Notice of Patients’ Rights

It is the policy of Berkshire Health Systems to respect our patients’ individuality and dignity in delivering medical care. Observing patients’ rights and advising patients of their responsibilities will result in better patient care and greater satisfaction for the patient, the patient’s family, the physician, and all other hospital staff.

In providing services to neonates, children, and adolescents (excluding emancipated minors or wards of the state), Berkshire Health Systems recognizes the rights of parents and/or legal guardians to participate fully in treatment planning and decisions.

Rights of Hospital Patients Under Massachusetts Law

Massachusetts General Laws Chapter 111, Section 70E (“M.G.L.ch. 111, §70E”) establishes rights that apply to every hospital patient. M.G.L.ch. 111, §70E requires that the hospital (1) provide every patient with written notice of the rights the patient has upon being admitted to the hospital and (2) conspicuously post in the hospital a copy of those rights. It is the policy of Berkshire Health Systems to provide its patients with those rights, which include the following:

• • Every hospital patient shall have the right to freedom of choice in his or her selection of a hospital or other health care facility, physician or health service mode, except in the case of emergency medical treatment or as otherwise provided for by contract; provided, however, that the physician, health care facility, or health service mode is able to accommodate the patient exercising such right of choice.
  • Every hospital patient, upon reasonable request, shall receive from the hospital an itemized bill reflecting laboratory and pharmaceutical charges and third-party credits and shall be allowed to examine an explanation of that bill regardless of the source of payment. The patient shall also be entitled, upon request, to copies of itemized bills or other statements of charges submitted to any third party by the hospital for care of the patient Copies of those bills or statements of charges shall also be made available to the patient’s attending physician.
  • Every hospital patient shall have the right:
    1. upon request, to obtain from the hospital the name and specialty, if any, of the physician or other person responsible for their care or the coordination of their care;
    2. to confidentiality of all records and communications to the extent provided by law;
    3. to have all reasonable requests responded to promptly and adequately within the capacity of the hospital;
    4. upon request, to obtain an explanation as to the relationship, if any, of the hospital to any other health care facility or educational institution if that relationship relates to the patient’s care or treatment;
    5. to obtain from a person designated by the hospital a copy of any rules or regulations of the hospital that apply to the patient’s conduct as a patient;
    6. upon request, to receive any information that the hospital has available about financial assistance and free health care;
    7. upon request, to inspect the patient’s medical records and to receive a copy of those records for a fee based on the hospital’s current copying costs schedule (except that no fee shall be charged to any applicant, beneficiary or individual representing an applicant or beneficiary for furnishing a medical record if the record is requested for the purpose of supporting a claim or appeal under any provision of the Social Security Act or federal or state financial needs-based benefit program);
    8. to refuse to be examined, observed, or treated by students or any other hospital staff without jeopardizing the patient’s access to psychiatric, psychological, or other medical care and attention;
    9. to refuse to serve as a research subject and to refuse any care or examination when the primary purpose is educational or informational rather than therapeutic;
    10. to privacy (within the physical capacity of the hospital) during medical treatment or other rendering of care;
    11. to prompt lifesaving treatment in an emergency without discrimination based on economic status or source of payment and without delaying treatment to first discuss of the source of payment, unless such delay can be imposed without material risk to the patient’s health;
    12. to informed consent to the extent provided by law;
    13. if refused treatment because of economic status or the lack of a source of payment, to prompt and safe transfer to a facility that agrees to receive and treat such patient. Any facility refusing to treat a patient shall be responsible for: ascertaining that the patient may be safely transferred; contacting a facility willing to treat such patient; arranging the transportation; accompanying the patient with necessary and appropriate professional staff to assist in the safety and comfort of the transfer, assuring that the receiving facility assumes the necessary care promptly; providing pertinent medical information about the patient’s condition; and maintaining records of the foregoing;
    14. if the patient is a female rape victim of childbearing age, to receive medically and factually accurate written information prepared by the commissioner of public health about emergency contraception; to be promptly offered emergency contraception; and to be provided with emergency contraception upon request;
    15. if the patient is a maternity patient, to receive, at the time of pre-admission, complete information from the hospital on its (i) annual rate of (1) primary caesarian sections, (2) repeat caesarian sections, and (3) total caesarian sections; (ii) annual percentage of (1) women who have had a caesarian section who have had a subsequent successful vaginal birth, (2) deliveries in birthing rooms and labor-delivery-recovery or labor-delivery-recovery-postpartum rooms, (3) deliveries by certified nurse-midwives, (4) deliveries that were (A) continuously externally monitored only, (B) continuously internally monitored only and (C) monitored both internally and externally, and (5) deliveries utilizing intravenous, inductions, augmentation, forceps, episiotomies, spinals, epidurals and general anesthesia, and (iii) annual percentage of women breast-feeding upon discharge from the hospital; and
    16. if the patient is suffering from any form of breast cancer to complete information on all alternative treatments that are medically viable. Berkshire Health Systems requires all persons, including students, who examine, observe or treat a patient of the hospital to wear an identification badge that discloses the first name, licensure status, if any, and staff position of the person so examining, observing, or treating a patient. Any person whose rights under M.G.L.ch. 111, §70E are violated may bring, in addition to any other action allowed by law or regulation, a civil action under Massachusetts General Laws Chapter 231, Sections 60B to 60E.

