S02 Attachment Eight 8 Patients Rights and Responsibilitiees.pdf

DEPARTMENT OF VETERANS AFFAIRS MEDICAL CENTER MEMORANDUM

MEDICAL CENTER NUMBER: 548-125-78

WEST PALM BEACH, FLORIDA March 10, 2013

PATIENTS' RIGHTS AND RESPONSIBILITIES

1. PURPOSE: To outline patients’/residents’ rights and responsibilities at the West Palm Beach VA Medical Center and outpatient clinic(s).

2. POLICY: Upon admission the patient or his/her representative shall be informed of the rights described in 38 Code of Federal Regulations (CFR) part 17.33. He/She shall be given a copy of a statement of those rights and shall be informed of the fact that the statement of rights is posted at each nursing station and other areas in the medical center.

Patients will have patients’/residents’ rights and responsibilities explained by staff in a manner that is understandable to the patient and/or family. This includes the use of an interpreter/translator when needed.

B. All patients/residents who are legally competent have the following rights and responsibilities. Many of the following still apply to legally incompetent patients

(1) Respect and Nondiscrimination

(a) 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.

(b)You will receive care in a safe environment free from excess noise, and with sufficient light to ensure comfort and safety.

(c)You have a right to have access to the outdoors.

(d) 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.

(e)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.

(f)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.

(g) 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.

(h) 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.

(i) You have the right to keep and use personal items as long as they are safe and legal.

(j) 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.

(k) 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.

(l) 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

ATTACHMENT EIGHT (8) -PATIENTS RIGHTS AND RESPONSIBILITIES

36C24821R0092 safety concerns require it. You will be told promptly about any visitor restriction and the reason for it.

(m) 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.

In order to provide a safe treatment environment for all patients and staff, you are asked to respect other patients and staff and to follow the facility’s rules. Avoid unsafe acts that place others at risk for accidents or injuries. Smoking is prohibited inside all medical center buildings. Smoking is permitted in outside designated areas only.

Please immediately report any condition you believe to be unsafe.

(2) Emotional Support

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, safety, or is medically or therapeutically contraindicated. The individual may or may not be the patient's surrogate decision-maker or legally authorized representative. You may also refuse to see anyone you do not wish to.

(3) Discrimination

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

(4) Information Disclosure and Confidentiality

(a) Your privacy will be protected.

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

(c) 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.

(d) 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.

(e) 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.

(5) Participation in Treatment Decisions

(a) 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.

(b) 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.

(c) 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.

(d) 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.

(e) 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.

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

(g) You will be informed of all outcomes of your care, including any possible injuries associated with your care.

(h) You will be informed about how to request compensation and other remedies for any serious injuries.

(i) 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.

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

(l) 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.

(k) 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.

(6)Complaints

(a) 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.

(b) If you believe that you or your family member 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 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.

3. Rights and Responsibilities of Family Members of VA Patients & Residents of Community Living Center 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.

A. 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.

B. 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.

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.

C. 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.

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.

7. PROCESS:

A. All patients will have patients’/residents’ rights and responsibilities explained to them in a language that they understand and be given a written copy of these rights/responsibilities upon admission. The document to be provided is attachment A. Patients on 3C, Psychosocial Rehabilitation and Recovery Center (PRRC), and in the Community Living Center (CLC) shall sign and date for receipt using the IMED Consent software. “Patients hospitalized elsewhere in the medical center (i.e., 6A, 6B, 7A and Intensive Care) as well as outpatient Mental Health clinics do not need to sign this form but shall be given a copy of the “Patients’ Rights and Responsibilities Form.” A Blind or visually impaired patient will be given a copy of the Patients’ Rights and Responsibilities in a format accessible to him/her individually, i.e. cassette tape or large print etc.

B. All patients who come in to register but seek no care that day will be provided attachment A by MAS Registration Staff.

C. Patients who newly register and need to be seen will have a copy provided by the Triage Nurse for those patients who are not expected to be admitted.

D. A copy will be provided to all patients who attend the New Patient Orientation class.

4. RESPONSIBILITY:

A. All employees are responsible for respecting patients’ rights. Service Chiefs are responsible for ensuring their staff members are familiar with this policy and that training related to this policy is documented in employees training records.

B. Employee Education Service is responsible for ensuring that all new employees receive training on this medical center policy.

