5100.52 STATEMENT OF PRINCIPLE
(a) Facilities. Upon voluntary or involuntary admission to an inpatient facility, each patient is given a copy of the summary statement of the Bill of Rights, contained in 5100.53 (relating to bill of rights for patients), Form MH-782, or the patient rights pamphlet (PWPE #605). This is to be done within 72 hours of admission and shall have them explained to them if they cannot read or understand them.
(b) Current patients
(c) Manual of rights
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Observations:
Based on a review of facility documents and employee interview (EMP), it was determined the facility failed to ensure that names, addresses, and telephone numbers of legal services and other available advocacy services were appended to the Bill of Rights, which is given to each patient upon voluntary or involuntary admission to an inpatient facility.
Findings include:
Review of the Mental Health Procedure Act Chapter 5100.52 revealed, " ... Upon voluntary or involuntary admission to an inpatient facility, each patient shall be given a copy of the summary statement of the Bill of Rights, ... Form MH-782, or ... You Have a Right to be Treated with Dignity and Respect. Appended to each of these documents shall be the names, addresses, and telephone numbers of legal and other available advocacy services. ..."
Review of facility documents revealed no evidence that patients were given a copy of the names, addresses, and telephone numbers of legal services, or that information about legal and advocacy services were appended to the Bill of Rights.
On February 14, 2025, at approximately 1:00 PM, EMP1 confirmed that patients were not given the names, addresses, and telephone numbers of legal services.
On February 14, 2025, at approximately 1:00 PM, EMP2 confirmed that information about legal and advocacy services were not appended to the Bill of Rights.
| | Plan of Correction - To be completed: 03/20/2025
The Chief Nursing Officer is ultimately responsible for this plan of correction. Education will be given to all Needs Assessment Coordinators (NAC) on the requirement that the names, addresses, and telephone numbers of legal and advocacy services will be physically appended to each patient's Bill of Rights. The NAC will explain the Bill of Rights along with the legal and advocacy services to each patient. A revised patient acknowledgement form will include the explicit statement: "I have received a copy of my Bill of Rights, including the appended information regarding legal and other available advocacy services, and they have been explained to me to my satisfaction."
Auditing of the process will begin on March 1st, 2025 and will be 10 records/month. This audit will continue until compliance with all components is 100% for three (3) consecutive months. Report of compliance will be at the Performance Improvement Oversight Committee meeting monthly.
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