Patient Rights

The patient has the right to participate in the development and implementation of his or her plan of care. 482.13(b)(1)

The hospital will actively include the patient in the development, implementation, and revision of his or
her plan of care. The hospital will plan the patient’s care, with patient participation, to meet the patient’s
psychological and medical needs. The patient’s (or patient’s representatives, as allowed by State law) right to participate in the development and implementation of his or her plan of care includes at a
minimum, the right to: participate in the development and implementation of his or her inpatient treatment and care plan or outpatient treatment and care plan, participate in the development and implementation of his or her discharge plan, and participate in the development and implementation of his or her pain management plan.

The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. 482.13 (b)(2)

The patient’s rights include being informed of his or her health status, being involved in care planning
and treatment, and being able to request or refuse treatment. This right must not be construed as a
mechanism to demand the provision of treatment or services deemed medically unnecessary or
inappropriate.

The patient has the right to formulate advance directives and to have hospital staff and practitioners who provide care in the hospital comply with these directives. 482.13(b)(3)

An advance directive is defined as a “written instruction, such as a living will or durable power of attorney for healthcare, recognized under State law relating to the provision of healthcare when the individual is incapacitated.” In the advance directive, the patient may provide guidance as to his or her wishes concerning provision of care in certain situations; alternatively the patient may delegate decision-making authority to another individual, as permitted by State law.

The patient has the right to have a family member or representative of his or her choice and his or her own physician notified promptly of his or her admission to the hospital. 482.13(b)(4)

For every patient admission, the hospital will ask the person whether the hospital should notify a family
member or representative about the admission. The hospital will also ask the patient whether the hospital should notify his or her own physician. If a patient is incapacitated or otherwise unable to communicate and to identify a family member or representative to be notified, the hospital will make reasonable efforts to identify and promptly notify a family member or patient’s representative. The notice will be provided promptly, which is defined as, as soon as possible after the physician’s or other qualified practitioner’s order to admit the patient has been given. The hospital will document that the patient, unless incapacitated, was asked no later than the time of admission whether he or she wanted a family member or representative notified, the date, time, and method of notification when the patient requested such, or if the patient declined to have notice provided.

The patient has the right to personal privacy. 482.13(c)(l)

The patient has the right to respect, dignity, and comfort and includes, at a minimum, privacy during
personal hygiene activities, during medical or nursing treatments, and when requested as appropriate. The right to privacy also includes limiting the release or disclosure of patient information such as name, age, address, income, and health information without prior consent from the patient. A patient’s right to privacy may be limited in situations where a person must be continuously observed, such as when restrained or in seclusion when immediate and serious risk to harm self or others exists.

The patient has the right to receive care in a safe setting. 482.13(c)(2)

The intention of this requirement is to specify that each patient receives care in an environment that a reasonable person would consider to be safe. Additionally, this standard is intended to provide protection for the patient’s emotional health and safety as well as his/her physical safety.

The patient has the right to be free from all forms of abuse or harassment. 482.13(c)(3)

All forms of abuse, neglect (as a form of abuse), and harassment are prohibited whether from staff, other patients, or visitors. The hospital has mechanisms and methods in place to ensure that all patients are free from the above.

The patient has the right to the confidentiality of his or her clinical records. 482.13(d)(l)

The hospital has sufficient safeguards to ensure that access to all information regarding patients is limited to those individuals designated by law, regulation, and policy; or duly authorized as having a need to know. No unauthorized access or dissemination of clinical records is permitted. Clinical records are kept secure and are only viewed when necessary by those persons having a part in the patient’s care.

The patient has the right to access information contained in his or her clinical records within a
reasonable time frame. The hospital must not frustrate the legitimate efforts of individuals to gain access to their own medical records and must actively seek to meet these requests as quickly as its record-keeping system permits. 482.13(d)(2)

In general, each patient should be able to see and obtain a copy of his/her records. Information can be
withheld in limited circumstances such as:

• Psychotherapy notes

• Information which could, in the opinion of the healthcare provider, cause sufficient harm to that person or to another person to warrant withholding

• Access to the information, in the opinion of a licensed healthcare professional, could likely
  endanger the life or physical safety of the individual or another person

• The information provided could reasonably reveal the source of data obtained under the promise of
  confidentiality

• Information is collected during the course of research where the individual has agreed to the
  denial of access of information

• Access to information is prohibited by law Information is being compiled for risk management purposes

The patient has the right to be free from physical or mental abuse and corporal punishment. (Restraint or Seclusion) 482.13(e)

All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time.

