1. Provide complete and accurate information to the best of his/her ability about his/her health, any medications, including over the counter products and dietary supplements and any allergies or sensitivities;
2. Follow the treatment plan prescribed by his/her provider;
3. Provide a responsible adult to transport him/her home from the facility and remain with him/her for twenty-four (24) hours, if required by his/her provider;
4. Inform his/her provider about any living will, medical power of attorney, or other directive that could affect his/her care;
5. Accept personal financial responsibility for any charges not covered by his/her insurance;
6. Be respectful of all the health care providers and staff, as well as other patients.

Advance Directive: Statement of Limitation
This facility does not provide implementation of advanced directives; based on conscience (the scheduled procedure is an elective procedure), regardless of the contents of any advance directive or instructions from a health care surrogate or attorney.   If an adverse event occurs at this facility, we will initiate resuscitative or other stabilizing measures and transfer patient to an acute care hospital for further evaluation. The receiving hospital will implement further treatment or withdrawal of treatment measures already begun in accordance with patient wishes, advance directive or health care power of attorney.

Disclosure of Ownership
To receive written information about their physician’s possible ownership in the Surgery Center.  Patients are informed about physician ownership prior to their procedure.

Grievance Policy
The Center strives to provide high quality of care and achieve patient satisfaction.  Patient grievances/complaints provide a means to measure achievement of this goal and to identify a need for performance improvement.

Grievance/Complaint – Grievances are defined as care that the ASC provided or allegedly failed to provide.

Neglect – Failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness (42 CFR 488.301).

Abuse – The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish (42 CFR 488.301).

All complaints received by the Center personnel shall be forwarded to the clinical director or his/her designee immediately, at least the same day.  The clinical director will respond to the grievance within 48 hours of receiving it.  For a full copy of the grievance procedure, please ask any Center personnel.

Advance Notice Rights
All patients will be advised, in advance of the procedure, the center’s policies on patient rights, patient responsibilities, patient grievance, advance directives, and disclosure of ownership.  The patient has the right to receive this information in a language and manner that the patient or the patient’s representative understands.  The center gives brochures to each patient being admitted with the center’s written policies regarding this information.   The nurse making the preoperative call informs the patient verbally of this information. 

To Report a Concern: 

Nebraska Department of Health & Human Services

P.O. Box 95026
Lincoln, Nebraska 68509-5026
402-471-3121

The TJC (The Joint Commission)

Mailing address:

Office of Quality Monitoring
The Joint Commission
One Renaissance Boulevard
Oakbrook Terrace, Illinois 60181

Fax:  630-792-5636
E-mail: complaint@jointcommission.org
Online: http://www.jointcommission.org/report_a_complaint.aspx

Office of the Medicare Beneficiary Ombudsman

Online:  http://www.medicare.gov/claims-and-appeals/medicare-rights/get-help/ombudsman.html

Visit the web site listed above or call 1-800-MEDICARE (1-800-633-4227) for more information, to ask questions, and to submit complaints about Medicare to the Office of the Medicare Ombudsman. TTY users should call 1-877-486-2048.