POLICY & PROCEDURE DATE ISSUED: SUBJECT: 09/26/83 MILWAUKEE COUNTY PATIENT RIGHTS POLICY AND PROCEDURE BEHAVIORAL HEALTH DIVISION DATE SECTION: POLICY NUMBER: PAGE(S) ADMINISTRATION REVIEWED* / REVISED: 06/15/91 02/01/11 ADM #020 1 of 9 03/14/97 PAGE(S)

Alpha - P Replaced MHC#206 R Patient Rights (03/14/97) and Acknowledgement of Patient Rights (04/10/97)

POLICY: This policy outlines the Patient Rights standards under Wisconsin Statute s.51.61 and the administrative rules found in c. DHS 94, HFS124, and Federal regulations 42CFR 482.13. Milwaukee County Behavioral Health Division (BHD) supports and protects the fundamental human, civil, constitutional and statutory rights of each patient* regardless of race, religion, gender/sexual orientation, ethnicity, age or disability. BHD adheres to state and federal regulations regarding patient* rights and will investigate allegations of rights violations and complaints. It is the policy that the employees of the Milwaukee County Behavioral Health Division are trained in the application of the above rights and regulations. It is BHD’s policy that staff inform patients* of their rights and adhere to state and federal regulations regarding notification of rights.

PATIENT RIGHTS STANDARDS

DEFINITIONS: In this Policy and Procedure, definitions are those as defined in DHS 94.02.

1. INFORMED CONSENT: Milwaukee County Behavioral Health Division, Medical Staff Policy 3.5.1.8. addresses informed consent. MCBHD staff will inform patients* and guardians upon assessment, of the recommended treatment and will involve patients* in treatment and care planning. BHD will provide the patient*, or the person acting on their behalf, complete and accurate information and time to study the information or seek additional information concerning the proposed treatment or services made necessary by and directly related to the person’s mental illness, developmental disability, alcoholism or drug dependency, including:

a. The benefits of the proposed treatment and services; b. The way the treatment is to be administered and the services are to be provided; c. The expected treatment side effects or risks of side effects which are a reasonable possibility, including side effects or risks of side effects from medications; c. Alternative treatment modes and services; d. The probable consequences of not receiving the proposed treatment and services; e. The time period for which the informed consent is effective, which shall be no longer than 15 months from the time the consent is given; and f. The right to withdraw informed consent at any time, in writing.

An informed consent document is not valid unless the patient* who has signed it is competent, that is, is substantially able to understand all significant information which has been explained in easily understandable language, or the consent form has been signed by the legal guardian of an incompetent patient* or the parent of a minor. The patient’s* informed consent is always required for participation in experimental research, subjection to drastic treatment procedures, or receipt of electroconvulsive therapy. POLICY & DATE: SUBJECT: PAGE(S) PROCEDURE 02/01/11 PATIENT RIGHTS POLICY AND PROCEDURE NUMBER 2 of 10

In emergency situations, or where time and distance requirements preclude obtaining written consent before beginning treatment and a determination is made that harm will come to the patient* if treatment is not initiated before written consent is obtained, informed consent for treatment may be temporarily obtained by telephone from the parent of a minor or the guardian of a patient*. Oral consent shall be documented in the patient’s* record, along with details of the information verbally explained to the parent or guardian about the proposed treatment. Reasonable attempts should be made to obtain informed consent in writing. The patient* or the person acting on behalf of the patient*, shall be given a copy of the completed informed consent form, upon request. When informed consent is refused or withdrawn, no retaliation may be threatened or carried out.

2. PATIENT RESPONSIBILITIES: The provision of mental health care is based upon a partnership between the patient* and medical staff and other health care professionals. We encourage patients* to participate in their treatment to the best of their ability by:

a. Providing accurate and complete information about present concerns, illnesses, medications, support systems, medical insurance, financial resources and other matters related to health, which may include information regarding trauma(s); b. Reporting unexpected changes in condition to a responsible staff member; c. Reporting whether he/she understands the course of action taken in the treatment plan and what is expected of him/her; d. Participating in treatment planning and treatment; e. Being responsible for his/her actions if treatment is refused or instructions not followed; f. Following rules and regulations affecting patient* care and conduct; g. Being considerate of the rights of other patients* and staff; h. Being respectful of the property of other persons and the hospital; i. Refraining from sexual or other intimate contact with anyone while in the hospital; j. Informing staff immediately if another individual attempts sexual or intimate contact or uses unwanted or harassing sexual language.