C. Patient Advocates are responsible for addressing Patient’s complaints, grievances, or areas of conflict.

D. Nursing Service will ensure each patient or family member receives a copy of “Patient Rights and Responsibilities”, and that they understand them. This will be documented in the nursing admission assessment. Nursing Service will ensure that 3C patients and Community Living Center residents sign using the IMED consent software.

E. Mental Health Service will ensure Day Treatment patients sign and date the form to acknowledge receipt of “Patients’ Rights and Responsibilities” using the IMED Consent software

F. Auditory amplification devices for hearing impaired patients that need this to understand his or her rights and responsibilities are available through Auditory and Speech Pathology.

G. Patients who cannot read the Patient Rights and Responsibilities document will be provided with an audio recording of these rights and responsibilities spoken in English or to the extend able in the patient’s/resident’s language.

Blinded or visually impaired patients will be provided the information in an accessible format. Patient/Resident rights will be posted in designated areas on each floor and clinic areas of the medical center.

5. REFERENCE:

38 CFR 17.33

Comprehensive Accrediation Manual, for Hospitals, Joint Edition.

MCM 548-11-199; Admission, Discharge, and Transfer.

MCM 548-00-140; Patient/Customer Satisfaction Coordination and Service Recovery.

Comprehensive JC Accrediation Manual, for Long Term Care, Current Edition.

National Patient Rights and Responsibilities updated by the Veterans Service and Advocacy Program Community dated September 2006.

6. FOLLOW-UP RESPONSIBILITY: Chief, Chaplain Service

7. RECISSIONS: MCM 548-136-78, March 10, 2011

8. EXPIRATION DATE: March 10, 2016.

Charleen R. Szabo, FACHE Medical Center Director

Attachment: A Distribution: Electronic

DEPARTMENT OF VETERANS AFFAIRS MEDICAL CENTER MEMORANDUM

MEDICAL CENTER NUMBER: 548-125-138

WEST PALM BEACH, FLORIDA March 10, 2013

ATTACHMENT A

PATIENT RIGHTS AND RESPONSIBILITIES

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 VA treatment team members or a Patient Advocate if you have any questions or would like more information about your rights. All of VA’s rules regarding your rights can be found in 38 Code of Federal Regulations Part 17 paragraph 33.

1. Respect and Nondiscrimination

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.

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

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.

While you are an inpatient or long-term care resident, you may wear your own clothes and keep personal items. This depends on your medical condition.

While you are an inpatient or long-term care 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.

While you are an inpatient or long-term care 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.

While you are a long-term care resident, you can organize and take part in resident groups in the facility.

Your family also can meet with the families of other residents.

In order to provide a safe treatment environment for all patients and staff, you are asked to respect other patients and staff and to follow the facility’s rules. Avoid unsafe acts that place others at risk for accidents or injuries. Smoking is prohibited inside all Medical Center buildings. Smoking is permitted in outside designated areas only. Please immediately report any condition you believe to be unsafe.

2. Information Disclosure and Confidentiality

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

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

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. You have the right to ask us to provide you with a copy of all external parties to whom we have disclosed your record You will be informed of all outcomes of care, including any injuries caused by your medical care. You will be informed about how to request compensation for injuries.

3. Participation in Treatment Decisions

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. Refusing treatment will not affect your rights to future care but you have the responsibility to understand the possible results to your health. If you believe you cannot follow the treatment plan, you have a responsibility to notify the treatment team.

While you are an inpatient or long-term care resident, you will be provided any transportation necessary for your treatment plan.

You will be given, in writing, the name and professional title of the provider in charge of your care.

As a partner in the healthcare process, you have the right to be involved in choosing your provider.

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

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 or have any concerns. This will help us to provide you the best care possible.

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.

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 may consult with the medical center’s Ethics Consultation Service and/or other staff knowledgeable about health care ethics. You will be included in resolving any ethical issues about your care.

If you or the medical center believes that you have been neglected, abused or exploited, you will receive help.

4. 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.

Note: It is intended that these rights can be exercised on the patient's behalf by a designated surrogate or proxy decision-maker if the patient lacks decision-making capacity, or is legally incompetent. In these cases, the patient’s designated surrogate or proxy decision-maker shall sign the form on the patient’s behalf.