Current through Register Vol. 35, No. 18, September 24, 2024
A. The agency takes all reasonable action(s)
to protect the health, safety, confidentiality, and rights of its clients. The
agency informs the client of his or her rights and responsibilities and
develops and implements policies and procedures that support and facilitate the
client's full participation in treatment and related agency activities. The
agency protects the confidentiality of client records through adherence to its
own set of policies and procedures governing access to, and release of,
confidential information.
B.
Materials describing services offered, eligibility requirements and client
rights and responsibilities are provided in a form understandable to the client
and client's legal guardian(s) with consideration of the client's/guardian's
primary language, and the mode of communication best understood by persons with
visual or hearing impairments.
(1) If the
client is unable to understand the materials for any reason, every effort is
made to explain his or her rights and responsibilities in a manner
understandable to the client. These efforts will be documented in the client's
record.
(2) Materials are available
or posted in the agency's reception area and/or handed to potential clients
during their initial contact with the agency.
C. The agency explains to each client what
his or her legal rights are in a manner consistent with the client's ability to
understand and makes this information available to the client in writing, or in
any other medium appropriate to the client's level of development. A written
explanation of these rights is given to the parent/legal guardian upon
admission.
(1) A client who receives
residential treatment services has the rights enumerated in the New Mexico
children's mental health and developmental disabilities Code, NMSA 1978,
Sections 32A-6-1 et seq. (1995). Explanation of rights to the client and
parents/legal guardian is documented in the client's record.
(2) The agency maintains and follows written
policy affirming that clients may refuse any treatment or medication, unless
the right to refuse treatment(s) has been limited by law or court order. The
agency informs the individual of the risks of such refusal. Client refusal of
treatment and advisement of risks of the refusal is documented in the client's
record.
(3) The agency specifies in
written policies and procedures the conditions under which it serves minors
without parental/legal guardian consent, and when parental/legal guardian
consent is not possible, designates who is authorized to give consent to treat
the minor.
(a) The client record contains all
applicable consents for treatment, including consent for emergency medical
treatment and informed consent for prescription medication.
(b) Exception: Day treatment services,
behavioral management skills development services and case management services
programs are not required to file consents for prescription medications that
are not taken during program hours unless the medications are prescribed by a
program physician.
(c) Consent
forms must contain the information identifying the specific treatment,
prescription medication, information release, or event for which consent is
being given prior to being signed by a client or guardian.
(4) Upon admission, each client receives an
orientation to the agency's services that includes the basic expectations of
the clients, the hours during which services are available, and any rules
established by the agency regarding client conduct, with specific reference to
behavior that could result in discontinuation of a service. Orientation of the
client and parents/legal guardians is documented in the client's
record.
(5) The agency maintains a
written grievance/complaint procedure that is reviewed with the client and
parent/legal guardian upon admission. The client's record contains
documentation of the agency's explanation of the grievance procedure to the
client and the parent/legal guardian.
(6) Financial arrangements are fully
explained to the client and/or his or her parent/legal guardian upon admission,
and at the time of any change in the financial arrangements.
(7) Procedures for protecting client assets:
The agency establishes and follows written policies and procedures to identify
how it manages, protects, and maintains accountability for client assets,
including the segregation of client funds when an agency assumes fiduciary
responsibility for a client's assets and/or disburses funds such as maintenance
or allowance funds to clients.
(8)
The agency establishes written procedures for providing client access to
emergency medical services.
(9)
Written agency policy specifies clinically appropriate and legally permissible
methods of behavior management and discipline and provides training in their
use to all direct service staff
. The agency prohibits in
policy and practice the following:
(a)
degrading punishment;
(b) corporal
or other physical punishment;
(c)
group punishment for one individual's behavior;
(d) deprivation of an individual's rights and
needs (e.g., food, phone contacts, etc.) when not based on documented clinical
rationale;
(e) aversive stimuli
used in behavior modification;
(f)
punitive work assignments;
(g)
isolation or seclusion, except as delineated in Section 24;
(h) harassment; and
(i) chemical or mechanical restraints, except
as delineated in Section 24.I.