Rights of Hospital Patients Under Federal Law

Under federal law (42 C.F.R. §482.13), a hospital participating in the Medicare and Medicaid programs must protect and promote each patient’s rights, and the hospital must inform each patient of his or her rights in advance of furnishing or discontinuing patient care whenever possible. It is the policy of Berkshire Health Systems to provide its patients with all rights provided under that law, including the right of the patient to:

• • • • Be informed of the hospital’s internal grievance (complaint) process, including whom to contact to file a grievance.
      • Participate in the development and implementation of the patient’s plan of care. This includes being informed of the patient’s health status, being involved in care planning and treatment and being able to request or refuse treatment. (Note that this right does not mean that the patient may demand that a medical provider provide treatment or services that are deemed medically unnecessary or inappropriate.)
      • Make informed decisions regarding their own care.
      • Formulate advance directives and have the hospital staff and practitioners who provide care in the hospital comply with those directives.
      • Have a family member or representative of the patient’s choice and the patient’s own physician notified promptly of the patient’s admission to the hospital
      • Personal privacy.
      • Receive care in a safe setting.
      • Be free from all forms of abuse or harassment.
      • Have their clinical records treated as confidential.
      • Access information contained in his or her clinical records within a reasonable time frame.
      • Be free from physical or mental abuse and corporal punishment.
      • 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.
      • Be informed of the patient’s visitation rights, including any clinical restriction or limitation on those rights and subject to the patient’s consent (which may be denied or withdrawn at any time), receive the visitors whom the patient designates, including, but not limited to, a spouse, domestic partner (including a same-sex domestic partner), another family member or friend.
      • Enjoy full and equal visitation privileges without restriction, limitation or other denial on the basis of race, color, national origin, religion, sex, gender identity, sexual orientation or disability, with all visitors enjoying full and equal visitation privileges consistent with the patient’s preferences.

Additional Rights of Patients

It is further the policy of Berkshire Health Systems that each patient has the right to:

• • • • • Receive impartial access to treatment or admission regardless of race, creed, ethnicity, culture, language spoken, gender, sexual orientation, gender identity or expression, physical or mental disability, age, nationality, religion, socioeconomic status or source of payment.
        • Access to pastoral care and spiritual services.
        • Receive appropriate assessment and management of pain.
        • Have issues related to care at the end of life addressed with sensitivity.
        • Receive information in a manner that the patient can understand. For example, if the patient cannot speak English, interpreter services are to be available, and if the patient is deaf or hard of hearing, a sign language interpreter is to be made available.

