3723cd43-934c-4b73-abcb-bdd93501bec9RIGHTS AND RESPONSIBILITIES - 2010 RIGHTS AND RESPONSIBILITI 0 3723cd43-934c-4b73-abcb-bdd93501bec9 3723cd43-934c-4b73-abcb-bdd93501bec9 0 0 0 0 3 2 true 1 100 bc3ae32b-ac12-4f14-92d9-632d2d3db9eeRI.01.01.01: The hospital respects, protects, and promotes patient rights.RI.01.01.01Respects and Protects03723cd43-934c-4b73-abcb-bdd93501bec93723cd43-934c-4b73-abcb-bdd93501bec9001132true1100 4412f83e-5cb6-44fe-a3d9-a3e2b39fd380EP4 The hospital treats the patient in a dignified and respectful manner that supports his or her dignity. Respectful to patient 0 3723cd43-934c-4b73-abcb-bdd93501bec9 bc3ae32b-ac12-4f14-92d9-632d2d3db9ee 0 0 2 2 3 0 true 1 100 3c2f17da-f67e-4d8c-882e-1b07094aa0ddEP5 The hospital respects the patient’s right to and need for effective communication. (See also RI.01.01.03, EP 1) Effective communication 0 3723cd43-934c-4b73-abcb-bdd93501bec9 bc3ae32b-ac12-4f14-92d9-632d2d3db9ee 0 0 3 2 3 0 true 1 100 602a60e4-8ea8-4544-af9c-4d8b5086d181EP6 The hospital respects the patient’s cultural and personal values, beliefs, and preferences. Cultural & personal value 0 3723cd43-934c-4b73-abcb-bdd93501bec9 bc3ae32b-ac12-4f14-92d9-632d2d3db9ee 0 0 4 2 3 0 true 1 100 ce3f7feb-8461-499c-9d65-0ee2e957a1aaEP7 The hospital respects the patient’s right to privacy. (See also IM.02.01.01, EPs 1-5) Resp Pt right to privacy 0 3723cd43-934c-4b73-abcb-bdd93501bec9 bc3ae32b-ac12-4f14-92d9-632d2d3db9ee 0 0 5 2 3 Note: This element of performance (EP) addresses a patient`s personal privacy. For EPs addressing the privacy of a patient`s health information, please refer to Standard IM.02.01.01. 0 true 1 100 0ef3caa0-fff4-45b6-9d5b-ce2836681759EP9 The hospital accommodates the patient’s right to religious and other spiritual services. Rights to religious serv 0 3723cd43-934c-4b73-abcb-bdd93501bec9 bc3ae32b-ac12-4f14-92d9-632d2d3db9ee 0 0 6 2 3 0 true 1 100 d9e1c390-c8cc-458c-8374-9a71bd005f67RI.01.01.03: The hospital respects the patient`s right to receive information in a manner he or she understands.RI.01.01.03Pt understands info03723cd43-934c-4b73-abcb-bdd93501bec93723cd43-934c-4b73-abcb-bdd93501bec9007132true1100 ca1b9d5e-963a-47ac-b929-86583d23fcd2EP1 The hospital provides information in a manner tailored to the patient`s age, language, and ability to understand. (See also RI.01.01.01, EPs 2 and 5; PC.04.01.05, EP 8) Tailored to ability 0 3723cd43-934c-4b73-abcb-bdd93501bec9 d9e1c390-c8cc-458c-8374-9a71bd005f67 0 0 8 2 3 0 true 1 100 7e6c8c92-2097-4ce4-b9fb-fde8466ce1cbEP2 The hospital provides interpreting and translation services, as necessary. (See also RI.01.01.01, EP 2) Interpreting/translation 0 3723cd43-934c-4b73-abcb-bdd93501bec9 d9e1c390-c8cc-458c-8374-9a71bd005f67 0 0 9 2 3 0 true 1 100 5e84a300-12b1-4a99-ae54-2c4c9ba08bd1EP3 The hospital communicates with the patient who has vision, speech, hearing, or cognitive impairments in a manner that meets the patient`s needs. (See also RI.01.01.01, EP 2) Cognitive impairments 0 3723cd43-934c-4b73-abcb-bdd93501bec9 d9e1c390-c8cc-458c-8374-9a71bd005f67 0 0 10 2 3 0 true 1 100 0031adde-d557-41e2-88a5-a9ef81fcd3e5RI.01.03.01: The hospital honors the patient`s right to give or withhold informed consent.RI.01.03.01Honors patient rights03723cd43-934c-4b73-abcb-bdd93501bec93723cd43-934c-4b73-abcb-bdd93501bec90011132true1100 7da88afd-ea8c-4bb6-9fc9-f73e7e225571EP13 