Homestead Program W Camdon Drive Casa Grande, AZ Phone: (520) Fax: (520)

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1 Homestead Program W Camdon Drive Casa Grande, AZ Phone: (520) Fax: (520) Homestead North Program 7345 N Hidden Hills Road Flagstaff, AZ Phone: (928) Fax: (926) To Our Referring Agency Partners: Thank you for referring your client/member to the Homestead/Homestead North Program. We ve tried to make our intake packet materials as user-friendly and streamlined as possible while adhering to the mandated rules and regulations that we must follow. While we would ideally like parents/guardians to accompany the child to the intake, we understand that is not always possible. If you cannot arrange for the parent/guardian to be present at our facility at intake, please note the list of items on our Documents Required at Admission page that we must have before the client is transported to Homestead/Homestead North. We look forward to working with you and other members of the Child and Family Team as we progress toward returning the child to his or her home community with greater supports, skills and strengths in place. Please don t hesitate to contact me if there is anything I can do to assist you in making this process go more smoothly, or at any other time I can be of assistance. Sincerely, Brad Waters Homestead/Homestead North Program Director Cell: (602) Community Provider of Enrichment Services 4825 N Sabino Canyon Road 2403 W Huntington Dr., Suite Highway 92 Tucson, Arizona Tempe, Arizona Bisbee, Arizona /884/ /431/ /432/ /884/0383 Fax /9538 Fax 520/432/2105 Fax

2 Homestead Client Information Sheet Emergency Contact and Medical Information for a Child Child s Name (Print) Provider: Guardian Name Guardian Address: NARBHA / Cenpatico (circle one) DOB M F Provider ID# AHCCCS ID# Case Manager Name Sex SSN# Guardian Phone: Physician Name Date of Last Visit: Phone ( ) Psychiatrist /Therapist Name Referring Agency Name Address: Phone ( ) Fax ( ) Phone ( ) WHAT QUESTION DO YOU WANT THE PSYCHOLOGICAL Date of Last Visit EVALUATION TO ANSWER? Primary Discharge Plan Secondary Discharge Plan PRIMARY EMERGENCY CONTACT Name: Relationship: School, Employer or Day Program: Address: Address: Home Phone ([ ]) Work Phone ([ ]) Phone ALLERGIES (FOOD, MED, ETC.)/SPECIAL HEALTH CONSIDERATIONS: Contact Name The average stay for a client in the Homestead Program is 2-4 weeks, and thus it is the responsibility of the case manager to relay any and all homework assignments via fax or snail mail to our site. CHILD MAY BE RELEASED TO THE FOLLOWING INDIVIDUALS UPON DISCHARGE I authorize (child name) to be released to the following individuals upon discharge: DESIGNEE NAME: PHONE ([ ]) Parent/Guardian Print & Sign DATE CPES Homestead Intake Packet 1

3 Admit Requirements We must have the following documents reviewed and signed (by the parent/guardian & licensed behavioral health personnel where noted) and sent to us before the child is transported. Documentation included in the intake packet Documentation you are required to obtain from the current treatment facility, case manager, guardian or client. 1. Client Information Sheet Please be sure to write a response to the question, What question do you want the psychological to answer? 2. List of agency phone numbers and addresses and other miscellaneous information. 3. General Consent and Authorization to Treatment 4. Informed Consent to Treatment 5. Authorization to Release Information 6. List of Client Rights 7. Homestead Grievance Policy and Procedure 8. Homestead Privacy Practices Guidelines 9. HIPPA Acknowledgement. 10. House Rules 11. The PRN Medication Form signed by the prescribing physician. 12. Informed Consent for Psychotropic Medication Treatment of Minor 13. Minors Consent to Participate in Telemedicine Care and Authorization for Release of Information ITP (INTENT TO PAY ) LETTER WITH AUTHORIZATION CODE - NARBHA A copy of the client s most recent comprehensive CORE ASSESSMENT (SIGNATURE PAGE-SIGNED BY SOMEONE LICENSED BY THE STATE WITH AN L IN THEIR CREDENTIALS, PART A, B, C,D, E AND DEMOGRAPHICS) A copy of the client s PHYSICAL EXAM (dated within 7 days of intake) PLEASE WAIT UNTIL INTAKE HAS BEEN SCHEDULED A copy of the client s skin test for tuberculosis (TB) indicating a negative reading. (DATED WITHIN 7 DAYS OF INTAKE!) PLEASE WAIT UNTIL INTAKE HAS BEEN SCHEDULED A copy of the client s most recent INSURANCE CARDS, including AHCCCS. A current copy of CRISIS/WRAP PLAN from referring agency. A list of the client s MEDICAL RESTRICTIONS, ALLERGIES AND/OR SPECIAL DIETARY NEEDS. BEHAVIORAL HEALTH SERVICE PLAN with Homestead Program and CCS listed as providing services. Strengths Needs and Cultural Discovery Assessment. (SNCD) A copy of all past psychological and/or psychiatric evaluations. REASON for referral. AT LEAST 30 DAY SUPPLY OF EACH PRESCRIBED MEDICATION IS REQUIRED TO BE ON THEIR PERSION AT TIME OF ADMIT. Thank you in advance for your cooperation in providing these items. Once all documentation is received a determination will be made in the best interest of the client and the resources available at our facility. These documents and materials will be reviewed with parents/guardians at the time the child is admitted to the facility. Again, please note that we will not be able to make any exceptions, all documentation must be received prior to admit due to OBHL Rules and Regulations.

