S02 - Attachment 15 COS-46 Patient Rights and Responsibilities.pdf

DEPT. OF VETERANS AFFAIRS

BLACK HILLS HEALTH CARE SYSTEM

Policy COS-46 February 24, 2012

PATIENT RIGHTS AND RESPONSIBILITIES

1. PURPOSE:

To establish a policy for the support and protection of the fundamental rights of the individual patient, to establish a procedure to inform and assist the patient in exercising those rights, and to establish a policy for patient responsibilities.

2. POLICY:

The VA Black Hills Health Care System, comprised of the Fort Meade and Hot Springs VA Medical Centers, affirms each patient's right to personal dignity, privacy and confidentiality. The Fort Meade and Hot Springs VA Medical centers recognize that the patient has the right to make decisions regarding his/her medical care, including the decision to discontinue treatment, to the extent permitted by law. Staff is committed to providing high quality medical care to patients in a climate in which the patient's personal values and beliefs are respected.

3. PROCEDURES:

A. Applicants for care will receive a copy of the financial counseling information they sign.

B. Inpatients will have access to a "Patient Handbook" in their patient rooms.

C. Copies of patient rights and responsibilities will be posted on inpatient units and in clinic areas, along with information for patients to access patient advocates.

D. Applicants for care will receive a copy of their rights and responsibilities.

4, RESPONSIBILITIES:

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

B. Business Office is responsible for providing eligibility and financial i formation to each patient at the times/he applies for care.

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

D. Patient advocates assist patients in understanding their rights and responsibilities, and mediate for patients and their families to address complaints and resolve problems. ·

E. Health care providers, including physicians; nurse practitioners, physician assistants, and clinical nurse specialists, are responsible for giving patients clear and concise information concerning the patient's condition, proposed treatment and procedures, alternative treatments and procedures, potential benefits and risks of each, likelihood of success, and ethical issues that impact care.

F. Human Resource Management Service is responsible for issuing a copy of VA Black Hills Patient and Nursing Home Resident Rights and responsibilities," to all new employees. Discussion of patients' rights and responsibilities will be scheduled as part of Phase 3 (initial) orientation.

G. Supervisors are responsible for ensuring that all staff members respect the patient's right to confidentiality, privacy and safety.

H. Employees are responsible for treating patients with dignity, respecting each patient's cultural, psychosocial, spiritual and personal values;

and protecting the patient's right to confidentiality.

5. REFERENCES:

A. Current Joint Commission standards for Hospital, Long Term, Ambulatory and Behavioral Health.

B. VA Black Hills Health Care System "Patient Handbook".

C. Patient Rights and Responsibilities (Appendix A).

6. RESCISSION:

Black Hills Health Care System Policy COS-46 dated June 14, 2010.

7. DATE OF COMPLETE REISSUANCE:

February 24, 2015

8. FOLLOW-UP RESPONSIBILITY:

Chief of Staff Office

STEPHEN R. DISTASIO, FACHE

Director

APPENDIX: A

PATIENT AND NURSING HOME 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) 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.

4) As an inpatient or nursing home resident you may wear your own clothes. You may keep personal items. This will depend on your medical condition.

5) As an inpatient or nursing home 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 an inpatient or nursing home 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.

7) As a nursing home resident, you can organize and take part in resident groups in the facility. Your family also can meet with the families of other residents.

8) 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. You also have the right to know the names and titles of those who provide you care. This includes studeµts, 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 patient or 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 any 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 pressure on you to participate.

9) You will be included in resolving any ethical issues about your care.

and/or

You may consult with the Medical Center's Ethics Consultation Service 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.

APPENDIX B

PATIENT RIGHTS AND RESPONSIBILITY FOR VISITORS

· The VABHHCS recognizes the right for every patient to allow the patient's family, and/or whomever the patient defines as family, as the most constant factor in each patient's life and who is considered a "partner in care" for emotional support and healing during the course of hospital and nursing home stays.

The medical center respects the patient's right to make decisions about his or her care, treatment and services, and to involve the patient's family in care, treatment, and services decisions to the extent permitted by the patient or surrogate decision-maker. 'Family' is defined as a group of two or more persons united by blood, or adoptive, marital, domestic partnership, or other legal ties. The family may also be a person or persons not legally related to the individual (such as significant other, friend or caregiver) whom the individual considers to be family. A family member may be the surrogate decision-maker, as defined in VHA Handbook 1004.02, if authorized to make care decisions for the individual, should he or she lose decision-making capacity or choose to delegate decision making to another. The medical center allows a family member, friend or other individual to be present with the patient for emotional support during the course of stay. The medical center allows for the presence of a support individual of the patient's choice, unless the individual's presence infringes on others' rights or safety, or is f(ledically or therapeutically contraindicated.

The individual may or may not be the patient's surrogate decision-maker or legally authorized representative. The hospital prohibits di.scrimination based on age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, and gender identity or expression.

Stephen R. DiStasio, as Director for Black Hills Health Care System attest to the following:

1) That my facility is in compliance with the memorandum from the Deputy Under

Secretary for Health for Operations and Management, dated February 10, 2012. This memorandum required that my facility have a visitation policy that contains the foJ/owing language:

The medical center respects the patient's right to make decisions about his or her care, treatment and services, and to involve the patient's family in care, services, and treatment decisions to the extent permitted by the patient or surrogate decision-maker. 'Family' is defined as a group of two or more persons united by blood, or adoptive, marital, domestic partnership, or other legal ties.

The family may also be a person or persons not legally related to the individual (such as significant other, friend or caregiver) whom the individual considers to be family. A 'family member may be the surrogate decision-maker, as defined in VHA Handbook 1004.02, if authorized to make care decisions for the individual, should he or she lose decision-making capacity. The medical center allows a family member, friend or other individual to be present with the patient for emotional support during the course of a stay. The medical center allows for the presence of a support individual of the patient's choice, unless the individual's presence infringes on others' rights or safety, or is medically or therapeutically contraindicated. The individual may or may not be the patient's surrogate decision-maker or legally authorized representative. The hospital prohibits discrimination based on age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, and gender identity or expression." ·

2) That the curricula for New Employee Orientation, and for at least one regularly scheduled training or educational forum for existing staff include discussions of visitation policies and practices, and Veteran rights to involve individuals of their choice to provide support; and

3) That copies of the Memorandum entitled "Notification to Patients of Joint Commission Standards Modifying Patient and Nursing Home Resident Rights and Responsibilities" have been posted in all inpatient care units and outpatient clinical areas throughout my facility.

Director

2f_ 29}. 1_