Informed consent is obtained in accordance with the hospital`s policy and processes and, except in emergencies, prior to surgery. (See also RC.02.01.01, EP 4) Informed consent obtained 0 3723cd43-934c-4b73-abcb-bdd93501bec9 0031adde-d557-41e2-88a5-a9ef81fcd3e5 0 0 12 2 3 0 true 1 100 8f598dd4-2934-44e1-9d98-b23308f673abRI.01.03.03: The hospital honors the patient’s right to give or withhold informed consent to produce or use recordings, films, or other images of the patient for purposes other than his or her care.RI.01.03.03Withhold Informed con03723cd43-934c-4b73-abcb-bdd93501bec93723cd43-934c-4b73-abcb-bdd93501bec90013132true1100 f14add54-4b35-4720-a87a-5a89fb7667c0EP8 The organization accommodates the patient`s right to rescind consent before the recording, film, or image is used. Right to rescind consent 0 3723cd43-934c-4b73-abcb-bdd93501bec9 8f598dd4-2934-44e1-9d98-b23308f673ab 0 0 14 2 3 0 true 1 100 51eec6a0-6809-4647-9dd8-1a536826ca37RI.01.03.05: The hospital protects the patient and respects his or her rights during research, investigation, and clinical trials.RI.01.03.05Respects rights/research03723cd43-934c-4b73-abcb-bdd93501bec93723cd43-934c-4b73-abcb-bdd93501bec90015132true1100 093ccbdb-d576-42c5-b14f-b9f5dcba8965EP4 The hospital documents the following in the research consent form: That the patient received information to help determine whether or not to participate in the research, investigation, or clinical trials. Pat received info 0 3723cd43-934c-4b73-abcb-bdd93501bec9 51eec6a0-6809-4647-9dd8-1a536826ca37 0 0 16 2 3 0 true 1 100 ed0c49db-c8d7-4215-a4bf-a974e0236fedEP9 The hospital keeps all information given to subjects in the medical record or research file along with the consent forms. Keeps all info in MR 0 3723cd43-934c-4b73-abcb-bdd93501bec9 51eec6a0-6809-4647-9dd8-1a536826ca37 0 0 17 2 3 0 true 1 100 ae5d87f3-ca3c-41be-adfe-4acefecc8325RI.01.04.01: The hospital respects the patient`s right to receive information about the individual(s) responsible for, as well as those providing, his or her care, treatment, and services.RI.01.04.01Providing for care/tx/ser03723cd43-934c-4b73-abcb-bdd93501bec93723cd43-934c-4b73-abcb-bdd93501bec90018132true1100 f11ae522-26ea-45b8-b400-5ea45bce0a6cEP1 The hospital informs the patient of the name of the physician, clinical psychologist, or other practitioner who has primary responsibility for his or her care, treatment, or services. Hospital informs Pat 0 3723cd43-934c-4b73-abcb-bdd93501bec9 ae5d87f3-ca3c-41be-adfe-4acefecc8325 0 0 19 2 3 Note: The definition of “physician” is the same as that used by the Centers for Medicare & Medicaid Services (CMS) (refer to the Glossary). 0 true 1 100 b81127ce-64e1-4d80-80d2-a65bb86b600fEP2 The hospital informs the patient of the name of the physician(s), clinical psychologist(s), or other practitioner(s) who will provide his or her care, treatment, and services. Informs Pt of physician 0 3723cd43-934c-4b73-abcb-bdd93501bec9 ae5d87f3-ca3c-41be-adfe-4acefecc8325 0 0 20 2 3 Note: The definition of “physician” is the same as that used by the Centers for Medicare & Medicaid Services (CMS) (refer to the Glossary). 