Trillium Place Rights and Responsibilities

ACCESS TO CARE.
You/Your Representative’s Rights Include:

1. To be informed of your rights.
2. To receive care that respects your individual, cultural, spiritual and social values, regardless of race, ethnicity, color, creed, religion, nationality, age, gender, sexual orientation, gender identity or expression, language, marital status, socioeconomic status, status with regard to public assistance, disability, or anyother classification protected by law.
3. To have your cultural, psychosocial, spiritual, and personal values, beliefs, and preferences respected.
4. Receiving a medical screening examination and stabilizing care, regardless of ability to pay.
5. To receive care, treatment, and services within the capability of the hospital or facility or to be evaluated, referred and transferred to another facility only after you have received complete information and explanation concerning the needs for an alternative provider.
6. Receiving a consultation or second opinion from another physician as well as to change physicians.
7. Ability to examine and receive a reasonable explanation of your medical bill regardless of source of payment.
8. To have a family member or representative of your choice and your own physician notified promptly of your admission to the hospital.
9. To receive communication in a manner consistent with your needs, including interpreters and assistive devices.

RESPECT/DIGNITY/ CONFIDENTIALITY/SAFETY.
You/Your Representative’s Rights Include:

1. To be treated with respect for property, personal space, and preservation of personal dignity.
2. To privacy, confidentiality, safety, and security for your person, clinical record, and protected health information.
3. To report safety concerns.
4. To an environment that preserves dignity, safety, and contributes to a positive self-image.
5. To be free from mental, physical, sexual, andverbal abuse, neglect, exploitation, corporal punishment, and all forms of abuse or harassment.
6. To be made aware of protective services. Specific information on protective agencies and procedures will be provided upon request.
7. To receive pastoral care and other spiritual services upon request to the extent possible.
8. To receive adequate information about the person(s) responsible for the delivery of your care, treatment, and services.
9. To be free from restraint and/or seclusion of any form unless needed for the purpose of protecting you or others from injury or with critical medical treatment. Restraints are used while preserving patient’s rights, dignity, and well-being. Patients will not be restrained as a means of coercion, discipline, convenience, or retaliation by staff.

INVOLVEMENT IN CARE/INFORMED CONSENT/RESEARCH.
You/Your Representative’s Rights Include:

1. Ability to access all information concerning your medical condition, treatment, prognosis and other treatment available and to choose among these alternatives.
2. To request a discussion of ethical issues relating to your care, including conflict resolution, resuscitation (being revived if you stop breathing) and life-sustaining treatment.
3. Ability to make informed decisions regarding your care. This right includes being informed of your health status and diagnosis, prognosis (possible outcome), proposed procedures (including risks involved), being involved in development / implementation / management of your plan of care and treatment, and being able to request and refuse treatment and to know what may happen if you don’t have this treatment.
4. To be informed about the outcomes of care, treatment, and services that have been provided, including unanticipated outcomes.
5. To receive care to make you as comfortable as possible at all stages of life, including end-of-life care, and have your spiritual needs and those of your family met.
6. Ability to designate a healthcare decision-maker if incapable of understanding a proposed treatment or if unable to communicate your wishes regarding care.
7. To formulate, review, revise, and revoke advance directives and to have hospital staff and practitioners comply with these directives consistent with applicable law and to receive comfort and dignity at the end of life.
8. Ability to participate in approved research studies, after giving informed consent. Ability to refuse to participate in research studies without such refusal affecting care.
9. To provide consent for recording or filming made for purposes other than identification, diagnosis, and treatment; to request cessation of recording or filming at any time; and to rescind consent before the recording or film is used.
10. Receive appropriate pain management support.
11. Ability to access your medical record or ability to request a copy of your medical record within a reasonable time frame (within 30 days of your request).
12. To be informed of the rules and regulations applicable to your conduct as a patient.

