Code of Colorado Regulations
500 - Department of Human Services
502 - Behavioral Health
2 CCR 502-1 - BEHAVIORAL HEALTH
Chapter 2 - General Behavioral Health Entity Licensing Standards
Section 2 CCR 502-1-2.7 - Individual Rights

Current through Register Vol. 48, No. 6, March 25, 2025

A. The BHE shall develop and implement a policy regarding individual rights. The policy must ensure that each individual or, when applicable, the individual's designated representative, has the right to:

1. Participate in all decisions involving the individual's care or treatment.

2. Be informed about whether the BHE is participating in teaching programs, and to provide informed consent prior to being included in any clinical trials relating to the individual's care.

3. Refuse any drug, test, procedure, service, or treatment and to be informed of risks and benefits of this action.

4. Receive care and treatment, in compliance with state statute, that is free from discrimination on the basis of physical or mental disability, race, ethnicity, socio-economic status, religion, gender expression, gender identity, sex, sexuality, culture, and/or languages spoken; and that recognizes an individual's dignity, cultural values and religious beliefs; as well as provides for personal privacy to the extent possible during the course of treatment.

5. Be informed of, at a minimum, the first names and credentials of the personnel that are providing services to the individual. Full names and qualifications of the service providers must be provided upon request to the individual or the individual's designated representative or when required by the department of regulatory agencies.

6. Receive, upon request:
a. Prior to initiation of non-emergent care or treatment, the estimated average charge to the individual. This information must be presented to the individual in a manner that is consistent with all state and federal laws and regulations.

b. The BHE's general billing procedures.

c. An itemized bill that identifies treatment and services by date. The itemized bill must enable individuals or their legal representatives to validate the charges for items and services provided and must include contact information, including a telephone number, for billing inquiries. The itemized bill must be made available either within ten (10) business days of the request, thirty (30) days after discharge, or thirty (30) days after the service is rendered - whichever is later.

7. Give informed consent for all treatment and services. The personnel must obtain informed consent for treatment they provide to the individual. Informed consent includes:
a. A written agreement executed between the BHE and the individual or the individual's legal representative at the time of admission. The parties may amend the agreement if there is written consent of both parties. No agreement will be construed to relieve the BHE of any requirement or obligation imposed by law or regulation.

b. Individual consents must include consent to treatment. If the individual is refusing treatment or an aspect of treatment, the BHE must have the individual sign a form to confirm their refusal.

c. If the governor or local government declares an emergency or disaster, a BHE may obtain documented oral agreements or consents in place of written agreements or consents. Documented oral agreements and consents may only be used as necessary because of circumstances related to the emergency or disaster. The BHE shall send a hard copy or electronic copy of the documented agreement or consent to the individual within two (2) business days of the oral agreement or consent.

8. Register disputes with the BHE and grievances with the BHA and to be informed of the procedures for registering complaints and grievances including contact information.

9. Be free of abuse and neglect.
a. The BHE must develop and implement policies and procedures that prevent, detect, investigate, and respond to incidents of abuse or neglect. This includes suspected physical, sexual, or psychological abuse; exploitation and/or caretaker neglect; as well as child abuse, neglect and/or child safety issues, which must include definitions of abuse and neglect under the Colorado Children's Code (Section 19-1-103, C.R.S.), and that are consistent with the reporting of child abuse allowed under federal law. Policies and procedures must also be consistent with definitions and mandated reporting requirements for mistreatment, abuse, neglect, and exploitation of at-risk adults under the Colorado Human Services and Criminal Codes (Sections 26-3.1-101, 26-3.1-102, 18-6.5-108, C.R.S.).
(1) Prevention includes, but is not limited to, adequate staffing to meet the needs of the individuals, screening personnel for records of abuse and neglect, and protecting individuals from abuse during investigation of allegations.

(2) Detection includes, but is not limited to, establishing a reporting system and training personnel regarding identifying, reporting, and intervening in incidences of abuse and neglect.

b. The BHE shall investigate all allegations of abuse or neglect against BHE personnel, or made against an individual, when the allegation occurs during service provision or on BHE premises. The BHE shall implement corrective actions in accordance with such investigations.

10. Be free from the improper application of restraints or seclusion. Restraints or seclusion may only be used in a manner consistent with part 2.14 of this Chapter.

11. Expect that the BHE in which the individual is admitted can meet the identified and reasonably anticipated care, treatment, and service needs of the individual.

12. Receive care from the BHE in accordance with the individual's needs.

13. Have the confidentiality of their individual records maintained.
a. A BHE must comply with all applicable state and federal laws and regulations for release of information including but not limited to 42 C.F.R. Part 2, Section 27-65-123, C.R.S. and HIPAA.

b. When obtaining informed consent or an authorization for release of information, the signed release must state, at a minimum:
(1) Persons who may receive the information in the records;

(2) The purpose for obtaining this information;

(3) The information to be released;

(4) That the release may be revoked by the individual, or legal representative at any time; and

(5) That the release of information is only valid for a time period specified but such time cannot exceed two (2) years from the date of signature.

14. Receive care in a safe setting.

15. Be notified if referrals to other providers are to entities in which the BHE has a direct or indirect financial benefit, including a benefit that has financial value, but is not a direct monetary payment.

16. Formulate medical and psychiatric advance directives and have the BHE comply with such directives, as applicable, and in compliance with applicable state statute.
a. When the BHE is aware that an individual has developed advance directives, the BHE shall make good faith efforts to obtain the directives and the directives must become part of the individual's record.

b. The BHE shall disclose the policy regarding individual rights to the individual or the individual's designated representative prior to treatment or upon admission, where possible. For any services requiring multiple individual encounters, disclosure provided at the beginning of such care or treatment course must meet the intent of the regulations.

Disclaimer: These regulations may not be the most recent version. Colorado may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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