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Wild Rose Community Memorial Hospital
601 Grove Ave
PO Box 243
Wild Rose, WI 54984
920-622-3257
920-622-5593 fax
Hours – 24/7

Waushara Family Physicians – Wild Rose
701 Grove Ave
PO Box 314
Wild Rose, WI 54984
920-622-5560
920-622-5598 Fax
Hours – 8a-8p

Waushara Family Physicians – Plainfield
N6493 Valley Circle Dr
PO Box 5
Plainfield, WI 54966
715-335-6506
715-335-6546 Fax
Hours – 8a-5p

Waushara Family Physicians – Wautoma
N2934 Hwy 22 N
PO Box 708
Wautoma, WI 54982
920-787-0840
920-787-0842 Fax
Hours – Please call for clinic hours

Waushara Family Physicians – Coloma
141 Front St
PO Box 219
Coloma, WI 54930
715-228-2300
715-228-2302 Fax
Hours – Please call for clinic hours

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Patient Rights & Responsibilites

PATIENTS RIGHTS AND RESPONSIBILITIES

In accordance with Wisconsin state law, Wild Rose Community Memorial Hospital, Inc. recognizes  these rights are intended to make your stay as pleasant as possible and to recognize your individual worth and dignity as a human being. If you have either a developmental disability or a mental illness, Wild Rose Community Memorial Hospital recognizes that you have additional rights as evidenced by Wisconsin legislative law, HFS 124,  s. 51.61 stats and DHS 94.

AS A PATIENT AT WILD ROSE HOSPITAL, WE AFFIRM YOUR RIGHT

  •  A patient may not be denied appropriate hospital care because of the patient’s race, creed, color, national origin, ancestry, religion, sex, sexual orientation, marital status, age, newborn status, handicap or source of payment.
  • Patients shall be treated with consideration, respect and recognition of their individuality and personal needs, including the need for privacy in treatment.
  • Every patient shall be entitled to know who has overall responsibility for the patient’s care.
  • Every patient, the patient’s legally authorized representative or any person authorized in writing by the patient shall receive, from the appropriate person at WRCMH, written information about the patient’s illness, course of treatment and prognosis for recovery in terms the patient can understand.
  • Except in emergencies, the consent of the patient or the patient’s legally authorized representative shall be obtained before treatment is administrated.
  • Any patient may refuse treatment to the extent permitted by law and shall be informed of the medical consequences of the refusal.
  • The patient or the patient’s legally authorized representative shall give prior informed consent for the patient’s participation in any form of research.
  • Except in emergencies, the patient may not be transferred to another facility without being given a full explanation for the transfer, without provision being made for continuing care and without acceptance by the receiving institution.
  • Every patient shall be permitted to examine his or her hospital bill and receive an explanation of the bill, regardless of source of payment, and every patient shall receive, upon request, information relating to financial assistance available through the hospital.
  • Every patient may designate persons who are permitted to visit the patient during the patient’s hospital stay.

 

AS A PATIENT AT WILD ROSE HOSPITAL, YOU HAVE THE RESPONIBILITY TO:

  • Provide to the best of your knowledge, accurate and complete information about present complaints, past illness, hospitalizations, medications, and other matters relating to your health.
  • Report unexpected changes in your condition to the responsible physician.
  • Make it known whether you clearly comprehend a contemplated course of action and know what is expected of you.
  • Follow the treatment plan recommended by the physician primarily responsible for your care. This includes following instructions of the nursing staff and health professionals as they carry out the coordinated plan of care and implement the responsible physician’s orders, and as they enforce the applicable rules and regulations.
  • Accept responsibility for your actions if you refuse treatment or do not follow the physician’s instructions.
  • Assure financial obligations of your health care are fulfilled as promptly as possible.
  • Follow hospital rules and regulations affecting patient care and conduct.
  • Be considerate of the rights of other patients and hospital personnel.
  • Control your own behavior in terms of noise, smoking, and number of visitors.
  • Be respectful of the property of other persons and of the hospital.
  • Provide the information necessary for insurance and processing and ask any questions you may have concerning the bill as soon as possible.
  • Inform us if you feel that your rights have been violated.

