D.19 VA Medical Center Memorandum HPM 589A4-86, 36C25522R0052.pdf

DEPARTMENT OF VETERANS AFFAIRS

Harry S. Truman Memorial Veterans’ Hospital

800 Hospital Drive Columbia, MO 65201

HPM 589A4-086

May 31, 2016

Issued by: HAS/136

PATIENT AND COMMUNITY LIVING CENTER (CLC) RESIDENT RIGHTS AND

RESPONSIBILTIES

1. PURPOSE: To state policy concerning specific rights and responsibilities of patients receiving care provided by this facility (see Attachment 1).

2. POLICY:

a. Each patient has the right to impartial access to treatment, personal dignity, and privacy. The patient, as an individual, has the right to make decisions regarding his/her medical care, including the decision to discontinue treatment to the extent permitted by law.

b. Patient rights outlined in this policy are assured unless contraindicated because of medical or safety reasons.

(1) A patient’s rights would be contraindicated if a valid and sufficient reason exists to restrict a listed right where exercise of the right would adversely affect a patient’s physical or mental health, infringe upon the rights of, or jeopardize the health or safety of others, or have a significant adverse impact on the operations of this facility.

(2) The decision to restrict a patient’s rights must be in writing by the appropriate professional and recorded in the patient’s medical record. The responsible Service Chief or Chief of Staff must concur with restrictions. The patient (or Durable Power of Attorney/Guardian) must be notified of any restriction(s) imposed and the reason(s).

(3) All restricting orders must be reviewed at least once every 30 days by the practitioner and must be concurred with by the Service Chief or Chief of Staff.

3. RESPONSIBLITY:

a. The Medical Center Director is ultimately responsible for ensuring each patient is advised of his/her rights and responsibilities and that each employee is aware of and respects these rights and responsibilities.

b. The Chief, Health Administration Service, is responsible for ensuring the information concerning the Patient Rights and Responsibilities is given to each patient at the time he/she applies for care and also provides information to the patient concerning eligibility and payment policies. The Health Eligibility Center provides each Veteran the “Notice of Privacy Rights” when applying for care.

c. Clinical Service Chiefs or designee at each outpatient clinic site assists in advising patients of their rights and responsibilities and of their right to seek assistance in the event questions or problems arise. This includes information on the complaint process and resolutions of conflict in care decisions.

d. Supervisors will ensure all new employees are informed of patients’ rights and it is documented as a part of their orientation process.

D.19 VA Medical Center Memorandum HPM 589A4-86, 36C25522R0052

HPM 589A4-086

May 31, 2016

e. Patients have the right to be free from mental, physical, sexual, and verbal abuse, neglect, and exploitation. Supervisors are responsible for ensuring that all staff members assigned to work with patients are aware of the Patient Rights and Responsibilities and ensure that proper conduct of employees in all interactions with Veteran patients, their family members and friends is observed.

f. Patients have the right to receive information in a manner they understand. This includes communication between the facility and the patient, as well as communication between the patient and others outside the facility. Health care providers are responsible for giving patients clear and concise information concerning.

(1) Proposed treatment/procedures.

(2) Alternative treatments/procedures.

(3) Potential benefits and risks of each.

(4) Recuperation problems.

(5) Likelihood of success.

(6) Ethical issues that impact care.

g. The right to register and vote is one of the explicit rights set forth in the VA patients' rights regulation at Title 38, CFR 1733. The Chief of Health Administration Service, Social Work Service, and Voluntary Service are responsible for informing all inpatients or residents of the opportunity to receive voting assistance information.

h. Employees are responsible for treating patients with dignity and respecting each patient’s cultural, psychosocial, spiritual, and personal values, as well as protecting the individual patient’s rights to personal privacy.

4. PROCEDURES:

a. Patient Rights and Responsibilities are printed on posters and displayed throughout the facility.

b. The Chief, Health Administration, or designee will provide a copy of Patient Rights and

Responsibilities to each patient at the time he/she applies for care.

c. The facility communicates with patients who have vision, speech, hearing, or cognitive impairments in a manner that meets the patient's needs. The Medical Center will provide communication assistance for the hearing and speech impaired. The facility will provide a certified sign language interpreter for patients or their family members who use sign language as the primary language of communication. When patients speak only a foreign language, the facility will utilize certified interpreters and community resources to facilitate communication and the treatment process.

5. REFERENCES: Code of Federal Regulations, Section 17.24a; VAF 10-7991a; M-2, Part 1, Chapter 31. The Joint Commission, Hospital Accreditation Standards.

