Patient Rights and Responsibilities
We respect the dignity and pride of each individual we serve. We comply with applicable Federal civil rights laws and do not discriminate on the basis of age, gender, disability, race, color, ancestry, citizenship, religion, pregnancy, sexual orientation, gender identity or expression, national origin, medical condition, marital status, veteran status, payment source or ability, or any other basis prohibited by federal, state, or local law. Each individual shall be informed of the patient’s rights and responsibilities in advance of administering or discontinuing patient care or otherwise at the earliest possible time in the course of hospitalization. We adopt and affirm as policy the following rights of patient/clients who receive services from our facilities:
Considerate and Respectful Care
- To receive competent, ethical, high-quality, safe and professional care and high professional standards that are continually maintained and reviewed without discrimination
- To be free from all forms of abuse and harassment
- To be treated with consideration, respect and recognition of their individuality, including the need for privacy in treatment. Case discussion, consultation, examination, and treatment are considered confidential and shall be conducted discreetly. This includes the right to request the facility provide a person of one’s own gender to be present during certain parts of physical examinations, treatments or procedures performed by a health professional of the opposite sex, except in emergencies, and the right not to remain undressed any longer than is required for accomplishing the medical purpose for which the patient was asked to undress
- A patient has the right to know what facility rules and regulations apply to his conduct as a patient
Information Regarding Health Status and Care
- To be informed of his/her health status in terms that patient can reasonably be expected to understand, and to participate in the development and the implementation of his/her plan of care and treatment, including diagnosis, treatment, prognosis, and possible complications. When it is not possible or medically advisable to give such information to the patient, the information shall be given on his/her behalf to the patient’s designee.
- The right to be informed of the names and functions of all physicians and other health care professionals who are providing direct care to the patient
- The right to be informed about any continuing health care requirements after his/her 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 discharge.
- To be informed of risks, benefits and side effects of all medications and treatment procedures, particularly those considered innovative or experimental
- To be informed of all appropriate alternative treatment procedures
- To be informed of the outcomes of care, treatment and services
- To appropriate assessment and management of pain
- To be informed if the hospital has authorized other health care and/or education institutions to participate in the patient’s treatment. The patient shall also have a right to know the identity and function of these institutions, and may refuse to allow their participation in his/her treatment
Decision Making and Notification
- To choose a person to be his/her healthcare representative and/ or decision maker. The patient may also exercise his/her right to exclude any family members from participating in his/her healthcare decisions.
- To have a family member, chosen representative and/or his or her own physician notified promptly of admission to the hospital
- To request or refuse treatment, medication, or procedures and to be informed of this right by his/her physician. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate
- To be included in experimental research only when he or she gives informed, written consent to such participation. The patient may refuse to participate in experimental research, including the investigations of new drugs and medical devices
- A patient has the right to be advised when a physician is considering the patient as a part of a medical care research program or donor program. Informed consent must be obtained prior to actual participation in such a program and the patient or legally responsible party, may, at any time, refuse to continue in any such program to which he has previously given informed consent. An Institutional Review Board (IRB) may waive or alter the informed consent requirement if it reviews and approves a research study in accord with federal regulations for the protection of human research subjects including U.S. Department of Health and Human Services (HHS) regulations under 45 CFR Part 46 and U.S. Food and Drug Administration (FDA) regulations under 21 CFR Parts 50 and 56. For any research study proposed for conduct under an FDA “Exception from Informed Consent Requirements for Emergency Research” or an HHS “Emergency Research Consent Waiver” in which informed consent is waived but community consultation and public disclosure about the research are required, any facility proposing to be engaged in the research study also must verify that the proposed research study has been registered with the North Carolina Medical Care Commission. When the IRB reviewing the research study has authorized the start of the community consultation process required by the federal regulations for emergency research, but before the beginning of that process, notice of the proposed research study by the facility shall be provided to the North Carolina Medical Care Commission. The notice shall include: (a) the title of the research study; (b) a description of the research study, including a description of the population to be enrolled; (c) a description of the planned community consultation process, including currently proposed meeting dates and times; (d) an explanation of the way that people choosing not to participate in the research study may opt out; and (e) contact information including mailing address and phone number for the IRB and the principal investigator. The Medical Care Commission may publish all or part of the above information in the North Carolina Register, and may require the institution proposing to conduct the research study to attend a public meeting convened by a Medical Care Commission member in the community where the proposed research study is to take place to present and discuss the study or the community consultation process proposed.