 

 Complaints or reports that a patient’s rights have been violated, a patient has been mistreated, neglected, exploited, may be made to the nurse in charge, the Director of Nursing at 920-622-6018, the Director of Patient Care Services at  (920) 622-5587 or contact the Administrative Offices at (920) 622-5582.  You may also communicate your concerns directly to the Wisconsin, Bureau of Quality Assurance, Health Services Section at the address listed below.

 

The State of Wisconsin Bureau of Health Services:

Division of Quality Assurance

PO Box 2969 

Madison, WI 53701-2969 

(608) 266-8481

Web site: www.dhs.wisconsin.gov 

If Medicare is paying for your services, you may also request review of your medical treatment by the peer review organization called Metastar.

 

Metastar
2909 Landmark Pl # 300
Madison, WI 53713

(608) 274-1940

Web site: www.metastar.com

  

SWING BED PROGRAM RESIDENT'S STATEMENT OF RIGHTS AND RESPONSIBILITIES

As a resident of the Swing Bed Program at Wild Rose Community Memorial Hospital, you have the right to a dignified existence, self determination, and communication with and access to persons and services inside and outside this facility. Wild Rose Community Memorial Hospital will protect and promote your rights, including each of the following:

You have the right to be informed, in language you can understand, of your total health status, including, but not limited to, your medical condition.

You have the right to refuse treatment, to refuse to participate in experimental research and to formulate an advanced directive.

You have the right to be fully informed prior to and at the time of admission and during your stay, of the services available in the facility and of the related charges including any charges not covered under Title XIX of the Social Security Act, or not covered by Wild Rose Community Memorial Hospital per diem rate.

You have the right to choose a personal attending physician.

You have the right to be fully informed in advance about care and treatment and of any changes in that care and treatment that may affect your well-being, and unless adjudged incompetent or otherwise found to be incapacitated under the laws of the State, participate in planning care and treatment or changes in care and treatment.

You have the right to personal privacy and confidentiality for your personal and clinical records. Personal privacy and confidentiality includes accommodations, medical treatment, written and telephone communications, personal care, visits and meetings of the family and residents groups, but does not require Wild Rose Community Memorial Hospital to provide a private room for each resident.

You have the right to approve or refuse the release of personal or clinical records to any individual outside the facility, except when you are being transferred to another health care facility or when the record release is required by law.

You have the right to refuse to perform services for Wild Rose Community Memorial Hospital.

You have the right to perform services for Wild Rose Community Memorial Hospital, if you choose, when:

  • The facility has documented the need or desire for work in the plan of care.
  • The plan of care specifies the nature of the services performed and whether the services are voluntary or paid.
  • Compensation for paid services is at or above prevailing rates.
  • You agree to the work arrangement described in the plan of care.

 

You have the right to privacy in written communications, including the right to:

  • send and promptly receive mail that is unopened; and
  • have access to stationary, postage and writing implements at your own expense.

 

You have the right and the facility must provide immediate access to any resident by the following:

  •  Subject to the resident’s right to deny or withdraw consent at any time, immediate family or other relatives of the resident and
  • Subject to reasonable restrictions and the resident's right to deny or withdraw consent at any time, others who are visiting with the consent of the resident.

 

You have the right to retain and use personal possessions, including some furnishings, and appropriate clothing, as space permits, unless to do so would infringe upon the rights or health of other residents.

You have the right to share a room with your spouse when married residents live in the same facility and both spouses consent to the arrangement.

Admission, Transfer and Discharge Rights

Definition: Transfer or Discharge includes movement of a resident to a bed outside of the certified facility whether that bed is in the same physical plant or not. Transfer and discharge does not refer to movement of a resident to a bed within the same certified facility.

Transfer and discharge requirements:

The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless:

  • The transfer or discharge is necessary for the resident’s welfare and the resident’s needs cannot be met in the facility;
  • The transfer or discharge is appropriate because the resident’s health has improved sufficiently so the resident no longer needs the services provided by the facility;
  • The safety of the individuals in the facility is endangered;
  • The health of individuals in the facility would otherwise be endangered;
  • The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility.  For a resident who becomes eligible for Medicaid after admission to a facility, the facility may charge a resident only allowable charges under Medicaid; or
  • The facility ceases to operate.

