ROPER ST. FRANCIS. Patient Handbook

Transcription

1 Patient Handbook

2 Table of Contents Section I Welcome...A Section II Important Patient Information Parking...1 Visiting Hours...2 Cafeteria...2 Gift Shop...2 Religious Services...3 Smoke Free Campus...3 ATM Machines...3 Vending Machines...3 Section III While You Are Here Special Communication Needs...5 Private Nurses/Sitters...5 Pastoral Care...5 Patient Representatives...6 Case Management and Social Work Services...6 Volunteers...6 Patient Valuables...7 Fire Drills...7 Telephone...7 Leaving the Unit...8

3 Section IV Going Home Check-out time...9 Home Care Services...9 Section V Hospital Bills and Insurance...10 Section VI Important Patient Information Notice of Information Practices...12 How We May Use and Disclose Your Health Information...14 Special Situations...17 Other Uses for Health Information...20 Your Rights Regarding Your Health Information...21 Patient Rights and Responsibilities...24 Advance Directives...28 Your Role in Patient Safety...30 Pain Management...33 If You Have Concerns...35 Compliance Program...37 Section VII Lewis Blackman Patient Safety Act...38

4 SECTION I Welcome Welcome to our facility. We are pleased that you and your doctor have selected us to provide your medical care. We will do our best to make your visit as comfortable as possible. If you have any questions or concerns, please don t hesitate to ask your doctor or nurse. If at any time you feel you are not receiving the best care, please notify our patient representatives by contacting your nurse or dialing 0 for the operator. The patient representative will assist you in addressing your concern. Thank you for choosing Bon Secours St. Francis Hospital. We wish you well. A

5 SECTION II Visitor Information Parking Bon Secours St. Francis Hospital Free parking on the Hospital campus 1

6 Visiting Hours Our hospital's primary concern is for the welfare and speedy recovery of our patients. Therefore, we ask that guests exercise special courtesy and sensitivity in scheduling visits. Brief visits are generally best. General visiting hours are from 9 a.m. to 9 p.m. Some patients in special care areas such as the Intensive Care Units do have restricted visiting hours. In the interest of security, we thank you for your cooperation in observing this schedule and any other visiting restrictions posted in these areas. Cafeteria A cafeteria offering full service meals and beverages is located on the first floor Gift Shop A variety of items are available including snacks, candies, toiletries, books, magazines, cards, fresh flowers, balloons, assorted gifts and a full line of specialty items for our newborn patients. The gift shop is located on the first floor. Visa and MasterCard are accepted. 2

7 Religious Services A chapel is available to you and your family 24 hours a day on the first floor of the hospital. Special prayer gatherings and worship services, usually led by the hospital chaplain, are held in the chapel at various times throughout the week. For Roman Catholics, Eucharistic ministers regularly bring communion to patients who have indicated that they are Catholic upon admission to the hospital. For Jewish patients, Sabbath candles are available upon request. Contact the Pastoral Care Office for service time and/or for your religious and spiritual needs by dialing "0" for the operator. Mass is held each Tuesday at 11:30 a.m. in the chapel. Smoke Free Campus As part of our commitment to good health for you and your family, all Roper St. Francis campuses are tobacco-free. Prohibiting tobacco use supports those who are trying to quit, eliminates exposure to secondhand smoke and decreases tobacco odors on individuals, which can trigger respiratory problems in vulnerable patients. Nicotine replacement therapies (NRT) are available in our gift shops. ATMs ATM machines are available in the vending area on the first floor of the East Medical office building to the left of the Grand Staircase in the Mall. Vending Vending machines are located on the first floor of the East Medical office building - to the left of the grand staircase in the Mall. 3

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9 SECTION III Special Communication Needs While You Are Here Arrangements for special communication needs such as foreign language interpreters, hearing devices and sign language resources may be made through your nurse. Private Nurses/Sitters A private duty nurse or sitter may be available upon request. Arrangements are made through a nursing supervisor by dialing 0 for the operator. Please be aware that financial arrangements for private duty nurses and sitters are the responsibility of the patient and his or her family. If you need assistance, please ask the charge nurse on your unit. Pastoral Care We believe in healing the whole person body, mind and spirit. We encourage the visitation of your clergy and provide a Department of Pastoral Care to serve the spiritual and emotional needs of you and your family during your stay with us, whether or not you have a religious faith. A chaplain is always available or may assist you in contacting your minister, priest, rabbi or congregational leader. An interdenominational chapel is located on the first floor and is open 24 hours a day to people of all faiths. Please contact your nurse for assistance in contacting a chaplain. After hours, you can leave a message or, in emergencies, dial 0 for the hospital operator. Bibles and other devotional materials are available upon request. 5

10 Patient Representatives In order to provide the best possible service to our patients, patient representatives are available to assist you. Should you or your family have questions about the hospital, comments about your care, suggestions for improving our services, a request for an advanced directive, or a need for someone to listen, you may either ask your nurse to contact a patient representative or dial 0 on your phone and the operator will connect you. Case Management and Social Work Services The case management department is staffed with RNs and Social workers to assist with coordination of your care. The case manager will be helpful in coordinating your care while you are hospitalized and arranging for your continued care needs post hospitalization. The case manager will offer information about a wide variety of community services available and assist you and/or your family in obtaining those services. Requests for case management services should be directed to your doctor, nurse, or to the Case Management Department. Volunteers We are fortunate to have a family of volunteers possessing a wide range of talents and experience. Whether they are greeting visitors, escorting patients, comforting a family in time of need, or helping in the gift shop, our volunteers are known for their devotion to others. Volunteers supplement the work of our professional staff to better meet your needs. 6

11 Patient Valuables We encourage patients to leave valuables at home whenever possible. Any personal belongings retained by patients during their hospital stay will become their full responsibility. The hospital does, however, provide safekeeping for valuables in the hospital vault. At your request, your nurse will be happy to deposit your valuables for you. The hospital does not accept responsibility for items of value unless they are deposited in the safe. If you lose something, please notify your nurse right away, and we will make every effort to help you find it. Fire Drills For your protection, the hospital conducts fire and disaster drills regularly. If a drill occurs while you are here, please remain in your room and do not become alarmed. The staff is trained in fire protection and disaster readiness. Telephone The telephone in your room is located either on the bedside table or the side panel of your bed. To make an in-hospital call, dial the four-digit extension. To make a local call, dial 9 + the seven digit number. To make a long distance call, dial 0 to speak to the hospital operator who will direct you to a long distance operator. All long distance calls must be collect or credit card calls. No calls can be charged to your room. Collect calls from outside the hospital to your room are not permitted. 7

