The Meeting begins at 10AM EST

The Meeting begins at 10AM EST MDHHS Office of Recipient Rights 07-24-19

The LPH Reciprocity PROJECT Inpatient Site Reviews MDHHS Office of Recipient Rights 07-24-19

Inpatient Site Reviews - Agenda 1. Changes in the Site Review Process 2. Process Overview 3. Recommended Tools 4. Review of Standards A. key elements B. issues identified C. areas requiring clarification 5. Final Thoughts/Questions 6. Homework Identified

Inpatient Site Reviews Changes in the Site Review Process • Number of Reviewers • Comprehensiveness • Timing • policy review • case reviews • notification of site review Number of Reviewers Comprehensiveness

Inpatient Site Reviews Policy Review • Review of policy every 3 years (unless changes) • Completed by the LPH ORR • Reviewed by CMH • Timeframe for review

Inpatient Site Reviews Case Review Review of cases by contract Review of cases prior to visit Review of cases on site

Inpatient Site Reviews • Notification of Site Review • COMPLAINT LOGS: • Provide an Excel file listing information for all allegations received for the period since the previous visit date. • From this log, you will be asked to provide evidence of complaint response/ resolution.

Inpatient Site Reviews • Notification of Site Review • TRAINING • Provide an Excel file listing all “hospital” employees and contract employees hired during the last year, … • If you have a new hire orientation training, please provide a list of the employees, start dates and training dates for those employees

Inpatient Site Reviews • Notification of Site Review • TRAINING • Provide recipient rights training materials, including curriculum used, and, if applicable, a sample of tests given to staff.

Inpatient Site Reviews • Notification of Site Review • CONTRACTS • If you are contracting with employees, or agencies to provide services to the hospital, please include one signed, current contract for each type of service provided: • - other service providers (food service, housekeeping, etc.) • - professional staff (psychiatrists, OTs, PTs, etc.)

Inpatient Site Reviews • Notification of Site Review POLICIES During the policy review year, you should complete the ORR Policy Review Standards document, identifying the name and number of the policy as well as page numbers where elements can be found. If you have already received documentation of policy compliance, please include that with the items above.

Inpatient Site Reviews • Notification of Site Review Requested items at visit: 1. Agency organization chart. 2. Job description for rights advisor and rights advisor alternate, chief administrative officer, designee 3. List of recipient rights advisory committee members. A list of categories represented on the committee. 4. Minutes of the RRAC for the assessment period.

Inpatient Site Reviews • Notification of Site Review Items at Visit: 5. Informational packets/brochures given to the public or consumers. (Include any poster which identifies the rights officer/advisors and the means of contacting them). 6. Documents reflecting Basic Skills training received by rights office staff (if hired since last visit) 7. Documents reflecting approved training received by rights office staff to address contractual requirements.

Inpatient Site Reviews • Notification of Site Review At Visit: Hospital CEO Chair of your RRAC to be made available during the site visit. If they cannot be at the hospital during the visit, your RRAC chair may contacted by phone.

Inpatient Site Reviews • Recommended Tools

Inpatient Site Reviews 4. Review of Standards A. key elements B. issues identified C. areas requiring clarification 5. Final thoughts/Questions 6. Homework identified

Section 1 Hospital Responsibilities MDHHS Office of Recipient Rights 07-24-19

Inpatient Site Reviews The hospital has an assigned rights advisor. The hospital has an assigned alternate rights advisor. The rights advisor has the education and training required for the office. The rights advisor reports only to chief administrative officer (CAO) of the hospital.

Inpatient Site Reviews In the absence of the CAO, there is a designee who can perform the duties required of the CAO. The hospital assures that the rights advisor has unimpeded access to all information/areas necessary to conduct investigations and perform monitoring functions.

Inpatient Site Reviews Staff are aware of the policy requiring staff to be knowledgeable of the complaint process, including how to file a complaint on behalf of a recipient and how to assist a recipient in filing a complaint. Staff are aware of this requirement and the process for carrying it out.

Section 2Rights Office Operations MDHHS Office of Recipient Rights 07-24-19

Inpatient Site Reviews As necessary, the office assists recipients or other individuals with the complaint process. Complaints are responded to within 5 business days. There is a mechanism for logging all complaints received by the office. Logs should identify the responsible CMH. Investigations and interventions are completed within the timeframes required by law and contract.

Inpatient Site Reviews Interventions are completed in accordance with the parameters established by contract and the guidelines established in Basic Skills training. Investigations, and resultant reports, are completed in accordance with the parameters established by law, rules, and guidelines established in Basic Skills training.

Inpatient Site Reviews Summary Reports are completed in accordance with the parameters established by law, rules, and guidelines established in Basic Skills training. ORR maintains all reports of apparent or suspected rights violations received & evidence collected to support the decision in the investigation. (file)

Inpatient Site Reviews ORR has established a mechanism for secure storage of all investigative documents and evidence, including files kept in the Rights Office, off site, and electronic files. ORR serves as a consultant to the director and to agency staff in rights related matters. Ensure that all reports of apparent or suspected violations of rights within the hospital investigated in accordance with section 330.1778.