- To formulate advance directives and have hospital staff and practitioners who provide care in the hospital comply with these directives
- To leave the healthcare facility against one’s physician’s advice to the extent permitted by law
Access to Services
- To receive, as soon as possible, the free services of a translator and/or interpreter, telecommunications devices, and any other necessary services or devices to facilitate communication between the patient and the hospitals’ health care personnel (e.g., qualified interpreters, written information in other languages, large print, accessible electronic formats)
- To bring a service animal into the facility, except where service animals are specifically prohibited pursuant to facility policy (e.g., operating rooms, patient units where a patient is immunosuppressed or in isolation)
- To pastoral counseling and to take part in religious and/or social activities while in the hospital, unless one’s doctor thinks these activities are not medically advised
- To safe, secure and sanitary accommodation and a nourishing, well balanced and varied diet
- To access people outside the facility by means of verbal and written communication
- To have accessibility to facility buildings and grounds. We recognize the Americans with Disabilities Act, a wide-ranging piece of legislation intended to make American society more accessible to people with disabilities. The policy is available upon request
- To a prompt and reasonable response to questions and requests for service
- To request a discharge planning evaluation
Access to Medical Records
- To have his/her medical records, including all computerized medical information, kept confidential and to access information within a reasonable time frame. The patient may decide who may receive copies of the records except as permitted by operation of law, required by law, or through appropriate third party contractual arrangements. A patient’s access to medical records may be restricted by the patient’s attending physician. If the physician restricts the patient’s access to information in the patient’s medical record, the physician shall record the reasons on the patient’s medical record. Access will be restricted only for sound medical reason. A patient’s designee may have access to the information in the patient’s medical records even if the attending physician restricts the patient’s access to those records.
- Upon leaving the healthcare facility, patients have the right to obtain copies of their medical records
- To participate in ethical decisions that may arise in the course of care including issues of conflict resolution, withholding resuscitative services, foregoing or withdrawal of life sustaining treatment, and participation in investigational studies or clinical trials
- If the healthcare facility or its team decides that the patient’s refusal of treatment prevents him/her from receiving appropriate care according to ethical and professional standards, the relationship with the patient may be terminated
- To access protective and advocacy services and other individuals or agencies authorized to act on the patient’s behalf to assert or protect the patient’s rights as described in this document
- To be free from restraints of any form that are not medically necessary or are used as a means of coercion, discipline, convenience, or retaliation by staff
- The patient who receives treatment for mental illness or developmental disability, in addition to the rights listed herein, has the rights provided by any applicable state law
- To all legal and civil rights as a citizen unless otherwise prescribed by law
- To have upon request an impartial review of hazardous treatments or irreversible surgical treatments prior to implementation except in emergency procedures necessary to preserve one’s life
- To an impartial review of alleged violations of patient rights
- To expect emergency procedures to be carried out without unnecessary delay
- To give consent to a procedure or treatment and to access the information necessary to provide such consent. Except for emergencies, a physician must obtain necessary informed consent prior to the start of any procedure or treatment, or both
- To be free from duplication of medical and nursing procedures as determined by the attending physician
- To receive medical and nursing treatment that avoids unnecessary physical and mental discomfort
- To not be required to perform work for the facility unless the work is part of the patient’s treatment and is done by choice of the patient
- To fi le a complaint with the Department of Health or other quality improvement, accreditation or other certifying bodies if he /she has a concern about patient abuse, neglect, about misappropriation of a patient’s property in the facility or other unresolved complaint, patient safety or quality concern
Payment and Administration
- To examine and receive an explanation of the patient’s healthcare facility’s bill regardless of source of payment, and may receive upon request, information relating to the availability of known financial resources
- The patient has a right to full information and counseling on the availability of known financial resources for his/her health care.
- A patient who is eligible for Medicare has the right to know, upon request and in advance of treatment, whether the health care provider or health care facility accepts the Medicare assignment rate
- To receive, upon request, prior to treatment, a reasonable estimate of charges for medical care
- To be informed in writing about the facility policies and procedures for initiation, review and resolution of patient complaints, including the address and telephone number of where complaints may be fi led
Additional Patient Rights
- When medically permissible, a patient may be transferred to another facility only after he or his next of kin or other legally responsible representative has received complete information and an explanation concerning the needs for and alternatives to such a transfer. The facility to which the patient is to be transferred must first have accepted the patient for transfer.
