Client Rights to Information and Grievance Procedure by jbk32955


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									                                              Patient Care
                                     POLICY AND PROCEDURE MANUAL
Title:                               MOST RECENT REVISION     PAGE: 1 of 1                 POLICY &
                                     APPROVAL DATE: 11/05                                  PROCEDURE #: 1.2
Patient Rights
HIPAA Policy Manual
Client Grievance Policy – Patient Care Manual
Confidentiality of Clients and Client Records – Patient Care Manual
POLICY: Supports the rights of each patient and is committed to ensuring the protection of those rights in its
provision of care, treatment and services.



    1. Will post Patient Rights information where patients can see them. Will make available written copies
       of Patient Rights in language patients can understand. Patients will be informed of their rights upon

    2. Any person receiving services has the following rights:
           The right to be treated in a humane and dignified manner at all times with respect to personal
             dignity, personal privacy, civil rights and civil liberties.
           Freedom from all forms of coercion, abuse or harm.
           The greatest degree of freedom possible, limited only by dangerousness to self or others, or (if
             inpatient), potential elopement risk or Court ordered commitments.
           Freedom from involuntary seclusion or restraints of any form unless medically there is
             imminent physical danger to client or others and a physician orders the seclusion or restraints.
           The right to participate in the treatment/service process, be present in meetings or discussions
             affecting treatment/service, play an active role in decision-making process, disagree with the
             conclusions of treatment team (if applicable), and to participate in discharge planning.
           The right to receive services that are sensitive to client beliefs, values, and culture.
           Confidentiality rights.
           Personhood, or right to maintain self-identity.
           Due process, which includes Grievance Rights and rights to file a lawsuit in superior court.
                                            Patient Care
                                   POLICY AND PROCEDURE MANUAL
Title:                        MOST RECENT REVISION       PAGE: 1 of 2              POLICY & PROCEDURE
                              APPROVAL DATE: 11/05                                 #: 1.3
Informed Consent

POLICY: It is the policy of its Medical and Professional Staff that every patient has the right to the
information necessary to enable him/her to participate in treatment or research decisions that reflect
his/her wishes to the maximum extent possible. This patient right is assured through the process of
“informed consent”, as described in this policy.
Definitions: Informed consent is the process by which the responsible treating clinician provides the
competent patient with material information regarding the proposed care, treatment, services,
medications, interventions, or procedures. This information will include the anticipated risks, benefits,
side effects, and alternatives to the proposed treatment, as well as the risks of non-treatment. The
informed consent process ascertains that the patient both understands the discussion and agrees to the
treatment, and includes documentation of that agreement.
    1. There are several components to informed consent:
         Disclosure of information
         Competency
         Understanding/Appreciation
         Voluntariness
         Decision

    2. Some patients are not capable of giving informed consent. In these circumstances consent may
       be obtained from a legally authorized representative. If a legally authorized representative has
       not been appointed, the Center may take the appropriate steps to have one appointed if the lack
       of competence is not transient.

    3. There are certain exceptions to the necessity to obtain informed consent, e.g., emergencies –
       when immediate treatment is required to preserve life or prevent a serious impairment to health,
       and it is not possible to obtain informed consent from the patient or a legally authorized

    4. It is the responsibility of the Medical and Professional Staff that each patient be treated by a
       clinician who is professionally capable of providing the necessary information, of engaging in
       appropriate discussion, and of ascertaining patient competence and understanding. This
       responsibility is executed by the Medical and Professional Staff, through its Credentials and Peer
       Review Committees.

    5. The Medical and Professional Staff is responsible for determining the method required for
       documentation of the patient’s informed consent. The Medical Records and Information
       Committee are responsible for monitoring clinician compliance with these methods.
6. The method of documentation required by the Medical and Professional Staff varies depending
   on the type of treatment procedure involved.

7. Written informed consent, documented by the signature of the patient, is required for the
   following procedures:
    Voluntary Commitment Application (Inpatient) {State of Connecticut, Department of Mental
       Health and Addiction Services Form MHCC-2}
    Application for Outpatient Treatment {Medical Records Forms #41A and 41B}
    Lumbar Puncture {Form #5}
    Video or audio recording {Form #7}
    Electro convulsive treatment {Form #21}
    Blood Test for HIV {Form #50}
    Permission to treat a minor {Form #4}
    Master Treatment Plan {Form #33}
   These consent forms must be obtained and filed in the patient medical record, except in
   circumstances specifically exempted by law.