0 true 1 100 ff9e1f46-60e7-44b0-ab05-780d4bf507fdRI.01.05.01: The hospital addresses patient decisions about care, treatment, and services received at the end of life.RI.01.05.01Addresses Pt decisions03723cd43-934c-4b73-abcb-bdd93501bec93723cd43-934c-4b73-abcb-bdd93501bec90021132true1100 9ca85a54-224b-442a-b188-9e4021439996EP5 The hospital implements its advance directive policies. Implements Adv Directive 0 3723cd43-934c-4b73-abcb-bdd93501bec9 ff9e1f46-60e7-44b0-ab05-780d4bf507fd 0 0 22 2 3 0 true 1 100 b85a02e8-b2ce-4109-9b42-b46f50507752EP6 The hospital provides patients with written information about advance directives, forgoing or withdrawing life-sustaining treatment, and withholding resuscitative services. Provides written info 0 3723cd43-934c-4b73-abcb-bdd93501bec9 ff9e1f46-60e7-44b0-ab05-780d4bf507fd 0 0 23 2 3 0 true 1 100 df46edce-f310-425c-8d3f-a749c936ef12EP8 Upon admission, the hospital provides the patient with information on the extent to which the hospital is able, unable, or unwilling to honor advance directives. Able, unable, unwilling 0 3723cd43-934c-4b73-abcb-bdd93501bec9 ff9e1f46-60e7-44b0-ab05-780d4bf507fd 0 0 24 2 3 0 true 1 100 a4ce27fa-b1e8-4974-b2e9-e01fbaa07564EP9 The hospital documents whether or not the patient has an advance directive. Doc Pt has Adv Directive 0 3723cd43-934c-4b73-abcb-bdd93501bec9 ff9e1f46-60e7-44b0-ab05-780d4bf507fd 0 0 25 2 3 0 true 1 100 10bbcb75-53c8-459c-81d9-b4cdf6801268EP10 Upon request, the hospital refers the patient to resources for assistance in formulating advance directives. Refers Pt to resources 0 3723cd43-934c-4b73-abcb-bdd93501bec9 ff9e1f46-60e7-44b0-ab05-780d4bf507fd 0 0 26 2 3 0 true 1 100 0f7347c7-036a-4698-9616-0f59d240001dEP11 Staff and licensed independent practitioners who are involved in the patient`s care, treatment, and services are aware of whether or not the patient has an advance directive. (See also RC.02.01.01, EP 4) Staff is aware of Adv Dir 0 3723cd43-934c-4b73-abcb-bdd93501bec9 ff9e1f46-60e7-44b0-ab05-780d4bf507fd 0 0 27 2 3 0 true 1 100 5273e9f0-bc14-4d6f-821b-d0459d88ff1dEP15 The hospital documents the patient’s wishes concerning organ donation when he or she makes such wishes known to the hospital or when required by the hospital`s policy, in accordance with law and regulation. Documents wishes 0 3723cd43-934c-4b73-abcb-bdd93501bec9 ff9e1f46-60e7-44b0-ab05-780d4bf507fd 0 0 28 2 3 0 true 1 100 600af83f-1c94-4369-9713-71e0c946ebceEP16 The hospital honors the patient`s wishes concerning organ donation within the limits of the hospital’s capability and in accordance with law and regulation. Organ donation 0 3723cd43-934c-4b73-abcb-bdd93501bec9 ff9e1f46-60e7-44b0-ab05-780d4bf507fd 0 0 29 2 3 0 true 1 100 09ca2d5f-1d52-49cf-91a6-6ffb24ba866dEP19 For outpatient hospital settings: The hospital communicates its policy on advance directives upon request or when warranted by the care, treatment, and services provided. Out Pt: Comm Adv Dir 0 3723cd43-934c-4b73-abcb-bdd93501bec9 ff9e1f46-60e7-44b0-ab05-780d4bf507fd 0 0 30 2 3 0 true 1 100 2a0b5d20-9840-45af-b580-0594d217d763EP20 For outpatient hospital settings: Upon request, the hospital refers patients to resources for assistance with formulating advance directives. Out Pt: Refers to resour 0 3723cd43-934c-4b73-abcb-bdd93501bec9 ff9e1f46-60e7-44b0-ab05-780d4bf507fd 0 0 31 2 3 0 true 1 100 81686f1e-b2f8-41fe-af9a-deb10743f5efRI.01.06.05: The patient has the right to an environment that preserves dignity and contributes to a positive self-image.RI.01.06.05Pt right to dignity03723cd43-934c-4b73-abcb-bdd93501bec93723cd43-934c-4b73-abcb-bdd93501bec90032132true1100 