 

Documentation:

When the facility transfers or discharges a resident under any of the circumstances specified in the transfer or discharge requirements section, the resident’s clinical record must be documented. The documentation must include the reasons for your transfer or discharge.

  • The resident’s MD/DO when transfer or discharge is necessary under paragraph (a)(2)(i) or paragraph (a)(2)(ii) of this section; and
  • A MD/DO when transfer or discharge is necessary under paragraph (a)(2)(iv) of this section

Notice before transfer:

Before a facility transfers or discharges a resident, the facility must:

  • Notify the resident, and, if known, a family member or legal representative of the resident of the transfer or discharge and the reasons for the move in writing in a language and manner they understand.
  • Record the reasons in the patient’s clinical record; and
  • Include in the notice the items described in paragraph (a) (6) of this section.       

Record the reasons for your transfer or discharge in your clinical record. The notice of the transfer or discharge or discharge must be made by Wild Rose Community Memorial Hospital at least 30 days before you are transferred or discharged unless:

  • Your safety in the facility would be endangered
  • The health of individuals in the facility would be endangered
  • Your health has improved sufficiently to allow for a more immediate transfer or discharge
  • You have not resided in Wild Rose Community Memorial Hospital for 30 days, or immediate transfer or discharge is required by your urgent medical needs.    

 

The written notice must include the following:

  • The reason for the transfer or discharge
  • The effective date of the transfer or discharge
  • The location to which you will be transferred
  • A statement that you have the right to appeal the action to the State
  • The name, address, and telephone number of the state long term care ombudsman
  • If you have a developmental disability, the mailing address and telephone number of the agency responsible for the protection and advocacy of developmentally disabled individuals established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act
  • If you are mentally ill, the mailing address and telephone number of the agency responsible for the protection and advocacy of mentally ill individuals established under the Protection and Advocacy for Mentally Ill Individuals Act

 

Wild must provide you with sufficient preparation and orientation to ensure a safe and orderly transfer or discharge from our facility.

You have the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat your medical symptoms.

You have the right to be free from any verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion.

As a patient of the Swing Bed Program at Wild Rose Community Memorial Hospital, you have the responsibility:

  • To provide, to the best of your knowledge, accurate and complete information about your present complaint, past illnesses, hospitalizations, medications, and other matters relating to your health.
  • To report unexpected changes in your condition to your physician.
  • To discuss any questions you may have regarding your plan of care and what is expected of you.

 

Complaints or reports that a patient’s rights have been violated, a patient has been mistreated, neglected, exploited, may be made to the nurse in charge, the Director of Nursing at 920-622-6018, the Director of Patient Care Services at  (920) 622-5587 or contact the Administrative Offices at (920) 622-5582.  You may also communicate your concerns directly to the Wisconsin, Bureau of Quality Assurance, Health Services Section at the address listed below.

The State of Wisconsin Bureau of Health Services:

Division of Quality Assurance

PO Box 2969

Madison, WI 53701-2969

(608) 266-8481

Web site: www.dhs.wisconsin.gov

 

Metastar

2909 Landmark Pl #300

Madison, WI 53713

(608) 274-1940

Web site:  www.metastar.com

CLIENT RIGHTS FOR PATIENTS RECEIVING SERVICES FOR MENTAL ILLNESS, ALCOHOL OR OTHER DRUG ABUSE OR DEVELOPMENTAL DISABILITIES

 When you receive inpatient services for mental illness, alcoholism, drug abuse or a developmental disability, you have the following rights under Wisconsin Statute 51.61 (I), 51.30, Wisconsin Administrative Code HFS 92, DHS 94, and HFS 124 and 42 CFR 482.13. If you require additional information regarding these rights please see a staff member of the facility or program providing your services and it will be provided to you.