8. The following treatment procedure requires written documentation of informed consent on
   the Medical Orders {Form #11}, by the prescribing physician or APRN:
     Beginning treatment with a prescription medication

9. When an individual participates in any clinical research other than chart review, such research
   requires that the Institutional Review Board (Human Investigation Committee) of the Yale
   University School of Medicine or Nursing approve the research protocol and the consent form.
   Research involving treatment trials including placebo, treatment discontinuation/delay, or
   symptom provocation require additional review and approval by the Yale University Department
   Protocol Review Committee. Informed consent for research is obtained through the following
     All patients asked to participate in a research project are given a description of the expected
       benefits, discomforts and risks, and a description of any alternatives that might prove
       advantageous to them.
     All patients are given a full explanation of the procedures to be followed, especially those
       that are experimental in nature.
     All patients will be assured that refusal to participate in a research project will not
       compromise their access to services.
     The decision to participate in clinical trials or research needs to be based on the patient’s
       competency and sound information. The following items are documented in the patient’s
       record: the name of the person who provided the information and the date on which the
       consent form was signed.
     The Principal Investigator will endeavor to eliminate any confusion, misinformation, stress,
       physical discomfort or other harmful consequences to the participant. All concerns related
       to these issues will be documented in the patient’s medical record.
                                                 Patient Care
                                        POLICY AND PROCEDURE MANUAL
Title:                            MOST RECENT REVISION/        PAGE: 1 of 2                        POLICY &
                                  APPROVAL DATE: 8/99, 10/99,                                      PROCEDURE #:
Patient Choice in                 10/02, 11/05                                                     1.5

POLICY: Clients receiving treatment or any one of the of satellites will not be restricted in their choices in
program, therapist or site by virtue of receiving services in a public sector program.


Ethical Principles

1)       Clients should not be more restricted in their choices by virtue receiving services in a public sector
         (i.e., as opposed to private sector) program.

2)       Choice will be influenced, however, by a number of factors, including the structure of treatment
         programs (e.g., disorder-based) and limited resources.

3)       As there traditionally has been a significant power difference between clients and providers, clients
         may feel intimidated by, or fear retribution from, their clinician when expressing dissatisfaction or
         asking for a change of provider.

4)       In addition, it is to be acknowledged both that a client’s psychotherapy may be expected to impact on
         his or her ability to develop and maintain a trusting relationship with a provider, and that inevitable
         impasses will occur in treatment that will need to be worked through rather than avoided for the client
         to benefit optimally from treatment.


1)       Clients initially will have their presenting difficulties and concerns evaluated by a clinician on an
         individual basis or within the context of their family. Following the initial evaluation, the assessing
         clinician will discuss the relevant details of the client’s or family’s needs with an inter-disciplinary
         team of mental health and/or substance abuse professionals and will return to the client or family with
         recommendations for their care and treatment. These recommendations will be based on a number of
         factors, including the nature of the presenting concerns and issues, the interdisciplinary clinical team’s
         collective knowledge base, professional expertise, and relevant experience, any potential barriers to
         learning or communication identified through the evaluation process, and the treatment resources at
         the time. Within these general guidelines, the clinician will inform clients of the treatments available
      for their concerns, and will work collaboratively with them to decide on a mutually agreeable course
      of action. The exact details of such a plan (e.g., date of first appointment, individual provider, level
      of care of treatment modality) may be determined initially by the clinician, but then will be negotiated
      in an ongoing fashion with clients in the following ways.

2)    Clients will be asked to meet with a newly assigned clinician at least twice, but no more than 6 times,
      before requesting a change in provider. Such requests will be honored with no questions asked and
      no delay or disruption in care the first 2 times they are made. In order not to disrupt care, changes
      should be made prior to the next regularly scheduled appointment.

