MAIL ALL FOUR COMPLETED FORMS TO NYS Commission on

MAIL ALL FOUR COMPLETED FORMS TO: NYS Commission on Quality of Care & Advocacy For Persons with Disabilities SDMC 401 State Street Schenectady, NY 12305 INSTRUCTIONS FOR CQCAPD FORM 200 Declaration for Surrogate Decision-Making If this is your first time preparing a case or you have questions, call 518-388-2820. 1a. Provide all requested information completely and accurately. Phone numbers must be where you are available during regular business hours. You must be available to answer any case-related questions, obtain additional information and assist in scheduling the hearing. Note: The scheduled date of hearing may be delayed until requested information has been received. 1b. 2. 3. List any other organization/agency providing services to the patient. Check all appropriate titles for the person completing CQCAPD Form 200. Write the title (not the name) of the treatment team member who explained the proposed major medical treatment(s) to the patient. This must be someone familiar to the patient. The procedure must be explained to the patient. 4. Write a description of how the patient responded to the information/description of the proposed major medical treatment(s), i.e., “patient walked away”, “patient responded yes, but was unable to explain procedures risks when questioned”, etc. 5a. List any Legally Authorized Surrogate in the boxes below based on the information in (b), (c), and (d). 5b. Check all legally authorized surrogates from the list that apply to this patient. Remember, if any of these individuals exist and are authorized, willing and available to give consent, they may provide consent on behalf of the person and the case would not need to be submitted to SDMC. If they exist but are not authorized, available or willing to give consent, provide documentation of this in response to question 5d of CQCAPD Form 200. This list only includes those who are considered legally authorized surrogates per MHL Article 80. 5c. If the parent(s) is/are not available, indicate whether they are deceased or their status is unknown. 5d. Fill in all of the information in the boxes for anyone living outlined in #5a and #5b, explaining your answers in the comments section in each box as applicable. MAIL ALL FOUR COMPLETED FORMS TO: NYS Commission on Quality of Care & Advocacy For Persons with Disabilities SDMC 401 State Street Schenectady, NY 12305 For Patients Residing in Facilities Licensed, Funded or Operated by the Office of Mental Retardation and Developmental Disabilities: Per OMRDD Regulations 633.11, actively involved adult siblings, actively involved other adult family members and the Consumer Advisory Board (CAB) can also give consent. If the patient has any of these family members or is represented by CAB, these individuals must be contacted to determine if they wish to give the consent. If any are authorized, willing and available, the case would not need to be submitted to SDMC. If they do not wish to give consent, they are listed on page 3, #6 of CQCAPD Form 200. For Patients Residing in Facilities Licensed, Operated or Funded by the Office of Mental Health: Siblings and other family members are considered correspondents only. They are not authorized to give consent. If you are unsure who is a surrogate or correspondent, please call SDMC at 518-388-2820. 6a. For patients living in OMH facilities, list only actively involved correspondents. For patients living in OMRDD facilities, list actively involved siblings or other actively involved adult family members who are unavailable or who have waived their right to make the decision. List the patient’s CAB representative when CAB is not available, any active correspondents or advocates, or a Family Care provider. If the patient has one or more actively involved siblings or other family members, explain why surrogate decision-making is needed. Provide an explanation for your answers in the comments section. Check none if patient has none of the individuals listed in 6a and 6b. Anyone listed in #5 or #6 who could not be contacted, explain the efforts made to contact them. Read CQCAPD Form 210 and fill in the psychiatrist or psychologist’s name and the date the CQCAPD Form 210 was signed. Write out the