Download
1 / 54
540 likes | 1.17k Views
2. 2. Introduction. Welcome to the on-line refresher trainingPurpose of TrainingFor annual refresher training for staff who have a good knowledge of the current Human Rights regulations andRecommended for staff who have successfully completed 5 or more years of in-class training. 3. . Tr
E N D
1. 1 NORTHERN VIRGINIA JOINT TRAINING COALITION Human Rights
Refresher Training
April 24, 2009
2. 2 Introduction Welcome to the on-line refresher training
Purpose of Training
For annual refresher training for staff who have a good knowledge of the current Human Rights regulations and
Recommended for staff who have successfully completed 5 or more years of in-class training
3. 3 Training Outline Format for the training:
This self-directed on-line refresher training should be completed within one hour.
This on-line training will consist of the following:
1. Power Point presentation – Read all slides
2. Complete 30 question True/False test
3. (Optional) Advanced scenarios/Question and Answer section
4. 4 Human Rights Regulations
The following slides will cover current Human Rights Regulations:
5. 5 Human Rights Regulations Dignity
Services
Participation in Decision Making
Confidentiality
Access to and Amendment of Service Records
Freedoms of Everyday Life
Use of Seclusion, Restraint, Time Out
Work
Research
Substitute Decision Making
Determination of Capacity to Give Consent or Authorization
Authorized Representatives
Complaint Resolution, Hearing, Appeals Process
Variances
Reporting Requirements
Responsibilities and Duties
6. 6 Legal Rights Acquire, retain, and dispose of property;
Sign legal documents;
Buy or sell;
Enter into contracts;
Register and vote;
Get married, separated, divorced, or have a marriage annulled;
Hold a professional, occupational, or vehicle operator’s license;
Make a will; execute an advanced directive or WRAP;
Have access to lawyers and the courts.
7. 7 Provider Responsibilities and Duties Assurance of Rights Providers will:
Prominently display a sign listing the rights of individuals under the Regulations and how individuals can contact a human rights advocate.
This document shall be presented in a manner, format, and languages most frequently understood by the individual.
8. 8 Provider Responsibilities and Duties Assurance of Rights (continued)
Notify each individual and his or her authorized representative (AR), as applicable, about these rights, including: how to file a complaint, how to contact a human rights advocate, and the advocate’s role in the complaint process.
This notice will be provided at the start of service and every year thereafter.
“Authorized Representative” means a person permitted by law or these regulations to authorize the disclosure of information or to consent to treatment and services or participation in human research. The decision-making authority of an authorized representative recognized or designated under these regulations is limited to decisions pertaining to the designating provider.
“Authorized Representative” means a person permitted by law or these regulations to authorize the disclosure of information or to consent to treatment and services or participation in human research. The decision-making authority of an authorized representative recognized or designated under these regulations is limited to decisions pertaining to the designating provider.
9. 9 Dignity
10. 10 In residential settings, each individual has the right to:
Have sufficient and suitable clothing for his/her exclusive use.
Receive nutritionally adequate and appetizing meals.
Live in a humane, safe, and sanitary environment.
Practice a religion and participate in religious services.
Have access to paper, pencils and stamps.
Have help in writing or reading mail as needed.
Communicate privately with any person by mail or telephone.
Have or refuse visitors.
Dignity (continued) Meals are consistent with any individualized diet program, prepared and served in sanitary conditions, and served at appropriate times and temperatures
Human, safe & sanitary: Toilets, sinks, showers and tubs are designed to accommodate individual’s physical needs; reasonable privacy and private storage space; direct outside air provided by a window that opens or an air conditioner; windows or skylights in all major areas; clean air, free of bad odors; and room temperatures that are comfortable year round and compatible with health requirements.
Religious services or practices that present a danger of bodily injury to any individual or interfere with another individual’s religious beliefs or practices may be limited. Need to discuss the reason with the individual, notify the human rights advocate prior, document the reason in the record and review.
