36C25019R0093-020.pdf

VA NORTHERN INDIANA HEALTH CARE SYSTEM (VANIHCS)

May 2017 POLICY NO. CSM-04-17

VETERAN RIGHTS AND RESPONSIBILITIES

1. PURPOSE: To design and implement a Veteran-centered culture at the Department of Veterans Affairs Northern Indiana Health Care System (VANIHCS) which demonstrates and supports respect for the rights of the Veteran and family members, recognizing that each is an individual with unique health care needs.

2. POLICY: It is the Policy of VANIHCS that high-quality care will be provided in a safe environment that meets the needs and concerns of the Veteran and protects individual interests, adhering to the attached Veteran Rights and Responsibilities set forth by the Veterans Health Administration (VHA). VANIHCS believes each Veteran has the right to considerate, respectful care; focused on individual needs; taking into consideration the physical, psychological, spiritual and cultural variables that influence the perception of illness and care; and providing protection of Veteran privacy and security of information.

3. DEFINITIONS: VHA Veteran Rights and Responsibilities are behavioral and procedural requirements for staff and Veterans.

4. BACKGROUND:

a. Every Veteran, or their representative, is assured the free exercise of Veteran rights unless the exercise of those rights infringes on the rights of other individuals.

Veterans are responsible for respecting other Veterans and staff and for following the rules of the health care system.

b. Every Veteran has the right to be free from humiliation.

c. Veterans have the right to make decisions regarding their medical care, including the right to decline or discontinue treatment, to the extent that is permitted by law. The Veteran has the right to designate a surrogate health care decision-maker.

d. The Veteran, or their representative, will be involved in all decisions about their care, including the choosing of their provider.

e. VANIHCS will make provision for fully informed consents to treatment options.

f. VANIHCS will assist the Veteran in the exercise of their rights and make sure the

Veteran and/or his representative are fully informed of these rights and responsibilities.

g. VANIHCS will assist the Veteran in seeking assistance if the Veteran believes

POLICY NO. CSM-04-17

he or she is neglected or abused in any way. VANIHCS provides information regarding protective services.

h. Veterans will be given information about how to contact the Patient Advocate

Liaisons/Veteran Advocate if they disagree with staff decisions about their care or denial of services. Veterans may complain verbally or in writing without fear of retaliation.

5. PROCEDURES:

a. Veterans being admitted will receive a copy of the VHA Veteran Rights and Responsibilities and their written acknowledgment of receipt and understanding is obtained.

b. If a Veteran’s medical, mental, or psychiatric condition prevents their immediate understanding of rights and responsibilities, they will be approached at a later time. If this condition persists, the Veteran’s representative will be provided this information.

c. Veterans’ Community Living Center (VCLC) residents or their next-of-kin will be provided updated copies of the VHA Veteran Rights and Responsibilities annually and will be asked to sign that they have been received.

d. Information regarding treatments, treatment options and outcomes of treatment, health benefits, cost of care, and the names of caregivers will be provided to Veterans or their representatives in a way they can understand.

e. If Veteran requests information contained in their medical record, that information will be provided. In rare instances, the VA provider may feel that this information would be harmful to the Veteran. In those cases, the provider will discuss this with the Veteran.

f. Information in medical records and information regarding a Veteran will not be released without Veteran consent unless required by law.

g. Veterans and/or their representatives will be involved in decisions about the Veteran’s care, and may refuse treatment if they wish. This includes being given information about potential risks and benefits, other treatment options, ethical issues of treatment or care, and participation in research projects. This also includes pain assessment and the development of a plan for pain management.

h. The health care system will ensure that processes are in place to ensure that as much as is feasible, Veterans may keep and spend their own money, and that Veterans and/or their representatives can receive an accounting of money held for them by the health care system.

i. Depending on their medical and psychiatric condition, Veterans will be allowed to wear their own clothing and keep personal items within the rules and regulations designed for safety of Veterans and staff.

j. The health care system will provide a means for Veterans to participate, or refuse to participate in, social interactions, religious worship and support, free and private communications, access to telephones, and to have visitors.

k. Veterans and/or their representatives are encouraged to seek assistance from their treatment team and/or Veteran advocate if they have problems or complaints.

l. The health care system will provide access to fair and impartial review of disputes regarding clinical determinations or denial of services when they are not resolved at the health care system level.