PERSONAL RIGHTS

  • You must be treated with dignity and respect, free from any verbal, physical, emotional, sexual abuse or harassment. 
  • You have the right to have staff make fair and reasonable decisions about your treatment and care.
  • You have the right to participate in religious services and social, recreational and community activities away from the living unit to the extent possible.
  • You may not be made to work except for personal housekeeping chores. If you agree to do other work, you must be paid, with certain minor exceptions.
  • You may make your own decisions about things like getting married, voting and writing a will, if you are over the age of 18, and have not been found legally incompetent.
  • You may not be treated unfairly because of your race, national origin, sex, age, religion, disability, sexual orientation, source of funding or marital status.
  • Your surroundings must be kept safe and clean.
  • You must be given the chance to exercise and go outside for fresh air regularly and frequently, except for health and security concerns.
  • You have the right to receive treatment in a safe, psychologically and physically humane environment.
  • You may contact a family member or representative and your personal physician to notify them of your admission to the hospital, or have a staff member do so on your behalf. You may refuse to have others contacted.

 

COMMUNICATION AND PRIVACY RIGHTS

  • You may call or write to public officials or your lawyer.
  • Except in some situations, you may not be filmed, taped or photographed unless you agree to it.                                                                                                
  • You may use your own money as you choose, within some limits.
  • You may send and receive private mail. (Staff may not read your mail unless you or your guardian asks them to do so). Staff may check your mail for contraband. They may only do so if you are watching.                                                                    
  • You may use a telephone daily.*
  • You may see visitors daily. *
  • You may designate who may visit. *
  • You must have privacy when you are in the bathroom and while receiving care for personal needs. *
  • You may wear your own clothing. *
  • You must be given the opportunity to wash your clothes. *
  • You may use and wear your own personal articles. *
  • You must have access to a reasonable amount of secure storage space.*

 

*Some of your rights may be limited or denied for treatment, safety or other reasons. (See the rights with an * after them). Your wishes and the wishes of your guardian should be considered. If any of your rights are limited or denied, you must be informed of the reasons for doing so. You may ask to talk with staff about it. You may also file a grievance about any limits on your rights.

 TREATMENT AND RELATED RIGHTS

  • You must be provided prompt and adequate treatment, rehabilitation and educational services appropriate for your condition, within the limits of available funding.
  • You must be allowed to participate in your treatment and care, including treatment planning.
  • You must be informed of your treatment and care, including alternatives to and possible side effects of treatment, including medications, including who is responsible and the possible consequences of refusing treatment.
  • No treatment or medication may be given to you without your written, informed consent, unless it is needed in an emergency to prevent serious physical harm to you or others, or a court orders it. (If you have a guardian, however, your guardian may consent to treatment and medications on your behalf.)
  • You have the right to have the consequences of refusing treatment explained to you.
  • You may not be subject to electro-convulsive therapy or any drastic treatment measures such as psychosurgery or experimental research without your written informed consent.
  • You must be informed in writing of any costs of your care and treatment for which you or your relatives may have to pay. You have a right to examine your hospital bill and receive an explanation of the bill, regardless of source of payment. Every patient shall receive, upon request, information relating to financial assistance available through the hospital.
  • You must be treated in the least restrictive manner and setting necessary to achieve the purposes of admission to the facility, within the limits of available funding.
  • You may not be restrained or placed in a locked room (seclusion) unless in an emergency when it is necessary to prevent physical harm to you or to others.
  • You have a right to be informed about your illness, course of treatment and prognosis for recovery and to have your legally authorized representative or any other person you have authorized in writing obtain this information as well.
  • You have a right to formulate Advance Directives.

 

RECORD PRIVACY AND ACCESS

 Under Wisconsin Statute sec. 51.30 and HFS 92, Wisconsin Administrative Code:

  • Your treatment information must be kept private (confidential), unless the law permits disclosure.
  • Your records may not be released without your consent, unless the law specifically allows for it.
  • You may ask to see your records. You must be shown any records about your physical health or medications. Staff may limit how much you may see of the rest of your records while you are receiving services. You must be informed of the reasons for any such limits. You may challenge those reasons through the grievance process.
  • After discharge, you may see your entire record, if you ask to do so. You may be charged for written copies.
  • If you believe something in your records is wrong, you may challenge its accuracy. If staff will not change the part of your record you have challenged, you may put your own version in the record.