3. NOTIFICATION OF RIGHTS: Before or upon admission or, in the case of an outpatient, before treatment is begun, the patient* shall be notified orally and given a copy of his or her rights in accordance with state and federal statutes. Oral notification may be accomplished by showing the patient a video about patient rights. Notification is not required before admission or treatment when there is an emergency.

a. The parent of a minor child and the guardian of an incompetent patient* shall be notified, if they are available. b. No patient* may be required to waive any rights under ch.51 as a condition of admission or receipt of treatment or services. c. Notification should be given at a time when the patient* is able to understand his/her rights. If the patient* is unable to understand his/her rights notification shall be made to a spouse, parent, guardian or another responsible person if available. d. All patients* shall be informed in writing of any liability that the patient or any of the patient’s* relatives may have of any financial liability for the cost of care and treatment and of the right to receive information about charges for care and treatment. POLICY & DATE: SUBJECT: PAGE(S) PROCEDURE 02/01/11 PATIENT RIGHTS POLICY AND PROCEDURE NUMBER 3 of 10

e. Patients* who receive services for an extended time period shall be orally re- notified of their rights and shall be given a copy of new rights if requested or if there has been a statutory change since the time of their admission. f. All notification of rights, both oral and written shall be in a language understood by the patient. g. The facility director may emphasize those rights that are most applicable to the particular facility or program. h. Each BHD Branch program is responsible for the development of procedures to ensure that patients* are informed of their rights and the grievance procedure.

4. POSTING OF RIGHTS: Patient Rights as stated under federal and state statutes shall be conspicuously posted in all patient* areas and in other public areas. The individual BHD programs and branches are responsible for maintaining the posting of current rights in areas that are accessible. Language translation can be obtained by following the Interpretive Services for Non-English Speaking or Hearing Impaired Patients policy. Cost and quality information for health care consumers required by 2009 Wisconsin Act 146 will be posted.

5. LIMITATION OR DENIAL OF RIGHTS: The rights provided under s. 51.61 (2) may be limited or denied for good cause, if the treatment facility director or designee have reason to believe the exercise of the right would create a security problem, adversely affect the patient’s* treatment or seriously interfere with the rights or safety of others. Limitations or denials of rights are to be documented and demonstrate that they are the least restrictive to accomplish the purpose. No limitation may be more stringent than necessary.

a. At the time of the denial or limitation, written notice shall be provided to the patient* and guardian, if any, and a copy of that notice shall be placed in the patient’s* treatment record. (Use the Client Rights Limitation or Denial Documentation form Division of Long Term Care, Division of Mental Health and Substance Abuse Services F-26100). b. A copy of the Denial or Limitation shall forms be sent to the Client Rights Specialist(s) of the Patient Rights Committee and put in patient’s* medical record. c. The patient* shall be informed that the decision to limit or deny rights may be grieved. Patients shall be assisted in the exercise of all rights.

6. LEAST RESTRICTIVE TREATMENT AND CONDITIONS: It is the policy of MCBHD to provide treatment in the least restrictive setting and provide for the maximum amount of personal and physical freedom. No person shall be transferred to a setting that increases personal or physical restrictions unless the transfer is justified by documented treatment or security reasons or by court order. BHD staff shall provide prompt and adequate treatment, habilitation or rehabilitation, supports, community services and educational services and identify patients who are ready for placement in less restrictive settings.

7. TREATMENT AND CARE DECISIONS: It is the policy of the BHD to inform patients* of their treatment and care, and encourage patients* to actively participate in their care and treatment planning. Recovery Plan Guidelines applicable to specific programs shall address patient* involvement in treatment planning. The MCBHD will inform patients* on assessment of the recommended treatment and will involve patients* in treatment and care planning. If a patient* refuses treatment, or expresses a concern about treatment, POLICY & DATE: SUBJECT: PAGE(S) PROCEDURE 02/01/11 PATIENT RIGHTS POLICY AND PROCEDURE NUMBER 4 of 10

the attending medical staff and the treatment team shall meet with the patient* to discuss the care dilemma and attempt to resolve the concern. A patient* may refuse treatment to include medications, except as provided under s.51.61(1)(g) and (h) stats., and HFS c. 94.09 (4). An involuntary patient* may request a second consultation from another staff member at no charge, who is not directly involved in providing treatment to the patient*. Any patient* may at his or her own expense, arrange for a second consultation from a person who is not employed by the treatment facility to review the treatment plan and record. When a voluntary patient* refuses treatment, the attending physician and the treatment team shall meet with the patient* to discuss continued need for hospitalization and what course of action to take.

