DATE: April 10, 2017.

http://vssc.med.va.gov/ http://www.va.gov/HEALTH/index.asp http://www.va.gov/HEALTH/patientadvocate/index.asp http://www.va.gov/health/patientadvocate/ http://www.va.gov/health/rights/patientrights.asp http://www.hospitalconnect.com/aha/about/pbillofrights.html

VA Health Care Upstate New York April 10, 2014

//Signed 4/10/14// Darlene A. DeLancey, MS

Interim Network Director

ATTACHMENTS: A, B

DISTRIBUTION: All Network Care Line Managers All Medical Center Directors

VA Health Care Upstate New York April 10, 2014

ATTACHMENT A

Rights and Responsibilities of VA Patients and Residents of

Community Living Centers

The Veterans Health Administration (VHA) is pleased you have selected us to provide your health care. We will provide you with personalized, patient-driven, compassionate, state-of-the-art care. Our goal is to make your experience as positive and pleasant as we can. As part of our service to you, to other Veterans and to the Nation, we are committed to improving health care quality. We also train future health care professionals, conduct research, and support our country in times of national emergency. In all of these activities, our employees will respect and support your rights as a patient or resident of a community living center (CLC). Your basic rights and responsibilities are outlined in this document. You will receive this information in your preferred language. Please talk with the VA treatment team members who are providing your care or to a patient advocate if you have any questions or would like more information about your rights and responsibilities.

1. Nondiscrimination and Respect

You will be treated with dignity, compassion, and respect as an individual. Consistent with Federal law, VA policy, and accreditation standards of The Joint Commission, you will not be subject to discrimination for any reason, including for reasons of age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, or gender identity or expression.

You will receive care in a safe environment free from excess noise, and with sufficient light to ensure comfort and safety.

You have a right to have access to the outdoors.

We will seek to honor your cultural and personal values, beliefs, and preferences. We ask that you identify any cultural, religious, or spiritual beliefs or practices that influence your care.

You or someone you choose has the right to keep and spend your money. You have the right to receive an accounting of any funds that VA is holding for you.

We will respect your personal freedoms in the care and treatment we provide you. This includes trying to accommodate your normal sleep and wake cycles, food likes and dislikes, and other personal preferences.

In the Community Living Center, you have the right to be free from chemical and physical restraints. In the inpatient acute care setting, and only in rare cases, the use of chemical and physical restraints may be used if all other efforts to keep you or others free from harm have not worked.

VA Health Care Upstate New York April 10, 2014

In the Community Living Center, you may keep personal items and are expected to wear your own clothes. As an inpatient, you may wear your own clothes depending on your medical condition.

You have the right to keep and use personal items as long as they are safe and legal.

You have the right to social interaction and regular exercise. You will have the opportunity for religious worship and spiritual support. You may decide whether to participate in these activities. You may decide whether or not to perform tasks in or for the Medical Center or in the Community Living Center.

You have the right to communicate freely and privately. You will have access to public telephones and VA will assist you in sending and receiving mail. You may participate in civic rights, such as voting and free speech.

When a loved one is involved in support and care of a VA patient or CLC resident, VA considers a patient or CLC resident's family to include anyone related to the patient or CLC resident in any way (for example, biologically or legally) and anyone whom the patient or CLC resident considers to be family. If you are an inpatient, any persons you choose can be with you to support you during your stay. Medical staff may restrict visitors for inpatients if medical or safety concerns require it. You will be told promptly about any visitor restriction and the reason for it.

In order to provide a safe treatment environment for all patients or CLC residents and staff, you and your visitors are expected to avoid unsafe acts that place others at risk for accidents or injuries. Please immediately report any condition you believe to be unsafe.

2. Information Disclosure and Confidentiality

Your privacy will be protected.

You will be given information about the health benefits you can receive. The information will be provided in a way you can understand.

You will receive information about the costs of your care (for example, co-payments), if any, before you are treated. You are responsible for paying your portion of any costs associated with your care.

Your health record will be kept confidential. Information about you will not be released without your authorization unless permitted by law (an example of this is State public health reporting). You have the right to have access to or request a copy of your own health records.

Please respect the privacy of other patients and CLC residents and do not reveal their health information that you may overhear or otherwise become aware of.

VA Health Care Upstate New York April 10, 2014

3. Participation in Treatment Decisions

You have a right to express your preferences concerning future medical care in an advance directive, including designating a health care agent to make health care decisions on your behalf when you can no longer do so.