 

RIGHT OF ACCESS TO COURTS

  • You may, instead of filing a grievance or at the end of the grievance process, or any time during it, choose to take the matter to court to sue for damages or other court relief if you believe your rights have been violated.
  • If you have been placed against your will, you may ask a court to review your commitment or placement order.

 

Complaints or reports that a patient’s rights have been violated, a patient has been mistreated, neglected, exploited, may be made to the nurse in charge, the Director of Patient Care Services at  (920) 622-5587, the Director of Nursing at (920) 622-6018 or contact the Administrative Offices at (920) 622-5582.  If issues or concerns are not resolved to your satisfaction, you may file a grievance following the procedure listed below.

 

GRIEVANCE RESOLUTION STAGES

Informal Resolution Process (Optional)

  • An informal resolution may be possible, and you are encouraged to first talk with staff about your concerns. If it is possible, the client rights specialist or another staff member may utilize dispute mediation or conflict resolution processes to address your concerns. However, you do not have to do this before filing a formal grievance with your service provider.

 

Level I -Grievance Investigation

  • If you want to file a grievance, you should do so within 45 days of the time you become aware of the problem. An extension of time beyond the 45-day time limit may be granted for good cause. This time limit does not apply to your rights under HFS 124 or 42CFR 482.13. You may file your grievance verbally or in writing. If you file verbally, you must specify that you would like it to be treated as a formal grievance.
  • You may file as many grievances as you want. However, they will usually only be investigated one at a time. You may be asked to rank them in order of importance.
  • A Client Rights Specialist will investigate your grievance and attempt to resolve it.
  • Unless the grievance is resolved informally, the Specialist will write a report within 30 days from the date you filed the formal grievance. You will get a copy of the report.

Level II - Program Manager's Review

  • The manager of the facility or the program providing your services will review the Specialist's report. If you and that manager are in agreement with the results of the report, any recommendations in it shall be put into effect. If there are disagreements, the manager shall issue a written decision within 10 days.
  • You will be informed of how to appeal the program manager's decision if you disagree with it. You will have 14 days to appeal.

County Level Review

  • If a county agency is paying for your services, there is an extra step available in the grievance process. You may appeal the Level II decision to the County Agency Director. . The County Agency Director must issue a written decision within 30 days, with a possible extension of another 30 days.

Level III - State Grievance Examiner

  • If your grievance went through the County Level Review and you are dissatisfied with the decision, then you may appeal it to the State Grievance Examiner. You have 14 days to appeal.
  • If you are paying for your services yourself, or through insurance, then you may appeal the Level II decision directly to the State Grievance Examiner, skipping the County Level Review You have 14 days to appeal.
  • The address is: State Grievance Examiner, Division of Disability and Elder Services, PO Box 7851, Madison, WI 53707-7851.

Level IV - Final State Review

  • Anyone directly affected by the Level III decision may request a final state review by the Administrator of the Division of Disability and Elder Services or designee. Any appeal to Level IV must be sent to the DDES Administrator, PO Box 7851 Madison, WI 53707-7851, within 14 days.

You may talk with staff or contact your CLIENT RIGHTS SPECIALIST, whose name is shown below, if you would like to file a grievance or learn more about the grievance procedure used by the program from which you are receiving services.

 

Your Client Rights Specialist is:

John Lemerond, PhD

500 Riverview Ave.

Waukesha, Wisconsin 53188

You may also communicate your concerns directly to the Wisconsin, Bureau of Quality Assurance, Health Services Section at the address listed below.

 

Bureau of Quality Assurance:

P.O. Box 2969

Madison, WI 53701-2969

Phone: (608)266-8481

Web site: www.dhs.wisconsin.gov

 

If Medicare is paying for your services, you may also request review of your medical treatment by the peer review organization called Metastar.

 

Metastar
2909 Landmark Pl # 300
Madison, WI 53713

(608) 274-1940

(800) 362-2320

Web site: www.metastar.com

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