6. RESPONSIBILITIES:

a. All VANIHCS employees are responsible for knowing, understanding, and observing the rights of Veterans.

b. The admission clerk or Administrative Officer of the Day (AOD) is responsible for providing VHA Veteran Rights and Responsibilities information to Veterans and/or their representatives during the admission process and for obtaining their signature on the face sheet if possible.

c. The inpatient medical support assistant (MSA) is responsible for:

(1) Obtaining the signature of the Veteran on the face sheet if it is not possible for the Veteran to sign the face sheet during the admission process. The MSA will approach the Veteran at a later time for this purpose.

(2) The MSA is responsible for annually providing Veteran Rights and Responsibility information to long-term care Veterans and/or their representative. The MSA is also responsible for maintaining this information on the unit and providing it to Veterans and visitors on request.

d. The Integrated Ethics Committee is responsible for being available to Veterans and/or families, as needed, to address medical-ethical concerns. Anyone can initiate a review by the Integrated Ethics Committee by speaking to a nurse, physician, Veteran advocate, or by contacting the Chairperson of the Integrated Ethics Committee.

e. The Veteran advocate or their representative is responsible for being available to Veterans and their families or representatives to provide assistance, information, guidance, and aid in conflict resolution. The Veteran advocate facilitates internal appeals and provides information regarding procedures for external appeals. The Veteran advocate facilitates Veterans’ requests for change of provider.

7. REFERENCES:

a. Joint Commission Accreditation Manual for Hospitals

b. VHA Veteran Rights and Responsibilities

c. VISN 11 Clinical Appeals Process, 10N11-11

d. Customer Service Standards

8. RESCISSIONS: Medical Center Policy CSM-04, Veteran Rights and Responsibilities, dated March 6, 2015.

9. REVIEW DATE: May 31, 2020

10. FOLLOW-UP RESPONSIBILITY: Customer Service Manager

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P R IS C IL L A S . D E L E O N , M B A

M a n a g e r , C u s t o m e r S e r v i c e D e p a r t m e n t

A U D R E Y L . F R IS O N , D M , M H A , B S N , R N

A s s o c i a t e D i r e c t o r P a t i e n t C a r e S e r v i c e s

W A YN E Z . M C B R ID E , D O , M P H

C h i e f o f S t a f f

J A Y H . M IL L E R

A s s o c i a t e D i r e c t o r f o r O p e r a t i o n s

J O H N P H IL L IP S H E A L E Y, M B A

A s s i s t a n t D i r e c t o r

M IC H A E L E . H E R S H M A N , M H A , F A C H E

D i r e c t o r

Link to Attachments: (A, B)

Attachment A

Rights and Responsibilities of VA Patients and Residents of Community Living Centers

I. 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.

▪ 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

Attachment A2 others at risk for accidents or injuries. Please immediately report any condition you believe to be unsafe.

ll. Health Information and Privacy

▪ 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.

III. Partnering in Care

▪ 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.

Attachment A3

▪ 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.

▪ 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.

IV. 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 e-mail vaoighotline@VA.gov.

V. Additional Rights and Responsibilities of Community Living Center Residents

Because the CLC serves as your home for short or long-stay services, you have the following additional rights and responsibilities as a CLC resident:

▪ Staff will knock on your bedroom door prior to entry.

▪ You have the right to receive care from the same staff member every day to the extent that consistent assignment is possible.

▪ You may have visitors at any time of the day or night provided visitors are respectful of you, your need for privacy and the privacy of others. You may refuse visitors at any time.

Attachment A4

▪ You have a right to conjugal visits and you have a right to privacy during those visits.

▪ Your care will be delivered in a setting that resembles home. Therefore, you will be invited to have your meals in a designated dining area and you will have access to those activities that contribute to meaningful use of time.

▪ In preparation for being discharged to your own home, you and or your care giver may be invited to participate in activities that prepare you to go home such as self-administration of medications and treatments.

▪ You and your care givers have a right to attend treatment planning meetings and participate in household or resident council.

This document was signed and issued by the VA Under Secretary for Health on January

15, 2013. IB 10-89, P91985

Attachment B

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

I. 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.

ll. 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.

III. 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.

Attachment B2

IV. 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 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.

V. 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.

Attachment B3

▪ 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.

VI. 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.

▪ You are encouraged and expected to seek help from the VA health care 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 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.