Welcome to New Hire �Recipient Rights Training.

• The training will begin at 10:05 am
• Please type your First and Last name into the Chat.
• Todays quiz was sent as an attachment to the email you received from orr.training@dwihn.org
• You are able to work on the quiz while we are holding todays training.
• If you are unable to print the quiz you can use a blank sheet of paper with your Name, Today’s Date, your Date of Birth, Employer and Date of Hire printed at the top of the quiz.
• All information at the top of the quiz is required for submission.
• The quiz should be numbered 1-15
• We will review the quiz questions together at the end of todays training.
• We will allow you to unmute your microphones at the end of the training to ask any unanswered questions.

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Detroit Wayne �Integrated Health Network�Office of �Recipient Rights

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NEW HIRE RECIPIENT RIGHTS TRAINING

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Class Will Begin Shortly.

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�PLEASE READ CAREFULLY!�

We are aware that some organizations require outside organizations to have an account and password to open encrypted emails. As a result, we are offering the following options to send your quiz for grading.

• Submit the quiz from your personal email address
• Take a photo of your answers and submit it through your phone
• Reply to the training email with your answers no later than 3pm.

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• Email address: Orr.training@dwihn.org

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Detroit Wayne �Integrated Health Network�Office of �Recipient Rights

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NEW HIRE RECIPIENT RIGHTS TRAINING

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Housekeeping

My name is ____________________

• The sound in this room.
• Speak up so everyone can hear you
• Bathrooms
• Don’t have to ask
• Women’s / Men’s
• Name tags / security door
• Keep your name tag visible
• Fire Drills
• Do what everyone else on this floor does.
• Stay together
• Personal emergencies
• Cell phones on silence / vibrate
• Emergency use – in the hall
• Food and drink
• Food and drink are welcome
• Put trash in cans as you leave, please.

Handouts

• Desk Reference Guide (DRG)
• Survey
• End of class procedure
• Four items to return
• Answer sheet to test – write your name and today’s date
• Survey – last question of your test
• Please respond to all areas
• Please give “concrete” examples
• Confirmation / Acknowledgement of Attendance
• One or the other & nothing else
• A of A should be complete
• Any test materials
• Borrowed pens
• Sign out :
• Survey, Test
• Bring above to instructor
• Remember YOU must ask your employer for your certificate in 3 to 5 days.

Housekeeping

• Emailed Attachments: Included in the Email sent this morning: PowerPoint Presentation, Desk Reference Guide (DRG) Survey and Quiz
• Camera on-NHF2F Training
• Microphone Off
• Please feel free to use the chat feature to ask questions throughout the presentation.
• Connectivity issues during class- Rejoin and wait to be let in.
• There will be a 10 minute break.
• Driving or laying down is not permitted.
• Certificates-You must be present for the entire class AND pass the quiz with a score of 80% or more.

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WELCOME

Welcome to the Detroit Wayne Integrated Health Network

Office of Recipient Rights

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The way for you to get the most out of this class is to:

put yourself fully into it.

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This class is required per the MHC.

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Feel free to: Ask questions. Share your experiences.

Participate.

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Thank You for being here !

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Purpose, Objectives, Process

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Your living room

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Laws * Procedures * Policy

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Individual Plans of Service

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Dignity and Respect

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Abuse & Neglect

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Mandatory Reporting

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Incident Reports/Complaints

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Closing Instructions

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*_____AGENDA_____*

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THE PURPOSE OF TODAYS CLASS IS

TO BE INFORMED OF AND BE CLEAR ABOUT THE RIGHTS OF THE PEOPLE

TO WHOM WE ARE PROVIDING SERVICES

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So you know the rights required to protect members

How you can prevent rights from being violated by you or others

What you must do if a violation has already occurred 

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OBJECTIVES OF THE CLASS

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Participants will have a basic understanding of the CMH system

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Participants will know the functions of the Office of Recipient Rights and how and when to reach us.

Participants will be exposed to the most common protected Recipient’s Rights violations

Participants will know where to look up information that explains the specific protected rights of the members.

Participants will know how and when to complete mandatory reporting of:

Abuse and Neglect ……. Incident Reports ……. Rights complaints

DWIHN - Office of Recipient Rights

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To ensure that members of mental health services in the Detroit Wayne Integrated Health Network system receive:

Services Suited to their condition as written in their Individualized Plan of Service that was developed using a Person Centered Planning process.

That they receive all services in a safe, sanitary, humane environment

Where they are treated with dignity and respect and are always free from abuse and neglect.

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How to contact the

Office of Recipient Rights

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You may call or email us any time.

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You must contact us to report Abuse and Neglect .

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It is a rights violation to prevent anyone from having access to the

Office of Recipient Rights.

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Online training site – www.dwctraining.com

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WHY ARE YOU HERE TODAY ?

IT IS THE LAW

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The answer to all questions are found in the:

LAWS

CONTRACTS

POLICIES

MEDICAL BEST PRACTICE GUIDELINES

PRACTICES

PROCESSES

PROCEDURES

PROTOCOLS

POSTINGS

RULES

REGULATIONS

COURT ORDERS

DOCTOR’S ORDERS

IPOS

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Mental Health Code

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ORR

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Your Living Room and Personal Life

�The Rights Of Individuals �Receiving Mental Health Services�Jurisdiction�

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1. Rights under the U.S. Constitution

Civil Rights

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2. Rights under the Mental Health Code

Chapter 7 & 7A

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1. Rights under the U.S. Constitution

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Federally Protected Civil Rights

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A person receiving services from the Community Mental Health system (CMH)

has all of the same rights promised by the U.S. Constitution as any other citizen.

