D.22 MCM RI-03 Patient and Nursing Home Residents Rights and Responsibilities.pdf

Butler VA Health Care System Medical Center Policy RI-03 Butler, PA March 5, 2021

VETERAN AND COMMUNITY LIVING CENTER RESIDENT RIGHTS AND

RESPONSIBILITIES (OOQ)

I. PURPOSE: To describe the personal rights and responsibilities of any Veteran receiving treatment at Butler VA Health Care System, and to establish procedures for informing Veterans and staff of these rights, responsibilities, and any restriction of these rights.

II. POLICY: This facility is committed to providing high quality medical care for Veterans in a climate in which the human needs and concerns of the Veterans are met, in which Veterans are involved in decisions about their care, treatment and services, and in which individual interests are protected. This climate must be based on respect for the dignity of the Veteran as an individual and on care that is provided in a courteous, concerned, and compassionate manner. In order to achieve these goals, the dedication of each employee to the principles outlined in this policy is essential. It is only through the willing assumption of this responsibility on the part of the staff that this facility is able to provide the type of Veteran care to which it is committed.

III. PROCEDURES:

A. All staff members of this facility are advised of Veteran Rights and Responsibilities through the general orientation process. A copy of Veteran and Community Living Center Resident Rights and Responsibilities is given to each employee during general orientation.

B. Upon admission, Veterans are given a Veteran Information Handbook containing information on Advance Directives and Do Not Resuscitate (DNR) to assist in decision making. Veterans will also be informed of the facility’s policies concerning parking, personal medications, funds, valuables, weapons, and privacy information. The Veteran and/or representative are asked to sign an admission form indicating receipt of this information (Attachment A). The signed admission form is scanned and maintained under the administrative tab of the Electronic Health Record (EHR).

C. All Veterans are informed of Patient and Community Living Center Resident Rights and Responsibilities upon admission to the Community Living Center (CLC) or Residential Treatment Center. If the Veteran is incapable of understanding the information of Patient and Nursing Home Resident Rights and Responsibilities, an explanation is given to the next-of-kin (NOK) or surrogate who is asked to sign the admission form (Attachment A) indicating receipt of this information. Additionally, the Veteran and Community Living Center Resident Rights and Responsibilities are reviewed at least annually in the CLC and at any time questions may arise. The Veteran and/or Veteran representative are asked to sign the admission form (Attachment A) indicating this has been accomplished.

D. In addition to dissemination of Veteran rights and responsibilities materials to each Veteran, a large print, detailed description of the rights and the process for

2 Medical Center Policy RI-03 presenting grievances are posted in the Domiciliary, the CLC, and other treatment areas.

E. Restrictions of Veteran’s Rights:

1. Veteran’s rights, as outlined in the Veteran Information Handbook, may be restricted within the Veteran’s treatment plan by a written order signed by a provider and a progress note detailing the indications for the restriction. The Interdisciplinary Team (IDT) should concur with the decision to impose a restriction and document the concurrence in a progress note. All documentation to restrict a right is maintained in the Veteran’s EHR.

2. The Physician must determine that the likelihood and seriousness of the consequences resulting from the full exercise of the right are so compelling as to warrant the restriction. Rights may be restricted when full exercise of the specific right would:

a. Adversely affect the Veteran’s physical or mental health;

b. Under prevailing community standards, likely stigmatize the Veteran’s reputation to a degree that would adversely affect the Veteran’s return to independent living;

c. Significantly infringe upon the rights of or jeopardize the health or safety of others;

d. Have a significant adverse impact on the operation of the facility.

F. Veteran’s Right to Privacy and Confidentiality of their Medical Information: The Veteran’s right to privacy and confidentiality of their medical information is discussed upon admission. Veterans are provided with the VA Notice of Privacy Practices (Attachment B). This Summary Notice provides an explanation of the VA Notice of Privacy Practices and briefly states: how health information may be used and disclosed; Veteran rights regarding their health information; and our legal duty to protect the privacy of Veteran health information. Written consent is needed to release verbal information to inquiries (i.e., phone calls or verbal contacts from family and friends). Authorization to release verbal information to specific contact persons listed on an overprinted Report of Contact (ROC), VA Form 119, (Attachment C) is completed by the Veteran or Veteran representative upon admission. The admitting staff will then verify contact information in the electronic record and update as needed. The original signed ROC is scanned and maintained under the administrative tab of the EHR. A copy of Attachment C may be kept on the unit to verify contact persons.