You, and any person(s) you choose, will be involved in all decisions about your care.

You will be given information you can understand about the benefits and risks of treatment in your preferred language. You will be given other options. You can agree to or refuse any treatment. You will be told what is likely to happen to you if you refuse a treatment. Refusing a treatment will not affect your rights to future care but you take responsibility for the impact this decision may have on your health.

Tell your provider about your current condition, medicines (including over-the-counter and herbals), and medical history. Also, share any other information that affects your health. You should ask questions when you do not understand something about your care. This will help us provide you the best care possible.

You will be given, in writing, the name and title of the provider in charge of your care.

You have the right to be involved in choosing your provider. You also have the right to know the names and titles of those who provide you care. This includes students and other trainees. Providers will properly introduce themselves when they take part in your care.

You will be educated about your role and responsibilities as a patient or CLC resident.

This includes your participation in decision making and care at the end of life.

If you believe you cannot follow the treatment plan, you have a responsibility to tell your provider or treatment team.

You will be informed of all outcomes of your care, including any possible injuries associated with your care. You will be informed about how to request compensation and other remedies for any serious injuries.

You have the right to have your pain assessed and to receive treatment to manage your pain. You and your treatment team will develop a pain management plan together. You are expected to help the treatment team by telling them if you have pain and if the treatment is working.

As an inpatient or CLC resident, you will be provided any transportation necessary for your treatment plan.

You have the right to choose whether or not you will participate in any research project.

Any research will be clearly identified. Potential risks of the research will be identified and there will be no pressure on you to participate.

VA Health Care Upstate New York April 10, 2014

You will be included in resolving any ethical issues about your care. If you have ethical issues or concerns, you may speak with the Medical Center's Ethics Consultation Service for help.

4. Concerns or Complaints

You are encouraged and expected to seek help from your treatment team or a patient advocate if you have problems or complaints. Any privacy complaints will be addressed by the facility Privacy Officer. You will be given understandable information about the complaint process in your preferred language. You may complain verbally or in writing, without fear of retaliation.

If you believe that you or your family member has been neglected, abused or exploited by VA staff, please report this promptly to the treatment team or patient advocate. You will receive help immediately.

If you believe the organization has failed to address or satisfy your concerns about health care quality and safety, you may contact the Joint Commission's Office of Quality Monitoring at 1-800-994-6610. If you believe that the organization has failed to address your concerns about suspected criminal activities, fraud, waste, abuse, or mismanagement, you may contact the VA Office of the Inspector General at 1-800-488- 8244 or email vaoighotline@va.gov.

mailto:vaoighotline@VA.gov

VA Health Care Upstate New York April 10, 2014

ATTACHMENT B

Rights and Responsibilities of Family Members of VA Patients and Residents of Community Living Centers (CLC)

The Veterans Health Administration (VHA) is pleased to provide health care to Veterans. We will provide personalized, patient-driven, compassionate, state-of-the-art care. Our goal is to make the experience as positive and pleasant as we can. As part of our service to Veterans and to the Nation, we are committed to improving health care quality. We also train future health care professionals, conduct research, and support our country in times of national emergency. In all of these activities, our employees will respect and support the rights of patients and residents of community living centers (CLC) as well as your rights as a family member. This document outlines the basic rights and responsibilities of family members. Please talk with the VHA treatment team or a patient advocate if you have any questions or would like more information about these rights and responsibilities.

1. Nondiscrimination and Respect

Our staff will create a treatment environment based on dignity, compassion, and respect. Consistent with Federal law, VA policy, and accreditation standards of The Joint Commission, Veterans and their family members will not be subject to discrimination for any reason, including for reasons of age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, or gender identity or expression.

We seek to honor the cultural and personal values, beliefs, and preferences of all patients, CLC residents, and their families. When a loved one is involved in support and care of a VA patient or resident, VA considers a patient or resident’s family to include anyone related to the patient or resident in any way (for example, biologically or legally) and anyone whom the patient or resident considers to be family.

Please help us offer care in a safe and respectful manner by treating patients, CLC residents, other family members and staff with respect and following the facility’s rules.

Family members are not allowed to do things that threaten the care of patients or interfere with staff members’ ability to do their job.

2. Keeping Health Information Private and Secure

The Veteran’s private health care information will be protected to the fullest extent authorized by law. Information about the Veteran may be disclosed to you if the Veteran authorizes the release or if you are the Veteran’s personal representative.