- Except in emergencies, the patient may be transferred to another facility only with a full explanation of the reason for transfer, provisions for continuing care and acceptance by the receiving institution
- To initiate their own contact with the media
- To get the opinion of another physician, including specialists, at the request and expense of the patient
- To wear appropriate personal clothing and religious or other symbolic items, as long as they do not interfere with diagnostic procedures or treatment
- To request a transfer to another room if another patient or a visitor in the room is unreasonably disturbing him/her
- To request pet visitation except where animals are specifically prohibited pursuant to the facility’s policies (e.g., operating rooms, patient units where a patient is immunosuppressed or in isolation)
- The patient has the right not to be awakened by hospital staff unless it is medically necessary.
The care a patient receives depends partially on the patient him/ herself. Therefore, in addition to the above rights, a patient has certain responsibilities. These should be presented to the patient in the spirit of mutual trust and respect.
- To provide accurate and complete information concerning his/her health status, medical history, hospitalizations, medications and other matters related to his/her health
- To report perceived risks in his/her care and unexpected changes in his/her condition to the responsible practitioner
- To report comprehension of a contemplated course of action and what is expected of the patient, and to ask questions when there is a lack of understanding
- To follow the plan of care established by his/her physician, including the instructions of nurses and other health professionals as they carry out the physician’s orders
- To keep appointments or notifying the facility or physician when he/ she is unable to do so
- To be responsible for his/her actions should he/she refuse treatment or not follow his/her physician’s orders
- To assure that the financial obligations of his/her healthcare care are fulfilled as promptly as possible
- To follow facility policies, procedures, rules and regulations
- To be considerate of the rights of other patients and facility personnel
- To be respectful of his/her personal property and that of other persons in the facility
- To help staff to assess pain, request relief promptly, discuss relief options and expectations with caregivers, work with caregivers to develop a pain management plan, tell staff when pain is not relieved, and communicate worries regarding pain medication
- To inform the facility of a violation of patient rights or any safety concerns, including perceived risk in his/her care and unexpected changes in their condition
We recognize the importance of family, spouses, partners, friends and other visitors in the care process of patients. We adopt and affirm as policy the following visitation rights of patients/clients who receive services from our facilities:
- To be informed of their visitation rights, including any clinical restriction or limitation of their visitation rights
- To designate visitors, including but not limited to a spouse, a domestic partner (including same sex), family members, and friends. These visitors will not be restricted or otherwise denied visitation privileges on the basis of age, race, color, national origin, religion, gender, gender identity, gender expression, sexual orientation or disability. All visitors will enjoy full and equal visitation privileges consistent with any clinically necessary or other reasonable restriction or limitation that facilities may need to place on such rights
- To receive visits from one’s attorney, physician or clergyperson at any reasonable time
- To speak privately with anyone he/she wishes (subject to hospital visiting regulations) unless a doctor does not think it is medically advised
- To refuse visitors
- Media representatives and photographers must contact the hospital spokesperson for access to the hospital
TO REPORT A PATIENT RIGHTS CONCERN, PLEASE CONTACT:
NC Division of Health Service Regulation
Complaint Intake Unit
2711 Mail Service Center
Raleigh, NC 27699
Toll Free: 800-624-3004 (NC only)
Outside NC: 919-855-4500
Quality Improvement Organization (QIO):
5201 West Kennedy Boulevard, Suite 900
Tampa, FL 33609
Toll Free Phone: 888-317-0751
Toll Free Fax: 844-878-7921
Local phone: 813-280-8256
The Joint Commission:
HCA Ethics Line: 1-800-455-1996
If you need access to services or to report a concern regarding discrimination in access to services, contact the Equity Compliance Coordinator:
Megan McKinney, Equity Compliance Coordinator (ECC)
125 Hospital Drive
Spruce Pine, NC 28755
Phone: (828) 766-1815
You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Equity Compliance Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office of Civil Rights Complaint Portal or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Notice of Privacy of Practices
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
If you have any questions about this notice, please contact the Facility Privacy Official by dialing the main facility number.
Effective date: September 23, 2013
Each time you visit a hospital, physician, or other healthcare provider, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, a plan for future care or treatment, and billing-related information. This notice applies to all of the records of your care generated by the facility, whether made by facility personnel, agents of the facility, or your personal doctor. Your personal doctor may have different policies or notices regarding the doctor’s use and disclosure of your health information created in the doctor’s office or clinic.