3265d4bb-b874-41ac-a3c2-122cde7a7cbcEP1 The hospital’s environment of care supports the patient’s positive self-image and dignity. Supports Pt self image 0 3723cd43-934c-4b73-abcb-bdd93501bec9 81686f1e-b2f8-41fe-af9a-deb10743f5ef 0 0 33 2 3 0 true 1 100 e9af2131-c708-44af-ac8a-a8b35048032fEP2 For hospital settings that provide longer-term care (more than 30 days): The number of patients in a room is based on the patients’ ages, developmental levels, clinical conditions, and diagnosis needs, and the hospital’s goals. Long term pt in room 0 3723cd43-934c-4b73-abcb-bdd93501bec9 81686f1e-b2f8-41fe-af9a-deb10743f5ef 0 0 34 2 3 0 true 1 100 cdae4e29-3a74-4db1-b00a-ed677d313aa5EP4 The hospital allows the patient to keep and use personal clothing and possessions, unless this infringes on others’ rights or is medically or therapeutically contraindicated, based on the setting or service. Personal clothing & Poss 0 3723cd43-934c-4b73-abcb-bdd93501bec9 81686f1e-b2f8-41fe-af9a-deb10743f5ef 0 0 35 2 3 0 true 1 100 149c23e9-abe4-4130-a77e-6429db35a832EP15 The hospital offers patients telephone and mail service, based on the setting and population. Telephone & mail service 0 3723cd43-934c-4b73-abcb-bdd93501bec9 81686f1e-b2f8-41fe-af9a-deb10743f5ef 0 0 36 2 3 0 true 1 100 47855551-a7a9-4cb2-a007-7fce4f9dda7aEP16 The hospital provides access to telephones for patients who desire private telephone conversations in a private space, based on the setting and population. Private telephone 0 3723cd43-934c-4b73-abcb-bdd93501bec9 81686f1e-b2f8-41fe-af9a-deb10743f5ef 0 0 37 2 3 0 true 1 100 476882ae-3f94-47a5-9d0c-0d0e511af20aEP18 For hospital settings that provide longer-term care (more than 30 days): When the hospital restricts a patient’s visitors, mail, telephone calls, or other forms of communication, the restrictions and their justification are documented in the medical record. Restrictions documented 0 3723cd43-934c-4b73-abcb-bdd93501bec9 81686f1e-b2f8-41fe-af9a-deb10743f5ef 0 0 38 2 3 0 true 1 100 3e865187-c26e-474f-ba2b-f010ede30b1eEP19 For hospital settings that provide longer-term care (more than 30 days): When the hospital restricts a patient’s visitors, mail, telephone calls, or other forms of communication, the restrictions are evaluated for therapeutic effectiveness. Restrictions evaluated 0 3723cd43-934c-4b73-abcb-bdd93501bec9 81686f1e-b2f8-41fe-af9a-deb10743f5ef 0 0 39 2 3 0 true 1 100 79eb6221-23ef-420f-9bda-f04f8e4c011aRI.01.07.01: The patient and his or her family have the right to have complaints reviewed by the hospital. RI.01.07.01Rights to review compl03723cd43-934c-4b73-abcb-bdd93501bec93723cd43-934c-4b73-abcb-bdd93501bec90040132true1100 9fd3a564-bfba-475c-9cd1-bbb3b19041beEP2 The hospital informs the patient and his or her family about the complaint resolution process. (See also MS.09.01.01, EP 1) Informs Pt & family 0 3723cd43-934c-4b73-abcb-bdd93501bec9 79eb6221-23ef-420f-9bda-f04f8e4c011a 0 0 41 2 3 0 true 1 100 4b951023-628b-4da8-9c9c-8086a02c9bb3EP4 The hospital reviews and, when possible, resolves complaints from the patient and his or her family. (See also MS.09.01.01, EP 1) Resolves complaints 0 3723cd43-934c-4b73-abcb-bdd93501bec9 79eb6221-23ef-420f-9bda-f04f8e4c011a 0 0 42 2 3 0 true 1 100 c8649a35-d168-43b0-816d-4b6a396d1767EP6 The hospital acknowledges receipt of a complaint that the hospital cannot