COMPLAINT/GRIEVANCE PROCEDURE.
You/Your Representative’s Rights Include:

1. Ability to discuss any concerns / dissatisfaction with the care received, which cannot be resolved by available staff, without being subject to coercion, discrimination, reprisal, unreasonable interruption of care, by contacting the Patient Relations department at (309) 672-5529 or ask any staff member to contact them on your behalf.
2. To be informed of the initiation, review, and when possible, resolution of patient complaints concerning safety, treatment, or services. Contact the Patient Relations department at (309)672-5529 or if you prefer, write your grievance and send to:
   Patient Relations department, Carle Health,
   611 W. Park St., Urbana, IL 61801.
   Patient.relationswest@carle.com
3. To receive a written response upon receipt of your grievance from Carle Health, on average, within 7 days.
4. To file a complaint with the following agencies as well as or instead of utilizing the organization’s grievance process: The Joint Commission at www.jointcommission.org, using the “Report a Patient Safety Event” link in the “action Center” on the home page of the website, fax to (630) 792-5636, or mail to The Office of Quality and Patient Safety (OQPS), The Joint Commission (One Renaissance Boulevard, Oakbrook Terrace, Illinois 60181); or the Illinois Department of Public Health hotline at (800) 252-4343 (535 W. Jefferson Street, Springfield, IL 62761).
5. Medicare patients may also refer their concerns to KePro which is the Medicare quality improvement organization for Illinois. KePro may be reached at (855) 408-8557 or at 5201 W. Kennedy Blvd., Suite 900, Tampa, FL 33609. (See Important Message from Medicare form.)
6. If you have questions about your rights, please contact the Patient Relations department at (309)672-5529.

VISITATION RIGHTS:

In concert with patient centered care, Carle Health has an open policy regarding patient visitation. Exceptions are as follows:

• If contraindicated by the patient’s condition
• If the patient’s physician requests a restriction
• If the patient requests a restriction
• In the following areas where specific restrictions are communicated:
  • Critical Care Units, Mother/Baby Unit, Laborand Delivery Unit, Nursery, Pediatrics, Behavioral Health Units, Addiction Recovery Center, Surgery, Post Anesthesia Recovery Unit and Emergency Department.
  • Addiction Recovery Center, Center for Senior Behavioral Health, Surgery / Post Anesthesia Recovery Unit, Critical Care Unit, and Emergency Department.
• For infection control reasons
• For minors
• If there are other clinically appropriate or reasonable restrictions such as:
  • disruptive behavior of a visitor
  • court order limiting or restraining contact
  • behavior presenting a direct risk to other patients or staff
  • the visitor’s presence infringes on others’ rights / safety
  • medically or therapeutically contraindicated
  • other clinical reason as determined by the hospital or facility

Carle Health will not deny visitation privileges on the basis of age, race, sex, color, gender identity, national origin, religion, sexual orientation, disability, or any other protected class in any manner prohibited by federal or state laws.

As a patient*, you have the right to receive or restrict any visitors you designate, including, but not limited to, a spouse, a domestic partner (including a same sex domestic partner), another family member, clergy, and/or friend. The individual may or may not be the patient’s surrogate decision-maker or legally authorized representative. You may modify your visitation request at any time by communicating your wishes to the staff.

If you have any questions or concerns about visitation, please contact the Patient Relations department at (309) 672-5529.

PATIENT RESPONSIBILITIES:
The Patient and / or, When Appropriate, Family is Responsible for:

1. Provide, to the best of your ability, accurate and complete information about your pain; medical history; including past illnesses, hospitalizations, medications, sensitivities or allergies to drugs and other agents; and other matters related to your health.
2. Inform appropriate healthcare professionals of any change in your condition or reaction to your treatment.
3. Ask questions when you do not understand what you have been told about your care or what is expected of you.
4. Express any concerns you may have about your ability to follow and comply with the proposed plan of care or course of treatment.
5. Accept the consequences for refusing treatment or not following healthcare providers’ instructions.
6. Show consideration for other patients / visitors and respect Carle Health staff and property. This includes controlling noise and observing the no-smoking policy.
7. Follow Carle Health rules and regulations affecting patient care, conduct, safety, and visiting.
8. Inform healthcare providers of any Advance Directives that are in effect and provide copies of such documents.
9. Notify healthcare providers as soon as possible if your rights have been or may have been violated.
10. Provide insurance information for processing billing.
11. Ensure that financial obligations are fulfilled as promptly as possible.