Rights of Patients in Facilities Licensed by the Massachusetts Department of Mental Health

Massachusetts General Laws Chapter 123, Section 23 and Section 27.13 of Title 104 of the Code of Massachusetts Regulations establish rights that are applicable to patients of facilities licensed by the Massachusetts Department of Mental Health (the “DMH”). It is the policy of Berkshire Health Systems that patients in its facilities subject to DMH licensure enjoy those rights, including the right to:

1. Subject to the patient’s giving informed consent, receive treatment suited to the patient’s needs that shall be administered skillfully, safely and humanely with full respect for dignity and personal integrity.
2. Reasonable access to a telephone to make and receive confidential telephone calls and assistance when desired and necessary to implement that right, provided that such calls do not constitute a criminal act or represent an unreasonable infringement of another person’s right to make and receive telephone calls.
3. Send and receive sealed, unopened, uncensored mail; provided, however, that the superintendent or director or designee of an inpatient facility may direct, for good cause and with documentation of specific facts in such patient’s record, that a particular patient’s mail be opened and inspected in front of such person, without it being read by staff, for the sole purpose of preventing the transmission of contraband. Writing materials and postage stamps in reasonable quantities shall be made available for use by patients. Reasonable assistance shall be provided to patients in writing, addressing and posting letters and other documents upon request.
4. Receive visitors of the patient’s own choosing daily and in private, at reasonable times. Hours during which visitors may be received may be limited only to protect the privacy of other persons and to avoid serious disruptions in the normal functioning of the facility and shall be sufficiently flexible as to accommodate individual needs and desires of the patient and the visitors of the patient.
5. A humane psychological and physical environment. Each patient shall be provided living quarters and accommodations that afford privacy and security in resting, sleeping, dressing, bathing and personal hygiene, reading and writing and in toileting (this does not require individual sleeping quarters).
6. Receive at any reasonable time, or refuse to receive, visits and telephone calls from the patient’s attorney or legal advocate, physician, psychologist, clergy member or social worker, even if not during normal visiting hours and regardless of whether the patient initiated or requested the visit or telephone call. An attorney or legal advocate working under an attorney’s supervision and who represents a patient shall have access to the patient and, with such patient’s consent, the patient’s record, the hospital staff responsible for the patient’s care and treatment, and any meetings concerning treatment planning or discharge planning where the patient would be or has the right to be present. Upon admission and upon request at any time after admission, to be provided with (i) the names, addresses, and telephone numbers of the Massachusetts Mental Health Protection and Advocacy Project, the Mental Health Legal Advisors Committee, the Committee for Public Counsel Services and any other legal service agencies funded by the Massachusetts Legal Assistance Corporation to provide free legal services and (ii) reasonable assistance in contacting and receiving visits or telephone calls from attorneys or legal advocates from such organizations; provided, however, that the facility shall designate reasonable times for unsolicited visits and for the dissemination of educational materials to persons by those attorneys or legal advocates.
7. Wear his or her own clothes, keep and use his or her own personal possessions including toilet articles, keep and be allowed to spend a reasonable sum of his or her own money for canteen expenses and small purchases, and have access to individual storage space for his or her private use.
8. Refuse shock treatment and lobotomy.
9. File complaints and have complaints responded to in accordance with 104 CMR 32.00.
10. Be free from unreasonable searches of the patient’s person or property.

Any dispute or disagreement concerning the exercise of the rights in clauses (b) to (f), inclusive, and the reasons therefor shall be documented with specific facts in the patient’s record and subject to timely appeal.

Any right set forth in clauses (b) and (d) above may be temporarily suspended, but only for a person in an inpatient facility and only after the superintendent, director, acting superintendent or acting director of such facility concludes, pursuant to standards and procedures set forth in DMH regulations that, based on experience of such patient’s exercise of such right, further exercise of such right in the immediate future would present a substantial risk of serious harm to such patient or others and that less restrictive alternatives have either been tried and failed or would be futile to attempt. The suspension shall last no longer than the time necessary to prevent the harm and its imposition shall be documented with specific facts in such patient’s record.

Any right set forth in clauses (g) and (h) above may be denied for good cause by the superintendent or his designee and a statement of the reasons for any such denial entered in the treatment record of such patient.

