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Ethics Committee

Ethics Committee 

Effective Date: [Original NPP Date] 

Revised Date: [Current Date] 

Policy Statement: 

Athena Health Care Systems maintains a standing Ethics Committee available for consultation to all Athena facilities. This committee provides guidance on ethical issues in resident care, ensuring decisions align with regulatory standards and ethical principles. 

Policy: 

  • Membership: The Ethics Committee is comprised of professionals from Athena and various facilities. Membership should always include: 

  • A physician 

  • An attorney 

  • A social service representative 

  • A nursing representative 

  • A licensed nursing home administrator 

  • The facility making the referral should be represented by their: 

  • Administrator 

  • Director of Nursing Services (DNS) 

  • Social Worker 

  • Attending Physician and/or Medical Director 

  • A psychiatrist should be available when appropriate. 

Procedure: 

  • Permission and Release: The facility must obtain permission and a signed release from the resident and/or responsible party to disclose information to the Ethics Committee. 

  • Request for Consultation: A request for consultation by the Ethics Committee should be made by calling Athena’s Director of Clinical Services. The committee should meet, if at all possible, within three (3) working days of the request. 

  • Meeting and Review: 

  • The Committee will meet with the facility representatives and review all available medical and social information. 

  • The Committee will address specific issues presented by the facility staff and make recommendations regarding resident care and/or disposition. 

  • Recommendations: The final decision regarding the case of any resident is the ultimate responsibility of the facility and its staff. The Ethics Committee’s role is primarily consultative. 

References: 

  • Centers for Medicare & Medicaid Services. State Operations Manual, Appendix PP - Guidance to Surveyors for Long Term Care Facilities. [Link to current CMS SOM] 

  • CMS Requirements of Participation for Long-Term Care Facilities. [Link to current guidelines] 

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