4 Agency Phone Numbers, Addresses and Miscellaneous Information AGENCY NAME ADDRESS PHONE Homestead Program W. Camdon Dr. Casa Grande, AZ Homestead North Program 7345 N Hidden Hills Rd, Flagstaff, AZ Div. of Behavioral Health Services 150 N 18 th Avenue, 2 nd Floor, Phoenix, AZ Office of Behavioral Health Licensure 150 N 18 th Avenue, #410, Phoenix, AZ Arizona DES Child Protective Services P.O.Box 44240, Phoenix, AZ Cenpatico 1501 W Fountainhead Parkway, Tempe, AZ NARBHA 1300 S Yale, Flagstaff, AZ Client Fees Homestead does not charge clients fees since all services provided at Homestead are covered through a contract between Homestead and the client s Regional Behavioral Health Provider. Refund Policy and Procedure Since Homestead does not accept fees for clients we have no policy governing refunds of client fees. Treatment Environment Homestead is licensed as an unlocked facility. Dress Code We encourage youth to express themselves appropriately through dress and personal appearance but do enforce the following guidelines for dress while at Homestead: Clothes endorsing drugs or drug paraphernalia, alcohol, sex or violence are prohibited. Gang or gang affiliated colors or articles of clothing, including bandanas, are prohibited Mid drifts, skull caps or undergarments must be covered by outer garments. Proper sleep attire (pajamas, night gowns, t-shirts and shorts, etc) is required. Shoes must be worn at all times Clients are asked not to borrow or give clothing or personal hygiene items to one another Please do not bring jewelry to the facility. In instances where jewelry is brought it will be secured and returned to the client upon discharge If articles of clothing not specified in this dress code are, in the judgment of Homestead Management, inappropriate, they will be secured and returned to the client s guardian at discharge. Client Name Signature of Parent/Guardian Date Reviewed

5 Homestead Program GENERAL CONSENT AND AUTHORIZATION I consent to the following treatment and authorizations. My consent is valid from the date the client is admitted through the day the client is discharged. (Please be sure to check all boxes for which you give consent/authorization) Yes No Necessary emergency treatment Yes No Routine Medical Care Yes No Emergency Dental Care Yes No Use of sedation/restraint when prescribed by a physician for medical/dental use Yes No Necessary educational, vocational, and therapeutic evaluation/assessments Yes No Participation in routine recreational/leisure activities Yes No Administration of over the counter medications and ongoing medications RELEASE OF THE FOLLOWING INFORMATION: Yes No Medical records Yes No Educational Yes No Social Yes No Psychological Yes No Financial Yes No Other For those categories marked "no", my signature is required prior to the occurrence of such events or the release of any information. The preceding has been explained to me and I certify that I understand it fully. I also understand that my consent may be withdrawn at any time by my written notification to this agency. Client Name (please print) Date of Admission Signature of Parent or Legal Guardian Date Reviewed and Signed CPES Homestead Intake 3

6 Homestead Program INFORMED CONSENT FOR CARE & TREATMENT 1. I, the undersigned, hereby grant permission to Homestead, a program of Community Provider of Enrichment Services, Inc. (Hereinafter known as CPES) to employ routine treatment services as may be deemed necessary or advisable for my diagnosis and treatment. 2. I understand that there is no guarantee that these treatment services will prove beneficial to me. 3. I have been advised that should medications be prescribed or administered, that such medications may or may not be effective and, in a small number of situations, I may have an adverse reaction to such medication. Any medication issues will be discussed with me prior to prescription or administration, or changes. 4. Additionally, the following has been specifically explained to me: The specific treatment being proposed; The intended outcome; The nature and procedures of the proposed treatment; Any risks and side effects of the proposed treatment, including any risks of not proceeding with the proposed treatment; and, That consent is voluntary (unless under court ordered treatment) and such consent may be withdrawn or withheld at any time. 5. Even though all information gathered in the course of my relationship with the CPES Homestead program is confidential, this confidentiality is not absolute. In the cases of medical emergency, child abuse or neglect, court order, or where otherwise legally required, essential information may be released. 6. I agree to collaborate in the treatment planning process to the best of my ability. 7. Services will be provided within the limitations of funding. 8. Services are made available regardless of race, national origin, religion, gender, sexual orientation, age, disability, marital status, diagnosis, or source of payment. 9. I understand that at some time, it may be in the best interest of me, or CPES, for me to obtain care elsewhere. In all cases of referral elsewhere, CPES will make every effort to facilitate continuity of care. CLIENT NAME (PRINTED) PARENT/GUARDIAN SIGNATURE DATE REVIEWED

