S02 - Attachment 1 CLC-139 Resident Rights and Responsibilities 12 20 12.pdf

DEPT. OF VETERANS AFFAIRS Policy CLC-139 BLACK HILLS HEALTH CARE SYSTEM January, 2013

RESIDENT RIGHTS AND RESPONSIBILITIES

1. PURPOSE:

To describe how Black Hills Health Care System recognizes and respects Community Living Center (CLC) Resident rights. This policy provides guidance to staff as they support and encourage residents/family (as appropriate) to:

exercise these rights, participate in their care and understand their responsibilities.

2. POLICY:

All residents entering the Community Living Center have rights and responsibilities that promote resident dignity, autonomy, estimations of self-worth, civil rights and involvement in his or her care. Each resident will be informed about their rights and responsibilities while receiving care on the CLC. All levels of staff and supporting services will be knowledgeable and respect the established Resident Rights and Responsibilities.

3. PROCEDURE:

A. The residents are treated respectfully and in a manner that supports their dignity. Therefore, staff will:

(1) Protect resident privacy by: knocking before entering the resident’s room, closing doors or curtains before providing resident treatment, assisting residents to have private conversations (either with guests or on the telephone), obtaining consent for recordings/ films/ or other images for purposes other than the resident’s care.

(2) Residents are encouraged to wear their own clothes and have personal “home-like” possessions in their room.

(3) Residents or someone they choose may keep and spend their money. The VA will provide an accounting of any VA held funds, upon request.

(4) Residents are assisted, as requested, with civic activities such as voting and free speech.

(5) Liberal visiting hours provide Veterans opportunity to have guests of their choosing.

(6) Residents/families are informed of room and roommate assignments and changes.

(7) Residents may send and receive mail, per BUS-06.

B. Residents and/or their family receive information, that they understand, about their medical care, health benefits and associated costs.

This is accomplished by determining a resident’s communication needs/preferences and making necessary adaptations. These adaptations may include: translation services, hearing aids, communication boards, white boards, and not using complex medical terminology when possible. Additional information on assisting residents with communication needs is available on DIR-22 (Effective Communication with minorities, hearing and speech impaired).

Translator service is available at 9-1-866-895-7373; the VA BHHCS Access Code is PL512.

C. Residents’ cultural, psychosocial, personal and spiritual values, beliefs and preferences are respected. The following are examples (resident options are not limited to this list):

(1) Residents choose their waking, sleeping, and eating times.

(2) Residents participate in worship, spiritual, recreational, relaxation, socializing, exercise and community activities of their choosing.

Staff assists, accommodates and provides support according to the needs and desires of the resident. If a resident’s participation in an activity or group is detrimental to the safety of the resident or others, the organization may not support the resident’s choice to participate.

(3) Residents may choose to perform or to not perform tasks in or for the Medical Center.

D. Resident’s pain is assessed and treatment to manage the pain is established by the resident and his/her treatment team.

E. The residents’ medical record is kept confidential. Information about the resident will not be released without their consent, unless authorized by law. Residents have a right to review information in their medical record, may request a copy. (Unless his/her VA physician feels the information would be harmful to the resident. Then the resident may discuss this with the physician.) The resident may request to amend his/her health information or obtain information on disclosures of this information. Additional information on Medical Record privacy may be found in DIR-01 (Privacy) and BUS-02 (Release of Patient information).

F. Residents receive information about policies related to transfers

(including room-to-room transfers) and discharges. Residents and family members (with proper consent of the resident) are involved in decisions related to transfers and discharges. More specific information regarding transfers and discharges can be found in: COS-22 (Inter-facility Acute transfer), CLC-142 (Notification of family member of resident transfer), CLC-148 (Resident room changes) and CLC-103 (Patient Assessment, Care Planning).

G. Residents and their families or surrogate decision-makers have the right to: receive understandable information about treatment options/alternatives/outcomes, participate in decisions about care and refuse care (including Advance Directives, Do-Not-Resuscitate, End-of-life care, and Informed Consent.)

(1) Residents receive written information about Advance Directives, forgoing or withdrawing life-sustaining treatment, and withholding resuscitative services. Resident’s care and treatment preferences are sought through the Advance Directive and ongoing dialogue with the resident.