G. Under Federal Law, the Health Insurance Portability and Accountability Act (HIPAA) effective April 14, 2003, Veterans have the right to opt-out of the facility inpatient directory. A Veteran may choose not to be listed in the inpatient directory upon admission to the facility or at any time they desire during the admission. Upon

3 Medical Center Policy RI-03 admission to the facility, the admitting Provider will ask the Veteran if they wish to opt out of the inpatient directory. If the Veteran is incapacitated and unable to make the decision, the admitting Provider will make the decision based on the interest of the Veteran. In the future, if the Veteran is able to make the decision, the Veteran will be asked if they wish to opt out. The admitting Physician will note the opt out decision in the Doctor’s orders and ward administration staff or nursing staff will enter the decision.

No information is provided to anyone including whether or not the Veteran is a resident in the facility. This includes refusal to accept all mail, correspondence, and items of delivery. The only exception to this policy is in regards to: (1) family members and significant others - if these individuals are involved in the care or payment for care of the Veteran in the best interest of the Veteran; (2) Law Enforcement Officials - when the official provides a written request in accordance with VHA Directive 1605.01 Privacy and Release of Information, dated August 31, 2016, section 27, Public Health Authorities, with the appropriate standing request letter in place; (3) Congressional Offices -when the member of Congress is making an inquiry on behalf of the Veteran;

(4) Other VA entities and any other legal authority. The Privacy Officer should be consulted prior to any disclosure.

H. This facility prohibits discrimination based on age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, and gender identity or expression.

IV. SCOPE: There is no one process that assures the implementation of Veteran rights, but rather it is an integrated system of policies, procedures, and protocols which guide health care providers. The following activities and functions provide the integrated framework in which Veteran rights are protected and exercised:

A. A Veteran is provided reasonable access to care. The mission of this facility and the applicable laws and VA regulations dictate the scope and type of care available to Veterans. If care is needed which is not available at the facility, the Veteran is referred or transferred to an appropriate health care provider or facility.

B. A Veteran is given considerate care that respects the Veteran’s personal value and belief systems. An environment is fostered which will provide considerate and respectful care.

C. The Veteran will have the opportunity to make informed decisions and participate in decisions regarding his/her care.

D. Veterans have the right to participate in the consideration of ethical issues that arise in the provisions of their care. This right is or can be exercised through an ethics consult as described in Medical Center Policy (MCP) RI-02 Integrated Ethics Program, dated August 8, 2019.

E. Veterans are assured personal privacy and confidentiality of information through procedures outlined in MCP IM-09 Privacy Policy and Procedures, dated February 23, 2021.

https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=3233 https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=3233 https://dvagov.sharepoint.com/:b:/r/sites/VHABUTvamc/Policies/MCM1/MCP%20PDF%20Files/RI%20-%20Ethics,%20Rights,%20and%20Responsibilities/RI-02%20INTEGRATED%20ETHICS%20PROGRAM.pdf?csf=1&web=1&e=1Ul6Cg https://dvagov.sharepoint.com/:b:/r/sites/VHABUTvamc/Policies/MCM1/MCP%20PDF%20Files/IM%20-%20Information%20Management/IM-09%20Privacy%20Policy%20and%20Procedures.pdf?csf=1&web=1&e=k9GtX4

4 Medical Center Policy RI-03

F. Veterans have the right to designate a representative decision-maker in the event they are incapable of understanding a proposed treatment or procedure or are unable to communicate their wishes regarding care. The procedure to designate a representative decision-maker is described in MCP RI-06 Advanced Directives, dated July 21, 2020.

G. Veterans have the right to access protective services (that is guardianship and advocacy services, conservatorship, and child and protective services). A list of resources to assist families in need of these services is maintained by Social Work Services and is provided upon request.

H. Every Veteran has the right to choose his/her own Physician within this facility.

The CLC has an assigned Attending Physician. Any Veteran expressing concern to be cared for by another Physician will notify the nursing staff and this facility will make a reasonable attempt to respond to the Veteran’s right to choose an alternate physician, dentist, or other Licensed Practitioner to provide that care.

I. A detailed description of Veteran and Community Living Center Resident Rights and Responsibilities is listed in the Veteran Information Handbook.

V. RESPONSIBILITIES:

A. The Director is responsible for the overall administration of the Veteran rights policy and ensuring fair and appropriate action is taken when behavior is found to be in violation of this policy according to an established protocol.