7 (First, Middle, Last) Name: COMMUNITY PROVIDER OF ENRICHMENT SERVICES, INC. Authorization and Consent to Release/Receive/Exchange Clinical Information (R B) Date of Birth: Address: City: State: Zip: I HEREBY AUTHORIZE: Name: Community Provider of Enrichment Services, Inc. Site/Setting: Licensed Address: City: State: Zip: To release, receive, and/or exchange the information described below and contained within my Clinical Records by phone, fax, or other written means. To/with: (A separate Authorization and Consent to Release/Receive/Exchange Clinical Information form must be completed for each entity, individual, or agency). Provider Name Hospital (specify) Medical Doctor (specify) Family (specify) Other Other Other Other The purpose of the disclosure is: Progress towards treatment goals and /or compliance with service site rules. 1. The specific information and the extent of that information that I wish released is: Psycho-Social Assessment Psycho-Social History Psychiatric Evaluation Medical Information Other: Diagnosis Test Results School Records Medical History Ongoing communication during: Residential Placement or Services Provided Service/Treatment Plan Outpatient Services 2. Records of the following specific information: 3. Records of the Period from to 4. Records of treatment for chemical dependency issues: Yes No Signature: Date: 5. Records of testing and/or treatment for AIDS and AIDS related disease: Yes No Signature: Date: I understand that my records are protected under State and Federal Confidentiality Regulations and cannot be disclosed under most circumstances without my written consent. I certify that this consent has been given freely and voluntarily. I understand that services are not contingent upon my consent for release of information made in good faith. I understand that this authorization will expire on the date determined below, immediately upon my revocation, or upon discharge from the current setting. I understand revocation of my authorization to release information must be requested in writing. Staff Member Printed First & Last Name/Title/ Credentials Staff Member Signature /Date Signature of client Date If client is unable to sign, give reason Other (First & Last Name) Date If other, relationship to client: Guardian, etc. Expiration Date Rev 1/11/13

8 CPES RIGHTS, AGREEMENT, NOTICES, and CONSENT SIGNATURE PAGE CLIENT RIGHTS: I have received a copy of the CLIENT RIGHTS policy Yes No. I accepted or declined the opportunity to have the rights explained to me. I understand that I may file a grievance if I believe that any of my Client Rights, or the rights of my child, ward, or person under my guardianship have been violated. Signature of Client or Legally responsible party Date GRIEVANCE/COMPLAINTS: I have received a copy of the GRIEVANCE/COMPLAINTS policy. Yes No. I accepted or declined the opportunity to have the policy explained to me. I understand and agree to the terms of the policy. Signature of Client or Legally responsible party Date RIGHTS OF PERSONS WHO HAVE BEEN DEEMED SMI: I have received a copy of the forms RIGHTS OF PERSONS WHO HAVE BEEN DEEMED SMI and NOTICE OF DISCRIMINIATION PROHIBITED FOR PERSONS WHO HAVE BEEN DEEMED SMI Yes No. I accepted or declined the opportunity to have the rights described on these documents explained to me. I understand how to obtain further information about the rights described in this document. Signature of Client or Legally responsible party Date HIPPAA NOTICE: I have received a copy of the HIPAA NOTICE OF PRIVACY PRACTICES form Yes No. I accepted or declined the opportunity to have the rights under HIPAA explained to me. I understand how to file a complaint if I believe my privacy rights or the privacy rights of my child, ward, or person under my guardianship have been violated. Signature of Client or Legally responsible party Date Employee / witness signature Date Rev Jan-13