BEHAVIORAL HEALTH PATIENT RIGHTS:
I have:

1. The Right to confidentiality and assurance that all information provided to the Center is protected by the Mental Health Confidentiality Act and/or the Federal (42CFR, part2) Confidentiality Act, and the Health Information Portability and Accountability Act (HIPAA) of 1996, and HITECH.
2. The Right to protection of all rights mandated to me by the Mental Health and Developmental Disabilities Code [405 ILCS 5]. You have the right to non-discriminatory access to services as specified in the Americans with Disability ACT of 1990 (42 USC 12101).
3. The Right to have justification for restriction of my rights under the statutes described in numbers 2 and 3 above documented in myclinical record. This documentation shall include a plan with measurable objectives for restoring my rights that is signed by me or my parent or guardian, the QMHP and the LPHA. Each client affected by such restrictions, his or her parent or guardian, as appropriate, and any agency designated by the client pursuant to number 5 below shall be notified of the restriction and given a copy of the plan to remove the restriction of rights.
4. The Right, in the event I feel my rights have been restricted in any way, to contact or have my therapist assist me to contact Equip for Equality [20 North Michigan Avenue, Suite 300, Chicago, IL 60602, 1-800-537-2632]; and/or the State of Illinois Guardianship and Advocacy Commission [PO Box 7009, Hines, IL 60141, 1-866-274-8023]; and/or the State of Illinois Division of Mental Health, Region 3 [309-346-2094 ext. 403]; and/or the Illinois Mental Health Collaborative for Access and Choice [PO Box 06559, Chicago, IL 60606,1-866-359-7953]; and/or the Office of Inspector General [1-800-368-1463]; and/or, if applicable, the State of Illinois Department of Children and Family Services [2011 N. Knoxville, Peoria, IL 61614, 1-800-252-2873]; or the Joint Commission [1-800-994-6610].
5. The Right to services without regard to sex, race, religion, age, sexual orientation, ethnicity, disability, or HIV status.
6. The Right to be provided mental health and/or addiction services in the least restrictive environment.
7. The Right to confidentiality of HIV/AIDS status and testing and anonymous testing and protected by the Aids Confidentiality Act (Ill. Rev. Stat. 1989 CH.111 ½, pars 7301 et seq.) and the Aids Confidentiality and testing code (77 Ill. Adm. Code 697): a request for and/or signed consent to do HIV antibody testing; an individual’s HIV antibody or AIDS status; the fact that an individual has been tested for HIV antibodies and/or the result of an HIV antibody test, whether negative, positive, or inclusive; and/or participation in pre-test and/or post-test counseling.
8. The Right to nondiscriminatory access and accommodation to services as specified in the American’s With Disabilities Act of 1990 (42USC 12102), section 504 of the Rehabilitation Act and the Human Rights Act [775 ILCS 5].
9. The Right to review with my individual therapist any recording by program staff, including the Individual Treatment Plan contained in my case record.
10. The Right of my family and/or responsible guardian to be informed of treatment plans if I become unable to exercise sound judgment.
11. The Right to be informed of the risk associated with the use of potentially hazardous drugs or procedures if such drugs or procedures are clinically indicated as part of treatment.
12. The Right to withdraw consent for treatment, any hazardous procedure, research, medication, etc., at any time and be informed of the consequences resulting from that refusal.
13. The Right to give or withhold informed consent regarding treatment and regarding confidential information about the consumer.
14. The Right for me and/or my guardian/representative to comment verbally or in writing any grievance that I might have with my services, and for each grievance to receive prompt attention and response. If I have agrievance, I understand that I may present this directly to the Manager where I receive treatment. If I am unable to reach a solution with the Manager, I may then present my grievance directly to the Director. If I am unable to reach a solution with the Director, I may then contact the Patient Relations department at (309) 672-5529.
15. The Right to contact my public or private payor and to receive information on their process of reviewing grievances.

IL Mental Health Code
IL Rule 2060.323
IL Rule 132.30
IL MH/DD Confidentiality Act

*If the patient is a minor (not of legal age) or unable to give consent, these rights and responsibilities apply to the patient’s parent, legal guardian, or representative.