It is further the policy of Berkshire Health Systems consistent with Section 27.13 of Title 104 of the Code of Massachusetts Regulations that:

• Any patient involuntarily committed to any facility licensed by the DMH who believes or has reason to believe he or she should no longer be retained may make written application to the superior court for judicial determination of the necessity of continued commitment pursuant to Massachusetts General Laws Chapter 123, Section 9(b).
• Whenever a court hearing is held under the provisions of Massachusetts General Laws Chapter 123 for the commitment or further retention of a person in a facility licensed by the DMH, such person shall have the right to a timely hearing and representation by counsel as provided by law.
• Aliens shall have the same rights under the provisions of Massachusetts General Laws Chapter 123 as citizens of the United States.

A member of the admitting staff of the facility shall give each patient, and, if applicable, that patient’s legally authorized representative at the time of admission a notice of the rights set forth above, or other materials explaining his or her rights prepared in accordance with DMH guidelines. The notice shall be in language understandable by the patient and translated for any patient who cannot read or understand English.

In addition, the facility shall post a copy of such notice in the admitting room of the facility, in each unit and in other appropriate and conspicuous places in the facility and shall make copies available upon request.

Section 27.14 of Title 104 of the Code of Massachusetts Regulations provides that the superintendent of a mental health inpatient facility funded or licensed by the DMH shall designate a person or persons employed by or affiliated with such facility as Human Rights Officer, to be responsible for assisting patients in the exercise of their civil rights. At Berkshire Medical Center, this person is Don Scherling, PsyD, Human Rights Officer.

Rights of Patients in Facilities for the Treatment of Drug Dependent Persons

In accordance with Massachusetts General Laws Chapter 111E, Section 18, it is the policy of Berkshire Health Systems to provide patients in facilities designed for the treatment of drug dependent persons with the right to:

• • Have a physician retained by him or her examine him or her.
  • Consult with an attorney.
  • Receive visitors and send and receive communications by mail, telephone and telegraph. Such communications may not be censored or read without the consent of the patient. (The facility administrator may prescribe reasonable rules governing visiting hours and the use of telephone and telegraph facilities.)
  • Not be detained without his or her consent.
  • A written comprehensive, individualized treatment plan kept by the facility’s administrator.
  • Adequate and appropriate treatment.

Rights of Patients in Facilities for the Treatment of Alcoholism

In accordance with Massachusetts General Laws Chapter 111B, Section 11, it is the policy of Berkshire Health Systems to provide patients in facilities designed for the treatment of alcoholism with the right to:

• • • Have a physician retained by him or her examine him or her.
    • Consult with an attorney.
    • Receive visitors and send and receive communications by mail, telephone, and telegraph. Such communications may not be censored or read without the consent of the patient. (The facility administrator may prescribe reasonable rules governing visiting hours and the use of telephone and telegraph facilities.)

Patient Responsibilities

Each patient of Berkshire Health Systems is responsible for:

1. Providing accurate and complete information about present complaints, past illnesses, hospitalizations, medications, and other matters relating to their health.
2. Reporting any unexpected change in their condition to their doctor or nurse.
3. Cooperating with all hospital personnel who care for them, following their instructions and asking questions when directions are not understood.
4. Being responsible for their actions if treatment is refused or the instructions of those providing care are not followed.
5. Complying with their physician’s recommendations regarding follow-up care, including keeping appointments.
6. Providing information regarding the existence of their advance directive (health care proxy, Medical Order for Life Sustaining Treatment (MOLST) or Physician Order for Life Sustaining Treatment (POLST)).
7. Providing a valid copy of their advance directive (health care proxy, MOLST or POLST) for inclusion in their medical record.
8. Being considerate of other patients and hospital personnel and seeing that their visitors are considerate.
9. Observing rules about noise, no smoking and the number of visitors.
10. Being respectful of others, their property, and the hospital’s property.
11. Leaving valuable personal items at home or sending them home with family if possible.
12. Sharing their concerns, complaints, and suggestions so we may continually improve our care.
13. Paying their bills or responding to questions about bills, providing information for insurance processing, and assuring that their financial obligations are promptly fulfilled to the extent of their ability.