Client’s Right/ Confidentiality

It is the policy of PCSCS, LLC to protect and assure the Rights of Persons Served in accordance with APSM 95-2 and NC General Statute 122C. In addition, information regarding their rights per the UN Declaration of Client Rights is given to consumers upon admission. It is the responsibility of PCSCS, LLC to protect all rights, including legal rights of the person served.

DEFINITIONS

Abuse: The infliction of mental or physical pain or injury by other than accidental means, or unreasonable confinement, or the deprivation by an employee of services which are necessary to the mental or physical health of the client.

Neglect: The failure to provide care or services necessary to maintain the mental or physical health and well-being of the client.

Mistreatment: The practice of treating someone or something badly.

Exploitation: The use of a client’s person or property for another’s profit or advantage or breech of a fiduciary relationship through improper use of a client’s person or property including situations where an individual obtains money, property, or services from a client from undue influence, harassment, deception or fraud.

PROCEDURES

Basic Human Rights for all persons served: The following basic human rights are afforded to every person’s served, receiving services from PCSCS, LLC:

❖ Right to dignity, privacy and humane care.

❖ Right to live as normally as possible while receiving care and treatment.

❖ Right to receive age-appropriate treatment, access to medical care and habilitation, and the right to a written person-centered treatment plan that reflects an individual’s desired goals and outcomes.

❖ Right to be informed in advance of the potential risks and future treatment needs. The information should be provided in a manner that is clear and understandable. This information is provided verbally, with some written literature available, in educational sessions and through active participation in treatment team meetings.

❖ Right to confidentiality of information.

❖ Right to be free from unnecessary or excessive medication. Medication shall not be used as punishment, discipline, or for staff convenience.

❖ All voluntary persons served have the right to consent to or refuse treatment offered, including opportunity to consent to or refuse planned interventions; right to identify whom information regarding the treatment of the person served can be released to and the right to refuse release of information; right to determine the composition of the service delivery team; and the right to consent of refuse involvement in research projects.

❖ Right to request notification after occurrence of any or specified interventions

❖ Right to be informed of emergency procedures.

❖ Right to exercise all civil rights; to dispose of property, execute instruments, make purchases, enter into contractual relationships, register to vote, bring civil actions, marry, and divorce – unless the persons served has been adjudicated incompetent and access or referral to legal entities for appropriate representation.

❖ Right to certain safeguards and carefully controlled circumstances when interventions are used.

❖ Right to social integration, self-governance groups and treatment in the least restrictive, most appropriate environment and access to self-help and advocacy support services.

❖ Right to be free from corporal punishment, neglect, abuse (physical, emotional, sexual, psychological), humiliation, retaliation, mistreatment, financial or other exploitation. Sexual abuse or harassment may include any gestures, verbal or physical, that reference sexual acts or sexuality or objectify the persons served sexually. Fiduciary abuse refers to any exploitation of the persons served for financial gain. This abuse may include misuse of the funds of the persons served or taking advantage of the provider relationship with the persons served.

❖ Right to be free from physical restraint and isolation time out.

❖ Right to informed consent, refusal or expression of choice regarding release of information.

❖ Right to be protected by PCSCS, LLC adhering to research guidelines and ethics when persons served are involved.

❖ Right to investigation and resolution of alleged infringement of rights or other legal rights. If the persons served feels that there has been an infringement of their rights, they must file a grievance report according to the Persons Served Grievance and Complaint Policy. If the infringement involves abuse, neglect or exploitation they must follow the procedure for the Abuse, Neglect, or Exploitation Policy.

❖ All persons who are under active court orders to receive treatment can receive services from PCSCS, LLC.

❖ All persons served have the Right to participate in more than one program/service within PCSCS, LLC.

❖ Right to have access to pertinent information in a sufficient time ensuring the ability to make an appropriate decision-making regarding treatment.

❖ Right to be free from participating in research projects since PCSCS, LLC does not participate.

Rights of persons served under the age of 18

Those persons served under the age of 18 are entitled to the same rights as adults, as well as the following additional rights.

❖ Proper adult supervision and guidance;

❖ Opportunity for normal maturation;

❖ Receive appropriate educational services and vocational training;

❖ Appropriate structure, supervision, and control consistent with rights; and;

❖ Treatment apart and separate from adult persons served, where practical and not in conflict with his/her needs

Restriction of Rights

Every effort is made to assist you in your recovery and avoid any need to restrict rights or services. However, there are situations when restrictions must be applied to ensure either personal safety or the benefit of services being provided. The following are situations when restrictions to program participation or services may occur:

❖ Any verbal, physical or sexual assault upon staff or other program participates*

❖ Possession or use of a weapon on Center premises *

❖ Attending Center programs or presenting for services while under the influence of alcohol or illicit drugs

❖ Disruptive behavior that deters from the program’s functioning or service delivery.