9 CPES BH POLICY AND PROCEDURE MANUAL POLICY TITLE: RULE NUMBER: 5.03 Client Rights R (C) MH 209 MH 211 PURPOSE: To ensure that CPES staff and clients are aware of client rights. POLICY STATEMENT: CPES will adhere to all client rights as stipulated by various government agencies. PROCEDURES: A. All CPES clients will be given a copy of the following statement regarding rights upon admission, and will acknowledge receipt of these rights via signature. If the consumer is enrolled by the Department of Behavioral Health Services or a local Tribal/Regional Behavioral Health Authority (T/RBHA) as an individual who is seriously mentally ill, the rights are contained in 9 AAC 21. A consumer who does not speak English or who has a physical or other disability is to be assisted in becoming aware of consumer rights: 1. to be treated with dignity, respect, and consideration; 2. not to be discriminated against based on race, national origin, religion, gender, sexual orientation, age, disability, marital status, diagnosis, or source of payment. 3. To receive treatment that: a. supports and respects the client's individuality, choices, strengths, and abilities; b. supports the client's personal liberty and only restricts the client's personal liberty according to a court order; by the client's general consent; or as permitted in this Chapter; and c. is provided in the least restrictive environment that meets the client's treatment needs. 4. not to be prevented or impeded from exercising the client's civil rights unless the client has been adjudicated incompetent or a court of competent jurisdiction has found that the client is unable to exercise a specific right or category of rights. 5. To submit grievances to agency staff members and complaints to outside entities and other individuals without constraint or retaliation. 6. To have grievances considered by a licensee in a fair, timely, and impartial manner. 7. To seek, speak to, and be assisted by legal counsel of the client's choice, at the client's expense; 8. To receive assistance from a family member, designated representative, or other individual in understanding, protecting, or exercising the client's rights. DATE ORIGINATED: 8/31/12 Page 1 of 14 LAST REVISION DATE: REVISION #

10 CPES BH POLICY AND PROCEDURE MANUAL POLICY TITLE: RULE NUMBER: 5.03 Client Rights R (C) MH 209 MH If enrolled by the Department or a Regional Behavioral Health Authority as an individual who is seriously mentally ill, to receive assistance from human rights advocates provided by the Department or the Department's designee in understanding, protecting, or exercising the client's rights. 10. To have the client's information and records kept confidential and released only as permitted under R (A)(3) and (B). 11. To privacy in treatment, including the right not to be fingerprinted, photographed, or recorded without general consent, except: a. for photographing for identification and administrative purposes, as provided by A.R.S (2); b. for a client receiving treatment according to A.R.S. Title 36, Chapter 37; c. for video recordings used for security purposes that are maintained only on a temporary basis; or d. as provided in R (A)(5). 12. To review, upon written request, the client's own record during the agency's hours of operation or at a time agreed upon by the clinical director, except as described in R (A)(6). 13. To review the following at the agency or at the Department: a. this Chapter; b. the report of the most recent inspection of the premises conducted by the Department; c. a plan of correction in effect as required by the Department; d. if the licensee has submitted a report of inspection by a nationally recognized accreditation agency in lieu of having an inspection conducted by the Department, the most recent report of inspection conducted by the nationally recognized accreditation agency; and e. if the licensee has submitted a report of inspection by a nationally recognized accreditation agency in lieu of having an inspection conducted by the Department, a plan of correction in effect as required by the nationally recognized accreditation agency. 14. To be informed of all fees that the client is required to pay and of the agency's refund policies and procedures before receiving a behavioral health service, except for a behavioral health service provided to a client experiencing a crisis situation. 15. To receive a verbal explanation of the client's condition and a proposed treatment, including the intended outcome, the nature of the proposed treatment, procedures involved in the proposed treatment, risks or side effects from the proposed treatment, and alternatives to the proposed treatment; DATE ORIGINATED: 8/31/12 Page 2 of 14 LAST REVISION DATE: REVISION #

11 CPES BH POLICY AND PROCEDURE MANUAL POLICY TITLE: RULE NUMBER: 5.03 Client Rights R (C) MH 209 MH To be offered or referred for the treatment specified in the client's treatment plan. 17. To receive a referral to another agency if the agency is unable to provide a behavioral health service that the client requests or that is indicated in the client's treatment plan. 18. To give general consent and, if applicable, informed consent to treatment, refuse treatment or withdraw general or informed consent to treatment, unless the treatment is ordered by a court according to A.R.S. Title 36, Chapter 5, is necessary to save the client's life or physical health, or is provided according to A.R.S To be free from: a. abuse; b. neglect; c. exploitation; d. coercion; e. manipulation; f. retaliation for submitting a complaint to the Department or another entity; g. discharge or transfer, or threat of discharge or transfer, for reasons unrelated to the client's treatment needs, except as established in a fee agreement signed by the client or the client's parent, guardian, custodian, or agent; h. treatment that involves the denial of: i. food, ii. the opportunity to sleep, or iii. the opportunity to use the toilet; and iv. restraint or seclusion, of any form, used as a means of coercion, discipline, convenience, or retaliation. 20. To participate or, if applicable, to have the client's parent, guardian, custodian or agent participate in treatment decisions and in the development and periodic review and revision of the client's written treatment plan. 21. To control the client's own finances except as provided by A.R.S (5); 22. To participate or refuse to participate in religious activities. 23. To refuse to perform labor for an agency, except for housekeeping activities and activities to maintain health and personal hygiene. 24. To be compensated according to state and federal law for labor that primarily benefits the agency and that is not part of the client's treatment plan. 25. To participate or refuse to participate in research or experimental treatment. DATE ORIGINATED: 8/31/12 Page 3 of 14 LAST REVISION DATE: REVISION #