12 Leaving the Unit If you must leave the unit, please check first at the nurses station to make sure your doctor has given approval and to let the staff know where you can be reached. It is important to stay in your room until your doctor has made rounds and treatments have been completed. 8

13 SECTION IV Going Home When your doctor decides you are ready to leave the hospital, a discharge order will be written. You may want to make arrangements with a family member or friend to help you when it s time to go home. Some important things to remember: Checkout Process Your doctor will complete the necessary paperwork for your discharge. If you have deposited valuables in the safe, please contact your nurse who will retrieve them. The expected check-out time is 11 a.m., so please make your transportation arrangements for leaving the hospital. Home Care Services Our healthcare system offers exceptional home care programs. Roper St. Francis Home Health is licensed and certified by Medicare and accredited by the Joint Commission on Accreditation of Healthcare Organizations. Services include skilled nursing, physical therapy, occupational therapy, speech therapy, home health aides and medical social work. Specialty services include home IV therapy, wound care, diabetic and registered dietician services and comprehensive rehabilitation services. Medicare, Medicaid and most private insurances provide benefits for home care services. Roper Home Infusion Therapies provides IV therapies such as antibiotics, injections, and nutritional therapies in the home setting. Licensed Pharmacists are on staff and available 24 hours a day. Our team of highly skilled healthcare professionals is dedicated to providing excellent service. For more information, call Roper St. Francis Home Health at or Roper Home Infusion at

14 SECTION V Hospital Bills and Insurance All patients should familiarize themselves with the terms of their insurance coverage. This will help you understand the hospital s billing procedures and charges. If there is a question about your insurance coverage, a member of the Access department will contact you or a member of your family while you are here for the information needed in order to process your claims. If You Have Health Insurance We will file an insurance claim on your behalf for services that are covered by your policy. To do this, verification of your health insurance coverage is necessary. You will be asked to provide a valid insurance identification card or claim form during the admission/registration process. This will assist us in determining the extent of your insurance coverage. You will be held responsible for the deductible, co-insurance and out-of-pocket amounts (as outlined in your insurance coverage) at time of outpatient service, or admission. Note: Even though the hospital files an insurance claim on your behalf, your assistance in resolving unpaid insurance claims is appreciated. If You Are a Member of an HMO or PPO Your plan may have special requirements, such as a second surgical opinion or pre-certification for certain tests or procedures. It is your responsibility to make sure the requirements of your plan have been met. If your plan s requirements are not followed, you may be financially responsible for all or part of the services rendered in the hospital. Some doctor specialists may not participate in your health care plan and their services may not be covered. If You Are Covered by Medicare We will need a copy of your Medicare card to verify eligibility and process your Medicare claim. You should be aware that the Medicare program specifically excludes payment for certain items and services, such as cosmetic surgery, some oral surgery procedures, personal comfort items, hearing evaluations and others. Deductibles and co-payments also are the responsibility of the patient. 10

15 If You Are Covered by Medicaid We will need a copy of your Medicaid card. Medicaid also has payment limitations on a number of services and items. If You Have No Insurance A representative from the Patient Financial Services will discuss financial arrangements with you. A hospital representative who is a representative of the Division of Family Services is also available to assist you in applying for Medicaid or other government assistance programs. Your Hospital Bill The hospital will take responsibility for submitting bills to your insurance company and will do everything possible to expedite your claim. But you should remember that your policy is a contract between you and your insurance company, and you have the final responsibility for payment of your hospital bill. We have several payment options available to assist you in paying your bill. Should any remaining account balance produce a financial burden to you, please inform the hospital of your hardship and an opportunity to apply for financial assistance will be given to you. After an insurance claim is resolved, you will be billed for any differences between the amount covered by insurance and total charges for hospital services not already paid by you. Please contact Patient Financial Services at or if you need assistance regarding your insurance coverage, financial responsibility and/or the opportunity to apply for financial assistance. For your convenience, our hospital accepts American Express, MasterCard, Visa and Discover. The charges for your attending and/or consulting doctors are called professional charges and are billed separately. Consulting doctors may include radiologists, pathologists, anesthesiologists, emergency doctors and any other consultants that your attending doctor deems necessary. These professional charges are not considered a part of the hospital bill. 11

16 SECTION VI Important Patient Information Notice Of Information NOTICE Practices OF INFORMATION PRACTICES Effective Date: April 14, 2003 Revised: November 1, 2007 Effective Date: April 14, 2003 Revised: May 1, 2009 This notice describes how information about you may be used and disclosed and This notice describes how information about you may be used and disclosed how you can get access to this information. Please review it carefully. and how you can get access to this information. Please review it carefully. Our OUR pledge PLEDGE regarding REGARDING health information: HEALTH INFORMATION: We understand that information about you you and and your your health health is personal. is personal. We are We committed are committed to protecting to protecting your health your health information. information. We will We create will a create record of a record the care of and the services care and you services receive you at the receive Roper at St. the Francis Roper Healthcare St. Francis (RSFH), (RSF), its its subsidiaries subsidiaries and and other other entities. entities. We We need need this this record record to to provide you with quality care and to comply with certain legal requirements. This provide you with quality care and to comply with certain legal record will be available to all physicians who may be treating you at any of requirements. This record will be available to all physicians who may RSFH s facilities. be treating you at any of RSF s facilities. This notice will tell tell you you about about the the ways ways we we may may use use and and disclose disclose your your health information. health information. We also We describe also describe your rights your and rights certain and obligations certain obligations we have regarding the use and disclosure of health information. we have regarding the use and disclosure of health information. We are required by law to: to: 1. Ensure the the health health information that that identifies identifies you is you kept is kept private. private. 2. Provide Provide you you with with this this notice notice as to as our to our legal legal duties duties and privacy and privacy practices practices with respect with respect to your to health your information. health information. 3. Follow the terms of the notice. Follow the terms of the notice. 12

17 WHO Who will WILL follow FOLLOW this notice? THIS NOTICE? This notice describes RSFH s RSF s practices and that of: Any health care care professional professional authorized authorized to to enter enter information information into into your your medical record, including doctors doctors on on our our medical medical staff. staff All All departments departments and and units units of of RSFH. RSF. 3. All employees, staff, volunteers and other RSF personnel. 3. All employees, staff, volunteers and other RSFH personnel. 4. In addition, these RSF facilities may share health information with 4. In each addition, other for these treatment, RSFH facilities payment may or share healthcare information operations purposes with each other as described for treatment, in this payment notice. or healthcare operations purposes as described in this notice. 13