Restraint or seclusion may not be used unless the use of restraint or seclusion is necessary to ensure the immediate physical safety of the patient, a staff member, or others. The use of restraint or seclusion
will be discontinued as soon as possible based on an individualized patient assessment and re-evaluation. The requirements contained in this standard are not specific to any treatment setting within the hospital and apply to all hospital patients regardless of location.

The patient has the right to be fully informed of and to consent or refuse to participate in any unusual, experimental, or research project without compromising his or her access to service.

The patient has the right to know the professional status of any person providing his or her care and services.

The patient has the right to know the reasons for any proposed change in the professional staff responsible for his or her care.

The patient has the right to know the reasons for his or her transfer either within or outside the hospital.

The patient has the right to know the relationship(s) of the hospital to other persons or organizations participating in the provision of his/her care.

The patient has the right to access the cost, itemized when possible, of services rendered within a reasonable period of time.

The patient has the right to be informed of the source of the hospital’s reimbursement for his or her services, and of any limitations which may be placed upon his or her care.

The patient has the right to have pain treated as effectively as possible.

The patient has the right to have visitors of his or her choice. 482.13(h)(1-4)

A hospital must have written policies and procedures regarding the visitation rights of patients, including
those setting forth any clinically necessary or reasonable restriction or limitation that the hospital may need to place on such rights and the reasons for the clinical restriction or limitation.

The hospital will comply with the following;

1. Inform each patient (or support person, where appropriate) of his or her visitation rights, including
   any clinical restriction or limitation on such rights, when he or she is informed of his or her other rights under this section
2. Inform each patient (or support person, where appropriate) of the right, subject to his or her consent, to receive the visitors whom he or she designates, including, but not limited to a spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend, and his or her right to withdraw or deny such consent at any time.
3. Not restrict, limit, or otherwise deny visitation privileges on the basis of race, color, national origin, religion, sex, gender identity, sexual orientation, or disability.
4. Ensure that all visitors enjoy full and equal visitation privileges consistent with patient
   preferences. The patient’s family has the right of informed consent for donation of organs and tissues.

The patient’s family has the right of informed consent for donation of organs and tissues.

Patient Responsibilities

You are responsible for giving complete and honest information.

Upon admission, you are responsible for providing accurate and complete information about your present complaints, past illnesses, allergies, hospitalizations, medications (including over the
counter), vitamins and herbal supplements, and other matters relating to your health.

You and your family are responsible for reporting perceived risks in your care as well as any unexpected changes in your condition.

You are responsible for providing feedback about your service needs and expectations.

You are responsible for following care service or treatment plan instructions, for asking any questions, and for accepting consequences of not following your plan of care.

You and your family should express any concerns and ask any questions you may have about your ability
to follow and comply with the proposed care plan or course of treatment.

The organization makes every effort to adapt the plan to the specific needs and limitations of the patients. When such adaptations to the care, treatment, and service plan are not recommended, patients and their families are informed of the consequences of care, treatment, and service alternatives and not following the proposed course. This is important as the patient, and their family are responsible for accepting the consequences and outcomes of the care, services, or treatment plan if not
followed.

You and your family are responsible for following hospital rules and regulations concerning patient care and conduct.

• You and your family must be considerate of the hospital’s staff and property.
  
• You and your family have the responsibility to cooperate to the best of your ability and to do so
  in a considerate and courteous manner with the hospital personnel.

You have the responsibility to be considerate of other patients and their property and to see that your visitors are considerate as well, particularly in regard to noise, use of the television, the number of visitors, and adherence to the no smoking policy.

You are responsible for providing the hospital with a copy of your advance directives if you have these, and for informing your surrogate decision-maker and family, as appropriate, of your healthcare wishes.