12 CPES BH POLICY AND PROCEDURE MANUAL POLICY TITLE: RULE NUMBER: 5.03 Client Rights R (C) MH 209 MH To give informed consent in writing, refuse to give informed consent, or withdraw informed consent to participate in research or in treatment that is not a professionally recognized treatment. 27. To refuse to acknowledge gratitude to the agency through written statements, other media, or speaking engagements at public gatherings. 28. To receive behavioral health services in a smoke-free facility, although smoking may be permitted outside the facility. 29. If receiving treatment in a residential agency, an inpatient treatment program, a Level 4 transitional agency, or a domestic violence shelter: a. If assigned to share a bedroom, to be assigned according to R (F) and, if applicable, R (A)(4)(a). b. To associate with individuals of the client's choice, receive visitors, and make telephone calls during the hours established by the licensee and conspicuously posted in the facility, unless: i. the medical director or clinical director determines and documents a specific treatment purpose that justifies restricting this right; ii. the client is informed of the reason why this right is being restricted; and iii. the client is informed of the client's right to file a grievance and the procedure for filing a grievance; c. To privacy in correspondence, communication, visitation, financial affairs, and personal hygiene, unless: i. the medical director or clinical director determines and documents a specific treatment purpose that justifies restricting this right; ii. the client is informed of the reason why this right is being restricted; and iii. the client is informed of the client's right to file a grievance and the procedure for filing a grievance; d. To send and receive uncensored and unopened mail, unless restricted by court order or unless: i. The medical director or clinical director determines and documents a specific treatment purpose that justifies restricting this right; ii. The client is informed of the reason why this right is being restricted; and iii. The client is informed of the client's right to file a grievance and the procedure for filing a grievance. e. To maintain, display, and use personal belongings, including clothing, unless restricted by court order or according to A.R.S (5) and as documented in the client record. f. To be provided storage space, capable of being locked, on the premises while the client receives treatment. DATE ORIGINATED: 8/31/12 Page 4 of 14 LAST REVISION DATE: REVISION #

13 CPES BH POLICY AND PROCEDURE MANUAL POLICY TITLE: RULE NUMBER: 5.03 Client Rights R (C) MH 209 MH 211 g. To be provided meals to meet the client's nutritional needs, with consideration for client preferences. h. To be assisted in obtaining clean, seasonably appropriate clothing that is in good repair and selected and owned by the client. i. To be provided access to medical services, including family planning, to maintain the client's health, safety, or welfare. j. To have opportunities for social contact and daily social, recreational, or rehabilitative activities. k. To be informed of the requirements necessary for the client's discharge or transfer to a less restrictive physical environment. l. To receive, at the time of discharge or transfer, recommendations for treatment upon discharge. B. If you have a serious or chronic mental illness, you have legal rights under federal and state law. These rights include: 1. the right to appropriate mental health services based on your individual needs; 2. the right to participate in all phases of your mental health treatment, including Individual Service Plan (ISP) meetings; 3. the right to a discharge plan upon discharge from a hospital; 4. the right to consent to or refuse treatment (except in an emergency or by court order); 5. the right to treatment in the least restrictive setting; 6. the right to freedom from unnecessary seclusion or restraint; 7. the right not to be physically, sexually, or verbally abused; 8. the right to privacy (mail, visits, telephone conversations); 9. the right to file an appeal or grievance when you disagree with the services you receive or your rights are violated; 10. the right to choose a designated representative(s) to assist you in ISP meetings and in filing grievances; 11. the right to a case manager to work with you in obtaining the services you need; 12. the right to a written ISP that sets forth the services you will receive; 13. the right to associate with others; 14. the right to confidentiality of your psychiatric records; 15. the right to obtain copies of your own psychiatric records (unless it would not be in your best interests to have them); 16. the right to appeal a court-ordered involuntary commitment and to consult with an attorney and to request judicial review of court-ordered commitment every 60 days; 17. the right not to be discriminated against in employment or housing. DATE ORIGINATED: 8/31/12 Page 5 of 14 LAST REVISION DATE: REVISION #