Residents have the right to create an Advance Directive but are not required to formulate an Advance Directive as a condition of care. See COS-53 (Advance Directive) for more information regarding the Advance Directive process.

(2) Information within the Advance Directive including surrogate decision-maker and care/treatment preferences is respected.

(3) When the provider believes the resident will benefit from a special treatment, test or procedure (for example – blood transfusion) the provider will utilize the informed consent process. This process helps the resident fully participate in his/her care by discussing the proposed procedure, test or treatment. Important information includes risks, benefits, options/alternatives and possible results of refusal. The resident or surrogate has the right to refuse the proposed treatment, test or procedure. Detailed information about the process is found in COS-12 (Informed Consent).

(4) The resident’s provider informs the resident and/or surrogate decision maker about unanticipated events according to COS-21 (Disclosure of Adverse Events to Patients).

(5) Residents will receive assistance to make and keep appointments with medical, dental and other providers. This includes transportation necessary for the resident’s treatment plan.

(6) Residents have the right to the name and credentials of their provider and others responsible for authorizing and performing procedures and treatments. They may also choose their attending provider, within limits.

H. Residents may choose to participate in research, investigations or clinical trials.

I. Residents have the right to be free from restraint, either physical or chemical. The CLC strives to be a restraint free environment. Non-physical interventions are preferred; restraint/seclusion will be initiated ONLY when other non-physical interventions have failed and there is an imminent risk of resident physically harming himself/herself or others. Additional guidance on restraint can be found in COS-08 (Restraint and Seclusion of Patients).

J. Residents are protected from neglect; exploitation; and verbal, mental, physical and sexual abuse. Details regarding BHHCS processes to protect residents and investigate allegations of suspected cases of abuse are available in DIR-18 (Code of Ethics) and COS-10 (Patient Abuse).

K. Resident Council is available to all residents and family members to voice and address concerns. The Council also promotes socialization and decision-making awareness. Additional information regarding Resident and Family Council can be found in CLC-138 (Resident Council).

L. Residents will have concerns, conflicts, and complaints addressed:

(1) In all cases, every effort will be made to address the concern to the Veteran/family’s satisfaction. Providers, Therapists, Unit managers or Associate Chief of Staff/Extended Care and Rehab may play a role in addressing resident concerns. In the event that the concern is not addressed to the satisfaction of the Resident the Patient Advocate at 720-7179 Fort Meade, or 745-2060 at Hot Springs is able to provide assistance. The resident or family member may also contact The Joint Commission for Accreditation of Healthcare Organizations at: complaints@jointcommision.org

(2) Ethics consults

M. Communication of resident responsibilities enhance the resident-provider partnership by: increasing resident understanding of care, clarifying expectations for quality care and safe environment, supporting mutual consideration and facilitating conversation about meeting financial obligations.

(1) Residents should tell their provider about their current condition, medicines (including over-the counter and herbals) and medical history. Also, share any other information that affects their health. They should ask questions when they do not understand something about their care.

(2) Residents are expected to work with the treatment team to develop a pain management plan. This includes telling the provider if the treatment is working.

(3) Residents should notify their provider or treatment team if they cannot follow the treatment plan.

(4) Residents are expected to respect other patients, residents and staff; and follow the facility’s rules. This includes: maintaining civil language and behavior; avoiding unsafe acts that place themselves and others at risk for injury and immediately reporting any condition they believe to be unsafe.

(5) Residents are responsible for paying their portion of any costs associated with their care.

4. RESPONSIBILITIES:

A. ACOS/EC&R is responsible for ensuring that each resident is advised of his/her rights and responsibilities, and that each employee is aware of and respects these rights and responsibilities.

B. Nurse Managers are responsible for providing residents with information about their rights and responsibilities and the process to seek assistance in the event questions or problems arise.

C. Social Workers/Patient Advocate assist residents in understanding their rights and responsibilities and mediate for residents and their families to address complaints and resolve problems.