resolve immediately and notifies the patient of follow-up to the complaint. Receipt of complaint 0 3723cd43-934c-4b73-abcb-bdd93501bec9 79eb6221-23ef-420f-9bda-f04f8e4c011a 0 0 43 2 3 0 true 1 100 624ca115-a669-48b4-8319-9aeadc44ba4fEP7 The hospital provides the patient with the phone number and address needed to file a complaint with the relevant state authority. (See also MS.09.01.01, EP 1) Provides number & address 0 3723cd43-934c-4b73-abcb-bdd93501bec9 79eb6221-23ef-420f-9bda-f04f8e4c011a 0 0 44 2 3 0 true 1 100 649bff12-50b3-4b7b-99a5-210cbdb803f5EP18 For hospitals that use Joint Commission accreditation for deemed status purposes: In its resolution of complaints, the hospital provides the individual with a written notice of its decision, which contains the following: Provides written notice 0 3723cd43-934c-4b73-abcb-bdd93501bec9 79eb6221-23ef-420f-9bda-f04f8e4c011a 0 0 45 2 3 2 true 1 100 9853aad6-4e01-4ac9-9bd5-d43aaab9a186The name of the hospital contact person Name of hospital/contact 0 3723cd43-934c-4b73-abcb-bdd93501bec9 649bff12-50b3-4b7b-99a5-210cbdb803f5 0 0 46 3 3 0 true 1 100 bfce9ad1-ed00-49c9-9bf4-76eea053e44dThe steps taken on behalf of the individual to investigate the complaint Investigate the complaint 0 3723cd43-934c-4b73-abcb-bdd93501bec9 649bff12-50b3-4b7b-99a5-210cbdb803f5 0 0 47 3 3 0 true 1 100 39744e9d-9d2a-4a08-bbb4-914452b7a6d3The results of the process Results of the process 0 3723cd43-934c-4b73-abcb-bdd93501bec9 649bff12-50b3-4b7b-99a5-210cbdb803f5 0 0 48 3 3 0 true 1 100 5fb5b8e4-fcb3-47a6-bddf-ab8db38aa6bbThe date of completion of the complaint process Date of complaint complet 0 3723cd43-934c-4b73-abcb-bdd93501bec9 649bff12-50b3-4b7b-99a5-210cbdb803f5 0 0 49 3 3 0 true 1 100 72d3223b-2805-4cbc-8a75-5f45f3d44caaRI.01.07.07: For hospital settings that provide longer term care (more than 30 days): The hospital protects the rights of patients who work for or on behalf of the hospital.RI.01.07.07Protects rights of Pt03723cd43-934c-4b73-abcb-bdd93501bec93723cd43-934c-4b73-abcb-bdd93501bec90050132true1100 953e20c1-5ce7-4c44-8ea8-6dd866efded6EP2 For hospital settings that provide longer term care (more than 30 days): The hospital implements its policy regarding patients who work for or on behalf of the hospital. Policy who work at hosp 0 3723cd43-934c-4b73-abcb-bdd93501bec9 72d3223b-2805-4cbc-8a75-5f45f3d44caa 0 0 51 2 3 0 true 1 100 b70cbefe-c175-4068-a0f3-90736bb7010dEP4 For hospital settings that provide longer term care (more than 30 days): The hospital incorporates work performed by the patient for or on behalf of the hospital into the plan of care. Incorporates work perform 0 3723cd43-934c-4b73-abcb-bdd93501bec9 72d3223b-2805-4cbc-8a75-5f45f3d44caa 0 0 52 2 3 0 true 1 100 263da30b-28f8-4056-a93d-23f64640378fRI.02.01.01: The hospital informs the patient about his or her responsibilities related to his or her care, treatment, and services. RI.02.01.01Pt responsibilites03723cd43-934c-4b73-abcb-bdd93501bec93723cd43-934c-4b73-abcb-bdd93501bec90053132true1100 d182114f-fb3c-4f26-a2c9-bdd9cacea978EP2 The hospital informs the patient about his or her responsibilities in accordance with its policy. Informs Pt on policy 0 3723cd43-934c-4b73-abcb-bdd93501bec9 263da30b-28f8-4056-a93d-23f64640378f 0 0 54 2 3 Note: Information about patient responsibilities can be shared verbally, in writing, or both. 0 true 1 100