6. RESCISSION: HPM 589A4-86 dated March 20, 2013.

APPROVED:

ROBERT G. RITTER, FACHE Date: May 31, 2016 Acting Director

Attachment

Keywords:

Rights Responsibilities Patient Treatment Privacy

CLC

Attachment 1

PATIENT RIGHTS AND RESPONSIBILITIES

(Asterisked (*) items are locally defined rights. Other asterisked (**) items are published by the Department of Veterans Affairs, Health Benefits Eligibility Center)in addition other asterisked (***) items are published by the Department of Veterans Affairs, National Veteran Service and Advocacy Program.

Veterans Health Administration (VHA) employees will respect and support your rights as a patient. We are pleased you have selected us to provide your health care. We plan to make your visit or stay as pleasant for you as possible. Your basic rights and responsibilities are outlined in this document. Please talk with Truman VA treatment team members or a patient advocate if you have any questions or would like more information about your rights.

1. Respect and Nondiscrimination:

a. You will be treated with dignity, compassion and respect as an individual. Your privacy will be protected. You will receive care in a safe environment. We will seek to honor your personal and religious values (***).

b. You or someone you choose have the right to manage personal funds. You have the right to receive an accounting of VA held funds (***).

c. Treatment will respect your personal freedoms. In rare cases, the use of medication and physical restraints may be used if all other efforts to keep you or others free from harm have not worked (***).

d. As an inpatient or CLC resident, you may wear your own clothes and keep personal items. This depends on your medical condition (***).

e. As an inpatient or CLC resident, 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 or not to participate in these activities. You may decide whether or not to perform tasks in or for the Medical Center (***).

f. As an inpatient or CLC resident, you have the right to communicate freely and privately including sending and receiving mail. You may have or refuse visitors. You will have access to bedside or public telephones. You may participate in civic rights, such as voting and free speech (***).

g. As a CLC resident, you can organize and take part in resident groups in the facility. Your family also can meet with the families of other residents (***).

h. In order to provide a safe treatment environment for all patients or residents and staff, you are expected to respect other patients, residents, and staff, and to follow the facility's rules. Avoid unsafe acts that place others at risk for accidents or injuries. Please immediately report any condition you believe to be unsafe (***).

i. Patients have the right to be free from mental, physical, sexual, and verbal abuse, neglect, and exploitation (*).

j. You will receive, to the extent you are eligible, prompt and appropriate treatment for physical or emotional disorders or disabilities, in the least restrictive environment necessary for that treatment, free from unnecessary or excessive medication (*).

k. If you are a female, you will have a female attendant present during pelvic examinations (*).

l. You have the right to request an attendant of the same sex when services are provided, which you may perceive as a personal intrusion, or your dignity or privacy is perceived to be compromised (*).

m. You are responsible for safekeeping your clothing, money, and personal items that you choose to keep with you while in the facility (*).

n. You may request a transfer to a different room if another patient or a visitor in the room is unreasonably disturbing you and another room equally suitable is available (*).

o. You are asked to respect the property of others and of the organization. This includes controlling noise, number of visitors, and following smoking regulations. You will not bring weapons or non-prescription drugs into the facility (*).

p. You will be afforded the opportunity to send and receive letters and be assisted in doing so when necessary (*).

q. As an inpatient or Community Living Center (CLC) resident, you will retain your legal rights while hospitalized except where State law provides otherwise (**).

r. If there is a reason to believe your mail may contain illegal materials, you will have to open the mail in the presence of an appropriate person (**).

s. Patients will not be subject to discrimination for any reason, including age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, or gender identity or expression.

2. Information Disclosure and Confidentiality:

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

b. You will receive information about the costs of your care, if any, before you are treated.

You are responsible for paying your portion of the costs associated with your care (***).

c. Your medical record will be kept confidential. Information about you will not be released without your consent unless authorized by law (i.e., State public health reporting). You have the right to information in your medical record and may request a copy of your records. This will be provided except in rare situations where your VA physician feels the information will be harmful to you. In that situation, you have the right to have this discussed with you by your VA provider (***).

d. You will be informed of all outcomes of care, including any potential injuries. You will be informed about how to request compensation for any injuries (***).

e. Data about your care may be grouped with data from other patients, excluding your name and personal information, to allow us to study the quality of care we provide (**).

f. You have the right to access, request amendment to, and obtain information relative to disclosures of your health information in accordance with law and regulation (*).