14 CPES BH POLICY AND PROCEDURE MANUAL POLICY TITLE: RULE NUMBER: 5.03 Client Rights R (C) MH 209 MH 211 Notice of Discrimination Prohibited: 1. Persons undergoing evaluation or treatment pursuant to this Chapter shall not be denied any civil right, including, but not limited to, the right to dispose of property, sue and be sued, enter into contractual relationships and vote. Court-ordered treatment or evaluation pursuant to the Chapter is not a determination of legal incompetency, except to the extent provided in A.R.S A person who is or has been evaluated or treated in an agency for a mental disorder shall not be discriminated against in any manner, including but not limited to: a. Seeking employment. b. Resuming or continuing professional practice or previous occupation. c. Obtaining or retaining housing. d. Obtaining or retaining licenses or permits, including but not limited to, motor vehicle licenses, motor vehicle operator s and chauffeur s licenses, and professional or occupational licenses. 3. "Discrimination" for purposes of this Section means any denial of civil rights on the grounds of hospitalization or outpatient care and treatment unrelated to a person's present capacity to meet the standards applicable to all persons. Applications for positions, licenses and housing shall contain no requests for information which encourage such discrimination 4. Upon discharge from any treatment or evaluation agency, the patient shall be given written notice of the provisions of this Section. If you would like information about your rights, you may request a copy of the "Your Rights in Arizona as an Individual with Serious Mental Illness" brochure or you may also call the Arizona Department of Health Services, Office of Human Rights at RELEVANT PROTOCOLS, FORMS AND EXAMPLES: See relevant protocols in the site's Protocol Manual; forms and examples on the corporate drive at K:\Master Forms\CPES\CPES-Clinical Services as applicable. Residential Services: Protocols: N/A Forms: Signature Sheet Rights and Notices DATE ORIGINATED: 8/31/12 Page 6 of 14 LAST REVISION DATE: REVISION #

15 CPES BH POLICY AND PROCEDURE MANUAL POLICY TITLE: RULE NUMBER: 5.03 Client Rights R (C) MH 209 MH 211 Client Rights and SMI Rights Outpatient Services: Protocols: N/A Forms: Signature Sheet Rights and Notices Client Rights and SMI Rights DATE ORIGINATED: 8/31/12 Page 7 of 14 LAST REVISION DATE: REVISION #

16 CPES BH MANUAL DE NORMAS Y PROCEDIMIENTOS TITULO DEL PROCEDIMIENTO: REGLAMENTO NÚMERO: 5.03 Derechos del Cliente R (C) MH 209 MH 211 PROPOSITO: Asegurar que CPES y sus clientes estén consientes de cuales son los derechos de los clientes. ENUNCIACION DE LA NORMA: CPES se adhiere a todos los derechos de los clientes según lo estipulado por las diversas agencias gubernamentales. PROCEDIMIENTOS: A. Una vez que son ingresados, todos los clientes de CPES deberán de recibir una copia de la siguiente declaración sobre sus derechos y confirmaran la recepción de este documento mediante su firma. Si el consumidor fue inscrito por el Departamento de Servicios de Salud Mental o una autoridad de salud mental tibutaria o regional (T/RBHA) como una persona que posee una enfermedad mental seria, los derechos están contenidos en 9 AAC 21. Un consumidor que no habla ingles o que tiene una incapacidad física o de otra índole deberá ser asistido en ser informado de sus derechos como consumidor los cuales incluyen: 1. a ser tratado con dignidad, respeto y consideración; 2. a no ser objeto de discriminación basándose en raza, nacionalidad de origen, religión, sexo, orientación sexual, edad, incapacidad, estado civil, diagnostico o fuente de pago. 3. a recibir un tratamiento que: a. apoye y respete su individualidad como cliente, sus opciones, fortalezas y habilidades; b. apoye la libertad personal del cliente y solo la restrinja de acuerdo con una orden judicial, mediante el consentimiento general del cliente o como es permitido en el presente capitulo, y c. se proporcione en el ambiente menos restrictivo que satisfaga las necesidades de tratamiento del cliente. 4. a no ser prevenido o impedido de ejercitar sus derechos civiles como cliente al menos que haya sido declarado incompetente por un juzgado de jurisdicción competente que haya encontrado que el cliente no puede ejercitar un derecho específico o categoría de derechos 5. A presentar quejas a los miembros del personal de la agencia y reclamaciones a entidades externas y a otros individuos sin restricciones o represalias. FECHA EN LA CUAL FUE ORIGINADO: 8/31/12 Pagina 8 of 14 FECHA DE LA ULTIMA REVISION: # de REVISION