B. The Veteran Experience Officer will act as a liaison between the Veteran, Veteran’s family, and the facility. Through the Veteran advocacy program, we will ensure that Veterans and their families are afforded the opportunity to voice complaints without interference, coercion, discrimination, or reprisal.

C. Supervisors will create a culture based on respect for the dignity of the Veteran as an individual and on care that is provided in a courteous, concerned, and compassionate manner.

D. It is a prime responsibility for all employees to endeavor to assure that the basic rights of Veterans are preserved. In providing care, the employees have the right to expect behavior on the part of Veterans and their relatives and friends which is reasonable and responsible. Employees will report their concerns related to violations of Veteran rights to their supervisors.

E. Veterans: Veterans, as appropriate to their condition, are responsible for providing information about matters related to their health care, asking questions when they do not understand, following the care and treatment plan developed, accepting consequences if they do not follow the plan, following the facility’s rules and regulations, showing respect to other Veterans, their families, staff, property, and for meeting their financial responsibilities as outlined in Attachment A.

https://dvagov.sharepoint.com/:b:/r/sites/VHABUTvamc/Policies/MCM1/MCP%20PDF%20Files/RI%20-%20Ethics,%20Rights,%20and%20Responsibilities/RI-06%20ADVANCE%20DIRECTIVES.pdf?csf=1&web=1&e=6HbTM3

5 Medical Center Policy RI-03

VI. REFERENCES:

The Joint Commission Comprehensive Accreditation Manual, 2021.

HIPAA (Public Law (Pub.L.) 104-191) implemented by 45 CFR Parts 160-164;

Confidentiality of Healthcare Quality Assurance Review Records, 38 U.S.C. 5705, implemented by CFR Sections 17.500-17.511. April 2003 Veteran Information Handbook, Butler VA Health Care System, November 2013 VHA Directive 1605.01 Privacy and Release of Information, dated August 31, MCP IM-09 Privacy Policy and Procedures, dated February 23, 2021 MCP RI-02 Integrated Ethics Program, dated August 8, 2019 MCP RI-06 Advanced Directives, dated July 21, 2020

VII. RESCISSION: Medical Center Memorandum RI-03, dated November 28, 2017.

KEVIN P. AMICK

Director

Attachments: A, B, C

(Automatic Review Date: March 5, 2026) https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=3233 https://dvagov.sharepoint.com/:b:/r/sites/VHABUTvamc/Policies/MCM1/MCP%20PDF%20Files/IM%20-%20Information%20Management/IM-09%20Privacy%20Policy%20and%20Procedures.pdf?csf=1&web=1&e=k9GtX4 https://dvagov.sharepoint.com/:b:/r/sites/VHABUTvamc/Policies/MCM1/MCP%20PDF%20Files/RI%20-%20Ethics,%20Rights,%20and%20Responsibilities/RI-02%20INTEGRATED%20ETHICS%20PROGRAM.pdf?csf=1&web=1&e=1Ul6Cg https://dvagov.sharepoint.com/:b:/r/sites/VHABUTvamc/Policies/MCM1/MCP%20PDF%20Files/RI%20-%20Ethics,%20Rights,%20and%20Responsibilities/RI-06%20ADVANCE%20DIRECTIVES.pdf?csf=1&web=1&e=6HbTM3

VA Butler Health Care ADMISSION FORM

□ Section 1 – Personal Property and Funds (Attachment A of MCM RI-03)

I acknowledge that upon my admission and for the duration of my admission at this facility, I was verbally counseled on the following information:

• Personal medication in my possession MUST be sent home or turned over to admitting personnel for safekeeping.

• Funds in excess of $20 should be sent home or deposited with the Agent Cashier. NOTE: Withdrawals from Patient Funds Accounts may NOT exceed $400 at any one time.

• Personal effects and valuables should be sent home or given to administrative staff for storage.

• I understand that additional items brought in or purchased while I am a resident must be added to the inventory sheet that was completed upon admission.

• All weapons (guns, knives, ammunition, etc.) MUST be turned over to security personnel.

• I understand that I will make arrangements for transportation for any non-VA appointments during my admission at VA Butler Healthcare.

Any questions or questionable items should be brought to the attention of personnel at the time of admission or during stay since the VA will assume NO responsibility if compliance of the above is not adhered to.