❖ Refusal to follow programs rules

❖ Developing patterns of inconsistency in coming in for treatment ad failing to keep appointments despite reminders from program staff

❖ Refusal to follow through with treatment objectives and interventions despite efforts to modify expectations.

❖ Breaches of confidentiality of other program participants

Individual programs may have more specific rules and restrictions that are communicated to clients at the time they are orientated to the program.

Whenever it becomes necessary to place a restriction on rights or services, you will be informed of the reason for the restriction, the duration of the restrictions, your rights to appeal if any, and what you must do to be either reinstated to the program or eligibility to receive service.

*May also result in police intervention

Rights Restriction Procedure

The restriction of a person served rights is individualized. PCSCS, LLC does not allow any standing practices that restrict person served rights.

If it is determined that restriction of a right is therapeutically indicated, the following procedures must be followed:

• A written statement will be placed in the persons served record indicating in detail the reason for the restriction. The restriction must be reasonable and related to a person served treatment or rehabilitation needs.

• Less intrusive alternatives are thoroughly, systematically, and continuously considered and used.

• A restriction is effective for a period not to exceed 30 days. An evaluation of each restriction shall be made by the qualified professional or the treatment team every seven days, at which time the restriction may be removed and the right or privilege be reinstated. Each evaluation of a restriction shall be documented in the persons served record.

• Restrictions on rights may be renewed only by a written statement entered by the Qualified Professional in the persons served record that states the reason for the renewal of the restriction.

• In the case of a competent adult, in each instance of initial restriction or renewal of restriction of rights, an individual designated by the persons served shall, upon consent of the persons served, be notified of the restriction and the reason for the restriction.

• In the case of a minor or incompetent adult, the legally responsible person shall be notified of each instance of the restriction of rights and the reason for the restriction of rights.

• Notification of the designated individual or legally responsible person shall be documented in writing in the persons served record.

• The Program Director and the staff involved in the implementation of the person centered plan shall be responsible for informing the persons served of the rights or privileges that are being restricted or reinstated.

Restrictive interventions Policy

It is the policy of PCSCS, LLC to not use seclusion, restraints, therapeutic holds, instructive procedures such as strip searches or pat downs, medical or behavioral intervention or any other form of restrictive interventions with consumers. PCSCS, LLC promote a safe and respectful environment that uses the least restrictive and most appropriate settings and methods, promote coping and engagement skills that are alternatives to injurious behavior to self or others, provide choices of activities meaningful to the individuals receiving treatment services or supports, and share the control over decisions with the consumer or legally responsible person and employees.

Procedures

1.​ Prior to being alone with consumers, employees are trained and demonstrate competence in utilizing least restrictive interventions, such as identification of warning signs, de-escalating behaviors, adjusting the environment, good communication, and providing positive feedback. Employees create an environment in which the likelihood of imminent danger of abuse or injury to a person with disabilities or others or property damage is prevented.

2.​ PCSCS, LLC does not permit the use of any procedure that has been prohibited by statute, rule or policy and includes:

a.​ any intervention that would be considered corporal punishment under G.S.122C-59;

b. ​the contingent use of painful bodily contact;

c.​ substance administered to induce painful bodily reactions (exclusive of Antabuse, if prescribed);

d.​ unpleasant tasting foodstuffs;

e. ​contingent application of any noxious substances which include but are not limited to noise, bad smells or splashing with water; and

f.​ any potentially physically painful procedure, excluding prescribed injections or stimulus that is administered to the consumer for the purpose of reducing the frequency or intensity of a behavior.

3.​ PCSCS, LLC is not a medical facility; therefore there would never be a time when electric or insulin shock would be utilized.

4.​ PCSCS, LLC does not permit the use of:

​a.​ seclusion;

​b.​ physical restraint;

​c.​ isolation time-out;

​d.​ any combination thereof; or

​e.​ protective devices used for behavioral control.

5.​ The following procedures are only to be employed when clinically or medically indicated as a method of therapeutic treatment (These procedures are not used by PCSCS, LLC):

a.​ planned non-attention to specific undesirable behaviors when those behaviors are health threatening;

b. contingent deprivation of any basic necessity; or

c.​ other professionally acceptable behavior modification procedures that are not prohibited in these procedures or physical restraint used for behavioral control.

6.​ The determination that a procedure is clinically or medically indicated, and the authorization for the use of such treatment for a specific individual, is only made by either a physician or a licensed practicing psychologist who has been formally trained and privileged in the use of the procedure.