18 HOW How We WE May MAY Use USE and AND Dislose DISCLOSE Your Health YOUR Information HEALTH INFORMATION The following categories describe the different ways we may use and disclose The following categories describe the different ways we may use and health information. For each category of uses or disclosures, we will explain disclose health information. For each category of uses or disclosures, we what is meant and provide some examples. Not every use or disclosure in a will explain what is meant and provide some examples. Not every use category will be listed. However, all of the ways we are permitted to use and or disclosure in a category will be listed. However, all of the ways we are disclose information will fall within at least one of the categories. permitted to use and disclose information will fall within at least one of the categories. For Treatment. Information obtained by a nurse, physician, or other For member Treatment. of your healthcare Information team obtained will be recorded by a nurse, in your physician record or and other used to member determine of the your course healthcare of treatment team that will should be recorded work best in your for you. record Your and used physician to determine will document the course in your of record treatment his or that her should expectations work of best thefor you. Your members physician of your will healthcare document team. in your Members record of his your or healthcare her expectations team record of the the actions members they take of your and healthcare their observations. team. Members In that way, of your the physician healthcare will team know record how you the are actions responding they take to treatment. and their observations. That way the physician will know how you are responding to treatment. We will also provide other physicians or a subsequent healthcare provider We with will copies also of provide various other reports physicians that should or assist a subsequent in arranging healthcare your care and provider treating you with once copies you of are various discharged reports from that our should care. These assist independent arranging your physicians care and treating healthcare you professionals once you are constitute discharged an organized from our health care. care These arrangement independent under certain physicians laws governing and healthcare the privacy professionals health constitute information an only. organized These individuals health care are arrangement otherwise independent under certain practitioners laws governing and are the not privacy agents of of any health of our information facilities. only. These individuals are otherwise independent practitioners and are not agents of any of our facilities. For Payment. We may use and disclose your health information so the For treatment Payment. and services We may provided use and by disclose RSFH may your be health billed information and payment so may the be treatment collected from and you, services an insurance provided company by RSF may or a third be billed party. and For payment example, we may tell be collected your insurance from company you, insurance about a treatment company you or a are third going party. to receive For example, to obtain prior we may approval tell your or to insurance determine company whether about your insurance a treatment will you cover are the going treatment. to receive We may to obtain also need prior to give approval your insurance or to determine company whether your information insurance about will a cover surgery the you treatment. had a RSFH We may facility also so need that to your give your insurance company will information pay us reimburse about a surgery you for you the had surgery. at a RSF facility so that your insurance company will pay us or reimburse you for the surgery. 14

19 For Health Care Operations. We We may may use use and and disclose your your health health information for healthcare operations. This This is necessary to run to run RSFH RSF and give and quality give quality care to care our to patients. our patients. For example, For example, we may we use may health use information health to information review the to treatment review the and treatment services provided and services to you, provided and to evaluate to you, the and performance to evaluate the of our performance staff in caring of our for staff you. in We caring may for also you. combine We may health information also combine about health many information RSFH patients about to many decide RSF what patients additional to decide services we should what additional offer, what services services we are should not needed, offer, and what whether services certain are not new needed, and whether certain new treatments are effective. We may disclose treatments are effective. We may disclose information to doctors, nurses, information to doctors, nurses, technicians and other personnel for technicians, and other personnel for review and learning purposes. review and learning purposes. Appointment Reminders. Reminders. We We may may use use and and disclose disclose health health information information to contact to contact you you as a as reminder a reminder that that you have you have an appointment an appointment for treatment for treatment or medical or medical care care at RSFH. at RSF. Treatment Alternatives. We We may may use use and and disclose health health information to tell to you tell you about about or or recommend possible possible treatment treatment options options or alternatives or alternatives that may be that of may interest be of to interest you. to you. Health-Related Benefits and and Services. We We may may use use and and disclose disclose health health information to to tell tell you you about about health-related benefits benefits or services or services that that may may be of interest be of interest to you. to you. Business Associates. There are some services RSF provides through Business Associates. There are some services RSFH provides through contacts with business associates. Examples include but are not limited contacts with business associates. Examples include but are not limited to to certain laboratory and radiology tests, and medical record copying certain services. laboratory For example, and radiology we may use tests, a and copy medical service record to make copying copies services. of your For medical example, record. we may When use we a copy hire service companies to make to perform copies of these your services, medical we record. may disclose When your we hire health companies information to perform so that these they services, can perform we may the disclose job your we ve health asked information them to do. so To that protect they can your perform health the information, job we ve asked however, them to do. we require To protect our your business health associates information, to appropriately however, we safeguard require our your business health associates information. to appropriately safeguard your health information. Fundraising Activities. We We may may use use your your health health information to contact to contact you in you an in effort an effort to raise to money raise money for RSFH for RSF and and its operations. its operations. We would We would only release only release contact contact information, information, such as such your as name, your address name, and address phone and number phone and number the dates and the you dates received you treatment received or treatment services. or If services. you do not If want you do RSFH not to want contact RSF you to contact for fundraising you for efforts, fundraising you must efforts, notify you the must RSFH notify Privacy the Officer RSF Privacy in writing. Officer in writing. 15

