36C24419R0052-015.pdf

Department of Veterans Affairs POLICY 122-15-393 Medical Center July 21, 2015 Wilkes-Barre, Pennsylvania 18711

PATIENT/RESIDENT RIGHTS AND RESPONSIBILITIES

1. SCOPE/EFFECT: All employees (including the Community Based Outpatient Clinics at Allentown, Berwick, Honesdale, Sayre, Tobyhanna, and Williamsport) are affected by this Medical Center Policy (MCP).

2. PURPOSE: The purpose of this policy is to describe the right and responsibilities of patients/residents treated at the Wilkes-Barre Veterans Affairs Medical Center, including Veterans serviced in the Home Care and Home Based Primary Care (HBPC) programs, to establish procedures for informing patients and staff of these rights and responsibilities and any restriction of rights.

3. POLICY:

a. It is the policy of the Wilkes-Barre VA Medical Center that patients/residents have a right to the following:

(1) Impartial access to treatment or accommodations.

(2) Personal freedom and dignity.

(3) Privacy.

(4) Confidentiality of their personal and medical records.

(5) Communicate freely and privately with persons of their choice.

(6) Manage their personal financial affairs or delegate this responsibility.

(7) Know the identity of the physician or any other professional status of individuals primarily responsible for their care and communicate with those responsible for their care.

(8) Be fully informed by a physician of their medical condition.

(9) Be informed of the nature and purpose of any technical procedures that are to be performed, as well as the person performing such procedures.

(10) Retain and use their personal clothing and possessions as space/condition permits.

(11) Expect all communications and other records pertaining to his/her care, to be treated as confidential.

(12) Exercise their rights as citizens.

(13) Be free from mental and physical abuse and free from chemical and physical restraints except as authorized in writing by a physician for a specified and limited time, or when necessary to protect the patient/resident from injury to himself/herself or to others.

(14) Recognize elder abuse and exploitation in the domestic setting.

(15) Be fully informed prior to or at the time of admission and during their stay, of service available in the facility.

(16) Refuse to talk to or see anyone officially connected with the facility but not directly involved in their care, or anyone not officially connected with the facility, including visitors and representative of agencies.

(17) Have the right to access people outside the Medical Center by means of visitors, and by verbal and written communications.

(18) At his/her own request and expense, to consult and request a second option concerning medical issues.

(19) Not be transferred to another facility unless he/she has received a complete explanation of the need for the transfer, and of the alternative to such as transfer, and unless the transfer is acceptable to other facility.

(20) To refuse treatment to the extent permitted by law. When refusal of treatment by the patient/resident of legal authorized representative prevents the provision of appropriate care in accordance with professional standards, the relationship with the patient/resident may be terminated upon reasonable notice.

(21) To be free to voice complaints and recommend changes without being subject to coercion, discrimination, reprisal, or unreasonable interruption of care, treatment and services. You have the right to have those complaints reviewed and when possible, resolved with your treatment team and/or patient advocate.

(22) You have the right to have your pain assessed and to receive treatment to manage your pain.

(23) You have the right to review your health information.

(24) You have the right to obtain a copy of your health information.

(25) You have the right to request your health information be amended or corrected.

(26) You have the right to request that the Wilkes-Barre VA Medical Center not use or disclose your health information.

(27) You have the right to request that the Wilkes-Barre VA Medical Center provide your health information to you in an alternative way or at an alternative location in a confidential manner.

(28) You have the right to receive an accounting or list of disclosures of your health information.

(29) You have the right to receive the Wilkes-Barre VA Medical Center Notice of the Privacy Practices upon request.

(30) Residents can have items such as pictures, clothing, photos, radio, furniture, afghans, and the like to help them personalize their living space.

b. These rights may be exercised as long as they do not infringe upon the rights of other patients/residents and/or they are not medically contraindicated.

c. Patients/residents are responsible for the following:

(1) Providing, to the best of their knowledge, accurate and complete information about present complaints, past illnesses and hospitalizations, medications and other matters related to their health.

(2) Reporting unexpected changes in their condition to the responsible practitioner.

(3) Making it known whether they clearly comprehend a contemplated course of action concerning their care and what is expected of them.

(4) Following the treatment plan recommended by the practitioner primarily responsible for their care, and following the instructions of the nurses and other health professionals as they carry out the coordinated plan of care, implement the responsible practitioner's orders, and enforce the applicable facility rules and regulations.

(5) Responsible for their actions if they refuse treatment or do not follow the practitioner's instructions.

(6) Assuring, if applicable, the financial obligations of his/her health care are fulfilled as possible.

(7) Following facility rules and regulations affecting patient/resident care and conduct.

(8) Being considerate of the rights of other patients/residents and facility personnel.

(9) Their personal behavior in the control of noise, smoking and number of visitors.

(10) You are responsible for informing your treatment team when you experience pain. It is important that you notify them when your pain is not relieved and to work with them to develop a plan to manage your pain.

d. Patients/residents are given a copy of the "Patient Handbook" which contains the patient rights and responsibilities and Patient Advocate information. Patient/resident acknowledges in writing receipt of rights, information as appropriate to populations served. This information is given to all patients/residents at the time of admission and annually for any patient/resident, who may reside in a program longer than one year.

(1) If a patient/resident has been adjudicated incompetent in accordance with state law, or is found by his/her physician to be medically incapable of understanding the facility's policy on patients'/residents' rights and responsibilities, or exhibits a communication barrier, the patient's/resident's rights and responsibilities are assumed by his/her guardian, next of kin or legally responsible person with an interpreter present if necessary.

(2) Patients/residents are encouraged and expected to seek help from their treatment team and/or Patient Advocate if they have problems, concerns or complaints.

Patients can express their problems, concerns or complaints verbally or in writing without fear of retribution or retaliation.

e. Copies of the Patients/Residents Rights and Responsibilities are posted in each unit/clinical area as well as Community Based Outpatient Clinics.

4. PROCEDURE:

a. If a patient or staff member feels that the policy on patient rights as outlined in this policy is being violated, the matter should be brought to the attention of the nurse manager or supervisor for the program area where the patient is being treated. A patient may also have the option of bringing their concerns to the Medical Center Patient Advocate. The staff contacted will document the concern brought to their attention and the efforts to resolve the concern.

b. Where a patient fails to abide by the responsibilities as outlined in this policy, the concerns will be brought to the attention of the treating physician. The treating physician will then make a determination what further action is warranted. If a decision is made to discharge a patient/resident from care due to their failure to comply, the Chief of Staff and Risk Manager will `be informed of the intended action.

5. RESPONSIBILITY: It is the responsibility of all Wilkes-Barre Veterans Affairs Medical Center employees to ensure that the rights of all patients/residents are fully respected as outlined in this policy. Patients are responsible for cooperating with their treatment plan and all regulations and rules of this Medical Center.

6. CUSTOMER SATISFACTION: Customer satisfaction issues were considered in the development of this policy.

7. REFERENCES: The Joint Commission (TJC) Comprehensive Accreditation Manual for Hospitals TJC Comprehensive Accreditation Manual for Long Term Care Facilities TJC Comprehensive Accreditation Manuals for Home Care Statement of Patient Rights and Responsibilities, dated September 22, 2009.

8. RESCISSION: Medical Center Policy 122-12-393, dated June 28, 2012, same subject.

9. DISTRIBUTION: Electronic Access to All Employees