Participation in religious services or practices may be reasonably limited in accordance with other general rules limiting privileges or times or places of activities.
Access to paper, pencils and stamps: If an individual has funds to buy paper, pencils, and stamps to send a letter every day, the provider does not have to pay for them.
Mail: If there is cause to believe an individual’s mail contains illegal or dangerous items, staff may open the mail, but not read it, in the presence of the individual.
The use of the phone may be limited to certain times and places to make sure that other individuals have equal access to the telephone and that they can eat, sleep, or participate in an activity without being disturbed .
Access to visitors may be limited when the visitors are suspected of bringing contraband or threatening harm.
Meals are consistent with any individualized diet program, prepared and served in sanitary conditions, and served at appropriate times and temperatures
Human, safe & sanitary: Toilets, sinks, showers and tubs are designed to accommodate individual’s physical needs; reasonable privacy and private storage space; direct outside air provided by a window that opens or an air conditioner; windows or skylights in all major areas; clean air, free of bad odors; and room temperatures that are comfortable year round and compatible with health requirements.
Religious services or practices that present a danger of bodily injury to any individual or interfere with another individual’s religious beliefs or practices may be limited. Need to discuss the reason with the individual, notify the human rights advocate prior, document the reason in the record and review.
Participation in religious services or practices may be reasonably limited in accordance with other general rules limiting privileges or times or places of activities.
Access to paper, pencils and stamps: If an individual has funds to buy paper, pencils, and stamps to send a letter every day, the provider does not have to pay for them.
Mail: If there is cause to believe an individual’s mail contains illegal or dangerous items, staff may open the mail, but not read it, in the presence of the individual.
The use of the phone may be limited to certain times and places to make sure that other individuals have equal access to the telephone and that they can eat, sleep, or participate in an activity without being disturbed .
Access to visitors may be limited when the visitors are suspected of bringing contraband or threatening harm.
11. 11 Sometimes a clinical approach is needed limiting an individual’s rights to:
Communicate by mail
Use the telephone
Limit or supervise an individual’s visitors
If there is cause to believe that an individual’s mail contains illegal or dangerous items, staff may open the mail, but not read it, in the presence of the individual.
Dignity (continued) Ability to communicate by mail may be limited if in the judgment of a licensed professional, the communication with another person or persons will result in demonstrable harm to the individual’s mental health.
Access to the telephone may be limited if in the judgment of a licensed professional, communication with another person(s) will result in demonstrable harm to the individual or significantly affect his treatment .
Access to visitors may be limited or supervised only when, in the judgment of a licensed professional, the visits result in demonstrable harm to the individual or significantly affect the treatment.
Ability to communicate by mail may be limited if in the judgment of a licensed professional, the communication with another person or persons will result in demonstrable harm to the individual’s mental health.
Access to the telephone may be limited if in the judgment of a licensed professional, communication with another person(s) will result in demonstrable harm to the individual or significantly affect his treatment .
Access to visitors may be limited or supervised only when, in the judgment of a licensed professional, the visits result in demonstrable harm to the individual or significantly affect the treatment.
12. 12 Dignity (continued) Prior to implementation of any limitations to an individual’s rights, staff will:
Discuss the issue with the individual.
Inform the local human rights advocate of the reasons for the restriction.
Document in the record the reasons for the restriction.
Review the need for the restriction by the team each month and document in the record.
13. 13 Anyone who knows of or has reason to believe that an individual may have been abused, neglected, or exploited will immediately report this information to the appropriate supervisor/director and within 24 hours to the appropriate agencies and the individual’s AR if there is one.
If abuse, neglect or exploitation is a crime, contact the appropriate law enforcement authorities.
Staff, in consultation with their supervisor/director, will:
Immediately take the necessary steps to protect the individual until an investigation is completed in accordance with agency policies and procedures and the human rights regulations.