We are required by law to maintain the privacy of your health information, provide you a description of our privacy practices, and to notify you following a breach of unsecured protected health information. We will abide by the terms of this notice.
Uses and Disclosures
How we may use and disclose Health Information about you.
The following categories describe examples of the way we use and disclose health information:
For Treatment: We may use health information about you to provide you treatment or services. We may disclose health information about you to doctors, nurses, technicians, medical students, or other facility personnel who are involved in taking care of you at the facility. For example: a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. Different departments of the facility also may share health information about you in order to coordinate the different things you may need, such as prescriptions, lab work, meals, and x-rays.
We may also provide your physician or a subsequent healthcare provider with copies of various reports that should assist him or her in treating you once you’re discharged from this facility.
For Payment: We may use and disclose health information about your treatment and services to bill and collect payment from you, your insurance company or a third party payer. For example, we may need to give your insurance company information about your surgery so they will pay us or reimburse you for the treatment. We may also tell your health plan about treatment you are going to receive to determine whether your plan will cover it.
For Health Care Operations: Members of the medical staff and/or quality improvement team may use information in your health record to assess the care and outcomes in your case and others like it. The results will then be used to continually improve the quality of care for all patients we serve. For example, we may combine health information about many patients to evaluate the need for new services or treatment. We may disclose information to doctors, nurses, and other students for educational purposes. And we may combine health information we have with that of other facilities to see where we can make improvements. We may remove information that identifies you from this set of health information to protect your privacy.
Fundraising: We may contact you to raise funds for the facility; however, you have the right to elect not to receive such communications.
We may also use and disclose health information:
- To remind you that you have an appointment for medical care;
- To assess your satisfaction with our services;
- To tell you about possible treatment alternatives;
- To tell you about health–related benefits or services;
- For population based activities relating to improving health or reducing health care costs;
- For conducting training programs or reviewing competence of health care professionals; and
- To a Medicaid eligibility database and the Children’s Health Insurance Program eligibility database, as applicable.
When disclosing information, primarily appointment reminders and billing/collections efforts, we may leave messages on your answering machine/voice mail.
Business Associates: There are some services provided in our organization through contracts with business associates. Examples include physician services in the emergency department and radiology, certain laboratory tests, and a copy service we use when making copies of your health record. When these services are contracted, we may disclose your health information to our business associates so that they can perform the job we’ve asked them to do and bill you or your third-party payer for services rendered. To protect your health information, however, business associates are required by federal law to appropriately safeguard your information.
Directory: We may include certain limited information about you in the facility directory while you are a patient at the facility. The information may include your name, location in the facility, your general condition (e.g., good, fair) and your religious affiliation. This information may be provided to members of the clergy and, except for religious affiliation, to other people who ask for you by name. If you would like to opt out of being in the facility directory please request the Opt Out Form from the admission staff or Facility Privacy Official.
Individuals Involved in Your Care or Payment for Your Care and/or Notification Purposes: We may release health information about you to a friend or family member who is involved in your medical care or who helps pay for your care or to notify, or assist in the notification of (including identifying or locating), a family member, your personal representative, or another person responsible for your care of your location and general condition. In addition, we may disclose health information about you to an entity assisting in a disaster relief effort in order to assist with the provision of this notice.
Research: The use of health information is important to develop new knowledge and improve medical care. We may use or disclose health information for research studies but only when they meet all federal and state requirements to protect your privacy (such as using only de-identified data whenever possible). You may also be contacted to participate in a research study.
Future Communications: We may communicate to you via newsletters, mail outs or other means regarding treatment options, health related information, disease-management programs, wellness programs, research projects, or other community based initiatives or activities our facility is participating in.
Organized Health Care Arrangement: This facility and its medical staff members have organized and are presenting you this document as a joint notice. Information will be shared as necessary to carry out treatment, payment and health care operations. Physicians and caregivers may have access to protected health information in their offices to assist in reviewing past treatment as it may affect treatment at the time.
Affiliated Covered Entity: Protected health information will be made available to facility personnel at local affiliated facilities as necessary to carry out treatment, payment and health care operations. Caregivers at other facilities may have access to protected health information at their locations to assist in reviewing past treatment information as it may affect treatment at this time. Please contact the Facility Privacy Official for further information on the specific sites included in this affiliated covered entity.