17 CPES BH MANUAL DE NORMAS Y PROCEDIMIENTOS TITULO DEL PROCEDIMIENTO: REGLAMENTO NÚMERO: 5.03 Derechos del Cliente R (C) MH 209 MH A que sus quejas sean examinadas por una autoridad competente de manera justa, oportuna e imparcial. 7. A hablar y ser asistido por un abogado elegido por el cliente, a expensas del cliente; 8. A recibir asistencia por parte de un familiar, representante designado u otro individuo en el entendimiento, protección o ejercicio de los derechos del cliente. 9. Si ha sido inscrito por el Departamento o Autoridad Regional de Salud como un individuo con una enfermedad mental seria, a recibir asistencia de parte de los defensores de derechos humanos proporcionados por el Departamento o la persona designada por el Departamento en la comprensión, protección y ejercicio de los derechos del cliente. 10. A que la información y los archivos del cliente sean mantenidos confidenciales y sean entregados exclusivamente como es establecido en R (A)(3) y (B). 11. A la privacidad en su tratamiento, incluyendo el derecho a no tomarle sus huellas, ser fotografiado o grabado sin un consentimiento general, excepto: a. a ser fotografiado con fines de identificación y administrativos como lo dispone A.R.S (2); b. para que un cliente reciba tratamiento como lo establece A.R.S. Titulo 36, Capitulo 37; c. para grabaciones de video que sean usadas por propósitos de seguridad y son mantenidas solo de manera temporal; o d. como esta establecido en R (A)(5). 12. A examinar, mediante previa solicitud por escrito, los archivos propios del cliente durante las horas hábiles de la agencia o durante un horario acordado con el director clínico, excepto como esta descrito en R (A)(6). 13. A revisar lo siguiente en la agencia o en el Departamento: a. este Capitulo; b. el reporte de la inspección mas reciente de las instalaciones conducida por el Departamento; c. un plan de corrección en efecto como se requiera por el Departamento; d. si el titular ha presentado un informe de inspección por parte de una agencia de acreditación reconocida a nivel nacional, en vez de tener una inspección llevada a cabo por el Departamento, el informe más reciente de la inspección realizada por la agencia de acreditación reconocida a nivel nacional, y e. si el titular en vez de tener una inspección llevada a cabo por el Departamento presenta un informe de inspección por parte de una agencia acreditada reconocida a nivel nacional, un plan de corrección en efecto como lo requiere la agencia de acreditación reconocida a nivel nacional FECHA EN LA CUAL FUE ORIGINADO: 8/31/12 Pagina 9 of 14 FECHA DE LA ULTIMA REVISION: # de REVISION

18 CPES BH MANUAL DE NORMAS Y PROCEDIMIENTOS TITULO DEL PROCEDIMIENTO: REGLAMENTO NÚMERO: 5.03 Derechos del Cliente R (C) MH 209 MH A ser informado de todas las cuotas que el cliente está obligado a pagar y de las políticas y procedimientos de rembolso de la agencia antes de recibir un servicio de salud mental, a excepción de servicios de salud mental proporcionados a un cliente que experimenta una situación de crisis. 15. A recibir una explicación verbal de la condición del cliente y el tratamiento propuesto, incluyendo el resultado esperado, la naturaleza del tratamiento propuesto, los procedimientos implicados en el tratamiento propuesto, los riesgos o efectos secundarios del tratamiento propuesto y las alternativas al tratamiento propuesto; 16. A que se le ofrezca o sea referido para el tratamiento especificado en el plan de tratamiento del cliente. 17. A recibir una referencia a otra agencia si la agencia no puede ofrecer el servicio de salud mental que el cliente solicite o que se indica en el plan de tratamiento del cliente. 18. A dar un consentimiento general y, si procede, consentimiento informado del tratamiento, a rechazar el tratamiento o retirar el consentimiento general o informado del tratamiento, a menos que el tratamiento sea ordenado por un tribunal de acuerdo con ARS Título 36, Capítulo 5, si es necesario para salvar la vida del cliente o su salud física, o se proporciona de acuerdo con ARS A ser libre de: a. abuso; b. negligencia; c. explotación; d. coerción; e. manipulación; f. represalias por presentar una queja al Departamento u otra entidad; g. a ser dado de alta o ser amenazado con ser dado de alta por razones que no están relacionadas con las necesidades de tratamiento del cliente, excepto con lo establecido en un acuerdo de pago firmado por el cliente, o el padre, tutor, custodio o agente del cliente; h. tratamientos que impliquen la negación de: i. i. alimentos, ii. la oportunidad de dormir, o iii. la oportunidad de ir al baño, y iv. la restricción o cualquier forma de reclusión usadas como medios de coerción, disciplina, conveniencia o represalia. 20. De participar o, en su caso, al padre, tutor o agente del cliente de participar en las decisiones terapéuticas y en el desarrollo y revisiones periódicas del plan escrito de tratamiento del cliente. FECHA EN LA CUAL FUE ORIGINADO: 8/31/12 Pagina 10 of 14 FECHA DE LA ULTIMA REVISION: # de REVISION