For peer-on-peer aggression, protect the individuals from the aggressor in accordance with sound therapeutic practice. Such instances may constitute potential neglect.
If the individual affected or the AR is not satisfied with the director’s actions, he/she or the AR may file a petition for an LHRC hearing.
Abuse, Neglect or Exploitation The Director is defined as the chief executive officer of any provider delivering services. In organizations that also include services not covered by these regulations, the director is the chief executive officer of the service or services licensed, funded, or operated by the Department.
The Director may direct the employee (s) to have no further contact with the individual or may temporarily reassign or transfer the employee (s) to a position that has no direct contact with individuals receiving services or may temporarily suspend the employee (s) pending completion of the investigation.
The provider is not required to inform the individual or his AR of the disclosure to APS/CPS if the provider, in the exercise of professional judgment, believes that informing the individual would place the individual at risk of serious harm or the provider would be informing the AR, and the provider reasonably believes that the AR is responsible for the abuse or neglect, and that informing the AR would not be in the best interests of the individual.
Peer-on-Peer: APS has stated that in long-term care programs to call them if one or more of the following criteria is met:
Injury requires medical attention from a doctor or nurse
Sexual abuse
One individual profited financially at the expense of another
Abuse is ongoing
Individual is fearful of the other
Staff has not taken action to stop or address the problem
If in doubt whether or not to call APS, place the call and let them decide whether or not to investigate.The Director is defined as the chief executive officer of any provider delivering services. In organizations that also include services not covered by these regulations, the director is the chief executive officer of the service or services licensed, funded, or operated by the Department.
The Director may direct the employee (s) to have no further contact with the individual or may temporarily reassign or transfer the employee (s) to a position that has no direct contact with individuals receiving services or may temporarily suspend the employee (s) pending completion of the investigation.
The provider is not required to inform the individual or his AR of the disclosure to APS/CPS if the provider, in the exercise of professional judgment, believes that informing the individual would place the individual at risk of serious harm or the provider would be informing the AR, and the provider reasonably believes that the AR is responsible for the abuse or neglect, and that informing the AR would not be in the best interests of the individual.
Peer-on-Peer: APS has stated that in long-term care programs to call them if one or more of the following criteria is met:
Injury requires medical attention from a doctor or nurse
Sexual abuse
One individual profited financially at the expense of another
Abuse is ongoing
Individual is fearful of the other
Staff has not taken action to stop or address the problem
If in doubt whether or not to call APS, place the call and let them decide whether or not to investigate.
14. 14 Service Delivery We partner with individuals to develop person-centered services in a welcoming environment with clarity about “who you call” when you have a concern.
We partner with individuals to develop case management plans and services tailored to their needs and preferences, using best practices.
We build on the strengths of individuals.
We support an individual’s interest in advance directives and Wellness Recovery Action Plans (WRAP) and document the existence of such tools in the individual’s record.
Person centered means focusing on the needs and preferences of the individual, empowering and supporting the individual in defining the direction for his life, and promoting self-determination, community involvement, and recovery.
Person centered means focusing on the needs and preferences of the individual, empowering and supporting the individual in defining the direction for his life, and promoting self-determination, community involvement, and recovery.
15. 15 Participation in Decision Making Each individual has a right to:
Participate meaningfully in decisions regarding all aspects of services affecting him/her, including requesting admission to or discharge from any service at any time.
Give or not give informed consent for participation in treatment/services that pose a risk greater than ordinarily encountered
Participate in human research. ISP and discharge plan shall incorporate the individual’s preferences consistent with his condition and need for service and the provider’s ability to address them.
Services record shall include evidence that the individual has participated in the development of his ISP and discharge plan, in changes to these plans, and in all other significant aspects of his treatment and services.
Services record shall include the signature or other indication of the individual’s or his AR’s consent.
Be accompanied, except during forensic evaluations, by a person (s) whom the individual trusts to support and represent him when he participates in services planning, assessments, evaluations, and discharge planning.