7.​ PCSCS, LLC employees are trained prior to being alone with a consumer and annually in CPI only), which is a program approved by the Division of MH/DD/SAS as meeting content requirements as required by rules 10A NCAC 27 E .0107. Staff demonstrate competencies in the following core areas:

​a.​ Knowledge and understanding of the people being served;

​b.​ Recognizing and interpreting human behavior;

c.​ Recognizing the effect of internal and external stressors and that they may affect people with disabilities;

d.​ Recognizing cultural, environmental and organizational factors that may affect people with disabilities;

e.​ Recognizing the importance of and assisting the person’s involvement in making decisions about their life;

f.​ Skills in assessing individual risk for escalating behavior and communication strategies for defusing and de-escalating potential dangerous behavior; and

g.​ Positive behavioral supports.

8. ​If a consumer should become aggressive or display assaultive behaviors, staff will implement the consumer’s individual plan and the techniques allowed in NCI. If these approaches do not resolve the behavior, 911 is called, as appropriate.

CONFIDENTIALITY OF CLIENT INFORMATION

All information acquired in the course of attending or treating a client of the agency shall be held confidential. Release or disclosure of this information shall be prohibited except under the conditions that follow, and the appropriate determination of a right or need to know. Whenever a facility receives confidential information from another facility, agency or individual, then such information shall be treated as any other confidential information generated by the area or state facility. Release or disclosure of such information shall be governed by the rules of this Subchapter

A. Client information may be released under the following conditions:

❖ Authorization for release of information given by client or client’s legal representative, in accordance with APSM 45-1 (Confidentiality Rules) provided by the NC Division of Mental Health, Developmental Disabilities, and Substance Abuse Services and in compliance with state statutes and federal rules/regulations.

❖ When determined by a delegated employee that disclosure is otherwise authorized and has been properly documented.

❖ When it has been determined by a delegated employee that there is imminent danger to the health or safety of another or there is likelihood of a commission of a crime.

❖ When in response to a court order (not a subpoena) by a judicial official of competent jurisdiction.

❖ When it has been determined by a delegated employee that disclosure of non-identifying client information is necessary for research, statistical, or program planning purposes.

❖ When reporting alleged abuse or neglect (see policy and procedure on Reporting Abuse, Neglect, and Exploitation).

❖ When in accordance with Senate Bill 771-G.S. 122C Amendment regarding Confidentiality of Client Records.

B. Authority to release or disclose client information is delegated to the following PCSCS, LLC staff. In addition, the Director may designate in writing additional staff to be responsible for the release of information. Such designations will be maintained on file in each office. The Program Director will serve as the overall resource person for questions concerning the release or disclosure of client information.

1. Director of Clinical Services

2. Qualified Professional

3. Medical Records Manager

4. Staff designated by Director

C. PCSCS, LLC will not release client information until a Release/Exchange of Client Information form is obtained. (See Consent for Release of Information form in the Appendix.) The Consent form needs to comply with all state and federal laws and identify: the name of the person whom the information is to be released, the content and to whom released to, the purpose, the date signed and the date it expires, information on how to revoke authorization and signature of the party responsible for authorizing. D. Prior to obtaining consent for release of confidential information, a delegated employee shall inform the client or the legally responsible person that the provision of services is not contingent upon such consent and of the need for such release. The client or legally responsible person shall give informed consent voluntarily. Whenever confidential information is released with consent, a delegated employee shall ensure that documentation of the release when required is placed in the client record. Such documentation shall include the consent form, the date the information was released and signature of the delegated employee releasing the information. Exceptions are authorized in accordance with GS 122C-52 through 122C-56 (see paragraph E below)

❖ PCSCS, LLC will honor requests for the release or exchange of information from other agencies provided the content of such request conforms to the confidentiality rules and contains the information specified on the PCSCS, LLC form.

❖ A clear and legible photocopy of consent for release of information will be considered as valid.

❖ Confidential information related to HIV, AIDS, or AIDS related conditions will only be released in accordance with GS 130A-143. When authorization is given for the release of this information, the consent will specify that the information to be released include information related to HIV, AIDS, or AIDS related conditions.

❖ Area or state facilities releasing confidential information shall inform the recipient that re-disclosure of such information is prohibited without client consent.

❖ A stamp may be used to fulfill this requirement

❖ The following persons may sign a consent for the release of confidential information: the client’s legally responsible person; the next of kin of a deceased client

❖ PCSCS, LLC will contact the client or legally responsible person to confirm that consent is valid whenever the validity of consent is in question. The determination of validity will be documented in the client record.

❖ The delegated staff member releasing confidential information will ensure that the documentation of the release is placed in the client record by completing the bottom section of Release/Exchange of Client Information Form.

❖ When repeated disclosures for the same client to another agency are required, the disclosure of the information may be documented in the client record one time.

❖ Whenever confidential information is disclosed in accordance with SG 122C-55(E), the reason written consent could not be obtained will be documented in the client record.

