PATIENT RIGHTS AND RESPONSIBILITIES POLICIES

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1. PURPOSE AND SCOPE

This policy establishes the rights and responsibilities of all patients receiving mental health and/or substance use disorder treatment services at this facility in accordance with Indiana Code 12-27, federal regulations, and Indiana Division of Mental Health and Addiction (DMHA) certification standards. This policy ensures that all healthcare activities are conducted with overriding concern for each patient's rights and dignity as a human being.

Scope: This policy applies to all patients receiving services and all staff providing care at this facility, including inpatient, outpatient, residential, and community-based services.

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2. POLICY STATEMENT

This facility is committed to protecting and promoting the rights of all patients while fostering an environment of mutual respect, dignity, and shared responsibility. Patients have both fundamental rights that must be protected and responsibilities that support effective treatment and a safe, therapeutic environment for all.

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3. PATIENT RIGHTS

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3.1 Right to Respectful Treatment (IC 12-27-2-1)

Every patient has the right to:

• Be treated with dignity, respect, and consideration regardless of race, color, religion, gender, sexual orientation, gender identity, age, national origin, disability, or source of payment

• Receive courteous and professional treatment from all staff members

• Be addressed by preferred name and pronouns

• Have cultural, spiritual, and personal values respected

• Be free from discrimination, harassment, or abuse of any kind

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3.2 Right to Appropriate Care and Treatment (IC 12-27-2-1)

Every patient has the right to:

• Receive mental health services and/or substance use treatment appropriate to their condition

• Services provided in accordance with current professional standards of care

• Treatment designed to afford a reasonable opportunity to improve their condition

• Individualized treatment planning based on comprehensive assessment

• Regular review and modification of treatment plans as needed

• Continuity of care and coordination among providers

• Referral to appropriate services when needs exceed facility capabilities

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3.3 Right to Participate in Treatment Planning (IC 12-27-2-1)

Every patient has the right to:

• Participate in the development of their individualized treatment plan

• Be informed of their diagnosis, prognosis, and treatment options in understandable terms

• Receive information about the nature, risks, benefits, and alternatives of proposed treatment

• Ask questions about their treatment and receive clear answers

• Request second opinions regarding their treatment

• Have family members or chosen advocates involved in treatment planning (with patient consent)

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3.4 Right to Refuse Treatment (IC 12-27-2-1)

Every patient has the right to:

• Refuse any treatment, medication, or procedure (subject to legal limitations)

• Be informed of the consequences of refusing recommended treatment

• Withdraw consent for treatment at any time

• Request discharge from voluntary treatment programs

• Have refusal decisions respected by all staff members

• Note: Involuntary patients may have limited rights to refuse treatment as determined by applicable law and court orders

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3.5 Privacy and Confidentiality Rights

Every patient has the right to:

A. Privacy During Treatment:

• Private conversations with treatment providers

• Privacy during examinations and procedures

• Confidential treatment of all personal information

• Privacy in personal care activities

• Reasonable accommodation for private telephone calls

B. Confidentiality of Records (IC 16-39, HIPAA, 42 CFR Part 2):

• Protection of all medical and treatment records

• Control over disclosure of personal health information

• Access to their own medical records (with limited exceptions)

• Request corrections to inaccurate information

• Receive notice of privacy practices

• File complaints regarding privacy violations

• For SUD patients: Enhanced confidentiality protections under 42 CFR Part 2

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3.6 Personal Property and Financial Rights

Every patient has the right to:

• Retain and use personal possessions (consistent with safety and treatment requirements)

• Have personal property protected from theft or damage

• Manage their own financial affairs (unless legally determined to be incapacitated)

• Be free from financial exploitation or coercion

• Receive written information about charges and payment policies

• Challenge billing errors or disputed charges

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3.7 Right to Safe Environment

Every patient has the right to:

• Receive care in a safe, clean, and comfortable environment

• Be free from physical, sexual, emotional, or financial abuse

• Be free from neglect or abandonment

• Report safety concerns without fear of retaliation

• Emergency medical care when needed

• Protection from other patients who may pose a threat

• Restraint and Seclusion Rights (if applicable):