A competent minor may independently consent to treatment for sexually transmitted or contagious diseases, family planning or pregnancy, or outpatient services or treatment for mental illness, emotional disturbance, or substance us disorders.ISP and discharge plan shall incorporate the individual’s preferences consistent with his condition and need for service and the provider’s ability to address them.
Services record shall include evidence that the individual has participated in the development of his ISP and discharge plan, in changes to these plans, and in all other significant aspects of his treatment and services.
Services record shall include the signature or other indication of the individual’s or his AR’s consent.
Be accompanied, except during forensic evaluations, by a person (s) whom the individual trusts to support and represent him when he participates in services planning, assessments, evaluations, and discharge planning.
A competent minor may independently consent to treatment for sexually transmitted or contagious diseases, family planning or pregnancy, or outpatient services or treatment for mental illness, emotional disturbance, or substance us disorders.
16. 16 In an emergency:
Providers may initiate, administer, or undertake a proposed treatment without the consent of the individual or the individual’s AR; and inform the AR as soon as possible.
All emergency treatment or services will be documented in the individual's services record within 24 hours.
Providers may provide treatment without consent in accordance with a court order or in accordance with other provisions of law that authorize such treatment or services.
Participation in Decision Making (continued) Providers shall continue emergency treatment without consent beyond 24 hours only after a review of the individual’s condition and if a new order is issued by a professional who is authorized by law and the provider to order treatment.
Providers shall notify the human rights advocate if emergency treatment without consent continues beyond 24 hours.
Providers shall develop and integrate treatment strategies into the ISP to address and prevent future emergencies to the extent possible following provision of treatment without consent.
Providers shall obtain and document in the services record the consent of the individual or his AR to continue any treatment initiated in an emergency that lasts longer than 24 hours after the emergency began.
The use of an advanced directive and/or wellness recovery action plan (WRAP) can also be used to guide the provision of emergency treatment agreed to ahead of time by the individual. Providers shall continue emergency treatment without consent beyond 24 hours only after a review of the individual’s condition and if a new order is issued by a professional who is authorized by law and the provider to order treatment.
Providers shall notify the human rights advocate if emergency treatment without consent continues beyond 24 hours.
Providers shall develop and integrate treatment strategies into the ISP to address and prevent future emergencies to the extent possible following provision of treatment without consent.
Providers shall obtain and document in the services record the consent of the individual or his AR to continue any treatment initiated in an emergency that lasts longer than 24 hours after the emergency began.
The use of an advanced directive and/or wellness recovery action plan (WRAP) can also be used to guide the provision of emergency treatment agreed to ahead of time by the individual.
17. 17 Informed Consent Voluntary written agreement by the individual or his/her AR is given freely without coercion for:
Surgical procedures
Electroconvulsive treatment
Use of psychotropic medications
Participation in human research
The signed form must be placed in the services record To be informed, consent for any treatment or service must be based on disclosure of and understanding by the individual or his authorized representative of the following information:
An explanation of the treatment, service, or research and its purpose;
When proposing human research, the provider shall describe the research and its purpose, explain how the results of the research will be disseminated and how the identity of the individual will be protected, and explain any compensation or medical care that is available if an injury occurs;
A description of any adverse consequences and risks associated with the research, treatment, or service;
A description of any benefits that may be expected from the research, treatment, or service;
A description of any alternative procedures that might be considered, along with their side effects, risks, and benefits;
Notification that the individual is free to refuse or withdraw his consent and to discontinue participation in any treatment, service, or research requiring his consent at any time without fear or reprisal against or prejudice to him; and
A description of the ways in which the individual or his authorized representative can raise concerns and ask questions about the research, treatment, or service to which consent is given.To be informed, consent for any treatment or service must be based on disclosure of and understanding by the individual or his authorized representative of the following information:
An explanation of the treatment, service, or research and its purpose;
When proposing human research, the provider shall describe the research and its purpose, explain how the results of the research will be disseminated and how the identity of the individual will be protected, and explain any compensation or medical care that is available if an injury occurs;
A description of any adverse consequences and risks associated with the research, treatment, or service;
A description of any benefits that may be expected from the research, treatment, or service;
A description of any alternative procedures that might be considered, along with their side effects, risks, and benefits;
Notification that the individual is free to refuse or withdraw his consent and to discontinue participation in any treatment, service, or research requiring his consent at any time without fear or reprisal against or prejudice to him; and
A description of the ways in which the individual or his authorized representative can raise concerns and ask questions about the research, treatment, or service to which consent is given.