19 CPES BH MANUAL DE NORMAS Y PROCEDIMIENTOS TITULO DEL PROCEDIMIENTO: REGLAMENTO NÚMERO: 5.03 Derechos del Cliente R (C) MH 209 MH Al control de las finanzas del propio cliente, salvo lo dispuesto por el ARS (5); 22. A participar o negarse a participar en las actividades religiosas 23. De negarse a realizar labores para una agencia, excepto para las actividades de limpieza y actividades para mantener la salud e higiene personal. 24. A ser indemnizado conforme a la ley estatal y federal por realizar labores que principalmente beneficien a la agencia y que no forman parte del plan de tratamiento del cliente. 25. A participar o negarse a participar en la investigación o el tratamiento experimental. 26. A dar su consentimiento informado por escrito, a negarse a dar su consentimiento informado, o a retirar su consentimiento informado para participar en la investigación o un tratamiento que no se un tratamiento profesional reconocido. 27. A negarse a expresar su gratitud a la agencia a través de declaraciones escritas, otros medios de comunicación, o charlas en reuniones públicas. 28. A recibir servicios de salud mental en un centro libre de humo de fumadores, aunque fumar puede ser permitido fuera de las instalaciones. 29. Si recibe tratamiento en una agencia residencial, un programa de tratamiento para pacientes hospitalizados, una agencia de transición de nivel 4, o un refugio de violencia doméstica: a. Si es asignado a compartir una habitación, a ser asignado de acuerdo con R (F) y, en su caso, R (A) (4) (a). b. A asociarse con individuos de la elección del cliente, recibir visitas y hacer llamadas telefónicas durante las horas establecidas por el titular de la agencia y las cuales deberán ser visiblemente publicadas en las instalaciones, a menos que: i. el director médico o el director clínico determine y documente un propósito especifico del tratamiento que justifica la restricción de este derecho; ii. el cliente es informado de la razón por la cual se restringe este iii. derecho, y se informa al cliente del derecho que tiene a presentar una queja formal y cual es el procedimiento para presentar una queja; c. A la privacidad en la correspondencia, las comunicaciones, visitas, asuntos financieros, e higiene personal, a menos que: i. el director médico o el director clínico determine y documente un propósito especifico del tratamiento que justifica la restricción de este derecho; ii. el cliente es informado de la razón por la cual se restringe este derecho, y FECHA EN LA CUAL FUE ORIGINADO: 8/31/12 Pagina 11 of 14 FECHA DE LA ULTIMA REVISION: # de REVISION

20 CPES BH MANUAL DE NORMAS Y PROCEDIMIENTOS TITULO DEL PROCEDIMIENTO: REGLAMENTO NÚMERO: 5.03 Derechos del Cliente R (C) MH 209 MH 211 iii. se informa al cliente del derecho que tiene a presentar una queja formal y cual es el procedimiento para presentar una queja; d. A enviar y recibir correo sin censura y sin que este sea abierto, a no ser que este restringido por una orden judicial o a menos que: i. el director médico o el director clínico determine y documente un propósito especifico del tratamiento que justifica la restricción de este derecho; ii. el cliente es informado de la razón por la cual se restringe este derecho, y iii. se informa al cliente del derecho que tiene a presentar una queja formal y cual es el procedimiento para presentar una queja; e. A mantener, mostrar y utilizar artículos personales, incluyendo ropa, a menos que este restringido por una orden judicial o de acuerdo con ARS (5) y como se documenta en el expediente del cliente. f. A que durante el tiempo que el cliente recibe el tratamiento se le proporcione un espacio que pueda ser cerrado para almacenamiento de sus pertenencias dentro de las instalaciones. g. A que se le proporcionen alimentos para satisfacer las necesidades nutricionales de cada cliente, teniendo en consideración las preferencias del cliente. h. A recibir asistencia para obtener ropa limpia, apropiada a la estación, que se encuentre en buenas condiciones y que sea selección y propiedad del cliente. i. A que se le proporcione acceso a servicios médicos, incluyendo la planificación familiar, para mantener la salud del cliente, su seguridad y su bienestar. j. A tener oportunidades de contacto social y actividades sociales cotidianas, recreativas o de rehabilitación. k. A ser informado de los requisitos necesarios para ser dado alta o para transferirlo a un ambiente de menor restricción física. l. A recibir, en el momento de ser dado de alta o transferido, las recomendaciones necesarias para continuar con el tratamiento posterior. B. Si usted tiene una enfermedad mental grave o crónica, usted tiene derechos legales bajo la ley federal y estatal. Estos derechos incluyen: 1. el derecho a servicios adecuados de salud mental basados en sus necesidades individuales; 2. el derecho a participar en todas las fases de su tratamiento de salud mental, incluyendo las reuniones del Plan de Servicio Individual (ISP); 3. el derecho a un plan para ser dado del tratamiento una vez que haya sido dado de alta de un hospital; FECHA EN LA CUAL FUE ORIGINADO: 8/31/12 Pagina 12 of 14 FECHA DE LA ULTIMA REVISION: # de REVISION

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