NORTHERN VIRGINIA JOINT TRAINING COALITION

1. NORTHERN VIRGINIA JOINT TRAINING COALITION Human Rights Refresher Training April 10, 2012

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 the in class training 2

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

4. Human Rights RegulationsTHE FOLLOWING SLIDES WILL COVER CURRENT 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

5. 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. 5

6. 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.

7. 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.

8. Dignity(continued) • 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, if religious practices are dangerous or may result in demonstrable harm. • 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.

9. Dignity(continued) • 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 or mail they are sending out contains illegal or dangerous items or may result in demonstrable harm, staff may open the mail, but not read it, in the presence of the individual.

10. 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.

11. Abuse, Neglect or Exploitation • 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 authorized representative 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 authorized representative is not satisfied with the director’s actions, he/she or the authorized representative may file a petition for an LHRC hearing.

12. 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.

13. 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.

14. Participation in Decision Making(continued) • In an emergency: • Providers may initiate, administer, or undertake a proposed treatment without the consent of the individual or the individual’s authorized representative; and inform the authorized representative 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.

15. Informed Consent • Voluntary written agreement by the individual or his/her authorized representative 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

16. 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.

17. Confidentiality (continued) • 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. Some conditions may not apply to 42 CFR Part 2

18. 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.

19. 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 Some conditions may not apply to 42 CFR Part 2

20. Access/Amendment of Records • Each individual and his/her authorized representative 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.

21. Access/Amendment ofRecord (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.

22. 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 thecriteria for removal is met. Program Rules Give the rules to and review them with each individual and the authorized representative if applicable in a way that the individual can understand them, including explaining possible consequences for violating them. Restrictions on Freedoms of Everyday Life

23. 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

24. 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)

25. 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)

26. 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.

27. 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.

28. 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.

29. Research (Continued) • Present research request, a copy of the approval from the Institutional Review Board or Research Review Committee, and sample informed consent form to the Local Human Rights Committee for approval before an individual receiving services may participate. • Obtain prior, written, informed consent from the individual or his/her authorized representative. • Provide periodic updates to the Local Human Rights Committee.

30. Substitute Decision Making • 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.

31. 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.

32. 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

33. 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 authorized representative 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 Local Human Rights Committee. • Conditions for removal of an authorized representative are outlined in 12VAC35-115-146, G.

34. Authorized Representatives (continued) • Conditions for removal of an authorized representative • Whenever an individual has regained capacity to consent, the director shall immediately remove any authorized representative, notify the individual and the authorized representative, and ensure that the services record reflects that the individual is capable of making his/her own decisions. • Whenever an individual with an authorized representative who is his legal guardian has regained capacity to give informed consent, the director may use the applicable statutory provisions to remove the authorized representative. • 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 authorized representative.

35. Authorized Representatives (continued) • The director shall remove the authorized representative if the authorized representative becomes unavailable, unwilling, or unqualified to serve. • The individual or the advocate may request the • Local Human Rights Committee review the director’s decision to remove an authorized representative. • Prior to any removal, the director shall notify the individual of the decision to remove the authorized representative, of his/her right to request that the Local Human Rights Committee review the decision, and of the reasons for the removal decision. This information shall be placed in the services record.

36. 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 advocacyagency.

37. RESOLVING ISSUES PRIOR TO BECOMING A COMPLAINT 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.

38. 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.

39. 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.

40. Complaint Resolution… Formal 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.

41. 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.

42. 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. 43

43. Provider Requirements for Reporting to the Department Information concerning abuse, neglect and exploitation will be collected in the following manner: • Report each allegation of abuse or neglect to the assigned human rights advocate within 24 hours from the receipt of the allegation. • Provide a written report of the results of the investigation of abuse or neglect to the Director and human rights advocate within 10 working days from the date the investigation began.

44. Deaths and serious injuries: in writing to the Department within 24 hours of discovery and by telephone to the authorized representative, 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 Local Human Rights Committee. Provider Requirements for Reporting to the Dept.(continued)

45. REFERENCES • Human Rights Regulations: http://www.DBHDS.virginia.gov/ documents/Human Rights/OHR-default.htm

46. Good Luck & High Scores! Congratulations! You have completed the on-line Human Rights portion of the Training. Please print out and complete the following 30 question True / False test

47. Human Rights Test Questions

48. Human Rights Test Questions

49. THE END!!! On-line Human Rights refresher developed by the following No VA Joint Training Coalition subcommittee members: • Stacy Boseman-MVLE • Jacque Scholl-Service Source/CFS • Judy Rutherford-Linden Resources, Inc. • Aldrina Maiden- Fairfax-Falls Church Community Services Board We’ll see you next year!!!