100-11 Programs of All-Inclusive Care for the Elderly (PACE)Manual: Chapter 5 - Participant Rights and Restraint Policies

Programs of All-Inclusive Care for the
Elderly (PACE)
Chapter 5 – Participant Rights and Restraint Policies
Table of Contents
(Rev. 2, Issued: 06-09-11)
Transmittals for Chapter 5
10 - Participant Bill of Rights
20 - Specific Rights to which a Participant is Entitled
20.1 - Right #1 - Respect and Nondiscrimination
20.2 - Right #2 - Information Disclosure
20.3 - Right #3 - Choice of Providers
20.4 - Primary Care Physician
20.5 - Informing Female Participants
20.6 - Right #4 - Access to Emergency Services
20.7 - Right #5 - Participation in Treatment Decisions
20.8 - Right #6 - Confidentiality of Health Information
20.9 - Right #7 - Complaints and Appeals
30 - Restraints

10 - Participant Bill of Rights
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11)
The PACE organization is required to have a written participant Bill of Rights designed
to protect and promote the rights of each participant. Those rights include; at a minimum,
those specified in 42 CFR § 460.112.
The PACE organization must inform a participant upon enrollment, in writing, of his or
her rights and responsibilities, and all rules and regulations governing participation. This
should include:
• 	Written policies: A PACE organization must have written policies and
implement procedures to ensure that the participant, his or her representative,
if any, and staff understand these rights;
• 	Explanation of rights: The PACE organization must fully explain the rights to
the participant and his or her representative, if any, at the time of enrollment
in a manner understood by the participant;
ο 	The participants rights must be available in writing in English and in any
other principal languages of the community;
ο 	The participant rights must be displayed in a prominent place within the
PACE center.
The PACE organization must protect and provide for the exercise of the participant’s
rights. The PACE organization must have established documented procedures to respond
to and rectify a violation of a participant’s rights. A template for the Bill of Rights may
be obtained from the following
link http://www.cms.hhs.gov/PACE/Downloads/participantrights.pdf.
[42 CFR §460.116]
20 - Specific Rights to which a Participant is Entitled
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11)
20.1 - Right #1 - Respect and Nondiscrimination
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11)
Each participant has the right to considerate, respectful care from all PACE employees
and contractors at all times and under all circumstances. Each participant has the right not
to be discriminated against in the delivery of required PACE services based on race,
ethnicity, national origin, religion, sex, age, sexual orientation, mental or physical
disability, or source of payment.
Specifically, each PACE participant has the right to the following:

• 	To receive comprehensive health care in a safe and clean environment and in
an accessible manner;
• 	To be treated with dignity and respect, be afforded privacy and confidentiality
in all aspects of care, and to be provided humane care;
• 	Not to be required to perform services for the PACE organization;
• 	To have reasonable access to a telephone;
• 	To be free from harm, including physical or mental abuse, neglect, corporal
punishment, involuntary seclusion, excessive medication, and any physical or
chemical restraint imposed for purposes of discipline or convenience and not
required to treat the participant’s medical symptoms;
• 	To be encouraged and assisted to exercise rights as a participant, including the
Medicare and Medicaid appeals processes as well as civil and other legal
rights;
• 	To be encouraged and assisted to recommend changes in policies and services
to PACE staff.
[42 CFR § 460.112(a)]
20.2 - Right #2 - Information Disclosure
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11)
Each PACE participant (or the designated representative of the participant) has the right
to receive accurate, easily understood information and to receive assistance in making
informed health care decisions.
Specifically, each participant has the following rights:
• 	To be fully informed, in writing, of the services available from the PACE
organization, including identification of all services that are delivered through
contracts, rather than furnished, directly by the PACE organization at the
following times:
ο 	Before enrollment;
ο 	At enrollment; and
ο 	At the time a participant’s needs necessitate the disclosure and delivery of
such information in order to allow the participant to make an informed
choice;

• 	To have the enrollment agreement, described in 42 CFR § 460.154, fully
explained in a manner understood by the participant;
• 	To examine, or upon reasonable request, to be assisted to examine the results
of the most recent review of the PACE organization conducted by CMS or the
State Administering Agency and any plan of correction in effect.
[42 CFR § 460.112(b)]
20.3 - Right #3 - Choice of Providers
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11)
Each participant has the right to a choice of health care providers, within the PACE
organization’s network, that is sufficient to ensure access to appropriate high-quality
health care.
Specifically, each participant has the right to the following:
• 	To choose his or her primary care physician and specialists from within the
PACE network;
• 	To disenroll from the program at any time;
• 	To request that a qualified specialist for women’s health services provide
routine or preventive women’s health services. The PACE organization must:
ο 	Provide access to all specialties within its network and explain to
participants that they are required to receive all services through the PACE
organization;
ο 	Give participants the choice of providers as well as communicate the right
of female participants to choose a qualified specialist in woman’s health;
ο 	Contract, when possible, with more than one provider of gynecological
services.
[42 CFR § 460.112(c); 71 FR 71291 (Dec. 8, 2006)]
20.4 - Primary Care Physician
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11)
A Primary Care Physician (PCP) is qualified to perform primary care including basic
Gynecological (GYN) services, but the PCP is not a ‘‘qualified specialist for women’s
health services.’’ Although female participants may choose their PCP for basic GYN
services, if a participant requests a GYN specialist or the participant requires more