Inpatient Site Reviews The Rights Advisor is able to access video surveillance for the purposes of investigation. The Rights Advisor is able to access incident reports for the purposes of monitoring and ascertaining if a right may have been violated and, as needed, to conduct an investigation. Recipients are aware of how to file a complaint.

Section 3Unit/Hospital Operations MDHHS Office of Recipient Rights 07-24-19

Inpatient Site Reviews The Unit/Hospital is free of health and safety concerns. The name of the Rights Advisor, and a method for contact, are conspicuously posted in areas where recipients, family members, guardians, and visitors have access. There is a copy of Chapter 7 and 7a available to recipients.

Inpatient Site Reviews Recipient Rights booklets are provided to recipients, family members, and guardians upon admission. Contact information for the Rights Advisor is provided on the rights booklets. The recipient’s record identifies the person who provided the explanation of rights, and, when the recipient is unable to read or their understanding is in question, an explanation of the materials used to explain rights.

Inpatient Site Reviews There is unimpeded access to complaint forms. There is a marked secure mechanism for filing complaints (lock box or other confidential method). There is a poster advising recipients that there are advocacy organizations available to assist in preparation of a written rights complaint…

Inpatient Site Reviews Current posters regarding the reporting of abuse and neglect are present and visible in staff areas. Staff are aware of abuse and neglect reporting requirements. If applicable, Unit Rules (i.e., telephone usage, visitation, etc.), including any exclusions (i.e., weapons, glass, aerosol), are posted.

Inpatient Site Reviews The Rights Advisor has reviewed the Unit rules. The Rights Advisor has determined that the Unit Rules are reasonable and lawful.

Inpatient Site Reviews When video surveillance is utilized in common areas, recipients are notified of the existence and location of videotaping upon admission and by posted signs. When video surveillance is utilized, private areas (bedrooms, bathrooms and showers) are excluded from videotaping or surveillance.

Inpatient Site Reviews Recipients are afforded an opportunity to sign into the hospital on a voluntary basis. When applicable, rights pertaining to voluntary admission are explained verbally and in writing. There is a mechanism for noting who provided the explanation when the recipient is unable to read or their understanding is in question, an description of the explanation is in the recipient’s record.

Section 4Education and Training MDHHS Office of Recipient Rights 07-24-19

Inpatient Site Reviews The primary and alternate rights staff have attended and successfully completed the Basic Skills Training program within 90 days of hire. The staff of the rights office have complied with the continuing education requirements identified in the contract attachment.

Inpatient Site Reviews A minimum of 12 of the required 36 CE hours were approved as either Category I or II. Both the primary and alternate Rights staff have earned at least 3 continuing education credits during the calendar year.

Inpatient Site Reviews All persons engaged by the LPH who will have contact with recipients have been trained on basic rights within 30 days of hire. All staff of the LPH (unit/hospital) have been trained on residential rights within 30 days. Training related to recipient rights protection addressed all training standards identified in the MDHHS ORR Training Standards (all aspects of chapter 4, 7, 7A).

Inpatient Site Reviews Education and training in recipient rights policies and procedures are provided to the recipient rights advisory committee and appeals committee.

Section 5Rights Advisory Committee MDHHS Office of Recipient Rights 07-24-19

Inpatient Site Reviews There is a Recipient Rights Advisory Committee in place either 1) by agreement with the local CMHSP or 2) appointment by the hospital. RRAC minutes reflect that meetings are held at least twice per year.

Inpatient Site Reviews The committee acts to protect ORR from pressures that could interfere with the impartial, even-handed, and thorough performance of its functions. The committee reviews the funding for the Office at least annually.

Inpatient Site Reviews The RRAC reviews the Semi-Annual and Annual reports and provides input for the Board of Directors on the Annual report.

Section 6Seclusion/Restraint MDHHS Office of Recipient Rights 07-24-19

Inpatient Site Reviews If seclusion or restraint has been utilized within the past 12 months, the usage was compliant with policy (including timeframes as outlined by CMS). If seclusion or restraint was utilized, the visit at 1 hour was completed by a physician or PA as required by state law.

Section 7Appeals Committee MDHHS Office of Recipient Rights 07-24-19

Inpatient Site Reviews For recipients who are under the authority of a CMHSP, the governing body of a licensed hospital has designated the appeals committee of the local community mental health services program to hear an appeal of a decision on a recipient rights matter brought by or on behalf of a recipient of that community mental health services program.

Inpatient Site Reviews For recipients who are not under the authority of a CMHSP, the Governing Body (Board) of the Hospital appointed an appeals committee to hear appeals of recipient rights matters OR entered into an agreement with MDHHS to use the MDHHS appeals committee. Notices of appeal rights refer recipients to appropriate appeals committee.

Section 8Policy MDHHS Office of Recipient Rights 07-24-19

Inpatient Site Reviews The policies of the hospital have been reviewed and accepted.

The Meeting begins at 10AM EST