20 Hospital Directory. Unless you you notify us us that that you you object, object, we we may may include certain include limited certain information limited information about you about in the you RSFH in the hospital RSF directory hospital while you directory are a patient.. while you This are information a patient. This may information include your may name, include location your in the hospital, name, location your general in the condition hospital, (e.g., your good, general fair, condition serious, etc.) (e.g., and good, yourfair, religious serious, etc.) affiliation. and your The religious directory affiliation. information, The except directory for your information, religious affiliation, except for may your also religious be released affiliation, to people may who also ask be for released you by to name. people Your who religious ask for you affiliation by name. may Your be given religious to a member affiliation of the may clergy be given affiliated to a member with your of the faith, clergy such affiliated as a priest with or your rabbi.. faith, If you such do as not a want priest to or be rabbi. included If you in the do hospital not want directory to be included you must in notify the hospital us in writing directory using you our must patient notify consent us in form. writing using our patient consent form. Individuals Involved in Your Care or Payment for Your Care. We may Individuals Involved in Your Care or Payment for Your Care. We release your health information to a family member, other relative, close may release your health information to a family member, other relative, personal friend, or any other person who is involved in your care or payment close personal friend or any other person who is involved in your care or related to your care. payment related to your care. Research. We may disclose information to researchers when their research has Research. been approved We may by disclose an institutional information review to board researchers who has when reviewed their the research proposal has been and approved established by an protocols institutional to ensure review the board privacy who of your has health reviewed information. the research proposal and established protocols to ensure the privacy of your health information. To Avert a Serious Threat to Health or Safety. We may use and disclose your To Avert health a Serious information Threat when to necessary Health or to prevent Safety. a We serious may threat use and to your health disclose and your safety health or the information health and when safety necessary of the public to prevent or another a serious person. Any threat disclosure, to your health however, and would safety only or the be to health someone and able safety to of help the prevent public or reduce another the person. threat. Any disclosure, however, would only be to someone able to help prevent or reduce the threat. South Carolina Department of Health and Environmental Control (DHEC). South Carolina As required Department by law, we of may Health disclose and your Environmental health information Control to (DHEC). as it As relates required to licensing by law, inspections we may disclose or other your requests health for information reviews by DHEC. to DHEC as it relates to licensing inspections or other requests for reviews by DHEC. The Joint Commission (TJC). As required by accreditation, we may disclose Joint Commission your health information on Accreditation to the TJC of Healthcare at the time of Organizations their surveys. (JCAHO). As required by accreditation, we may disclose your health information to the JCAHO at the time of their surveys. 16

21 SPECIAL Special Situations SITUATIONS ROPER ST. FRANCIS Disaster Relief. We We may may release release your your health health information information to an to entity an entity assisting in in a disaster relief relief effort effort so so that that your your family family can can be notified be notified about about your condition, status, and and location. Organ Organ and and Tissue Tissue Donation. Donation. We We may may release release health health information information to to organizations organizations that that handle handle organ organ procurement procurement or or organ, organ, eye eye or tissue or tissue transplantation transplantation or or to to an an organ organ donation donation bank, bank, as as necessary necessary to facilitate to facilitate organ organ or tissue donation and transplantation. or tissue donation and transplantation. Military and Veterans. If you are a member of the armed forces, we Military and Veterans. If you are a member of the armed forces, we may may release your health information as required by military command release your health information as required by military command authorities. authorities. We may also release health information about foreign We may also release health information about foreign military personnel to military personnel to the appropriate foreign military authority. the appropriate foreign military authority. Workers Compensation. We may release your health information for workers Workers compensation Compensation. or We similar may programs. release your These health programs information provide for benefits workers for compensation work-related or similar injuries programs. or illnesses. These programs provide benefits for work-related injuries or illnesses. Public Health Risks. We may disclose your health information for public Public health Health activities. Risks. We These may disclose activities your generally health information include the following: for public health activities. These activities generally include the following: 1. To prevent or control disease, injury or disability. 2. To To prevent report or births control and disease, deaths. injury or disability. 3. To To report births child and abuse deaths. or neglect. 4. To To report child reactions abuse or to neglect. medications or problems with products. 5. To To report notify reactions people to of medications recalls of products or problems they with may products. be using. 6. To To notify notify people a person of recalls who of may products have been they exposed may be using. to a disease or may be at risk for contracting or spreading a disease or condition. To notify a person who may have been exposed to a disease or may be at 7. risk To for notify contracting the appropriate or spreading government a disease or authority condition. if we believe an adult patient has been the victim of abuse, neglect or domestic violence. To We notify will the only appropriate make this government disclosure if authority you agree if we or when believe required an adult or patient authorized has been by law. the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law. 17

22 Health Oversight Activities. We We may may disclose your your health health information to a health to a health oversight oversight agency agency for activities for activities authorized authorized by law. by These law. oversight These activities oversight include, activities for include, example, for audits, example, investigations, audits, investigations, inspections, and licensure. inspections, These and activities licensure. are These necessary activities for the are government necessary to for monitor the the health government care system, to monitor government the health programs, care system, and compliance government with programs, civil rights laws. and compliance with civil rights laws. Lawsuits and Disputes. If If you you are are involved involved in a lawsuit a lawsuit or a or dispute, a dispute, we may we may disclose disclose your your health health information information response in response to a court to a or court administrative or order. administrative We may order. also disclose We may your also health disclose information your health in response information to a in subpoena, response to discovery a subpoena, request, discovery or other request lawful process or other by lawful someone process else involved by in someone the dispute. else involved in the dispute. Law Law Enforcement. Enforcement. We We may may release release health health information information if asked if asked to do to so do by so a law by a enforcement law enforcement official: official: 1. In response to a court order, subpoena, warrant, summons or similar process. In response to a court order, subpoena, warrant, summons or similar 2. process. To identify or locate a suspect, fugitive, material witness or missing person. To identify or locate a suspect, fugitive, material witness, or missing person. 3. About the victim of a crime if, under certain limited circumstances, About we are the unable victim to of obtain a crime the if, under person s certain agreement. limited circumstances, we are unable to obtain the person s agreement. 4. About a death we believe may be the result of criminal conduct. About a death we believe may be the result of criminal conduct. 5. About criminal conduct at RSF. About criminal conduct at RSFH. 6. In emergency circumstances to report a crime; the location of the In emergency crime or victims; circumstances or the to identity, report a description crime; the location or location of the of crime the person or victims; who or committed the identity, the description crime. or location of the person who committed the crime. Coroners, Medical Examiners and Funeral Directors. We may Coroners, release health Medical information Examiners to a and coroner Funeral or medical Directors. examiner. We may This release may health be necessary, information example, to a coroner to identify or medical a deceased examiner. person This or may determine be necessary, for the example, cause of to death. identify We a may deceased also person release or health determine information the cause to of funeral death. We directors may also as necessary release health for them information to carry to out funeral their directors duties. as necessary for them to carry out their duties. 18

