D.11 MCM 658-136-33 Patient Rights and Responsibilities.pdf

Department of Veterans Affairs VAMC MEMORANDUM 658-136-33 VA Medical Center January 9, 2017 Salem, VA 24153

PATIENT RIGHTS AND RESPONSIBILITIES

1. PURPOSE: To establish policy for patient rights and responsibilities for the Salem VA Medical Center.

2. POLICY: It is the policy of this Medical Center to ensure that all patients are provided quality health care in a respectful and courteous manner, and receive the benefits and rights to which they are entitled. 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.

3. RESPONSIBILITY: The responsibility of this policy applies to all personnel of the Salem VA Medical Center.

4. ACTIONS:

a. The medical center is committed to providing individualized, high-quality care in a safe and caring environment, and will recognize and respect fundamental human, civil, constitutional, and statutory rights of each patient, as follows:

(1) reasonable access to care;

(2) considerate care that respects his/her personal values and beliefs;

(3) informed participation in decisions regarding all aspects of his/her care, and participation in investigational studies and/or clinical trials;

(4) participation in the consideration of ethical issues that arise in the provision of his/her care, including resolution of conflict, withholding of resuscitative services, and foregoing or withdrawing of life-sustaining treatment.

(5) personal privacy and confidentiality of information;

(6) designation of representative decision maker in the event that the patient is incapable of understanding a proposed treatment or procedure, or is unable to communicate his/her wishes regarding care; and

(7) Information will be provided regarding all of the above-listed issues.

b. The following description of rights are in addition to, and not in derogation of any statutory, constitutional, or other legal rights (Title 38 U.S.C. §17.34):

(1) Patients are provided a copy of the Rights and Responsibilities of VA Patients and Residents of Community Living Centers (Appendix A) upon admission to the

D.11 MCM 658-136-33 Patient Rights and Responsibilities 36C24621R0068

VAMC MEMORANDUM 658-136-33

inpatient unit by nursing staff. Outpatient rights and responsibility posters are displayed near all key elevators, included in the New Patient Orientation package, and upon request at any clinic or through the Patient Advocate. Family Rights and Responsibilities are posted on each inpatient unit (Appendix B). Outpatient rights will be made available for all patients at the clinic reception area and included in the New Patient Orientation package. New employees will be given a copy of Patient Rights during orientation.

(2) The patient has the right to access protective services through a social worker at the Medical Center when there is evidence of neglect, abuse, or exploitation. This may also include questions on guardianship, advocacy services, and conservatorship.

(3) Each patient has the right to information necessary to enable him/her to make decisions that reflect his/her wishes. Each patient has a right to know the Medical Center has a policy on informed consent that is developed by the medical staff governing body and is consistent with any legal requirements.

(4) Each patient or his/her designee has the right to participate in the consideration of ethical issues that arise in the patient’s care. Patients have a right to know the organization has a mechanism in place for consideration of ethical issues in the care of the patient. Patients or family members may contact their physician, Social worker or anyone on the care team for a referral to the Ethics Advisory Committee regarding dilemmas about care decisions.

(5) Each patient, or his/her designee, will have information provided and mechanisms explained, if they or their designee, request the option to donate, or decline to donate any tissues or organs. This is in accordance with established policy on organ and tissue donation.

(6) Each patient has the right to be informed of any clinical trials or other educational research projects affecting his/her care or treatment. Patients may refuse to participate in clinical trials or educational research projects, and are advised that their refusal will not compromise their access to care.

(7) If a patient has a guardian, next of kin, or legally authorized responsible person, that person can exercise (to the extent permitted by law), the right delineated on behalf of the patient if the patient has been adjudicated incompetent in accordance with the law, or if found by his/her physician to be medically incapable of understanding the proposed treatment or procedure, and if unable to communicate his/her wishes regarding treatment.