*Reference pamphlet provided with additional information regarding inventory of personal items*

□ Section 2 – Rights and Responsibilities and Release of Medical Information

(Patient and Nursing Home Rights and Responsibilities – Outlined in Veteran Information Handbook) A copy of the VA “Patient Rights and Responsibilities” has been provided and explained to me. I understand that I have the r ight to privacy and confidentiality regarding my medical information and that this information cannot be released without my permission.

Written consent is required to release verbal information regarding my medical condition to inquiries (i.e., telephone calls or verbal contacts from family and/or friends). I have completed Attachment C of MCM RI-03 to name the individuals authorized to receive verbal communication regarding my medical information.

□ I acknowledge receipt of the Patient information folder containing information regarding facility rules and regulations.

Attachment A

□ Section 3 – Agreement to be Escorted by Compensated Work Therapy (CWT) Workers

The Compensated Work Therapy Program has been explained to me and I understand that one of the assignments of the CWT workers is patient escort. During my hospital stay, should I need an escort:

___ I give my consent to be escorted by CWT Workers

___ I would prefer not to be escorted by CWT Workers

□ Section 4 – Advance Directives (AD), Power Of Attorney (POA) & Do Not Resuscitate (DNR)

Information and instruction regarding an Advance Directive (AD), Power of Attorney (POA), and Do Not Resuscitate (DNR) have been provided and explained to me. I understand that I may change or revoke my Advance Directive at any time.

□ Section 5 – Wandering Risk / Project Lifesaver Package (for wandering risk residents only)

I consent to the following:

□ The Wandering Risk Package which includes authorization of photograph for file & completion of the Project Lifesaver questionnaire

□ Red vest will be worn while away from the secure unit

□ Project Lifesaver Sensor to be worn at all times

□ Section 6 – Respite or Hospice Admissions (N/A for all others)

□ Respite Pamphlet

□ Hospice Pamphlet

ALL PATIENTS OR A PATIENT’S REPRESENTATIVE MUST SIGN AND DATE THIS FORM

I attest the above information is complete and accurate to the best of my knowledge

Signature of Patient or Representative Date

Relationship to Patient

ATTACHMENT B

Attachment B

3 Medical Center Policy RI-03

4 Medical Center Policy RI-03

5 Medical Center Policy RI-03

6 Medical Center Policy RI-03

ATTACHMENT C

REPORT OF CONTACT

NOTE: This form must be filled out in ink or on typewriter as it becomes a permanent record in the Veterans’ folders.

VA OFFICE

VA Butler Healthcare

IDENTIFICATION NOS. (C, XC, SS, XSS, V, K, etc.)

LAST NAME-FIRST NAME-MIDDLE NAME OF VETERAN

(Type or print)

DATE OF CONTACT

ADDRESS OF VETERAN

TELEPHONE NO. OF VETERAN

PERSON CONTACTED

TYPE OF CONTACT (Check)

· PERSONAL · TELEPHONE

ADDRESS OF PERSON CONTACTED TELEPHONE NO. OF PERSON CONTACTED

BRIEF STATEMENT OF INFORMATION REQUESTED AND GIVEN

Admissions to CLC or Residential Treatment Center

A copy of the VA "Veteran Rights and Responsibilities" has been provided and explained to me. I acknowledge that I understand these rights and responsibilities.

Veterans have the right for the privacy and confidentiality of his/her medical information. This information cannot be released without your permission. Therefore, your written consent is needed to release verbal information regarding your medical condition to inquiries (i.e., phone calls or verbal contacts from family and/or friends). I give permission to release verbal information to the individuals listed below:

Contact #1 Contact #2

Name: Name:

Relationship to Veteran: Relationship to Veteran:

Address: Address:

Telephone number: Work Telephone number: Work

Home Home

Cell Phone Cell Phone

Comments:

I authorize the following types of specific information for verbal communication to the above contact persons:

_______ Diagnosis

_______ Condition

_______ Treatments by various disciplines

_______ All other callers will receive general information only such as Good, Fair, etc.

_______ I request No medical information be released verbally to family or significant others.

Veteran and/or Representative Signature Date

Facility Representative Signature Date

Instructions: Admitting clerk will explain and obtain written consent

Signed ROC will be scanned and maintained under the administrative tab of CHR, and keep copy on unit to update information annually

DIVISION OR SECTION

EXECUTED BY (Signature and Title)