Current through Register Vol. XLI, No. 50, December 13, 2024
Section 69-9-7 - PATIENT RIGHTS AND PARENTAL/LEGAL REPRESENTATIVE RIGHTS AND RESPONSIBILITIES7.1. Policies and Procedures. 7.1.a. The governing body of the center shall establish written policies and procedures regarding the rights and responsibilities of patients and legal representatives. The policies adopted shall be consistent with the provisions of this rule.7.1.b. Through the administrator, the governing body is responsible for on-going development of and adherence to procedures implementing policies regarding the rights and responsibilities of patients. 7.1.c. The center shall make its policies and procedures available upon request.7.1.d. The center shall have a non-discrimination policy, a patient bill of rights and a family bill of rights.7.1.e. Prominently display a copy of the patient rights and responsibilities, the names, addresses, and telephone numbers of all associated state agencies including licensing agencies.7.2. Civil Rights. 7.2.a. A center shall not segregate a patient, give separate treatment, restrict the enjoyment of any advantage or privilege enjoyed by others in the center, or provide any aid, care services, or other benefits that are different from or are provided in a different manner from those provided to others in the center on the grounds of race, color, religion or national origin, age, disability, gender or other protected class.7.2.b. A center shall not deny admission to a prospective patient on the grounds of race, religion or national origin, age, disability, gender or other protected class.7.3. Abuse, Neglect, and Misappropriation of Property. 7.3.a. All patients have the right to be free from verbal, sexual, physical, and mental abuse financial exploitation, discrimination, denial of privileges, corporal punishment, and involuntary seclusion.7.3.b. The center shall develop and implement written policies and procedures that prohibit neglect, abuse of patients, and misappropriation of patient property. The policy and procedures shall address the screening, training, prevention, identification, investigation, protection, reporting and response of allegations of patient neglect, abuse, and misappropriation of patient property.7.3.c. The center shall ensure all alleged violations involving mistreatment, abuse, neglect, and misappropriation of property, including injuries of unknown origin are reported in accordance with State law.7.3.d. The center shall ensure all alleged violations involving mistreatment, abuse, neglect, and misappropriation of property, including injuries of unknown origin are reported to the state oversight agency immediately, and no later than within 24 hours. In addition, the facility shall submit a five-day follow up report. These shall be submitted on the form developed by the state oversight agency.7.3.e. The center shall document that all alleged violations are thoroughly investigated and shall take appropriate steps to prevent further potential abuse while the investigation is in progress.7.3.f The results of all investigations shall be reported to the administrator or his or her designated representative and to other officials in accordance with State law, including the Director, within five working days of the incident, and if the alleged violation is verified appropriate corrective action shall be taken.7.3.g. The center provides all employees with information regarding abuse, neglect, and misappropriation of property and related reporting requirements, including prevention, intervention and detection. This shall occur during orientation and annually as a continuous staff development program.7.3.h. The center shall protect patients from abuse, neglect and misappropriation of property during the investigation of any allegations.7.3.i. The center must have policies and procedures in place to protect patients from abuse, neglect, and misappropriation of property of all forms, whether from staff, visitors, or any other persons.7.3.j. The center must have policies and procedures in place to identify the mandatory reporting requirements of abuse and neglect in accordance with state law and regulations.7.4. Legal Representatives. 7.4.a. The center shall maintain in the patients' medical record verification of the authority of the legal representative and shall provide the legal representative with a general description of the scope of the legal representative's decision-making authority.7.4.b. The center shall inform the parents and/or legal representative of his or her rights and responsibilities under the provisions of this rule. All rules governing parent and/or legal representative conduct must be fully explained prior to or at the time of admission and within 30 days of any changes. The parent and/or legal representative must acknowledge receipt of this information in writing, and shall be permanently retained by the center in accordance with this rule.7.4.c. Parents and/or legal representative must have the right to be informed of the patient's medical condition, care and treatment.7.4.d. Parents and/or legal representatives have the right to voice all grievances without discrimination or reprisal and have prompt resolution.7.5. Duties of Staff 7.5.a. All staff and personnel of the center shall ensure that every patient under their care is accorded all rights set forth in this rule.7.5.b. The center staff shall at least annually receive training in the proper implementation of patient rights policies under the provisions of this rule.7.5.c. When the center's staff limits or restricts the rights of a patient for medical reasons, the staff will document the specific reasons for the limitation or restriction in the patient's medical record, and the specific period of time the limitation or restriction will be in place. The patient or the patient's legal representative shall be notified of the limitation or restriction.7.6. Informed Consent. 7.6.a. The center must have a policy to address how and when informed consent will be provided to the parents and/or legal representative.7.6.b. Legal representatives shall be informed of their rights and responsibilities in writing, prior to admission.7.6.c. Legal representatives shall be informed of the policies and procedures governing the facility.7.6.d. Legal representatives shall be clearly informed of the responsibilities of the neonatal abstinence center for the care of the patient.7.6.e. Legal representatives shall be clearly informed in writing of the costs of services to be provided and of any required services or procedures not included in the charge of the center.7.7. Participate in Care Planning. 7.7.a. Legal representatives shall have the right to participate in the development of the patients' care plans.7.7.b. Efforts shall be made by the center to accommodate the family and/or legal representative when scheduling all care planning meetings and reviews.7.8. Confidentiality and Access to Records and Information. 