23 National Security and Intelligence Activities. We We may may release release your your health health information information to authorized to authorized federal officials federal for officials intelligence, for counterintelligence, counterintelligence and other national security and other activities national authorized security by activities law. We authorized may also disclose by law. We your may health also information disclose your to authorized health information federal officials to authorized so they may federal provide officials so protection they may to provide the President, protection other to authorized the President, persons other or foreign authorized heads persons of state or foreign conduct heads special of investigations. state or conduct special investigations. Inmates. If If you are are an an inmate of of a a correctional institution institution or under or under the the custody custody of a of law a enforcement law enforcement official, official, we may we release may release your health your information health information to the correctional to the institution correctional law institution enforcement law official. enforcement This release official. would This be necessary: release would (1) for be the necessary: institution (1) to provide for the institution you with health to provide care; (2) you towith health protect care; your (2) health to protect and safety your or health the health and and safety safety or the of others; health (3) and for safety the of others; safety and (3) security for the of safety the correctional and security institution. of the correctional institution. Blood Testing. While you are receiving care, a health care worker may Blood Testing. While you are receiving care, a health care worker may accidentally be exposed to blood or other body fluids. If this occurs, your accidentally be exposed to blood or other body fluids. If this occurs, your blood will be tested for the presence of certain diseases (for example, HIV, blood will be tested for the presence of certain diseases (for example, HIV, Hepatitis B and C). These tests are necessary to help protect the health Hepatitis and C). These tests are necessary to help protect the health care care worker. The results of these tests will be a part of your medical record worker. The results of these tests will be a part of your medical record and and will not be released except with your prior consent or as required or permitted will not be by released law. except with your prior consent or as required or permitted by law. 19

24 OTHER Other Uses USES for Health OF HEALTH Information INFORMATION Other uses and disclosures of health information not covered by this notice Other uses or the and laws disclosures that apply of health to us will information be made not only covered with your by this written notice or permission. the laws that apply to us will be made only with your written permission. If you you provide provide us us permission permission to to use use or or disclose disclose your your health health information, information, you you may may revoke revoke that permission, that permission, in writing, in writing, at any time. at any If time. you revoke If you your revoke your permission, permission, we will we no will longer no longer use or disclose use or disclose your health your information health information for the for reasons the reasons covered covered by your written by your authorization. written authorization. You understand that we are unable to take back any disclosures we have You understand that we are unable to take back any disclosures we have already made with your permission. We are required to retain records of already made with your permission. We are required to retain records of the the care that we provided to you. care that we provided to you. South Carolina Law. In the event that South Carolina Law requires us to give South more Carolina protection Law. to In your the event health that information South Carolina than Law stated requires in this us notice to give or more required protection by Federal to your Law, health we information will give that than additional stated in this protection notice or to your health required information. by Federal Law, In addition, we will give state that law additional mandates protection regarding to medical your health record information. retention In addition, periods may state be law more mandates stringent regarding than medical federal law. record Please be retention aware periods that any may request be more release stringent of PHI than must federal be law. considered Please be on aware a caseby-case that any basis. request If or you release desire of further PHI must information be considered about on specific a case-by-case state laws basis. and If you regulations desire further that information may not be about preempted specific by state HIPAA, laws and please regulations contact that the RSF may not Legal be Department. preempted by HIPAA, please contact the RSFH Legal Department. 20

25 Your YOUR Rights RIGHTS Regarding REGARDING Your Health YOUR Information HEALTH INFORMATION Right to Inspect and and Copy. You You have have the the right right to to inspect inspect and and obtain obtain a copy a of copy the of health the health information information that may that be may used be to used make to decisions make decisions about your about care. your care. Usually, Usually this includes this includes medical medical and billing and records, billing records, but may but not may include not psychotherapy include psychotherapy notes or psychiatric/substance notes or psychiatric/substance abuse notes. abuse notes. To To inspect inspect and and copy copy health health information, information, you you must must sign sign an an authorization Authorization to release to Release the the information Information which Form can which be obtained can be in obtained the Medical in the Record Medical department Record department of the appropriate of the appropriate RSFH treatment RSF treatment facility. If facility. you request If you a copy request a copy of the information, we may charge a fee for the costs of of the information, we may charge a fee for the costs of copying, mailing, or copying, mailing or other supplies associated with your request. other supplies associated with your request Right to Request an Amendment. If you feel that health information Right to Request an Amendment. If you feel that health information we we have about you is incorrect or incomplete, you may ask us to amend have about you is incorrect or incomplete, you may ask us to amend the the information. You have the right to request an amendment for as long information. as the information You have is kept the right by or to for request RSF. an amendment for as long as the information is kept by or for RSFH. To request an amendment, your request must be made in writing to the To Director request of an Medical amendment, Records your at request the appropriate must be made RSF in treatment writing to facility. the Director In addition, of Medical you must Records provide at the a reason appropriate that supports RSFH treatment your request. facility. In addition, you must provide a reason that supports your request. We may deny your request for an amendment if it is not in writing or We does may not deny include your a request reason to for support an amendment the request. if it is In not addition, in writing we or may does not deny include your request a reason if to you support ask us the to request. amend information In addition, we that: may deny your request if you ask us to amend information that: 1. Was not created by us, unless the person or entity that created the information is no longer available to make the amendment. Was not created by us, unless the person or entity that created the 2. information Is not part is of no the longer health available information to make kept the by amendment. or for RSF. 3. Is Is not not part part of of the the health information information which kept you by or would for RSFH. be permitted to inspect and copy. Is not part of the information which you would be permitted to inspect and 4. Is accurate and complete. copy. Is accurate and complete. 21