3. Participation in Treatment Decisions:

a. You, and any persons 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. You will be given other options. You can agree to or refuse treatment. You will be told what is likely to happen to you if you refuse treatment. Refusing treatment will not affect your rights to future care but you take responsibility for the possible results to your health (***).

b. 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 don't understand something about your care. Being involved is very important for you to get the best possible results (***).

c. You will be given, in writing, the name and professional title of the provider in charge of your care. As our partner in healthcare, 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, residents, and trainees. Providers will properly introduce themselves when they take part in your care (***).

d. You will be educated about your role and responsibilities as a patient or resident. This includes your participation in decision-making and care at the end of life (***).

e. If you believe you cannot follow the treatment plan, you have a responsibility to notify your provider or treatment team (***).

f. 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 (***).

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

h. You have the right to choose whether 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 (and this will not jeopardize your right to care, treatment, and services unrelated to research) (*)(***).

i. If you choose to participate in a Research protocol, you will be made aware of how any information collected about you is used. (**)

j. You will be included in resolving any ethical issues about your care. You may consult with the Medical Center's Ethics Consultation Service and/or other staff knowledgeable about health care ethics (***).

k. If you or the Medical Center staff believes that you have been neglected, abused or exploited, you will receive help (***).

l. You have the right to leave the Medical Center, if you so desire, against the advice of your physician (*).

m. You or your surrogate has the right to request the withholding or withdrawing of life sustaining treatment in this facility. Information regarding this right, as well as other information about Advance Directives, will be provided you upon request. Your right to review and/or revise your Advance Directive will be honored by this facility. The existence or lack of an Advance Directive will not determine your right to access care, treatment and services (*).

n. You have the right to complete advance directives to plan and decide in advance what your wishes would be if faced with a life/death situation, an unexpected death, or a terminal illness. If you wish, you may name someone else to make health care decisions for you (**).

o. You have the right to be educated about your role and responsibility as a patient, for the safe delivery of care (*).

p. You have the right to reasonable continuity and coordination of care from the interdisciplinary team, including discharge planning, and to know in advance the time and location of appointments (*).

q. You have the responsibility to report unexpected changes in your condition to the health care staff and to the responsible practitioner (*).

r. You have the right to be informed of any unanticipated outcomes of care, treatment, and services (*).

s. You have the right to give an informed consent before any procedure. This means you will be knowledgeable about the procedure, the alternate procedure or courses of treatment or nontreatment, risks and benefits of the procedure or treatment and the name(s) of the person(s) who will carry out the procedure or treatment. You or your surrogate's wishes to withhold informed consent will also be honored by this facility. You or your surrogate also have the right to give or withhold informed consent to produce or use recordings, films, or other images for purposes other than your care (*).

t. When the facility cannot meet a request or need for your care due to a conflict with its mission or philosophy, you may be transferred to another facility when medically permissible.

Prior to any transfer, you will receive complete information and explanation concerning the needs for, and alternatives to, such a transfer (*).

4. Complaints:

a. You are encouraged and expected to seek help from your treatment team or a patient advocate if you have problems or complaints. You will be given understandable information about the complaint process and the phone number and address to file a complaint with the relevant state authority as applicable. You may complain verbally or in writing, without fear of retaliation (***).

b. You are responsible for asking questions if you are unsure of, or do not understand, something. You have the right to expect a reasonable response to any reasonable requests made for service (*).

c. You should assist by alerting staff when another patient is having difficulty (*).

d. You should avoid interfering with the treatment of other patients, particularly in emergent situations (*).

e. If you have any concern about patient safety in the facility that we have not addressed, you are encouraged to contact Medical Center management (*).

5. Confidential Communications:

It is VA's policy that all patients have a right to receive written communication or correspondence pertaining to health information in a confidential manner by alternative means or at an alternative location other than the patient's permanent address of record.

Once requested, all future correspondence and communication will be sent to the alternative address. In addition, a start date must be specified for use of the confidential address and a stop date may also be indicated when the use of this address should end (**).

6. Appealing Clinical Decisions:

A process has been established to handle disputes that you may have with your treatment team. Make your concerns known to the nurse or doctor who is treating you, and then present any unresolved issues to the Patient Advocate (**).

7. Appealing Administrative Decisions:

If you disagree with VA's decision on your request for a benefit, you have one year from the date of notification of VA's decision to appeal. Contact the Health Eligibility Officer for further information and instruction (**).