complete name of the proposed major medical treatment(s) being requested as written by the doctor, dentist or podiatrist on the CQCAPD Form 220-A, #5a and 5b. Check yes or no based on the answer to #7b on CQCAPD Form 220-A. Read CQCAPD Form 220-A and fill in the doctor, dentist or podiatrist’s name and the date the CQCAPD Form 220-A was signed. Was a second opinion obtained? Check yes or no. If yes, include a copy in the case. A second opinion is (for our purposes) when the treatment team seeks an opinion from another unaffiliated physician, dentist or podiatrist, not including the patient’s primary care physician, regarding the treatment being proposed. NOTE: A second opinion is not required. Based on your personal knowledge of and interactions with the patient, describe in your own words why you think the patient lacks capacity to give or withhold informed consent. (Can the patient understand the risks and benefits of having and of not having the proposed major medical treatment(s)? 6b. 6c. 7. 8. 9. 10. 11. 12. 13. MAIL ALL FOUR COMPLETED FORMS TO: NYS Commission on Quality of Care & Advocacy For Persons with Disabilities SDMC 401 State Street Schenectady, NY 12305 14. 15a. 15b. 15c. 15d. 15e. 16. 17. Based on your personal knowledge of and interactions with the patient, explain in your own words how the proposed major medical treatment(s) is/are going to benefit the patient. Write the patient’s name, complete mailing address, and phone number. Write the patient’s date of birth, age, mental disability(ies), including level of mental retardation, physical disability(ies), sex, religion, primary language and any communication needs. Check the type of the patient’s residence. Is the patient a Willowbrook Class Client? Check Yes or No. List county of residence. Accurately complete all of the requested information for a second person to be contacted about the case if you, the declarant, cannot be reached or are not available. Print clearly your (the declarant’s) name as listed on page 1. You must sign the form and date it. This date must be the same as or later than the dates on the other CQCAPD forms in the case. (Rev. 1/2009) DO NOT STAPLE FORMS SURROGATE DECISION-MAKING COMMITTEE PROCEEDING FOR THE REVIEW OF THE NEED FOR SURROGATE DECISION-MAKING ON BEHALF OF Page 1 of 5 CQCAPD Form 200 DECLARATION FOR SURROGATE DECISION-MAKING Declaration # (CQCAPD Use Only) (Patient’s Name) ALL QUESTIONS MUST BE ANSWERED TO PREVENT A DELAY IN PROCESSING THE CASE To the Surrogate Decision-Making Committee: 1a. I am the declarant for the above named individual; my name, work address and telephone numbers are: Name: Organization Name: Full Mailing Address: (You will be contacted regarding this declaration. Please list contact information where you can be reached Monday through Friday, during regular business hours.) Title: Work Phone FAX Phone Beeper Work Cell Email 1b.   2. ( ( ( ( ) ) ) ) EXT. Does the patient receive services from any other organization/agency? If yes, list: Yes No My relationship with the patient is (check all that apply): Direct Care Staff Family Care Provider Social Worker Service Coordinator Case Manager Nurse Executive Director Physician/Dentist/Podiatrist Who explained the proposed major medical treatment(s) to the patient? (Title Only) Psychiatrist/Psychologist Physician Assistant Residence Manager Other: 3. 4. Describe the patient’s reaction when the proposed major medical treatment(s) was/were explained, and any opinions expressed: (Rev. 1/2009) DO NOT STAPLE FORMS 5a. Page 2 of 5 CQCAPD Form 200 List in the boxes below any Legally Authorized Surrogate as recognized by Article 80 of the Mental Hygiene Law. Parent Spouse Adult Child Committee of the Person Living 5b. Check all that apply: Guardian/Conservator Health Care Proxy Unknown 5c. Indicate the status of the patient’s parents. Deceased 5d. Provide the following information for anyone living listed above. Explain your answers in the comments section below. Name: Address: Phone: ( Relationship: Agree Other Name: Address: ) Disagree No Opinion Does Not Wish to Make Decision Phone: ( Relationship: Agree Other ) Disagree No Opinion Does Not Wish to Make Decision How contacted? Comments: Phone mail in person Unable to contact (see #7) How