26 Right to Request an Accounting of of Disclosures. You You have have the the right right to to request an accounting of of disclosures. This This a is list a list of the of the disclosures we we made concerning your health information; but but does does not not include include disclosures disclosures made for treatment, payment, payment, or or for for healthcare healthcare operations, operations, or for for purposes purposes or or disclosures disclosures specifically specifically authorized authorized by you. by you. To To request request this this list list or or accounting accounting of of disclosures, disclosures, you you must must submit submit your your request To request in writing this list or to accounting the RSFH of Privacy disclosures, Officer. you Your must request submit must your request state a time request in writing period in writing to which to the RSFH may the Privacy not RSF be Privacy Officer. longer Officer. than Your six request years Your request must and may must state not time include state a dates time period before which April 14, may not be The longer first than list you six request years and within may not 12 include month period dates period before which will be April may free. not 14, For be additional longer The than first lists, six list years we you may and request charge may not within you include for a 12 the dates month costs of period before providing April will be 14, the free list. For We The additional will first notify list you lists, you request we of may the within cost charge involved a 12 you month for and the period you costs may choose of will providing be free. to withdraw For the additional list. or We modify will lists, notify your we may request you charge of the at you that cost for time involved the before costs and of any providing you costs may are choose the incurred. list. to We withdraw will The notify list or will you modify include of the your cost the request involved date of at the and that disclosure, you time may before choose to any whom tocosts health are withdraw incurred. information modify The list was your will disclosed request include at (including the that date time of before their disclosure, address, any costs if are known), to incurred. whom a description health The list information of the information will include was the date disclosed disclosed, of the (including and disclosure, their reason to whom address, for health if the information known), disclosure. a description of the information disclosed, and the reason for the disclosure. Right was disclosed to Request (including Restrictions. their address, You if have known), the right a description to request of the a restriction Right information limitation to Request disclosed, on the Restrictions. health and the information reason You have the we the disclosure. use right or disclose to request about a restriction you for treatment, or limitation payment on the or health health information care operations. we use You or disclose also have about the you right for to Right request to Request a limit on Restrictions. the health information You have the we right disclose to request about a restriction you to or someone treatment, who payment is involved or health in your care care operations. or the payment You also for have your the care, right like a family to limitation request member on a limit the or health on friend. the information health For example, information we use you or we could disclose disclose ask about that about you we you not for use to or disclose someone treatment, information who payment is involved or about health in a your care surgery operations. care you or the had. You payment To also request have for your restrictions, the right care, tolike you a must family request make member a limit your on or request the friend. health in For writing. information example, In your we disclose could request, about ask you that you must we to not tell someone use (1) or what disclose who involved information your about want care a or to surgery the limit; payment you (2) whether had. for your To you request care, want like restrictions, to a family limit our you use, must member disclosure make or friend. your or request both; For example, and in writing. (3) to you whom could In your ask request, that want we the you not limits use must or to tell disclose apply, us (1) for example, what information disclosures you to want your to spouse. limit; (2) whether you want to limit our information about a surgery you had. To request restrictions, you must make use, disclosure or both; and (3) to whom you want the limits to apply, for We example, your are request not disclosures required in writing. to to your In agree your spouse. to request, your request. you must If tell we us do (1) agree, whatwe will comply information with your want request to limit; unless (2) whether information you want is to needed limit our to provide use, you emergency We disclosure are not or treatment. required both; and to (3) You agree to may whom to not your you limit request. want uses the and If limits we disclosures do to apply, agree, that for we will we are legally comply example, required with disclosures your or request allowed to your unless to spouse. make. the information is needed to provide you emergency treatment. You may not limit uses and disclosures that we are legally We are required not required or allowed to agree to to make. your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. You may not limit uses and disclosures that we are legally required or allowed to make. 22

27 Right to 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 can ask that we only contact you at work or at home, or send billing information to an alternative billing address. To request confidential communications, you must notify us in writing using our patient consent form. Your request must specify how or where you wish to be contacted. Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may obtain a copy of this notice at any time from our website, or from the RSF facility where you obtained treatment. CHANGES TO THIS NOTICE We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for health information we already have about you as well as any information we receive in the future. The notice will contain the effective date on the first page. You can view the current notice at our website, COMPLAINTS If you believe your privacy rights have been violated, you may file a complaint with RSF or with the Secretary of the Department of Health and Human Services. If you have any questions about this notice or any complaints about our privacy practices, or would like to know how to file a complaint with the Secretary of the Department of Health and Human Services, please contact our Privacy Officer at (843) You will not be penalized for filing a complaint. 23

28 Your Rights: ROPER ST. FRANCIS Patient Rights and Responsibilities You have the right to considerate, compassionate and respectful care. You have the right to have your values, religion and philosophy respected. You have the right to privacy concerning your medical care program. All communications and records pertaining to your care will be treated as confidential. You have the right to know the persons and the professional relationships of the individuals serving you, as well as the right to know who is primarily responsible for your care. You have the right to discuss with your doctor any ethical issues that arise in the course of your care. You have the right to request access to the hospital s Ethics Committee. You have the right to receive information from your doctor that you need to make decisions about your care and treatment. You and your family have the right to be involved in making decisions as well as resolving disagreements about care decisions. This information includes the decision to stop treatments. When refusal of treatment prevents the proper care in accordance with professional standards, you will be informed of the medical consequences of your action, and the medical relationship with you may be ended upon reasonable notice. You have the right to effective communication and information from your doctor and other caregivers about your diagnosis, your treatment and what your doctor expects will happen as a result of your care. This information should be current and complete, and you should be able to understand it. You have the right to consent to surgery. You or your legal representative must sign a consent form for treatment and/or surgery. In some critical emergency situations where consent is not possible, we will act to care for you to the best of our ability. (Consent forms for minors are signed by the parent or legal guardian). You should always feel free to ask any questions you may have before signing any consent forms. 24

29 You have the right to information about Advance Directives such as a Living Will and/or a Health Care Power of Attorney. If you have an Advance Directive, we will work with your doctor to honor your wishes as stated in your directive. If you wish to formulate an Advance Directive, hospital personnel will assist you if at all possible. You have the right to have issues addressing autopsy and organ donation conducted in a sensitive manner. You have the right to effective and timely pain management. You have the right to request and receive pastoral counseling. You have the right to express any concerns you may have about the quality of care and how the concerns will be resolved. You have the right to be provided protective services should they be required. You have the right to request and expect the hospital to arrange for the prompt and orderly transfer of your care to others when the hospital cannot meet your request or needs for treatment or services. Transfer will occur only after the hospital has given you complete information about the transfer, has explained to you other choices other than the transfer, and another doctor and/or hospital has accepted you as a patient. You have the right to know if your care is affected by the hospital's relationship with another healthcare organization or educational organization. You have the right to be informed about the outcomes of your care, including unanticipated outcomes. You have the right to have your own physician promptly notified upon your admission to the hospital. 25

30 Your Responsibilities: You are to provide accurate and complete information regarding any past illnesses, hospitalizations, medications and other matters about your health to the hospital and your doctor. You are to take an active role in making decisions about services provided to you by discussing your condition and treatment with your doctor, reporting any changes in your condition and providing your Advance Directive, and/or expressing your wishes about using life support. You are to cooperate with hospital staff members who provide care and treatment, follow directions about your care, and ask questions if you do not clearly understand the plans and directions of your care. You are to follow and respect hospital rules and regulations concerning patient care and conduct. You are to be considerate of the rights of other patients and hospital staff. Please help us by controlling noise and the number of visitors; honoring smoking regulations, and using telephone, television, air conditioning, and lighting in a manner considerate of other people and acceptable to the hospital. You are to follow quidelines with respect to cameras. The camera function of cell phones equipped with cameras is never to be used while on the premises of Roper St. Francis, unless otherwise permitted by authorized Roper St. Francis personnel. If it is discovered that an employee, vendor, patient or visitor is taking pictures or video with their cell phone, the camera-equipped cell phone is subject to immediate confiscation and erasure of those photos that were taken while on premises. Vendors, patients, and/or visitors can retrieve confiscated camera-equipped cell phones from Security upon their departure from the hospital. Repeat offenders of this policy will be subject to being denied access to Roper St. Francis. You are to accept responsibility for your actions if you refuse treatment or do not follow your doctor s instructions. 26