a. Except in an emergency when it is necessary to prevent serious harm to self or others, no medication may be given to any patient* or treatment performed on any patient* without the prior informed consent unless the patient* has been found not competent to refuse medication and treatment under s.51.61(1)(g) or (Chapter 54), and the court orders medication or treatment. Informed consent of the guardian is required for patients* found incompetent under Chapter 54. Temporary informed consent may be obtained by telephone in accordance with c.94.03(2m).

b. A voluntary patient* may refuse any treatment, including medications, at any time and for any reason, except in an emergency, under the following conditions:

1) If the prescribed treatment is refused and no alternative treatment services are available within the treatment facility, it is not considered coercion if the facility indicates that the patient* has a choice of either participating in the prescribed treatment or being discharged from the facility, and

2) The treatment facility shall counsel the patient* and, when possible, refer the patient* to another treatment resource prior to discharge.

8. FAMILY OR DESIGNATED OTHER INVOLVEMENT IN CARE DECISIONS: BHD recognizes the importance of natural support systems in care and treatment. In the case of a minor, the family or guardian is responsible for care decisions consistent with Wisconsin law. When a patient* consents to family or significant others to be involved in care, BHD will attempt to involve identified persons in the treatment process. If a patient* lacks the mental or physical capacity to make care decisions, family or identified others will be involved consistent with the patient’s* known request or from direction given in a legal advance directive. If there is no advance directive and the person is believed to be incompetent, the BHD may assess competency and proceed with a petition for guardianship.

9. FAMILY NOTIFICATION Spouse, patient* and child notification of a patient’s* admission to the hospital is limited. Refer to ch. 51.30(4). Questions regarding this matter shall be directed to the HIPAA Officer. POLICY & DATE: SUBJECT: PAGE(S) PROCEDURE 02/01/11 PATIENT RIGHTS POLICY AND PROCEDURE NUMBER 5 of 10

10. SECLUSION AND PHYSICAL RESTRAINT: MCBHD will maintain policies covering, seclusion and physical restraint.

a. All patients* at MCBHD have the right to be free from physical or mental abuse and corporal punishment.

b. All patients* have the right to be free from restraint or seclusion of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff.

c. All patients* can expect Trauma-Sensitive Care that incorporates a collaborative and respectful approach with individuals who have experienced trauma to promote personal healing and recovery.

d. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient*, staff or others, and must be discontinued at the earliest possible time.

11. ELECTROCONVULSIVE THERAPY: No patient* shall be administered electroconvulsive therapy except as provided by law and administrative rule. (Medical Staff Policy 3.1.6.5).

12. RESEARCH: BHD will establish a research and human rights committee in accordance with 45 CFR 46, s. 51.61 (4) and c. 94 to monitor research involving human subjects. The committee shall include two members who are consumers or who represent either an agency or organization, which advocates rights of patients*. See Medical Staff Bylaws regarding the duties of the Human Research Review Committee.

All proposed research involving patients* shall meet the requirements of state and federal guidelines. No one may be subjected to any experimental diagnostic or treatment technique or to any other experimental intervention unless the informed consent is given.

13. LABOR PERFORMED BY PATIENTS: Any labor performed by a patient* at BHD which is of financial benefit to BHD shall be conducted within the requirements under s.51.61 (1)(b), Stats. and c.94. Patients* will not be required to perform tasks that are in excess of personal housekeeping chores equivalent to those performed in common or private living areas of an ordinary home, i.e., light cleaning of personal areas, personal laundry, etc. a. Payment for therapeutic labor authorized under s.51.61 (1)(b), Stats., shall be made in accordance with wage guidelines established under state and federal law. b. Documentation shall be made in the treatment record of any compensated, uncompensated, voluntary or involuntary labor performed by any patient*. c. The document used to obtain informed consent for application of a patient’s* wages toward the cost of treatment shall conspicuously state that the patient* has the right to refuse consent without suffering any adverse consequences.

14. RELIGIOUS WORSHIP: All inpatients* shall be allowed to exercise their right to religious worship as specified under s.51.61(1)(l), stats. BHD will seek clergy to be available to meet the religious needs of inpatients*. Reasonable provisions shall be made for inpatients* to attend religious services inside or outside of the facility, except for documented safety reasons. BHD will honor any reasonable request for religious POLICY & DATE: SUBJECT: PAGE(S) PROCEDURE 02/01/11 PATIENT RIGHTS POLICY AND PROCEDURE NUMBER 6 of 10

visitation by the representative of any faith or religion. A patient* whose disruptive behavior interferes with other’s right to worship can be removed from worship services. Consult with the Spirituality Committee regarding clerical rules and credentialing of clergy. POLICY & DATE: SUBJECT: PAGE(S) PROCEDURE 01/01/11 PATIENT RIGHTS POLICY AND PROCEDURE NUMBER 7 of 10

15. CONFIDENTIALITY OF RECORDS: Recognizing that all treatment records are confidential, BHD will maintain a policy and procedure statement addressing the confidentiality of treatment records and the ability of the patient* or guardian to inspect, copy and challenge records as authorized under state and federal statutes. See BHD Medical Record Department Policy Manual.