complex GYN services, the participant must be provided a GYN specialist and, when
possible, be provided a choice of GYN specialists.
[71 FR 71291 (Dec. 8, 2006)]
20.5 - Informing Female Participants
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11)
The Interdisciplinary Team (IDT) physician or alternative IDT member identified in the
organization’s care planning policy must inform female participants that they are entitled
to choose a qualified specialist for women’s health services to provide routine or
preventive women’s health services from the PACE organization’s network. In some
PACE organizations, the physician makes this notification during intake, the enrollment
process, or at the initial physician assessment. If notification has not been made prior to
development of the care plan, 42 CFR § 460.104(b) requires the IDT team to make this
notification during the care plan development or when the proposed care plan is
subsequently presented to the participant and/or care giver for discussion, revision, and
incorporation of the participant’s preferences.
[42 CFR § 460.104(b); 71 FR 71296 (Dec. 8, 2006)]
20.6 - Right #4 - Access to Emergency Services
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11)
Each participant has the right to access emergency health care services when and where
the need arises without prior authorization by the PACE IDT.
[42 CFR § 460.112(d)]
20.7 - Right #5 - Participation in Treatment Decisions
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11)
Each participant has the right to participate fully in all decisions related to his or her
treatment. A participant who is unable to participate fully in treatment decisions has the
right to designate a representative.
Specifically, each participant has the right:
• 	To have all treatment options explained in a culturally competent manner and
to make health care decisions, including the right to refuse treatment, and be
informed of the consequences of the decisions;
• 	To have the PACE organization explain advance directives and to establish
them, if the participant so desires, in accordance with 42 CFR §§ 489.100 and
489.102;

• 	To be fully informed of his or her health and functional status by the
interdisciplinary team;
• 	To participate in the development and implementation of the plan of care;
• 	To request a reassessment by the interdisciplinary team;
• 	To be given reasonable advance notice, in writing, of any transfer to another
treatment setting and the justification for the transfer (that is, due to medical
reasons or for the participant’s welfare, or that of other participants). The
PACE organization must document the justification in the participant’s
medical record.
[42 CFR § 460.112(e)]
20.8 - Right #6 - Confidentiality of Health Information
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11)
Each participant has the right to communicate with health care providers in confidence
and to have the confidentiality of his or her individually identifiable health care and other
information protected. Each participant also has the right to review and copy his or her
own medical records and request amendments to those records.
Specifically, each participant has the following rights:
• 	To be assured of confidential treatment of all information contained in the
health record, including information contained in an automated data bank;
• 	To be assured that his or her written consent will be obtained for the release of
information to persons not otherwise authorized under law to receive it;
• 	To provide written consent that limits the degree of information and the
persons to whom information may be given.
[42 CFR § 460.112(f)]
20.9 - Right #7 - Complaints and Appeals
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11)
Each participant has the right to a fair and efficient process for resolving differences with
the PACE organization, including a rigorous system for internal review by the
organization and an independent system of external review.
Specifically, each participant has the following rights:

• 	To be encouraged and assisted to voice complaints to PACE staff and outside
representatives of his or her choice, free of any restraint, interference,
coercion, discrimination, or reprisal by the PACE staff;
• 	To appeal any treatment decision of the PACE organization, its employees, or
contractors through the process described in 42 CFR § 460.122.
[42 CFR § 460.112(g)]
30 - Restraints
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11)
The use of restraints must be based on the assessed needs of the participant, be monitored
and reassessed appropriately, and be ordered for a defined and limited period of time. The
least restrictive and most effective method available must be utilized and it must conform
to the participant’s plan of care. Restraints may only be used as a last resort and must be
removed or ended at the earliest possible time. Restraints of any kind should never be
used as a preferred approach to care and PACE organizations are expected to ensure that
their programs are ‘‘restraint free’’ to the greatest extent possible.
The term restraint includes physical or chemical restraints. A physical restraint is any
manual method or physical or mechanical device, materials, or equipment attached or
adjacent to the participant’s body that he or she cannot easily remove and that restricts
freedom of movement or normal access to one’s body. A chemical restraint is a
medication used to control behavior or to restrict the participant’s freedom of movement,
and that is not a standard treatment for the participant’s medical or psychiatric condition.
If the IDT determines that a restraint is needed to ensure the participant’s physical safety
or the safety of others, the use must meet the following conditions:
• 	Be imposed for a defined, limited period of time, based upon the assessed
needs of the participant;
• 	Be imposed in accordance with safe and appropriate restraining techniques;
• 	Be imposed only when other less restrictive measures have been found to be
ineffective to protect the participant or others from harm;
• 	Be removed or ended at the earliest possible time.
A PACE organization must have policies and procedures regarding restraints that:
• 	Define physical and chemical restraints as described above;
• 	Include the conditions on use described above;

• 	Describe how personnel will continually assess, monitor and reevaluate
(specify time intervals) the participant’s condition while in restraints.
[42 CFR § 460.114; 71 FR 71299 (Dec. 8, 2006)]

Transmittals Issued for this Chapter
Rev # 	Issue Date 	Subject 	Impl Date CR#
R2PACE 06/09/2011 	Initial Publication of Manual 	06/03/2011 NA
R1_SO 06/03/2011 	Initial Publication of Manual - Rescinded and
replaced by Transmittal 2
06/03/2011 NA
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