7.8.a. The center shall assure confidential treatment of each patient's personal and medical records. The center may approve or deny their release to any person outside the center, except in the case of his or her transfer to another health care institution, as required by law, or for a third party payment contract.7.8.b. Upon request, the center shall provide to each patient and legal representative access to all of his or her records, including current clinical records, within 24 hours of the request. Records may only be available during normal business operating hours, excluding weekends and holidays.7.8.c. The center may charge a fee for providing copies of the patient's medical record in accordance with W. Va. Code § 16-29-1 et seq. The facility will provide the photocopied materials to the patient or legal representative within two working days of the request.7.8.d. Any person shall have the right to review the most recent and past state and federal inspection and complaint reports with the center's plan of correction.7.8.e. The center shall make the results of surveys and inspections, as well as plans of correction, available for examination in a place readily accessible to patients and legal representative and shall post a notice of their availability.7.8.f The center may charge an amount not to exceed $0.25 per page for copies of reports requested by any person.7.8.g. The center shall adopt policies and procedures that will protect the confidentiality of the patient as it relates to use of the patient's name and photographs.7.9. Visitation. 7.9.a. The neonatal abstinence center shall have a policy that addresses visitation responsibilities and requirements for parents, legal representatives, and family. The policy must address, at a minimum, the following: 7.9.a.1. Regular visitation hours;7.9.a.2. Off-hours visitation to accommodate working parents;7.9.a.3. Visitor identification;7.9.a.4. Monitoring and documenting the visitation;7.9.a.5. Hand washing and protective clothing covers for visitors when handling patients;7.9.a.6. Limiting the items (bags, purses, jackets) visitors may take into the center and/or into the visitation area;7.9.a.7. Prohibiting illegal substances on the premises of the center;7.9.a.8. Prohibiting prescription and non-prescription medications and supplements on the premises of the center;7.9.a.9. Prohibiting weapons of any kind on the premises of the center;7.9.a.10. Identifying where visitation is permitted within the center;7.9.a.11. Identifying circumstances that may prohibit or limit visitation rights of parents, legal representatives and/or family;7.9.a.12. Detailing how visitors will be identified, logged in and monitored;7.9.a.13. Informing and educating visitors of the visitation policy and other relevant policies;7.9.a.14. Handling visitors that do not abide by the visitation policies and other relevant policies of the center.; and7.9.a.15. Addressing any medical needs of parents or guardians who stay overnight with their infant.7.9.b. The center shall provide all parents, legal representatives, and family with a copy of the center's visitation policy.7.9.c. All visitors have the responsibility to abide by the center's visitation policy.7.9.d. The center shall have posted and consistent visitation hours with the exception of working parents who may visit during off hours set by the center.7.9.e. The center must set hours for quiet time to maintain dimmed lights and a quiet environment.7.9.f Parents and/or the legal representative must be given a form of identification that matches their baby's identification wrist or ankle band.7.10. Refusal of Treatment and of Experimental Research. 7.10.a. A parent and/or legal representative have the right to refuse treatment and to refuse to participate in experimental research unless mandated by court order.7.10.b. When a refusal of treatment occurs, the center shall assess the reasons for the refusal, clarify and educate the parent and/or legal representative as to the consequences of the refusal, and offer alternative treatments, and continue to provide all other services.7.10.c. When refusal of treatment is assessed by the physician to place or potentially place the patient in immediate jeopardy or harm, the patient shall be transported to the hospital. The state oversight agency and the protective services agency shall be notified.7.10.d. The center shall maintain documentation in the patient's medical record of the treatment refusal and the actions taken.7.10.e. The parent and/or legal representative shall have the opportunity to refuse to participate in experimental research prior to the start of the research. The center shall inform a parent and/or legal representative of the patient being considered for participation in experimental research of the nature of the experiment and of the possible consequences for participation.7.10.f. The center shall not transfer or discharge a patient for refusing treatment unless criteria for transfer or discharge are met under the provisions of this rule.7.11. Complaint or Grievance Procedures. 7.11.a. The center must have a complaint and grievance policy in place to ensure parents, legal representatives and/or family have a procedure to resolve grievances and complaints in a timely manner.7.11.b. The policy must address how the center will manage the complaint or grievance process in a timely and objective manner.7.11.c. The policy must address how the center will inform the parents, legal representatives and/or family on the process for filing a complaint with the state oversight agency.7.11.d. The policy must address how the center will inform the parents, legal representatives and/or family on the process to report suspected or alleged abuse and neglect to the state protective services agency and the state oversight agency, including address and phone number for filing complaints.7.11.e. Information about how to file a complaint with the state protective services and state oversight agencies shall be posted in locations easily accessible by staff and visitors.7.11.f. The policy must address how the center will inform parents, legal representatives and/or family on the process to report fraud, waste and abuse to the appropriate state agencies.7.11.g. The policy must address how the center will inform parents, legal representatives and/or family on the process to report suspected crimes to law enforcement.7.11.h. The policy must be posted in a location that is accessible to visitors. 7.12. Issues with Parental Participation. 7.12.a. If a biological mother is unwilling or refuses to visit or participate in the care of her baby, the center's staff will document each attempt to reach the biological mother, work to include other family members, and report all attempts and documentation to the protective services agency. The staff must document their attempts to assist the biological mother, including linkage and referral to necessary services and supports, including addiction treatment.7.12.b. If the biological mother is unable to care for her baby, the center will investigate to determine the underlying cause of her inability and take appropriate steps to help her if it is her desire to participate in the care of her patient. This may include factors such as transportation issues, employment during visitation, disability, or other mitigating factors.7.12.c. If a parent arrives at the center, and he or she is clearly under the influence of drugs or alcohol, the parent will be escorted from the facility, and the case record will be documented. This requirement is applicable to any visitor of the center. The center must have policies and procedures to identify how these situations will be handled.