  • Be free from unnecessary restraints or seclusion

  • Have restraints used only as last resort for safety

  • Receive monitoring and medical evaluation during restraint use

  • Have restraint use documented and reviewed

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3.8 Grievance and Complaint Rights (IC 12-27-2-1)

Every patient has the right to:

• Voice complaints or grievances about care or treatment

• Have grievances investigated promptly and fairly

• Receive written responses to formal complaints

• Appeal decisions regarding their complaints

• Access to patient advocacy services

• File complaints with external regulatory agencies

• Be free from retaliation for making complaints

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3.9 Discharge and Transfer Rights

Every patient has the right to:

• Reasonable advance notice of discharge or transfer

• Participation in discharge planning

• Continuity of care through appropriate referrals

• Copy of their treatment records upon discharge

• Appeal inappropriate discharge decisions

• Safe and appropriate discharge planning

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4. PATIENT RESPONSIBILITIES

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4.1 Treatment Participation Responsibilities

Patients are expected to:

• Provide accurate and complete health history information

• Participate actively in their treatment planning and care

• Keep scheduled appointments or provide reasonable notice of cancellation

• Follow agreed-upon treatment recommendations

• Communicate openly and honestly with treatment providers

• Notify staff of changes in their condition or circumstances

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4.2 Respect for Others

Patients are expected to:

• Treat staff, other patients, and visitors with courtesy and respect

• Respect the privacy and rights of other patients

• Avoid disruptive behavior that interferes with others' treatment

• Follow facility rules and policies designed to ensure everyone's safety and well-being

• Respect cultural, spiritual, and personal differences of others

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4.3 Financial Responsibilities

Patients are expected to:

• Provide accurate insurance and financial information

• Pay for services according to agreed-upon payment arrangements

• Notify facility of changes in insurance coverage or financial circumstances

• Ask questions if they do not understand charges or billing procedures

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4.4 Safety and Compliance Responsibilities

Patients are expected to:

• Follow safety rules and instructions

• Report safety concerns or hazards to staff

• Comply with facility policies regarding prohibited items

• Notify staff of any adverse reactions to medications or treatments

• Cooperate with infection control and public health measures

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5. SPECIAL POPULATIONS

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5.1 Minors (Under Age 18)

Additional Rights:

• Age-appropriate information and communication

• Involvement of parent/guardian in treatment decisions (unless contraindicated)

• Educational services continuation when appropriate

• Special protections regarding confidentiality and consent

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5.2 Adults with Guardians or Conservators

Rights Considerations:

• Maximum self-determination within legal limitations

• Involvement in decisions to the extent of their capacity

• Respect for personal preferences and values

• Regular review of capacity and need for guardianship

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5.3 Individuals with Disabilities

Additional Rights:

• Reasonable accommodations for disabilities

• Accessible facilities and communications

• Assistive devices and services as needed

• Equal access to all programs and services

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6. IMPLEMENTATION PROCEDURES

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6.1 Rights Communication

A. Upon Admission:

• All patients receive written copy of Patient Rights and Responsibilities

• Rights explained orally in understandable language upon request

• Interpreter services provided when needed

• Patient acknowledgment of receipt documented

• Family members/advocates receive copy when appropriate

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B. Ongoing Communication:

• Rights posted in common areas at all times

• Additional copies available upon request from Chief Operations Officer

• Rights reviewed periodically during treatment

• Staff trained to answer questions about patient rights

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6.2 Language and Literacy Accommodations

For patients with language barriers or reading difficulties:

• Qualified interpreters provided at no cost to patient

• Rights translated into commonly spoken languages in service area

• Visual aids and simplified language used when appropriate

• Staff trained to assess understanding and provide additional explanation

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6.3 Documentation Requirements

Staff must document:

• Delivery of patient rights information

• Patient acknowledgment of receipt

• Any questions or concerns raised by patients

• Accommodations provided for language or disability needs

• Rights violations reported or observed

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7. GRIEVANCE PROCEDURE

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7.1 Informal Complaint Resolution