You are responsible for keeping appointments. In order to ensure continuity of your care, it is important for you to keep your scheduled appointments for treatments and tests and to cooperate with all personnel who are assisting you in carrying out your healthcare plan.

You have the responsibility to settle hospital bills promptly. You and your family are responsible for
promptly meeting any financial obligation agreed to with the hospital. You have the responsibility to provide the information necessary for insurance processing and to be prompt about asking questions concerning your bills.

Kettering Health’s Responsibility to You

Complaint and resolution process

Our responsibility to you is to provide quality healthcare in an atmosphere that promotes physical, emotional, and spiritual recovery and growth.

Kettering Health is committed to resolving any concerns that you may have. We receive, review, and, when possible, resolve complaints from patients and their families. You have the right to freely voice complaints and recommend changes without being subject to coercion, discrimination, reprisal, or unreasonable interruption of care, treatment, and services. The hospital responds to individuals making a significant (as defined by the hospital) or recurring complaint.

Kettering Health participates in national accreditation programs. Our organizations are committed to quality patient outcomes and experiences. There are many ways to provide us with your feedback concerning patient safety and quality of patient care.

To voice a concern, please contact one or more of the following:

• The caregiver or person in charge
  
• Unit or department manager
  
• A patient representative
  
• Hospital administration

If a satisfactory resolution has not been met by contacting the patient’s direct caregiver, the person in charge, unit or department manager, the Patient Relations department, or administration, the patient has the right to file a formal grievance. For more information concerning the grievance process, please get in touch with the Patient Relations department.

Patients also have the right to file a complaint with the Ohio Department of Health or other state agency, regardless of whether or not the patient decides to contact Kettering Health’s Patient Relations department to share their concern or utilize the grievance process.

Patients may reach the Ohio Department of Health through their hotline at 1-800-342-0553 or at the following address:

Ohio Department of Health
ATTN: Complaint Unit/QA
246 N. High St.
Columbus, OH 43215

Additionally, patients have the right to file a complaint with the Secretary of the U.S. Department of Health and Human Services and the Centers for Medicare and Medicaid Services (CMS). The Secretary of the U.S. Department of Health and Human Services may be reached by dialing 1-877-696-6775. Their mailing address is:

The U.S. Department of Health and Human Services
200 Independence Ave. SW
Washington, DC 20201

CMS is available by calling 1-800-633-4227 or writing to:

Centers for Medicare and Medicaid Services
7500 Security Blvd.
Baltimore, MD 21244-1850

If your concerns have not been addressed through the channels identified above, you may contact the facility’s accrediting organization.

To contact the Accreditation Commission for Health Care:

139 Weston Oaks Ct.
Cary, NC 27513
customerservice@achc.org
1-855-937-2242

If you have a complaint or concern with your care, please call a patient representative in the Patient Relations department:

Kettering Health Main Campus, Kettering Health Miamisburg, and Kettering Health Troy:
(937) 395-8613

Kettering Health Dayton and Kettering Health Washington Township:
(937) 723-3213

Kettering Health Greene Memorial and Soin Medical Center:
(937) 702-4005

Kettering Health Hamilton:
(513) 867-3399

Kettering Health Medical Group
(937) 558-3216

To contact the nursing supervisor who is available 24/7, call the hospital operator by dialing “0” inside the hospital.

To talk to someone about discharge planning, call the appropriate number below:

Kettering Health Main Campus and Kettering Health Miamisburg:
(937) 395-8616

Kettering Health Dayton and Kettering Health Washington Township:
(937) 298-3399 ext. 33300

Kettering Health Greene Memorial:
(937) 352-2136

Soin Medical Center:
(937) 702-4000

Kettering Health Hamilton:
(513) 867-2173

Kettering Health Troy:
(937) 980-7131

To contact administration, please call:

Kettering Health Main Campus and Kettering Health Miamisburg:
(937) 395-8688

Kettering Health Dayton and Kettering Health Washington Township:
(937) 723-4988

Kettering Health Greene Memorial:
(937) 352-2230

Soin Medical Center:
(937) 702-4010

Kettering Health Hamilton:
(513) 867-2127

Kettering Health Troy:
(937) 980-7191

Kettering Health Medical Group:
(937) 558-3267