16. FILMING AND TAPING: No patient may be recorded, photographed, or filmed for any purpose except as allowed under s.51.61(1), Stats. Informed consent should be obtained for recording, video taping, photographing or filming and will include notification of the right of the patient* to rescind informed consent prior to any release after the patient* views or hears the material. See BHD Policy and Procedure: Electronic Video Monitoring # 1500.

17. MAIL: BHD allows each inpatient to send and receive sealed mail without restriction. Mail received will be delivered to inpatients as promptly as possible. Upon request, any patient* shall be provided with letter writing materials and up to 2 stamped non- letterhead envelopes each day. Upon request of patient* or his or her guardian, mail shall be opened by a facility staff member and read to him or her. The initial request shall be documented in the treatment record. Inspection of any suspect mail would be in accordance with U.S. Postal Regulations.

18. TELEPHONE CALLS: Patients* shall be allowed reasonable access to a telephone to make and receive a reasonable number of phone calls. Patients* shall be permitted to make an unlimited number of phone calls to legal counsel and to receive an unlimited number of phone calls from legal counsel. Each Patient* shall be permitted to make a reasonable number of private, personal calls. The number and duration of the calls may be limited for legitimate management reasons. Each inpatient treatment unit will have at least one phone designated for patient use twenty-four hours per day.

19. VISITORS: BHD inpatient units will provide adequate and reasonable private space for visitation. BHD may require prior identification of potential visitors and may search visitors. Visitors, adults and children, are to be considered guests. Visitors are encouraged to visit when patients* are not in scheduled treatment activities and should be advised when the patient* would be available to receive visitors.

20. VOTING: BHD shall ensure that patients* have an opportunity to vote, unless they are otherwise restricted by law from voting. The BHD will allow a patient* to receive campaign literature or to place political advertisements in personal quarters and shall permit candidates to campaign during reasonably regulated times at designated locations on the premises. The BHD will:

a. Announce major elections and survey patients* 18 years of age or over to ascertain their interest in registering to vote, obtaining absentee ballots and casting ballots. This shall be done far enough in advance to allow sufficient time for voter registration and acquisition of absentee ballots. b. Make arrangements with state and local election officials to register voters and to enable interested inpatients* to cast ballots at the facility, and c. With a patient’s* consent, assist election officials in determining the patient’s* place of residence for voting purposes. POLICY & DATE: SUBJECT: PAGE(S) PROCEDURE 02/01/11 PATIENT RIGHTS POLICY AND PROCEDURE NUMBER 8 of 10

21. DISCHARGE OF VOLUNTARY PATIENTS: When a voluntary patient* requests a discharge, the facility director or designee shall either release the patient within 24 hours or file a statement of emergency detention by the treatment director with the court as provided under ss.51. If a voluntary inpatient* requests a discharge and he or she has no other living quarters or is in need of other services to make the transition to the community, the following actions shall be taken by the facility director or designee prior to discharge:

a. Counsel the patient* and, when possible, assist the patient* in locating living quarters; b. Inform the applicable program director, if any, of the patient’s* need for residential and other necessary transitional services; and c. If no living quarters have been made by the time of discharge, refer the patient* to an appropriate service agency for emergency living arrangements.

22. HUMANE PSYCHOLOGICAL AND PHYSICAL ENVIRONMENT: The BHD will provide a clean, safe and humane environment in all treatment facilities. Each patient* shall be treated with respect and dignity by BHD staff and contracted staff.

Fingerprinting: If a patient* has no means of identification and cannot otherwise be identified, fingerprinting of the individual may be done to establish accurate identity of a person.

23. SEARCHES: Patient* searches of person and belongings may only be conducted per hospital policy and procedure (See BHD Search and Contraband Policy).

24. PATIENT FUNDS: Except as otherwise provided under s.51.61 (1)(q), Stats., a patient* shall be permitted to use his/her own money as he/she wishes. BHD, when holding funds for a patient,* shall give the patient* an accounting of those funds in accordance with s.51.61 (1)(v), Stats.

