Patient Rights


EFFECTIVE DATE: 12/2/97
REVIEWED/REVISED: 4/1/04; 04/05; 01/06; 04/07; 6/08; 06/09; 8/10; 8/11; 5/12; 1/13; 1/14; 1/18; 1/21


Regulatory: Rehabilitation Hospital Licensing Standards NJAC 8:43H-17.2 TJC. RI.01.01.01

Purpose:
To establish and implement written policies and procedures which ensure the safeguarding of patient rights.

Policy
WCRH respects the rights of all patients and has established appropriate mechanisms to ensure the protection of those rights by all staff. The Hospital respects the patient’s right to and need for effective communication and the need for privacy. The patient is allowed to access, request amendment to and obtain information on disclosures of his or her health information, in accordance with law and regulation.

These policies and procedures shall be available to patients, staff, and the public and shall be conspicuously posted in the hospital.

The staff of the hospital shall be trained to implement policies and procedures regarding patient rights as part of orientation, annual mandatory education, and departmental inservices.

The hospital shall comply with all applicable State and Federal statutes and rules concerning patient rights, including N.J.S.A. 52:27G.7.1.

Procedure

1. The hospital’s policies and procedures will ensure that at a minimum, each patient admitted to the hospital:

a. Is informed of these rights, as evidenced by his/her written acknowledgment, and received an explanation, in terms that he/she can understand.
b. Is entitled to care, treatment and services without discrimination based on race, age, religion, national origin/culture, religion, language, physical or mental disability, sex, sexual orientation, gender identity or expression, diagnosis, socioeconomic status (ability to pay), or source of payment
c. To be given, prior to the initiation of care, a written copy of the patient rights set forth in Subchapter 17 of the Licensing Standards for Rehabilitation Hospital (8:43H-17.2) effective April 22, 2005, and any additional policies and procedures established by the facility involving patient rights and responsibilities. If the patient is unable to respond, the notice shall be given to a family member or an individual who is a legal representative of the patient;

2. To be informed in writing of the following:
a. Services available from the rehabilitation hospital;
b. The names and professional status of personnel providing and/or responsible for care; and
c. Information regarding the filing of complaints with the New Jersey Department of Health and Senior Services, including the telephone number for the 24 hour Complaint Hotline at 1-800-792-9770 and the address for written complaints:
New Jersey Department of Health and Senior Services
Inspection, Compliance and Complaints Program
PO Box 360, Room 601
Trenton, New Jersey 08625-0360
d. To receive, in terms that the patient understands, an explanation of his or her plan of care, its expected results, and reasonable alternatives. If this information would be detrimental to the patient’s health, or if the patient is not able to understand the information, the explanation shall be provided to a family member or an individual who is a legal representative of the patient and so documented in the patient’s medical record;
e. To receive, as soon as possible, the services of a translator or interpreter to facilitate communication between the patient and health care personnel;
f. To receive the care and health services that have been ordered;
g. To participate in the planning of his or her rehabilitation care and treatments;
h. To refuse services, including medication and treatment, provided by the facility and to be informed of available rehabilitation hospital treatment options, including the option of no treatment, and of the possible benefits and risks of each option;
i. To refuse to participate in experimental research. If he or she chooses to participate, his or her written informed consent shall be obtained;
j. To receive full information regarding financial arrangements, including, but not limited to:
(1) fees and charges, including any fees and charges for services not covered by sources of third party payment;
(2) Copies of written records of financial arrangements;
(3) Notification of any additional charges, expenses or other financial liabilities in excel of the predetermined fee; and
(4) A description of agreements with third-party payors and/or other payors and referral systems for patients’ financial assistance;
k. To express grievances regarding care and services to the rehabilitation hospital’s staff and governing authority without fear of reprisal, and to receive an answer to those grievances within a reasonable period of time;
l. To be free from mental and physical abuse and from exploitation;
m. To be free from restraints, unless they are authorized by a physician for a limited period of time to protect the patient or others from injury; and to be free from restraints and seclusion in any form when used as a means of coercion, discipline, convenience for the staff, or retaliation;
n. To be assured of confidential treatment of his or her medical/health record, including the opportunity to approve or refuse in writing its release to any individual outside the rehabilitation hospital, except as required by law or third party payment contract;
o. To be treated with courtesy, consideration, respect and recognition of dignity, individuality and right to privacy, including, but not limited to, auditory and visual privacy and confidentiality concerning patient treatment and disclosures;
p. To be assured of respect of the patient’s personal property;
q. To retain and exercise to the fullest extent possible all the constitutional, civil, and legal rights to which he or she is entitled by law, including religious liberties, the right to independent personal decisions, and the right to provide instructions and directions for health care in the event of future decision making incapacity in accordance with the New Jersey Advance Directives for Health care Act, N.J.S.A. 26:2H-53 et seq., and any rules which may be promulgated pursuant thereto;
r. To be informed by the attending physician and other providers of health care services about any continuing health care requirements after the patient’s discharge from the hospital. The patient shall also have the right to receive assistance from the physician and appropriate hospital staff in arranging for required follow-up care after discharges.
s. To receive sufficient time before discharge to make arrangements for health care needs after hospitalization;
t. To be informed by the hospital about any discharge appeal process to which the patient is entitled by law;
u. To be transferred to another facility only for one of the following reasons, with the reason recorded in the patient’s medical record.
(1) The transferring hospital is unable to provide the type or level of medical care appropriate for the patient needs. The hospital shall make an immediate effort to notify the patient’s primary care physician and the next of kin and document that the notifications were received; or
(2) The transfer is requested by the patient, or by the patient’s next of kin or guardian when the patient is mentally incapacitated or incompetent;
v. To receive from a physician an explanation for the transfer to another facility, information about alternatives to the transfer, verification of acceptance from the receiving facility and assurance that the movement associated with the transfer will not subject the patient to substantial, unnecessary risk of deterioration of his or her medical condition. This explanation of the transfer shall be given in advance to the patient, and/or to his or her next of kin or guardian except in a life-threatening situation where immediate transfer is necessary;
w. To have prompt access to the information contained in his or her medical record, unless a physician prohibits such access as detrimental to the patient’s health, and explains the reason in the medical record. In that instance, the patient’s next of kin or guardians shall have a right to see the record. This right continues after the patient is discharged from the hospital for as long as the hospital has a copy of the record; and
x. To obtain a copy of the patient’s medical record, at a reasonable fee, within 30 days of a written request to the hospital. If access by the patient is medically contraindicated (as documented by a physician in the patient’s medical record), the medical record shall be made available to a legally authorized representative of the patient or the patient’s physician.