Health Information Exchange/Regional Health Information Organization: Federal and state laws may permit us to participate in organizations with other healthcare providers, insurers, and/or other health care industry participants and their subcontractors in order for these individuals and entities to share your health information with one another to accomplish goals that may include but not be limited to: improving the accuracy and increasing the availability of your health records; decreasing the time needed to access your information; aggregating and comparing your information for quality improvement purposes; and such other purposes as may be permitted by law.
As required by law. We may disclose information when required to do so by law.
As required by law, we may also use and disclose health information for the following types of entities, including but not limited to:
- Food and Drug Administration
- Public Health or Legal Authorities charged with preventing or controlling disease, injury or disability
- Correctional Institutions
- Workers Compensation Agents
- Organ and Tissue Donation Organizations
- Military Command Authorities
- Health Oversight Agencies
- Funeral Directors and Coroners
- National Security and Intelligence Agencies
- Protective Services for the President and Others
- A person or persons able to prevent or lessen a serious threat to health or safety
Law Enforcement: We may disclose health information to a law enforcement official for purposes such as providing limited information to locate a missing person or report a crime.
For Judicial or Administrative Proceedings: We may disclose protected health information as permitted by law in connection with judicial or administrative proceedings, such as in response to a court order, search warrant or subpoena.
Authorization Required: We must obtain your written authorization in order to use or disclose psychotherapy notes, use or disclose your protected health information for marketing purposes, or to sell your protected health information.
State-Specific Requirements: Many states have requirements for reporting including population-based activities relating to improving health or reducing health care costs. Some states have separate privacy laws that may apply additional legal requirements. If the state privacy laws are more stringent than federal privacy laws, the state law preempts the federal law.
Your Health Information Rights
Although your health record is the physical property of the healthcare practitioner or facility that compiled it, you have the Right to:
- Inspect and Copy: You have the right to inspect and obtain a copy of the health information that may be used to make decisions about your care. Usually, this includes medical and billing records, but does not include psychotherapy notes. We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to health information, you may request that the denial be reviewed. Another licensed health care professional chosen by the facility will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.
- Amend: If you feel that health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for the facility. Any request for an amendment must be sent in writing to the Facility Privacy Official. We may deny your request for an amendment and if this occurs, you will be notified of the reason for the denial.
- An Accounting of Disclosures: You have the right to request an accounting of disclosures. This is a list of certain disclosures we make of your health information for purposes other than treatment, payment or health care operations where an authorization was not required.
- Request Restrictions: You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a surgery you had. Any request for a restriction must be sent in writing to the Facility Privacy Official.
- We are required to agree to your request only if 1) except as otherwise required by law, the disclosure is to your health plan and the purpose is related to payment or health care operations (and not treatment purposes), and 2) your information pertains solely to health care services for which you have paid in full. For other requests, we are not required to agree. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.
- Request Confidential Communications: You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you may ask that we contact you at work instead of your home. The facility will grant reasonable requests for confidential communications at alternative locations and/or via alternative means only if the request is submitted in writing and the written request includes a mailing address where the individual will receive bills for services rendered by the facility and related correspondence regarding payment for services. Please realize, we reserve the right to contact you by other means and at other locations if you fail to respond to any communication from us that requires a response. We will notify you in accordance with your original request prior to attempting to contact you by other means or at another location.
- A Paper Copy of This Notice: You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. If the facility has a website you may print or view a copy of the notice by clicking on the Notice of Privacy Practices link.
To exercise any of your rights, please obtain the required forms from the Privacy Official and submit your request in writing.
CHANGES TO THIS NOTICE
We reserve the right to change this notice and the revised or changed notice will be effective for information we already have about you as well as any information we receive in the future. The current notice will be posted in the facility and on our website and include the effective date. In addition, each time you register at or are admitted to the facility for treatment or health care services as an inpatient or outpatient, we will offer you a copy of the current notice in effect.
If you believe your privacy rights have been violated, you may file a complaint with the facility by following the process outlined in the facility’s Patient Rights documentation. You may also file a complaint with the Secretary of the Department of Health and Human Services. All complaints must be submitted in writing.
You will not be penalized for filing a complaint.
OTHER USES OF HEALTH INFORMATION
Other uses and disclosures of health information not covered by this notice or the laws that apply to us will be made only with your written authorization. If you provide us permission to use or disclose health information about you, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose health information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your authorization, and that we are required to retain our records of the care that we provided to you.
Facility Privacy Official Telephone Number: 828-213-8540