18. 18 Confidentiality Each individual is entitled to have all identifying information that a provider maintains or knows about him remain confidential.
When providers disclose identifying information, they shall attach a statement that informs the person receiving the information that it must not be disclosed to anyone unless the individual authorizes the disclosure or unless state law or regulation allows or requires further disclosure without authorization.
19. 19 Authorizations
Providers may encourage individuals to name family members, friends, and others who may be told of their presence and general condition or well-being.
Providers may disclose to a family member, other relative, a close personal friend, or any other person identified by the individual, information that is directly relevant to that person’s involvement with the individual’s treatment, payment or health care operations, if certain conditions are met as outlined in 12VAC35-115-80.
Authorizations must be obtained and documented in the services record.
Confidentiality (continued) Except for information governed by 42 CFR Part 2 (see slide 18), providers may disclose to a family member, other relative, a close personal friend, or any other person identified by the individual, information that is directly relevant to that person’s involvement with the individual’s treatment, payment or health care operations for his healthcare, if:
The provider obtains the individual’s agreement
The provider provides the individual with the opportunity to object to the disclosure, and
The individual does not object or the provider reasonably infers from the circumstances, based on the exercise of professional judgment, that the individual does not object to the disclosure.
If the opportunity to agree or object cannot be provided because of the individual’s incapacity or an emergency circumstance, the provider may, in the exercise of professional judgment, determine whether the disclosure is in the best interest of the individual and, if so, disclose only the information that is directly relevant to the person’s involvement with the individual’s health care.
Except for information governed by 42 CFR Part 2 (see slide 18), providers may disclose to a family member, other relative, a close personal friend, or any other person identified by the individual, information that is directly relevant to that person’s involvement with the individual’s treatment, payment or health care operations for his healthcare, if:
The provider obtains the individual’s agreement
The provider provides the individual with the opportunity to object to the disclosure, and
The individual does not object or the provider reasonably infers from the circumstances, based on the exercise of professional judgment, that the individual does not object to the disclosure.
If the opportunity to agree or object cannot be provided because of the individual’s incapacity or an emergency circumstance, the provider may, in the exercise of professional judgment, determine whether the disclosure is in the best interest of the individual and, if so, disclose only the information that is directly relevant to the person’s involvement with the individual’s health care.
20. 20 Confidentiality (continued) 42CFR Part 2
If an individual’s services record pertains in whole or in part to diagnosis and referral or treatment of substance use disorders, providers shall disclose information only according to 42 CFR Part 2.
Generally, under 42 CFR Part 2 the program may not tell a person outside the program that an individual participates in any substance abuse treatment or disclose any information identifying an individual as an alcohol or drug abuser unless:
the individual consents in writing
the disclosure is allowed by a court order
the disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit or program evaluation.