31 You are to give the hospital complete information to process insurance claims, and be prompt in asking questions about your bill. Make arrangements to pay your hospital bills within an acceptable time period. You are to begin planning early for your hospital discharge so you can leave when you no longer need to be in the hospital. You are to be responsible for your own belongings and take them with you upon discharge. Do not bring unnecessary items or valuables to the hospital. You are responsible for informing your nurse or doctor of all information, which may affect your care and safety. 27

32 Advance Directives Living Will and Healthcare Power of Attorney What is an Advance Directive? An advance directive is a legal document that tells your doctor what treatments you want or do not want if you can no longer speak for yourself and if you are in the hospital as a patient. Advance Directives do not apply when you are treated as an outpatient. Who should have an Advance Directive? Anyone over the age of 18 has the legal right to make an advance directive. What if I am pregnant? South Carolina law requires that life saving treatment be CONTINUED while you are pregnant. What are the legal Advance Directive documents in South Carolina? Living Will A Living Will says that you want to be allowed to die a natural death if you are so sick or hurt that medical treatment, heroic measures, or artificial means will make your dying longer; or if you are in a coma that you will not wake from. Healthcare Power of Attorney A Health Care Power of Attorney is a document in which you give another person ( your agent ) the power to make decisions related to your healthcare if you cannot speak for yourself. What if I change my mind? You can revoke your Advance Directive at any time while you are competent by informing your agent, your doctor, or throwing away your Advance Directive. Be sure to tell your doctor or nurse if you are in the hospital. Will a hospital honor an Advance Directive from another state? Yes, as long as the document conforms to South Carolina law, which is called The Patient Self-Determination Act. 28

33 Who should have a copy of my Advance Directive? You should always give one to a family member, your doctor, your agent and your attorney. ALWAYS BRING A COPY WHEN YOU ARE ADMITTED TO THE HOSPITAL. What is our facilities policy about Advance Directives? Our facility will honor a patient s Advance Directives according to South Carolina law and will not condition the provision of care or otherwise discriminate against a patient based on whether or not the individual has executed an Advance Directive. How can I formulate an Advance Directive if I am already in the hospital? You can contact a patient representative for assistance. NOTE: The Patient Self-Determination Act is a law that requires hospitals to ask each patient if they have an Advance Directive. This law also requires that patients be given Advance Directive information. 29

34 Your Role in Patient Safety ROPER ST. FRANCIS Our mission is to provide high quality health care services to every patient. You and your family are a vital part of your healthcare team. As a team member, you share responsibility for ensuring your safety. Outlined below you will find advice that helps us to provide safe care for you. These tips are meant to help you during your stay and even after you go home. Safety Tips Inform your healthcare team of all information which may affect your care or safety: Medicines you are taking (including over-the-counter medicines, dietary supplements, vitamins, and herbal remedies) Allergies you may have (i.e. to medicines, environmental (pollen, dust, grass) or foods) Side effects or bad reactions to medicines, treatments, or tests you have had in the past Previous hospitalizations, surgeries, or illnesses REMEMBER: Do not assume every team member has all of your personal information. Inform your healthcare team about your wishes concerning life support or resuscitation. Bring Advance Directives, Living Wills or other documents which might outline your wishes regarding specific wishes. Tell your doctor about your specific wishes. Educate yourself about your condition and your treatment options. Gather information about your condition. Know who will be taking care of you. 30

35 Know how long the treatment should last. Know how you should feel. More tests or medications may not always be better. Ask your doctor what each test or medication is supposed to do. Do not be afraid to ask for a second opinion if you are uncomfortable. Seek the advice of others who have had the treatment you are considering. Be an active team member. Pay attention to the care you are receiving. Read all medical forms and make sure you understand them before signing anything. Tell a team member if something does not seem right. Your team members should introduce themselves when they enter your room. If you are unsure who someone is, ask. Your team members should wash their hands before giving care. Do not be afraid to remind them. Know what time of day you normally receive a medicine. If you do not receive it, tell your nurse. Know what your medicines look like, how much you take, and what side effects you may feel. Make sure your doctor or nurse checks your name before giving any medicine or treatment. Follow all hospital rules and policies. They are meant to keep you safe. 31

36 Ask someone you trust to be your advocate. Your advocate can ask questions that you may not think of, may help you remember answers to your questions, and may speak up for you if you cannot. Ask this person to stay with you (even overnight) when you are in the hospital. Make sure your advocate knows your wishes for care and your wishes concerning resuscitation and life support. If you wish, ask your advocate to review medical forms you need to sign. Make sure your healthcare team understands who your advocate is and what information they are able to give that person. REMEMBER: If you have questions, ask. If you have concerns, tell one of the members of your healthcare team. Tell your team everything. Do not leave information out or assume that we know it. 32

37 Pain Management Our facilities healthcare providers will: Inform patients at the time of the initial evaluation that relief of pain is an important part of their care, and they will respond quickly to their reports of pain. Ask patients on initial evaluation and as part of regular assessments about their presence, quality, and intensity of pain and use the patient s self report as the primary indicator of pain. Work together with the patient and other healthcare providers to establish a goal for pain relief and develop and implement a plan to achieve that goal. Review and modify the plan of care for patients who have unrelieved pain. For more information about pain management, please talk with your doctor or nurse. As a patient, you can expect: Information about pain and pain relief measures. A concerned staff committed to pain prevention and management. A healthcare professional to respond quickly to your report of pain. Your reports of pain will be believed. State-of-the-art pain management. Dedicated pain relief specialists. 33

38 As a patient, we expect that you will: Ask your doctor or nurse what to expect regarding pain and pain management. Discuss pain relief options with your doctors and nurses. Work with your doctor and nurse to develop a pain management plan. Ask for pain relief when pain FIRST begins. Help your doctor and nurse assess your pain. Tell your doctor or nurse if your pain is not relieved. Tell your doctor or nurse about any worries you have about taking pain medication. 34

39 If You Have Concerns Every patient has the right to file comments, positive or negative, about his/her care and treatment and not be penalized in any way for doing so. The managers and staff will be responsive to the concerns of patients and their families or guardians. All employees are considered patient advocates. Patient concerns are considered a priority and staff will respond immediately. Patients and their legally authorized representatives are encouraged, but not required to utilize the facility s complaint/grievance process before registering a complaint with the appropriate outside agency such as Department of Health and Environmental Control (DHEC), Center for Medicare Services (CMS), Carolinas Center for Medical Excellence , and the utilization committee of your insurance carrier. You may contact your nurse, your doctor, the hospital administrator, the risk manager, a patient representative or the compliance officer if you have concerns and wish to report them. To file a grievance with the South Carolina Department of Health and Environmental Control, contact: SC DHEC Division of Health Licensing 2600 Bull Street Columbia, S.C (803)