Process:

1. Patients encouraged to first discuss concerns with direct care providers

2. Supervisor involvement if initial discussion doesn't resolve issue

3. Documentation of informal resolution attempts

4. Timeline: Initial response within 2 business days

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7.2 Formal Grievance Process

Filing a Grievance:

• Written or verbal grievances accepted

• Assistance provided for patients unable to write

• No retaliation against patients filing grievances

• Anonymous grievances accepted when possible

Investigation Process:

1. Grievance acknowledged within 2 business days

2. Investigation completed within 7 business days (or longer if complex)

3. Written response provided to patient

4. Documentation maintained in separate grievance file

Appeal Process:

• Patients may appeal grievance decisions

• Appeal reviewed by senior administrator not involved in original decision

• External review options explained to patients

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7.3 External Complaint Resources

Patients may file complaints with:

• Indiana Protection and Advocacy Services

• Indiana State Department of Health

• Indiana Division of Mental Health and Addiction (DMHA)

• Centers for Medicare and Medicaid Services (if applicable)

• Joint Commission (if applicable)

• Local law enforcement (for suspected crimes)

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8. STAFF RESPONSIBILITIES

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8.1 All Staff Members

• Must: Respect and protect all patient rights

• Must: Report observed rights violations immediately

• Must: Assist patients in understanding their rights

• Must: Provide culturally sensitive care

• Cannot: Retaliate against patients exercising their rights

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8.2 Clinical Staff

• Additional responsibilities: Involve patients in treatment planning

• Monitor for capacity issues affecting rights exercise

• Document patient choices regarding treatment options

• Recognize and report signs of abuse or neglect

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8.3 Administrative Staff

• Oversight: Monitor compliance with patient rights policies

• Investigation: Investigate reported rights violations

• Corrective Action: Implement improvements based on grievance patterns

• Training: Ensure ongoing staff education on patient rights

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9. MONITORING AND QUALITY IMPROVEMENT

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9.1 Regular Monitoring

• Monthly review of grievance reports and trends

• Annual patient satisfaction surveys including rights awareness

• Regular chart audits for rights documentation

• Staff training records review

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9.2 Quality Improvement

• Annual analysis of rights-related incidents

• Policy updates based on regulatory changes or identified issues

• Staff feedback sessions on rights implementation challenges

• Patient and family input on rights protection effectiveness

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10. REGULATORY COMPLIANCE

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10.1 State Requirements

Indiana Code 12-27: Rights of Individuals Treated for Mental Illness/Developmental Disabilities 440 IAC 4.4: Certification of Addiction Service Providers 440 IAC 7.5: Residential Living Facilities for Individuals with Psychiatric Disorders or Addictions

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10.2 Federal Requirements

42 CFR Part 2: Confidentiality of Substance Use Disorder Patient Records HIPAA Privacy Rule: 45 CFR Parts 160 and 164 Americans with Disabilities Act: Accessibility and reasonable accommodations Civil Rights Laws: Non-discrimination requirements

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11. FORMS AND RESOURCES

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11.1 Required Forms

• Patient Rights and Responsibilities Statement (for signature)

• Grievance/Complaint Form

• Rights Violation Incident Report Form

• Interpreter Request Form

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11.2 External Resources

Indiana Protection and Advocacy Services Phone: 1-800-622-4845 Website: www.in.gov/ipas

Indiana Division of Mental Health and Addiction Phone: 317-232-7800 Website: www.in.gov/fssa/dmha

National Suicide Prevention Lifeline Phone: 988

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12. POLICY REVIEW AND UPDATES

This policy will be reviewed annually and updated to reflect:

• Changes in state and federal regulations

• DMHA certification requirement updates

• Accreditation standard changes

• Patient feedback and quality improvement initiatives

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13. CONTACT INFORMATION

For Questions About Patient Rights: Practice mangers Concerns@mindsetbh.com

For Formal Grievances: Patient Rights Officer Concerns@mindsetbh.com

For Legal/Compliance Issues: Legal Counsel Concerns@mindsetbh.com

 

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