21. 21 Confidentiality (continued) Authorization to disclose PHI is not needed under specified conditions for certain circumstances such as:
Emergencies; Protection of public safety
Providers (employees of the agency, consultants, agents, the Department, the CSB) for treatment, payment and health care operations (TPO)
Health Plans; Other statutes or regulations on Health Records Privacy (Code of Virginia §32.1-127.1:03)
Court proceedings; Protection and advocacy agency
Legal counsel; A law enforcement official under specific circumstances
Human rights committees; Others authorized or required such as State licensing, human rights, Medicaid, certification, accreditation, and quality assurance reviews
Pre-admission screening, services and discharge planning (not for ICFMR)
Historical Research
22. 22 Access/Amendment of Records Each individual and his/her AR has the right to:
See, read, and obtain a copy of his/her own services record.
Let certain other people see, read, or get a copy of his/her own services record.
Challenge, request to amend or receive an explanation of anything in the record.
Let anyone who sees his/her record, regardless of whether amendment have been made, know that the individual has tried to amend the record or explain his/her position and what happened as a result.
23. 23 Access/Amendment of Record (continued) A provider may deny access to all or a part of an individual’s services record in accordance with the Human Rights regulations. To do so, an involved physician or clinical psychologist must:
Sign a statement in the record that access would be reasonably likely to endanger the life or physical safety of the individual or another person.
Tell the individual as much about his/her record as possible.
Notify the individual of any restrictions and time limits placed on access and conditions for their removal.
Notify the Human Rights Advocate.
24. 24 Service providers will:
Encourage each individual’s participation in normal activities.
Not limit or restrict any individual’s freedom more than is needed to achieve a therapeutic benefit, maintain a safe and orderly environment, or intervene in an emergency.
Ensure that a qualified professional regularly reviews every restriction and that it is discontinued when the criteria for removal is met.
Program Rules
Give the rules to and review them with each individual and the AR if applicable in a way that the individual can understand them, including explaining possible consequences for violating them.
Restrictions on Freedoms of Everyday Life
25. 25 Use of Seclusion, Restraint, and Time Out Each individual is entitled to be completely free from any unnecessary use of restraint or time out.
No programs will use seclusion under any circumstances.
Restraints must be justified and implemented in accordance with agency procedures.
Restraints will not exceed 20 minutes or according to agency procedures.
A qualified professional will review every use of physical restraint ASAP after it is carried out and document the results in the record.
No individual will be placed in time out for more than 30 minutes per episode
26. 26 Providers shall not use restraint unless other less restrictive techniques have been considered.
Documentation must be placed in the services plan that this is the least restrictive technique
Programs may use restraint or time out in a behavioral treatment plan, but only if:
All plans are initiated, developed, carried out, and monitored by a qualified professional.
Reviewed and approved in advance by the Behavior Management Committee (BMC) and LHRC.
Reviewed quarterly by the BMC and LHRC. Use of Seclusion, Restraint, and Time Out (continued)
27. 27 Behavior Management Committee (BMC)
Members may be comprised of CSB & contract staff
Reviews from a clinical perspective restrictive behavioral plans
Follows best practice
Local Human Rights Committee (LHRC)
Group of at least five people appointed by the State Human Rights Committee
One-third of the appointments are individuals who receive services or family members, at least one health care provider, and other appointments may be professionals such as lawyers or persons with interest, knowledge or training in the field of mental health, substance use, or intellectual disabilities.
Meets monthly or as otherwise scheduled
Use of Seclusion, Restraint, and Time Out (continued)
28. 28 Work Individuals have a right to engage or not engage in work or work-related activities consistent with their service needs while receiving services.
Personal maintenance and personal housekeeping by individuals receiving services in residential settings are not subject to this provision.
29. 29 Research Each individual has a right to choose to participate or not participate in human research.
Exemptions under Code of Virginia (32.1-162.17)
Research involving collection or study of existing data, documents, records…if the information is recorded in a manner that subjects cannot be identified, directly or through identifiers linked to the subjects.
30. 30 Research (Continued) Human research projects must follow all other state and federal laws and regulations including:
Obtain review and approval from an institutional review board (IRB) or research review committee (RRC) prior to performing or participating in human research.