contacted? Comments: Phone mail in person Unable to contact (see #7) Name: Address: Phone: ( Relationship: Agree Other Name: Address: ) Disagree No Opinion Does Not Wish to Make Decision Phone: ( Relationship: Agree Other ) Disagree No Opinion Does Not Wish to Make Decision How contacted? Comments: Phone mail in person Unable to contact (see #7) How contacted? Comments: Phone mail in person Unable to contact (see #7) (Rev. 1/2009) DO NOT STAPLE FORMS 6a. Page 3 of 5 CQCAPD Form 200 List in the boxes below any actively involved adult siblings, or other adult family members, who do not wish to give, or are not authorized to give consent. List the patient’s CAB representative when CAB is not available or willing to make the decision. Also include correspondents, community advocates, and Family Care Providers. 6b. For patients living in OMRDD facilities ONLY: If the patient has one or more actively involved sibling or other adult family member explain why surrogate decision-making is needed (e.g.: family members are unavailable, family members do not wish to make the decision and/or they want SDMC to resolve a possible objection or difference of opinion). Explain your answers in the comments section below. 6c. None __________ Name: Address: Phone: ( Relationship: Agree Other Name: Address: ) Disagree No Opinion Does Not Wish to Make Decision Phone: ( Relationship: Agree Other ) Disagree No Opinion Does Not Wish to Make Decision How contacted? Comments: Phone mail in person Unable to contact (see #7) How contacted? Comments: Phone mail in person Unable to contact (see #7) Name: Address: Phone: ( Relationship: Agree Other Name: Address: ) Disagree No Opinion Does Not Wish to Make Decision Phone: ( Relationship: Agree Other ) Disagree No Opinion Does Not Wish to Make Decision How contacted? Comments: Phone mail in person Unable to contact (see #7) How contacted? Comments: Phone mail in person Unable to contact (see #7) (Rev. 1/2009) DO NOT STAPLE FORMS 7. Page 4 of 5 CQCAPD Form 200 For persons listed in sections 5 and 6 who were not able to be contacted, please list what efforts were made to contact them to discuss this case. 8. I have read CQCAPD Form 210 (Certification on Capacity) completed by signed on (Name of Psychiatrist or Psychologist) (Date) indicating his/her professional opinion that the patient does not have the capacity to provide informed consent for the proposed major medical treatment(s). 9. The proposed major medical treatment(s) is/are as follows (per CQCAPD Form 220-A, #5a and 5b): 10. Is the use of general anesthesia anticipated? Yes No (per CQCAPD Form 220-A, #7b) 11. I have read CQCAPD Form 220-A (Certification of Need for Major Medical Treatment) completed by signed on (Name of Physician/ Dentist/Podiatrist) (Date) describing the patient’s medical/dental condition, the proposed major medical treatment(s), the risks and benefits and alternative(s) to the proposed procedure. 12. Has there been a second medical/dental/podiatrist opinion obtained regarding the proposed major medical treatment(s)? Yes No If yes, attach copy. 13. In my opinion, the patient cannot give informed consent for this procedure because: 14. It is my opinion that the proposed major medical treatment(s) is/are in the best interest of the patient because: (Rev. 1/2009) DO NOT STAPLE FORMS 15. This declaration is made on behalf of: b. Date of Birth: (Month Page 5 of 5 CQCAPD Form 200 a. Patient’s Name: Address: / Day / Year) Age: Mental Disability: Physical Disability: Sex: Male Female Religion: Primary Language: Communication Needs (Interpreter): Phone: ( ) (Phone Number of Patient’s Residence) c. Type of Residence: ICF CR DC FC IRA Waiver Services OMH funded or approved housing Other: d. Willowbrook Class Client? e. County of Residence: Yes No 16. Name of Second Contact: Title: (List name of alternate contact if Declarant cannot be reached.) Second Contact’s Full Mailing Address (Organization Name): Street City State Zip Work Phone FAX Phone Beeper Work Cell Email 17. ( ( ( ( ) ) ) ) EXT. To the best of my knowledge, the above information and statements are truthful and complete. Print Declarant’s Name Clearly Declarant’s Signature Date NOTE: This form must be dated the same or later than the other CQCAPD Forms in the case.