40 The Joint Commission accredits healthcare organizations compliance with nationally established Joint Commission standards. Roper St. Francis, which includes Roper Hospital, Bon Secours St. Francis Hospital, Roper St. Francis Home Health and Roper St. Francis Medical Center Berkeley, is a Joint Commission accredited organization. The Public has the right to notify The Joint Commission about any quality concerns they may have related to Roper St. Francis. Such notifications should be addressed to: Division of Accreditation Operations Office of Quality Monitoring, The Joint Commission One Renaissance Blvd. Oakbrook Terrace, IL Telephone: (800) Fax: (630) complaint@jointcommission.org 36

41 Compliance Program Our healthcare system s Corporate Compliance Program is designed to reflect our commitment to our mission, to the highest standards of business conduct and to applicable laws and regulations. All employees are trained on the Compliance Program and are expected to follow the standards in "Our Code of Conduct: The Right Thing To Do". These standards are: Patient Care Confidentiality Conflicts of Interest Finance and Records Billing Admissions and Referrals Media Inquiries and Advertising Safety: Your Health and Environment Political and Regulatory Safeguarding Property and Technology Equal Employment for All and Workplace Behavior Our billing standard states "The system bills only for care and services which are properly ordered and medically necessary. All coding and billing will be performed in accordance with our policies as well as federal and state regulations." If patients have questions about bills they should call Patient Customer Service at Other concerns may be expressed to clinical staff or patient representatives during your stay. The Compliance Officer or Corporate Compliance HelpLine may be utilized to report unresolved compliance concerns. The number for the Corporate Compliance HelpLine is

42 SECTION VII Lewis Blackman Patient Safety Act The following is intended to serve as information to be provided to each Roper St. Francis patient presenting for inpatient services or outpatient surgical services. The purpose of such information is to communicate with each patient the role of the clinical medical providers for the patient and provide a mechanism whereby the patient may contact his or her attending physician or clinical manager, if necessary. The following individuals may be involved with patient care during the patient s visit with Roper St. Francis. This list does not include all clinical staff that may be involved in the patient s care, but should provide each patient with a sound understanding of the role of the primary medical providers. Attending Physician medical physician directly responsible for admitting patient to hospital and/or responsible for patient s care; Resident Physician medical physician who has graduated from a medical education program who may assist the attending physician with patient care under the direction of the attending physician and an ongoing further medical educational program; Intern Physician individual who is an advanced student or graduate of a medical education program and is participating in direct patient care for the purpose of gaining practical medical experience under the direction and supervision of the attending physician; Consulting Physician an individual physician that may be assisting or called to consult with the patient for a specific medical purpose, but who is not necessarily taking the role of attending physician; Clinical Trainees included individuals who may be observing or seeking advanced clinical training in a medical field or hospital environment, such as nursing, medical training or other training. Such trainees are supervised by the attending physician (as described here) or directly supervised by a licensed nurse or clinical manager during the care of the patient. 38

43 Medical Student individual who observes the medical care provided by the attending physician, working with and under the direct supervision of the attending physician. A list of approved abbreviations for use on the clinical and medical staff s identification badges has been provided with this written information for your benefit and review. Please note: your attending physician may change during your hospitalization, please check with your nurse or clinical manager if you have any questions regarding your attending physician. You may also have one or multiple consulting physicians taking part in your medical care; however, these consulting physicians are not considered your attending physician unless informed otherwise. Also, Medical students and interns may be rounding with your attending physician during normal rounds, these individuals are not your attending physician, but may participate in the clinical treatment you receive. You may contact your attending physician or his/her designee, at any time, by asking your nurse the following: You may request that the nurse place a call to your attending physician, or his/her designee, to inform the attending physician or his/her designee of the patient s concern; OR You may request that the nurse provide you with the attending physician s telephone number so that the patient may contact the attending physician or his/her designee directly; OR If you are unable to place a call yourself, you may request that your nurse assist you with placing the call to the attending physician or his/her designee. Finally, you may access the Patient Assistance Program in order to contact the clinical manager for your current nursing unit to discuss any clinical concern you may have that may not require the need of the attending physician or his/her designee. Please see the following document for information and an explanation to access the Patient Assistance Program 39

44 PATIENT ASSISTANCE PROGRAM LEWIS BLACKMAN PATIENT SAFETY ACT The following is intended to serve as a written procedure for Roper St. Francis patient s access to the Patient Assistance Program. The purpose of this Program is to provide clinical assistance to patients, at their request, that may not require the attending physician s assistance. This Program will be available at all times to the patient while hospitalized with Roper St. Francis. Each nursing unit will make available a clinical manager with telephone number and/or pager number for patients to access from their rooms. The clinical manager or house-nursing supervisor should promptly assess the patient s concern based on the contact made by the patient and document appropriately in the patient s chart. The clinical manager shall be available to patients during normal scheduled hours. The house nursing supervisor(s) shall be available during abnormal scheduled working hours pursuant to the hospital s employee schedules. Telephone number and pager number will be available for the appropriate clinical manager or house-nursing supervisor 24-hours a day, 7-days a week. The purpose of this Program is not intended to replace or in any way act as the method for handling general patient complaints, this is for clinical assistance only. The Patient Assistance Program information will be made available on each nursing unit and the policy shall be made available in the written information provided to each patient upon admission for inpatient services and outpatient surgery. The contact information for each unit s clinical manager or housenursing supervisor, and the times in which each is available for contact, shall be posted at the nursing unit on a specially prepared location and made available for the patients without requesting assistance. The telephone number and pager number of each unit s clinical manager or house-nursing supervisor are available by being posted at each nursing station on the nursing unit. The clinical manager is available during the times and 40

45 days posted on the information sheet and the house-nursing supervisor is available during all other times. The patient may use the telephone located within each patient room or area or may use any personal telephone system available to contact the clinical manager or house-nursing supervisor when necessary. A patient may contact the listed individual during the hours provided for prompt assistance with personal medical care concerns. This Program is not provided for the use or purpose of addressing patient complaints, for which another policy and procedure for each hospital currently exists, but rather it is available for the prompt assessment of such medical care concerns 41