31. 31 Research (Continued)
Present research request, a copy of the approval from the IRB or RRC, and sample informed consent form to the LHRC for approval before an individual receiving services may participate.
Obtain prior, written, informed consent from the individual or his/her AR.
Provide periodic updates to the LHRC.
32. 32 If the capacity of an individual to consent to treatment, services, or research, or authorize the disclosure of information is in doubt, the provider shall obtain an evaluation from a professional who is qualified by expertise, training, education, or credentials and not directly involved with the individual.
Providers shall determine the need for an evaluation whenever the individual’s condition warrants, the individual requests a review, at least every six months, and at discharge. Substitute Decision Making
33. 33 Determination of Capacity If the individual’s record indicates that the individual is not expected to obtain or regain capacity, the provider shall document annually that it has reviewed the individual’s capacity to make decisions and whether there has been any change in that capacity.
If the individual or his/her family objects to the results of the qualified professional’s determination, the provider shall immediately inform the human rights advocate.
34. 34 Authorized Representatives When an individual lacks capacity to consent or authorize disclosure of information, consent can be obtained from:
An attorney-in-fact
A health care agent appointed by the individual under an advance directive or power of attorney
A legal guardian
35. 35 Authorized Representatives (continued) If an attorney-in-fact, health care agent, or legal guardian is not available, the agency director shall designate a substitute decision-maker as an AR according to a priority system.
Family member chosen by the individual.
Best qualified person according to the following order: spouse, adult child, parent, adult brother or sister, any other blood relative.
Next friend, according to human rights regulations and after review by the LHRC.
Conditions for removal of an AR are outlined in 12VAC35-115-146, G.
36. 36 Authorized Representatives (continued) Conditions for removal of an AR
Whenever an individual has regained capacity to consent, the director shall immediately remove any AR, notify the individual and the AR, and ensure that the services record reflects that the individual is capable of making his/her own decisions.
Whenever an individual with an AR who is his legal guardian has regained capacity to give informed consent, the director may use the applicable statutory provisions to remove the AR.
If powers of attorney and health care agents do not cease on their own accord when the individual is no longer incapacitated, the director shall seek the consent of the individual and remove the person as an AR.
37. 37 Authorized Representatives (continued) The director shall remove the AR if the AR becomes unavailable, unwilling, or unqualified to serve.
The individual or the advocate may request the LHRC review the director’s decision to remove an AR.
Prior to any removal, the director shall notify the individual of the decision to remove the AR, of his/ her right to request that the LHRC review the decision, and of the reasons for the removal decision. This information shall be placed in the services record.
38. 38 Complaint and Fair Hearing Each individual has a right to:
Complain that his/her service provider has violated any of the rights assured under these regulations.
Have a timely and fair review of any complaint.
Have someone file a complaint on his/her behalf.
Use program and other complaint procedures.
Complain under any other applicable law, including complain to the protection and advocacy agency.
39. 39 Not all questions, issues or concerns need to rise to the level of a human rights complaint; many may be resolved within the context of the treatment/service delivery setting.
Staff are to work with individuals served to resolve human rights questions, issues or concerns at the service delivery level.
Questions, issues or concerns resolved at the service delivery level are NOT considered official human rights complaints. RESOLVING ISSUES PRIOR TO BECOMING A COMPLAINT
40. 40 Complaint Resolution Anyone who believes a provider has violated an individual’s rights may report an official complaint to the agency’s director/designee, or the State Human Rights Advocate.
If the report is made only to the director, he/she shall immediately notify the human rights advocate or by the next business day.
If the report is made only to the human rights advocate, he/she shall immediately notify the director or by the next business day.
The director or advocate shall discuss the report with the individual, explain the informal and formal complaint process, ask the individual if he/she understands the choice, and then ask how he/she would like to pursue the complaint.
41. 41 Complaint Resolution…Informal Process Informal Complaint Process
The director/designee shall attempt to resolve the complaint immediately.