Please respect the privacy of patients, residents, and other family members and do not reveal private health care information that you may overhear or otherwise become aware of.

VA Health Care Upstate New York April 10, 2014

3. Partnering in Care

Families are valued members of the VA care team. As members of the care team we encourage you to:

Share your insights, opinions and observations about the Veteran’s care and progress.

Let the nursing staff know right away if you feel that the Veteran’s condition has changed.

Tell us right away if you are worried about the Veteran’s care or treatment. Please ask questions if you do not understand the purpose of any part of the Veteran’s care.

If you are a family member of a CLC resident, you have a right to participate and share your voice and opinions in family and resident or household councils.

4. Family Members’ Role in Treatment Decisions

Veterans have a right to make their own health care decisions as long as they are able to understand and tell their doctor and health care team what they want. Veterans have a right to include or not include others, such as family members or friends, in decisions about their care.

Veterans have a right to express their preferences about future medical care in an advance directive. This includes the right to name a health care agent who will make health care decisions on their behalf if they can no longer communicate for themselves.

We will respect these preferences.

If you are asked to make health care decisions for a Veteran in VHA, the treatment team will offer you:

Treatment options based on the Veteran’s unique medical circumstances and needs.

Information you can understand about the benefits and risks of these treatment options.

An interpreter or assistive device, if needed, to help you understand the Veteran’s medical circumstances and treatment options.

As the health care decision maker, you generally have the same rights and responsibilities as the Veteran would have in making treatment decisions.

You may agree to or refuse any treatment option offered by the treatment team.

Refusing treatment will not affect the Veteran’s right to future care.

Your decision about whether to accept or refuse treatments must be based on what you know the Veteran would want. If you do not know what the Veteran would want, the

VA Health Care Upstate New York April 10, 2014 treatment team is available to help you consider what decisions are in the Veteran’s best interest.

When you are the health care decision maker, please:

Share accurate and complete information about the Veteran’s medical history to help us develop the best treatment plan.

Take part in discussions and decisions about the Veteran’s care.

Help the treatment team understand how they can provide care that takes into account the Veteran’s cultural and personal values, beliefs, and preferences.

Talk with the treatment team when you think the Veteran’s treatment plan may need to be changed.

Let the treatment team know if you are not willing or able to follow the treatment plan. If the treatment team understands why the plan may be a problem, they may be able to make changes that address your concerns.

Help us plan for the Veteran’s move to the next level of care.

5. Visiting the Veteran

Family visits can help you support the Veteran as he/she copes with illness or injuries.

Schedule your visit to meet the Veteran’s medical and emotional needs. For example, many patients get tired easily, so short visits may be better.

VA Community Living Centers have unrestricted visiting hours.

On VA acute care inpatient units, medical staff may need to restrict visiting hours or place other visiting restrictions if medical or safety concerns require it. You will be promptly informed about any visitor restriction and the reason for it.

Please keep a close eye on your children for their own safety and the safety of others.

Children should never be left unattended.

At times, patients or CLC residents may not wish to have visitors or may wish to set other limits on visits. We will respect the Veteran’s wishes for visits.

6. Concerns or Complaints

If you need advice on how to resolve an ethical concern about the Veteran’s care, you may speak with the Medical Center’s Ethics Consultation Service.

VA Health Care Upstate New York April 10, 2014

You are encouraged and expected to seek help from the VA healthcare treatment team and/or a patient advocate if you have problems or complaints. You will be given understandable information about the complaint process in your preferred language.

Any privacy complaints will be addressed by the facility Privacy Officer. You may complain verbally or in writing, without fear of retaliation.

If you believe that you or the Veteran has been neglected, abused or exploited by VA staff, please report this promptly to the treatment team or patient advocate. You will receive help immediately.

If you have concerns about the quality of the health care that the Veteran is receiving, you may contact the VHA Office of the Medical Inspector at 1-800-634-4782.

If you believe the organization has failed to address or satisfy your concerns about healthcare quality and safety, you may contact the Joint Commission’s Office of Quality Monitoring at 1-800-994-6610. If you believe that the organization has failed to address your concerns about suspected criminal activities, fraud, waste, abuse, or mismanagement, you may contact the VA Office of the Inspector General at 1-800-488- 8244 or email vaoighotline@VA.gov.