3)    Requests made to change providers either after an initial 6 sessions, or after an initial 2 requests have
      already been made to change previous providers, will be reviewed with the clients by the responsible
      Team/Operations Associate Director within 3 working days. The clients and Team/Operations
      Associate Director will incorporate input from the involved clinician(s), and will weigh the benefits of
      changing providers with the possible costs to clients’ treatment as explained by the Team/Operations
      Associate Director in coming to a mutually agreeable solution.

4)    It is expected that these first 2 policies will resolve most requests to change providers and most issues
      arising in relation to such requests. In the exceptional cases in which clients and the Team/Operations
      Deputy Director cannot come to an agreement about the change being requested following such a
      review, the Patients Rights Officer will attempt to reach a mutually agreeable solution through
      mediation. Clients have the right to be accompanied in this process by an advocate of their choice.
      The mediation process should be brought to conclusion within 1 week of coming to the Patients
      Rights Officer’s attention.

5)    In cases in which a mutually agreeable solution cannot be achieved through these steps, clients either
      may file a grievance with the Department of Mental Health and Addiction Services or may obtain
      independent legal representation (e.g., from the Connecticut Legal Rights Project, the Yale Law
      Clinic, or a private attorney).

Date First Approved: 8/99
Dates of Revision:   10/99
Dates Reviewed:      10/02
                                              Patient Care
                                     POLICY AND PROCEDURE MANUAL
Title:                          MOST RECENT REVISION        PAGE: 1 of 2                        POLICY &
                                APPROVAL DATE: 11/05                                            PROCEDURE #:
Client Grievance Process                                                                        1.6
Patient Rights Policy
Commissioner’s Statement: The Grievance Procedure
POLICY: The Office of Client Rights will provide avenues for clients and families to address the rights of
clients, obtain explanations, address grievances and serve as an advocate for clients who feel that their rights
have not been properly respected.
    1. Clients are encouraged to resolve conflicts that arise in the course of their treatment by speaking with
         their primary clinicians and/or with the team leader of their treatment team. They also have the right
         to consult with the Client Rights Officer as well as the Connecticut Legal Rights Project in order to
         protect their rights.
    2. Clients who feel that their rights have been violated and who are unable to resolve their issues through
         the above mechanisms, may file a grievance with the Client Rights Officer.
    3. A grievance must be filed within forty-five (45) days of the violation, unless good cause is shown for
         late filing.
    4. A grievance should be filed in writing with the Client Rights Officer. Complaint forms are available
         in the Client Rights Office.
    5. If necessary, a client may ask another individual for help in completing the complaint form. The
         client may also appoint, in writing, a representative of choice to assist in pursuing the grievance.
    6. The Client Rights Officer will send a letter acknowledging the grievance within seven (7) days of its
    7. The Client Rights Officer investigates the client’s complaint, with support as needed, from the Office
         of Medical Director and/or the office of the Director of Clinical Operations.
    8. The Client Rights Officer prepares a written response to the client within seven (7) days. This
         response includes steps taken on behalf of the client to investigate the grievance, and proposes a
         resolution of the client’s complaint. The written response also includes information about the client’s
         right to appeal.
    9. If a proposed resolution cannot be completed within seven (7) days, an acknowledgement letter must
         be sent to the client. This letter must include a date by which the resolution/response will be
    10. The client will have 10 business days to review and comment on the resolution report.
    11. The client may appeal the conclusions of the Client Rights Officer’s report to the Executive Director,
         and further, the client may choose to appeal to the DMHAS Office of the Commissioner.
    12. Upon request, a complete copy of the Grievance Procedure may be obtained from the Client Rights
    13. The Client Rights Officer reports information related to client complaints to the Senior Leadership
         Group on a quarterly basis, and maintains responsibility for yearly trending reports as requested.

1.   Description
     The facility serves as the Local Mental Health Authority for Catchment Area 7 of the
     Department of Mental Health and Addiction Services. This Catchment Area covers the
     Greater New Haven area encompassing the four townships of New Haven, Hamden, Bethany,
     and Woodbridge, and is composed of a consortium of 16 community agencies called the
     Community Services Network (CSN). Additionally, the CSN has formal oversight of the
     Supportive Housing Program and New Haven Shelter Plus Care. CSN agencies provide 1)
     clinical programs (encompassing emergency/crisis, inpatient, and outpatient); 2) case
     management and outreach services; 3) residential support services (supportive housing
     programs to assist individuals to reside in the community, including the provision of
     emergency shelter, respite care, as well as crisis services as an alternative to hospitalization);
     and 4) social and vocational rehabilitation programs. The majority of funding for these
     services is provided by the Department of Mental Health and Addiction Services, but also
     includes a range of federal sources. The Lead Agency, has primary responsibility for the
     management of the service system, for system-wide service planning and development, and
     for administrative and financial management and oversight.