If the complaint is resolved, no further action is required.
If not resolved within five working days, the director/designee shall refer it for resolution under the formal process.
The individual may extend the informal process 5-day time frame for good cause. All such extensions shall be reported to the human rights advocate by the director/designee.
42. 42 Complaint Resolution… Formal Process Formal Complaint Process
The director/designee shall try to resolve the complaint by contacting/meeting with the individual, any representative chosen, the human rights advocate, staff within 24 hours of receipt of the complaint or next business day.
Conduct an investigation of the complaint, if the complaint is going forward.
43. 43 Complaint Resolution Formal Process (Continued) The director/designee gives the individual and AR a written preliminary decision and, where appropriate, an action plan for resolving the complaint within 10 working days of receipt of the complaint.
If the individual reports disagreement with the preliminary decision or action plan and reports his/her disagreement to the director in writing within 5 working days after receiving the decision or action plan, the director/designee shall investigate further as appropriate and make a final decision regarding the complaint within 5 days.
If the individual disagrees with the final decision or action plan, he/she may file a petition for a hearing by the LHRC.
44. 44 Variances Variances to these regulations shall be requested and approved only when the provider has tried to implement the relevant requirement without a variance and can provide objective, documented information that continued operation without a variance is not feasible, or will prevent the delivery of effective and appropriate services and supports to individuals.
All variances shall be approved for a specific time period and must be reviewed at least annually by the SHRC.
45. 45 Provider Requirements for Reporting to the Department Information concerning abuse, neglect and exploitation will be collected in the following manner:
46. 46
Deaths and serious injuries: in writing to the Department within 24 hours of discovery and by telephone to the AR, as applicable, within 24 hours.
An annual report of each instance of restraint by the 15th of January each year to the office of Health and Quality Care.
An annual report of all human rights complaints processed informally and formally is given to the LHRC. Provider Requirements for Reporting to the Dept. (continued)
47. 47 REFERENCES Human Rights Regulations:
http://www.dmhmrsas.virginia.gov/documents/HumanRights/OHR-RevisedRegulations.pdf
48. 48
Good Luck
&
High Scores!
49. Human Rights Test Questions
50. Human Rights Test Questions
51. 51 Scenarios for Advanced Human Rights Training: A. An individual with a learning disability, at a community worksite, occasionally takes off or reports late to work due to personal reasons; such as not being able to arrange for child care during snow days. He has enough leave to cover those absences. However, the manager at the job site refuses to grant him leave saying that he needs to make arrangements
for child care and report to work on time just like everybody else. He further adds that he has to treat everyone equally.
Questions:
1. Is the manager wrong in saying that he needs to treat everyone equally?
2. Should the manager look into this individual’s special needs and accommodate accordingly?
52. 52 Scenarios for Advanced Human Rights Training: (Continued) B. A staff overheard another staff greeting a consumer by saying “hi sweetheart”. The consumer replies “excuse me, I am formal name to you”
Questions:
1. What was wrong with the way the staff addressed the consumer?
2. How did the consumer exercise his rights?
3. If you were the other staff who overheard the conversation and the consumer said nothing, how would you address this in your worksite?
53. 53 Scenarios for Advanced Human Rights Training: (Continued)
54. 54 Scenarios for Advanced Human Rights Training: (Continued)
D. An adult consumer, at his annual meeting, states that he wants to vote. His mother says to him “you can’t vote”. His mother is his legal guardian.
Questions:
1. Can his mother determine whether he can or cannot vote?
2. Can staff do anything about it?
PLEASE GIVE YOUR TESTS TO YOUR SUPERVISOR
55. 55 THE END!!! On-line Human Rights refresher developed by the following No. Va Joint Training Coalition subcommittee members:
Stacy Boseman-MVLE
Jacque Scholl-CFS
Judy Rutherford-SOC
Aldrina Maiden-CSB-MR Services
We’ll see you next year!!!