(8) Each patient has the right to social interaction and to communicate freely and privately with persons outside the facility, including government officials, attorneys, and clergymen in person, by telephone, or by mail. Patients may receive unopened mail;

however, if there is a reason to believe the mail may contain contraband, it may be necessary to open the mail in the presence of an appropriate person. Patients will be afforded the opportunity to write letters or use the telephone, and be assisted in doing so when necessary. Sensory impaired patients will be assured communication assistance by appropriate personnel and the means to do so. Patients/visitors requiring assistance with interpretation, translation, sign language, hearing impairment or other like difficulties may be referred to the Administrative Officer of the Day (AOD) in the Admissions Office. The AOD will assist staff and/or Veteran in the use of the Language Line, MCM 168-136-12.

(9) Each patient has the right to social interaction, exercise, and worship of his/her own religion in accordance to his/her personal beliefs and values. Patient care shall include the recognition of psychosocial, spiritual, and cultural values that impact the patient’s response to the care given. Organizational policies and procedures shall allow the patient to express spiritual beliefs and cultural practices that do not harm others or interfere with the planned course of medical therapy for the patient.

(10) Each patient/designee has the right to make decisions about withholding resuscitative services and withdrawing life-sustaining treatment.

(11) Respectful care at the end of life shall be provided to optimize his/her comfort by treating primary and secondary symptoms that respond to treatment as desired by the patient or designated decision maker, effectively managing pain, and acknowledging the psychosocial and spiritual concerns of the patient and the family regarding the end of life and the expression of grief by the patient and the family.

(12) Each patient or designee has the right to be involved in all aspects of care.

(13) Each patient has a right to receive, to the extent of eligibility under the law, prompt and appropriate treatment for any physical or emotional disability. All patients requiring hospital treatment for a service-connected disability will be afforded immediate care. Arrangements will be made later for transfer to an appropriate VA Medical Center, if facilities are not available to care for the patient.

(14) Each patient has the right, within the limits of the law, to personal privacy and confidentiality of information, including the right:

(a) to be interviewed, examined, and treated in surroundings designed to give reasonable visual and auditory privacy; and,

(b) to have a secure and locked storage area for limited personal items.

(15) Each patient has a right to make his/her wishes known regarding Advance

Directives. The patient, or designee, may review and modify the Advance Directive any time throughout the episode of care.

(16) Each patient has a right to file a complaint/grievance through the Patient

Advocate.

(17) Each patient has the right to appropriate assessment and/or management of pain. Notification of these rights will be posted in all patient care areas.

(18) A right set forth may be restricted within the patient’s treatment plan if ordered and documented by a physician that it adversely affects the patient’s physical or mental health, or the health and safety of others in accordance with applicable policies and local, state and federal laws.

5. ETHICAL DOMAIN:

a. Shared Decision Making with Patients

b. Ethical Practices in End-of-Life Care

c. Patient Privacy and Confidentiality

d. Professionalism in Patient Care

e. Ethical Practices in Business and Management

f. IntegratedEthics Program

6. REFERENCES:

a. Comprehensive Accreditation Manual for Hospitals, the Joint Commission, Current Edition.

b. Comprehensive Accreditation Manual for Nursing, Rehabilitation Centers, Behavior Health, and Home Care Accreditation Standards, the Joint Commission, Current Edition.

7. FOLLOW-UP RESPONSIBILITY: Chief, Health Administration Service.

8. RESCISSION: Medical Center Memorandum 658-136-33, “Patient Rights and Responsibilities, dated May 31, 2013.

9. EXPIRATION: January 9, 2020.

Rebecca J. Stackhouse, CTRS, FACHE Medical Center Director

Attachments

APPENDIX A

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.

A-1

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.

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.

A-2

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.

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.

A-3

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.

5. 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.

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.

VA 10-88

January 2013

APPENDIX B

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.

B-1

• 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.

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 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.

B-2

• 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.

• 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.

VA 10-88

January 2013 mailto:vaoighotline@VA.gov

PATIENT RIGHTS AND RESPONSIBILITIES