(10) The agency establishes and follows
written policies and procedures for the use of therapeutic time-out in
accordance with these certification requirements, including the following
directives:
(a) therapeutic time-out can only
be used for the length of time necessary for the client to resume self-control
and/or to prevent harm to the client or others;
(b) therapeutic time-out is not used as a
means of punishment;
(c)
therapeutic time-out is not used for the convenience of staff; and
(d) therapeutic time-out is monitored closely
and frequently to ensure the client's safety.
D. The agency prohibits the use or depiction
of individuals (residents, clients, etc.), either personally or by name or
likeness (e.g., photograph), in material (photographs, videotape or audiotape),
presented in a context that is either commercial or public-service oriented in
nature. An exception to this prohibition applies to children presented on the
"Wednesday's child" television program, Los Ninos or other adoption exchange
publications, in which case any participation and presentation is in accordance
with the department's rules and regulations and with the knowledge, consent and
active participation of the department.
E. Client information and case review: The
agency maintains records and follows policies and procedures governing the
access to, and release of, confidential information. The agency provides
adequate facilities for the storage, processing and handling of clinical
records, including suitably locked and secured rooms.
(1) The agency's written policies govern the
retention, maintenance, and destruction of board administrative records, and
records of former clients and personnel. These policies address:
(a) protection of the privacy of former
clients and personnel; and
(b)
legitimate future requests by former personnel or clients for information,
particularly information that may not be available elsewhere.
(2) The agency has policies
governing the disposition of records, security of records and timely access and
retrieval of records in case of the agency's dissolution. The retention of
records is required for the later of:
(a) four
years after the client is released from treatment; or
(b) two years after the client reaches age
18; or
(c) two years after a client
has been released from most recent legal guardianship, and is no longer under
legal guardianship.
(3)
The agency specifies in written policies and procedures how it releases
information. Any release is in accordance with applicable state and federal
laws. The agency does not request or use any information release form that has
been signed by a client, parent, guardian or other party prior to pertinent
information being completed on the form.
(4) In the event of a medical emergency that
warrants immediate intervention in order to protect the life or safety of the
client, access to information regarding the client's diagnoses and treatment
plan/service plan may be provided to medical personnel.
F. Contents of the client record:
(1) Agency policy defines information to be
contained in the client record. At the time of admission, the client's date of
admission to each and any certified service is documented in a consistent
location in the client record.
(2)
Agency policy and practice provide that entries in the client record are made
in an accurate, objective, factual, legible, timely, and clinically-based
manner.
(a) Entries made in the client record
pursuant to these certification requirements clearly identify the person
completing the entry and his or her credentials.
(b) Late entries are identified as such; late
entries include the actual date of the entry and the signature of the person
completing the entry.
G. When prescribing medication or other
treatments, the prescribing professional documents the indication for any
medical procedures and/or prescription medications.
(1) When a client is seen by the prescribing
professional, subsequent to a medical prescription or treatment, the
professional documents the response to the prescription or treatment and any
observed side effects.
(2)
Medication, including non-prescription medication that is administered by a
nurse or is self-administered, is documented by the agency staff with the date
and time of administration, the name and dosage and any side effects
observed.
H. A written
discharge summary is placed in the client's record within 15 days of
termination of services and includes:
(1)
clinical and safety status;
(2)
medications being taken at discharge;
(3) documentation of notification to primary
care physician;
(4) specification
of referrals/appointments made with specific names;
(5) target behaviors addressed;
(6) services provided;
(7) progress attained, or lack
thereof;
(8) description of
interventions to which the client did and did not respond, including
medications;
(9) recommendations
for continued treatment and services.
I. Client review of case record:
(1) An individual may review his or her case
record in the presence of a therapist or licensed independent practitioner of
the agency on the agency's premises unless to do so would not be clinically
indicated. The reasons why review is not clinically indicated are documented in
the client's record. The confidentiality of other individuals
is protected.
(2) The agency's
policies and procedures allow the client to insert a statement into the record
about his or her needs or about services he or she is receiving or may wish to
receive. Any agency statements or responses are documented with evidence that
the client was informed of insertion of such responses.