25. CLOTHING AND LAUNDRY: Patients* shall be permitted to wear their own clothing as authorized under s.51.61(10(q), Stats., and c.94. If the patient* does not have enough clothing, he/she shall be furnished with appropriate non-institutional clothing of proper size as follows:

a. There shall be sufficient clothing to allow each patient* at least one change of underwear a day and 3 changes of clothing a week; and

b. There shall be clothing which is appropriate for patients* to wear out of doors and on trips or visits in all weather conditions.

c. All patients* shall be provided with laundry services or access to a washer and dryer. The BHD will make all reasonable measures to prevent the loss of clothing during use of laundry services. Personal clothing and laundry may be denied for patient* safety or health reasons.

26. STORAGE SPACE: BHD will provide sufficient and convenient space for clothing, toilet articles and other personal belongings for patients*. At least one storage space will be lockable and if requested, additional secure storage space will be provided if available. Personal storage space may be searched only if there is reason to be concerned about safety and the patient* is given the opportunity to be present during the search. POLICY & DATE: SUBJECT: PAGE(S) PROCEDURE 02/01/11 PATIENT RIGHTS POLICY AND PROCEDURE NUMBER 9 of 10

27. RIGHT TO FILE GRIEVANCES: MCBHD will provide a mechanism to register grievances and provide assistance to a consumer, family member, guardian or concerned party in initiating a grievance. The BHD will provide a timely response and attempt to resolve grievances through informal means. MCBHD staff will not hinder, retaliate or discriminate against any person filing a grievance, nor interfere with the communication between a consumer and any public official or any other person. MCBHD will not reprimand, hinder, retaliate or sanction an employee who assists a patient* in filing a grievance. MCBHD staff will not deprive a patient* of the ability to seek redress for alleged violations of his or her rights by unreasonably precluding the patient from using the grievance procedure or from communicating, subject to any valid telephone or visitor restrictions, with a court, government official, grievance investigator or staff member of a protection and advocacy agency or with legal counsel. See BHD Patient Grievance Policy and Procedure for more information.

28. PATIENT RIGHTS AWARENESS COMPLIANCE: MCBHD will ensure that all employees who have patient* contact are aware of the requirements of s. 51.61 and c. 94 and that there are criminal and civil penalties for violations of applicable law.

Administrators are responsible for ensuring that all relevant employees receive in-service training covering the provisions of s.51 and c.94.

29. APPLICATION OF OTHER RULES AND REGULATIONS: In applying the requirements of this chapter, when a different state rule or federal regulation also applies to the protection of a particular right of patients*, the different state rule or federal regulation shall be controlling if it does more to promote patient* rights than the counterpart requirement in c.94.

NOTIFICATION OF RIGHTS PROCEDURE

1. At the time of admission, staff shall notify patients* orally and provide a written copy of the Client Rights and Grievance Procedure brochure.

2. Staff shall encourage patients* to ask questions and discuss any concerns they may have about these rights. Staff shall attempt to answer these questions or refer the patient to the Client Rights Specialist.

3. The Acknowledgment of Patient Rights form will be completed upon admission. Refer to form for staff and patient instruction. The Rights of Detention form will also be utilized, when legally applicable with oral presentation of such rights presented by staff and written confirmation obtained by the patient.* Staff shall file the completed form(s) in the “Legal Section” of the patient’s* medical record.

4. Staff shall notify the guardian of a patient* who is incompetent and the parent of a minor patient of patient rights if available. Notification is not required before admission or treatment when there is an emergency. A patient’s* legal guardian is to be provided a copy of the Client Rights and Grievance Procedure brochure and an opportunity to ask questions.

5. Patients* (guardians) who receive services for an extended period of time shall be orally re-notified of their rights at least annually and be given another copy of their rights in writing if they request a copy or if there has been a statutory change in any of their rights since the time of admission. POLICY & DATE: SUBJECT: PAGE(S) PROCEDURE 02/01/11 PATIENT RIGHTS POLICY AND PROCEDURE NUMBER 10 of 10

6. Staff shall ensure all notification of rights, both oral and written, shall be in a language understood by the patient, including the use of an interpreter as indicated.

7. A posted copy of Client Rights and the Grievance Procedure shall be posted in each patient* care area.

8. Staff responsible for patient rights notification will receive annual training regarding all aspects of this policy.

“*Patient” designates Psychiatric Crisis Service and Acute Inpatient consumers, and long-term residents. Wherever applicable the term also applies to outpatients in community services.

Reviewed and Approved by the Patient Rights Committee and BHD Clinical Operations Team

Jennifer Bergersen Patient Rights Co-Chair Date Director of Acute Inpatient Services

Desirine Vann Patient Rights Co-Chair Date Client Rights Specialist

Thomas Harding, MD Clinical Operations Committee Chair Date Medical Director