D. Health care providers are responsible for giving residents/family clear and concise information concerning the resident’s condition, proposed treatment and procedures, alternative treatments and procedures, potential benefits and risks of each, likelihood of success, and ethical issues that impact their care.

E. Employees are responsible for treating residents with dignity;

respecting each resident’s cultural, psychosocial, spiritual and personal values; and protecting the resident’s right to privacy and confidentiality.

mailto:complaints@jointcommision.org

5. REFERENCES:

A. The Joint Commission for Accreditation of Long Term Care Manual, Current version

B. BHHC System Policies

(1) CLC-103 Interdisciplinary Patient Assessment care Planning

(2) CLC-138 Resident Council

(3) CLC-142 Notification of Family Member of Resident Transfer

(4) CLC-148 Resident Protection from Assaults

(5) BUS-02 Release of Patient Information

(6) BUS-06 Mail Processing

(7) COS-08 Seclusion and Restraint

(8) COS-10 Patient Abuse

(9) COS-12 Informed Consent

(10) COS-21 Disclosure of Adverse Events to Patients

(11) COS-22 Inter-facility Acute Transfer of Patients

(12) COS-53 Advance Directive

(13) DIR-01 Privacy Policy

(14) DIR-18 Code of Ethics

(15) DIR-22 Effective Communication with Minorities, Hearing or

Speech Impaired

6. RECISSION:

CLC-139, Resident Rights and Responsibilities, Jan 2009

7. DATE OF COMPLETE REISSUANCE:

January, 2016

8. FOLLOW-UP RESPONSIBILITY:

Administrative Officer for EC&R

Sheila Eckrich, MD

ACOS/EC&R

APPENDIX: A

COMMUNITY LIVING CENTER (CLC) RESIDENT RIGHTS AND RESPONSIBILITIES

The Veterans Health Administration (VHA) is pleased you have selected us to provide your healthcare. We want to improve your health and well-being. We will make your visit or stay as pleasant for you as possible. As part of our service to you, to other veterans and to the Nation, we are committed to improving healthcare quality. We also train future healthcare 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. Your basic rights and responsibilities are outlined in this document. Please talk with VA treatment team members or a patient advocate if you have any questions or would like more information about your rights.

I. Respect and Nondiscrimination:

1) 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.

2) You or someone you choose has the right to keep and spend your money. You have the right to receive an accounting of any VA held funds.

3) In rare cases, if your behavior places you or others at risk for harm you may be transferred to a more appropriate level of care.

4) As a CLC resident you may wear your own clothes. You may keep personal items.

5) As a 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 to participate in these activities. You may decide whether or not to perform tasks in or for the Medical Center.

6) As a CLC resident, you have the right to communicate freely and privately. You may have or refuse visitors. You will have access to public telephones. You may participate in civic rights, such as voting and free speech. You may send mail. You may receive mail that the treatment team feels does not put you at risk for harm.

7) You and your family member (if you desire) will be informed about room and roommate assignments. You will also be informed in the event that a room change, transfer or discharge is necessary.

8) 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.

9) 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.

II. Information Disclosure and Confidentiality:

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

2) You will receive information about the costs of your care, if any, before you are treated. You are responsible for paying your portion of any costs associated with your care.

3) Your medical record will be kept confidential. Information about you will not be released without your consent unless authorized by law (an example of this is 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 when your VA physician feels the information will be harmful to you. In that case, you have the right to have this discussed with you by your VA provider.

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

III. Participation in Treatment Decisions:

1) 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 yours rights to future care but you take responsibility for the possible results to your health.

2) 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. Being involved is very important for you to get the best possible results.

3) You will be given, in writing, the name and professional title of the provider in charge of your care. As our partner in the healthcare, you have the right to be involved in choosing your provider, within limits. 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.

4) You will be educated about your role and responsibilities as a CLC resident. This includes your participation in decision-making and care at the end of life.

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

6) 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.

7) As an inpatient or nursing home resident, you will be provided transportation necessary for your treatment plan.

8) 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.

9) 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 healthcare ethics.

10) If you or the Medical Center believes that you have been neglected, abused or exploited; you will receive help.

IV. Complaints:

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. You may complain verbally or in writing, without fear of retaliation.