❖ Human Rights Committee members will have access to confidential information only with the written consent of the client or the legally responsible person; and such information will be released only when the committee members are fulfilling their function as specified in 10 NCAC 14G.0207 and when involved in or consulted in connection with the training or treatment of client.

E. The following situations constitute a basis or authorization for disclosing client information without consent. Disclosure of the information and basis will be documented in the client record.

1. When a need to enhance continuity of client care within the state Mental Health, Developmental Disabilities and Substance Abuse System exists.

2. In situations where it would be extremely detrimental to the well- being of the client not to disclose the information.

3. In medical emergencies or life threatening situations that may necessitate medical treatment.

4. When a qualified or delegated employee determines that there is imminent danger to the health and safety of another client and/or there is the likelihood of the commission of a crime.

5. When required pursuant to the General Statutes of the State of NC regarding the reporting of child abuse or neglect.

6. When the exchange of confidential information between employees, students, consultant or volunteers involved in the care, treatment, or habilitation of a client within PCSCS, LLC is needed for the purpose of carrying out their responsibility in serving that client.

7. When a physician who referred the client to PCSCS, LLC makes a specific request for confidential information.

F. Kimberly Wilder’s OPT Inc. will ensure confidentiality of client information.

❖ All employees, consultants and any other individuals having access to client information will indicate an understanding of the rules governing the confidentiality of client information by signing an acknowledgement of confidentially forms. This form shall be signed upon employment and again when changes occur.

❖ The understanding of the rules governing the confidentiality of the client information will be documented by a responsible staff member having person indicated in subparagraph 1 above sign the Acknowledgement of Confidentiality form (see Appendix) stating compliance with and understanding ofPCSCS, LLC policies.

❖ An introduction to the confidentiality rules will be provided as a part of orientation to all staff (see Confidentiality Laws Outline in Appendix).

❖ All individuals having access to client information will be apprised of the nature of liabilities incurred in the event of failure to comply with the provisions of the confidentiality rules.

G. Each client will be notified in writing upon admission toPCSCS, LLC that PCSCS, LLC at some time may disclose information of a pertinent nature without expressed authorization in accordance with NC General Statutes. Any such disclosure will be made only in the best interests of public safety. The reason of such disclosure will be documented in the client record and each time the information is released. A delegated employee shall ensure that documentation of the disclosure is recorded in the client record containing the following:

1. Name of recipient

2. Extent of information disclosed

3. Specific reasons for disclosure

4. Date signature obtained and date, event or condition of which it expires.

5. Full and legible signature of the individual who disclosed the information and their title.

6. Information on how to revoke authorization.H. Clients will be allowed access to review or obtain copies of information in their record provided the provisions of the State Confidentiality rules and 42 CFR, part 2 Regulations are followed. See Client Access to Records policy for additional information.

1. The client makes a written request using the Client Access to Record Review Form.

2. A determination is made of the appropriateness of such review by a qualified professional as defined in APSM 30-1, Rules for Mental Health, Developmental Disabilities and Substance Services.

3. Consultation between the qualified professional and Director occurs.

4. Consultation between the LME and qualified professional occurs.

5. The qualified professional reviews the record or copies with the client or legally responsible person.

6. Documentation of the request and decision will be in writing using the forms specified in the Client Access to Records Policy.

7. Disagreement between staff on the appropriateness of the request, or what portions of the record to make available will be brought to the Director of Clinical Services.

8. Documentation of the review to include any copies of the record provided to the client or legally responsible person, contested portions of the record and other pertinent information from the review will be documented in record.

I. PCSCS, LLC make every effort to provide security for and safeguard of client records.

❖ PCSCS, LLC stores client records in secure locked areas in each office. File cabinets are locked and protected from public eye.

❖ Access to client records is controlled and limited to authorized staff.

❖ The Qualified Professional will be present to explain and protect the record whenever a client or legally responsible person reviews the record.

❖ Any confidential information that is stored electronically will be pass word protected.

❖ Fax machines will be located in offices so that persons in the vicinity who do not have a “need to know” do not easily view information. Any information that is received or sent via fax will be done so with notification of the employee receiving the fax. Our facsimile cover sheet will have the privacy (confidentiality) notice printed on the sheet. Anytime documentation can be sent with just consumer initials versus entire names, such steps will be utilized. All precautions feasible will be utilized when sending documents via facsimile or electronically.

❖ When communicating electronically all precautions will be utilized that will protect the identity of our consumers. PCSCS, LLC does not scan documents into computers for them to be sent electronically. Until the agency develops a secure means of doing so, scanners will not be part of our equipment. Currently any correspondence sent electronically will reference an inconspicuous way of identifying whom the consumer is. Only the parties involved will be able to identify the consumer. Computers will not face doors or open spaces that might expose client information of the screen.