A.   Mission
     The mission of the Community Services Network is to help families and individuals enjoy
     meaningful and satisfying lives through the coordination of excellent behavioral health

B.   Goals and Objectives

     The goals and objectives of the CSN, and as the Lead Agency, include:
        Assessing service needs.
        Assuring access to services for those in need (i.e., no one who is eligible to enter the
          system is refused services).
        Overseeing the decision-making process regarding the allocation of limited resources.
        Assuring effective service delivery (e.g., amount, appropriateness, and quality).
        Facilitating interagency treatment planning.
        Resolving interagency conflict (e.g., mediating disputes regarding patient care).
        Providing fiscal oversight of allocated funds.
        Conducting a system-wide quality assurance and improvement program.
        Implementing staff development and training programs.
        Assuring consumer and family involvement in the planning, assessment, and review of
          services and in the development of new programs and policies.
        Facilitating grant and program development.
C. Structures

In order to accomplish these goals and objectives, collaboration with Member agencies has developed
a series of organizational structures as outlined below:

      Director Level Meetings: Directors of Community Services Network agencies meet monthly
       to review major system developments, to formulate policy recommendations, and facilitate
       program planning, strategic planning and continuous quality improvement.

      Service System Coordination Meetings: Middle managers from member agencies meet
       monthly to ensure coordination of services and address issues that affect the system as a
       whole. The committee also develops procedures to implement policies established for the
       CSN and focuses on continuous quality improvement.

      Interagency Treatment Planning Meetings: These meetings are largely patient-focused, but
       also serve to identify problems in the functioning of the service system. Identified systems
       problems are referred to the appropriate committee for review and action.

      Liaisons: Individual or agency staff serve as liaisons to coordinate for patients who are
       treated either simultaneously or consecutively by different agencies.

      Case Managers: These individuals work individually at agency boundaries to access services
       for patients.

      System-Wide Functions: There are several system-wide functions performed for the
       Community Services Network by leadership as described in the attached Table of
       Organization. These include the involvement of the Medical Director in the areas of medical
       and quality assurance and improvement, the involvement of the Director of Clinical
       Operations in the area of clinical programming, fiscal oversight by the Chief Operating
       Office, and involvement in overall management by the Chief Executive Officer.
D. Member Agencies
 AGENCY                                 SERVICES PROVIDED
                                        Emergency/Crisis, Inpatient, Sub-Acute Transitional
 (Lead Agency)                          Living Program, Case Management, Substance Abuse,
                                        Outpatient, Social Rehabilitation, Consultation and

                                        Clinical (Outpatient)
Yale Behavioral Health Services
at Hamden

                                        Residential Support, Case Management, Shelter
Columbus House                          Outreach to Individuals who are Homeless

Continuum of Care, Inc.
                                        Residential Support, Crisis/Respite
Coordinating Council for Children in
Crisis, Inc.                            Case Management

ALSO – Cornerstone, Inc.                Residential Support, Clinical (Outpatient)
Dixwell/Newhallville Community Mental Clinical (Outpatient)
Health Services

Easter Seal Goodwill Industries
Rehabilitation Center, Inc.             Vocational Rehabilitation

Fellowship Place
                                        Social and Vocational Rehabilitation

Hill Health Center                      Clinical (Outpatient; Inpatient Substance Abuse), Case

Hospital of St. Raphael                 Clinical (Outpatient)

Liberty Community Services              Residential Support, Case Management

Marrakech Day Services, Inc.            Vocational Rehabilitation
New Haven Home Recovery                 Residential Support, Shelter

Workers Achieving Gainful Employment Vocational Rehabilitation
Yale New Haven Hospital                 Emergency/Crisis

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