Communication of Patient Rights

Mahaska Health will take steps to effectively communicate principles regarding patient and resident rights. Mahaska Health will be sensitive to the communication needs of our patients and will comply with Civil Rights laws that require alternative communication methods for certain individuals who speak or read languages other than English, the visually or hearing impaired, patients on ventilators and the cognitively impaired and children.

Participation in Healthcare Decision-Making, Informed Consent and Advance Directives

Patients have the right to participate in decisions involving their healthcare either personally or through a surrogate decision maker.

  • Informed Consent- Informed consent will be obtained from patients or their legally authorized representative.
  • Advance Directives – Patients have the right to formulate, review and revise.

Patients will not be involved in research without thorough and detailed informed consent.

Patients have the right to:

  • Care that is free from discrimination. This means that you should not be treated differently because of age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation or gender identity or expression.
  • Obtain current information from their provider regarding their diagnosis, treatments and prognosis unless it is not medically advisable in the provider’s professional opinion. This information should be given in terms easily understood by patients.
    Appropriate assessment and management of their comfort, including their level of pain. They have the right to determine their own acceptable comfort level and can expect that their decisions will be respected.
  • Refuse care, treatment and services, to the extent permitted by law, and to be informed of the possible medical consequences of their action.
  • Every consideration of their privacy concerning their own medical care program, including the right to exclude those not directly involved in their care.
  • Expect that all communications and records pertaining to their care should be available only to those directly concerned with such care, except as required by law or by the instructions of the patient.
  • Expect that, within its capacity, a hospital must make a reasonable response to their request for services in an emergency. The hospital must provide evaluation, service and/or referral as indicated by the urgency of the case. When medically permissible, patients may be transferred to another facility only after they have received complete information and explanation concerning the need for alternatives to such transfer. The institution to which the patient is to be transferred and the provider to be responsible for the case must first have accepted the patient for transfer.
  • Examine and receive an explanation of their hospital bill.
  • Know what hospital rules and regulations apply to their conduct as patients.
  • Expect reasonable continuity of care for the illness or injury for which they are hospitalized. For services provided in the hospital, they have the right to know in advance what appointment times and providers are available. Patients have the right to expect that the hospital will provide a mechanism whereby they are informed by their provider or a delegate of the provider of their continuing healthcare requirements for the present illness or injury following discharge.
  • Express concerns, grievances or suggestions for improvement regarding their care. They are encouraged to start by telling a nursing staff member or a nursing manager or supervisor who is on duty. If the response is not satisfactory you may do any of the following:
    • Contact the Mahaska Health Patient Representative at 641.672.3239.
      • Contact the Beneficiary Family Centered Care Quality Improvement Organization (BFCC-QIOs), KEPRO toll free: 1.855.408.8557 or TTY number is 1.855.843.4776.
    • The Joint Commission at 800.994.6610
    • Department of Inspections and Appeals at 515.281.3790.
  • Request and receive pastoral care/spiritual services while hospitalized. They can request that a specific member of the clergy be contacted or they can ask to see the hospital’s chaplaincy program clergy person who is on call.
  • Assurance of reasonable safety within the hospital.
  • Knowledge of the identity of the physician or other practitioner who is primarily responsible for their care as well as the identity and professional status of others providing services to them while in the hospital.
  • To consult with a specialist at the patient’s request and expense.
  • To accept visitors of their choosing for emotional support and comfort while receiving care. The visitors designated by the patient or support person may include, but not limited to, a spouse, a domestic partner (including a same sex domestic partner), another family member or a friend. The individual may or may not be the patient’s surrogate decision-maker or legally authorized representative.
    • Mahaska Health does not restrict, limit or otherwise deny visitation based on age, race, color, ethnicity, national origin, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation and gender identity or expression.
    • The term “support person” means an individual recognized verbally or in writing by the patient to make visitation determinations on behalf of the patient.
    • A “support person” includes but is not limited to a person who is the patient’s spouse, a domestic partner, adult child, a sibling of the patient, another family member of the patient, a same sex partner, a person with whom the patient is in a civil union, or a same sex marriage, a friend, or a person who has durable power of attorney in health care or a health care proxy for the patient documented in a manner recognized under state law.
    • Facility shall encompass inpatient and outpatient services available at MHP.
    • At the time of admission to Mahaska Health, the patient or support person will be:
      • informed of their right to receive visitors whom he or she chooses
      • informed how to withhold or withdraw consent to receive visits by individuals through notification of a staff member of their request at any time
      • provided notification using alternative communication services to accommodate patients and support persons with Limited English Proficiency, visual impairment or health literacy challenges
      • provided a copy of MHP’s patient rights and responsibilities in written format as well as electronically on our website.
    • The patient’s visitors may be limited or restricted when clinically necessary to provide safe care to the patient and other patients. In the event of visitor limitation or restriction, an explanation will be provided to the patient or support person. The justified clinical restriction may include but not limited to such things as:
      • An order from a court limiting or restraining contact;
      • Behavior presents as direct risk or threat to the patient, hospital staff, or others in the immediate environment.
      • Infection control issues
      • Is medically or therapeutically contraindicated such as the patient needs rest or privacy.
      • The patient is undergoing clinical interventions that the treating health care professional believes to be in the best interest of the patient to limit visitors during that time.
      • Interferes with the care of other patients.
      • To provide a therapeutic milieu

Patient’s Responsibilities

As a patient or the legally authorized representative of a patient, you have the responsibility:

  • To provide accurate and complete information about present complaints, past illnesses, hospitalizations, medications and other matters relating to your health, including advanced directives. You will report perceived risks in your care and unexpected changes in your condition; and you will affirm whether you clearly comprehend a contemplated course of action and what is expected.
  • To follow the treatment plan recommended by the practitioner primarily responsible for your care. This may include following the instructions of nurses and other healthcare professionals as they implement the practitioner’s orders and enforce the applicable hospital rules and regulations.
  • For your actions if you refuse treatment or if you do not follow the practitioner’s instructions.
  • To fulfill the patient’s financial obligations as soon as possible following discharge.­­
  • To follow hospital rules and regulations affecting patient care and conduct.
  • To be considerate of the rights of other patients and hospital personnel, and for assisting in the control of noise and the number of visitors in your room.
  • To ask questions when you do not understand what you have been told about your care or what you are expected to do.

Statement of Principles Regarding Residents’ Rights

The resident has a right to a dignified existence, self-determination and communication with and access to persons and services inside and outside the facility. A facility must protect and promote the following rights of residents:

  • A family member or representative of the patient’s choice and his or her physician will be promptly notified of the patient’s admission.
  • To exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.
  • To be free from chemical and physical restraint.
  • To have the freedom from interference, coercion, discrimination and reprisal from the facility in exercising his or her rights.
  • To be free from neglect, exploitation and verbal, mental, physical and sexual abuse.
  • Upon oral or written request, to access all records pertaining to him or herself including current clinical records to view within 24 hours.
  • To be fully informed of his or her health status, including his or her medical conditions.
  • The critical access hospital provides environmental adaptations to help residents with dementia, cognitive impairment or temporary confusion.
  • To have access to stationery, postage and writing implements at the residents’ own expense.
  • To refuse treatment, to refuse to participate in experimental research and to formulate an advance directive.
  • To receive and restrict visitors.
  • To be informed by the facility when he or she becomes eligible for Medicaid.
  • To be informed of the services provided by the facility, the charges and those that are covered by Medicaid. The resident may not be required to request any item or service as a condition of admission or continued stay.
  • To be informed about the manner in which the facility protects residents’ personal funds.
  • The critical access hospital protects the rights of residents who work for or on behalf of the critical access hospital. The residents have the right to refuse to work for or on behalf of the critical access hospital.
  • To a written description of the requirements and procedures for establishing eligibility for Medicaid, including the right to request an assessment under section 1924(c) which determines the extent of a couple’s non-exempt resources at the time of institutionalization and attributes to the community spouse an equitable share of resources which cannot be considered available for payment toward the cost of an institutionalized spouse’s medical care in his or her process of spending down to Medicaid eligibility levels.
  • To transportation services, as appropriate to his or her care or service plan.
  • To have posted the names, addresses and telephone numbers of all pertinent State client advocacy groups. See Addendum at the end of this document.
  • To choose a personal physician and the right to information regarding the name, specialty and means of contacting his or her physician.
  • To manage his or her own funds. The resident may not be required to deposit personal funds within the facility. Any funds which the resident chooses to deposit with the facility and so authorizes in writing, must be separately maintained or accounted for and may not be co-mingled with facility or other residents’ funds. Amounts in excess of $50 must be placed in interest-bearing accounts. Upon the death of the resident, the funds must be conveyed to the resident’s estate within thirty days.
  • To voice grievances without discrimination or reprisal and to prompt efforts by the facility to resolve grievances, including those involving the behavior of other residents.
  • To privacy of communications, verbal and written, and to share a room with his or her spouse if both spouses agree.
  • To retain and use personal possessions as space permits and within bounds of the rights and safety of other residents.
  • To self administer drugs if the interdisciplinary team at the facility determines that the practice is safe.
  • To refuse a transfer to another room within the facility under certain conditions set out in 42 CFR 483.10(o).
  • To remain in the facility and not be transferred outside the facility unless:
    • The transfer or discharge is necessary for the resident’s welfare and the resident’s needs cannot be met at the facility;
    • the transfer or discharge is appropriate because the resident’s health has improved sufficiently;
    • the safety of the individuals in the facility is endangered;
    • the health of individuals in the facility would otherwise be endangered;
    • the resident has failed, after reasonable and appropriate notice, to pay for or to have paid under Medicare or Medicaid a stay at the facility;
    • or the facility ceases to operate.
  • To be notified in writing of the facility’s bed hold policy before the resident is transferred to a hospital or goes on therapeutic leave.
  • The facility may not:
    • Require residents or potential residents to waive their rights to Medicare or Medicaid;
    • require oral or written assurances that residents or potential residents are not eligible for, or will not apply for Medicare or Medicaid benefits; or
    • require a third party guarantee of payment to the facility as a condition of admission or expedited admission or continued stay within the facility.
  • The facility must immediately notify the resident, consult with the resident’s physician and, if known, notify the resident’s legal representative or an interested family member when there is:
    • An accident involving the resident which results in injury and has the potential for requiring physician intervention.
    • A significant change in the resident’s physical, mental or psychosocial status.
    • A need to alter treatment significantly or to commence a new form of treatment.
    • A decision to transfer or discharge the resident from the facility.

Open Admissions Policy Statement

It is and has always been the policy of Mahaska Health to admit and treat all people without regard to race, color, creed, national origin, gender, religion, disability or age. All Mahaska Health facilities are available to patients and visitors without distinction.