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Just because they receive mental health services, does not mean they have given up any of their Federally protected rights.

A violation of a Civil Right is a violation of Recipient Rights.

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Recipients of CMH services have the RIGHT to: A free public education, Marry, Freedom of Speech

Freedom from unreasonable search and seizure

Practice the religion of their choice

Vote-A member should be asked if they wish to participate in an election.

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And to not be discriminated against because of their:

Age, color, race, national origin, gender, sexual orientation, religion, weight, height,

and physical or mental disabilities.

Members shall be allowed to conduct business affairs to the maximum extent possible

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In 1955, Congress passed the Mental Health Study Act, leading to the establishment of the Joint Commission on Mental Illness and Mental Health.^[2] That Commission issued a report in 1961,^[3] which would become the basis of the 1963 Act.^[2]

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The Community Mental Health Act of 1963 (CMHA) (also known as the Community Mental Health Centers Construction Act, Mental Retardation Facilities and Construction Act, Public Law 88-164, or the Mental Retardation and Community Mental Health Centers Construction Act of 1963) was an act to provide federal funding for community mental health centers in the United States. This legislation was passed as part of John F. Kennedy’s New Frontier. ^[1] It led to considerable deinstitutionalization.

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Suitable Services

PCP

GENERAL RIGHTS

Individual Plan of Service

1. Rights under the U.S. Constitution

Civil Rights

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2. Rights under the Mental Health Code

Chapter 7 & 7a

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Policies

Second Opinion

Psychotropic Medication

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Willowbrook – The way it was.

https://www.youtube.com/watch?v=AiTy-fxukY4

�The Michigan Mental Health Code�

In 1974 the Michigan Legislature

passed Public Act 258.

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This Act became known as the

Mental Health Code.

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5 & 6

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The Mental Health Code

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The Michigan Mental Health Code is state law.

It is the law that created the Community Mental Health (CMH) system and describes how mental health services are to be provided.

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The Mental Health Code (MHC) requires

the Office of Recipient Rights (ORR) to write policies

that add detail to the MHC.

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To ensure services delivery meets the requirements of the MHC,

staff must have access to and be familiar with

both the laws and policies.

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A copy of the Mental Health Code and ORR policies must be

readily available at all contracted locations.

Ask your employer where they are located.

Rights Guaranteed by Chapter 7 of the MHC

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MENTAL HEALTH RIGHTS - CATEGORIES

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7060 Notice/Explanation of Rights AR 7011

RIGHTS PROTECTION SYSTEM

• Citation number in the Mental Health Code have 7 numbers
• They always start … 330.1
• Then add the first 3 numbers from the grid page 8.
• And you get … 330.1706

�MENTAL HEALTH CODE (EXCERPT)�Act 258 of 1974

��330.1706 Notice of rights.

Sec. 706.

Except as provided in section 707, applicants for and members of mental health services and in the case of minors, the applicant's or member's parent or guardian, shall be notified by the providers of those services of the rights guaranteed by this chapter. Notice shall be accomplished by providing an accurate summary of this chapter and chapter 7a to the applicant or member at the time services are first requested and by having a complete copy of this chapter and chapter 7a readily available for review by applicants and members.

�History: 1974, Act 258, Eff. Aug. 6, 1975 ;-- Am. 1995, Act 290, Eff. Mar. 28, 1996

�© 2015 Legislative Council, State of Michigan�

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GENERAL RIGHTS established in Chapter 7 of the MHC:

The right to be informed of their Rights.

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• Members have the right to be informed of the Rights System and their specific rights when their services begin and again at least annually there after. They must be given a summary of Chapter 7 & 7A of the MHC. The most common form of a summary is known as the “Blue Book”. It describes their additional rights, explains how to file a rights complaint, and gives other laws and resources that may be of interest to all people concerned with the well being of the members.

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The Right to be treated as a competent person.

• All members are to be considered as competent. Just like you or me.

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• A competent adult has the right to:
• Have a driver’s license
• Marry and divorce
• Make a will
• Buy and sell property
• Manage their own life.

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• The member must continue to be treated as competent unless a court of law decides they are legally incompetent. The court would then assign a guardian to make certain decisions for the member.
• The guardian decides only those things specifically listed in the court order.
• This may include:
• Managing money * Making medical decisions * Determining where the member will live.

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• Staff should be certain of what is written in the court order and what responsibilities the guardian does and does not have.

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GENERAL RIGHTS (Continued) Members have the right to Confidentiality.

The member has the right to have the information about all of their services kept private. Their treatment information cannot be given to anyone else except as required or allowed by law or authorized purpose.

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Information can be released if:

• The member or their legal guardian gives consent
• A court order requires it.
• If it is required to prevent harm to self or others
• In order to obtain third party benefits

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HIPAA Standards Relative to PHI

HIPAA permits health care providers to disclose to other health providers any protected health information (PHI) contained in the medical record about an individual for treatment, case management, and coordination of care and, with few exceptions, treats mental health information the same as other health information. (Additional information found in the DRG Q&A section).

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Some examples of the types of mental health information that may be found in the medical record and are subject to the same HIPAA standards as other protected health information include: medication prescription and results of clinical test.

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Mental Health and Other Health Information

Privacy Rule applies uniformly to all protected health information, without regard to the type of information. One exception to this general rule is for psychotherapy notes, which receive special protections.

See DRG Pages 42 and 43 for additional information.

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*Information shared as necessary per HIPAA*

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HIPAA (Health Insurance Portability and Accountability Act of 1996) is United States legislation that provides data privacy and security provisions for safeguarding medical information.

�https://searchhealthit.techtarget.com/definition/HIPAA

Members Right to Give Consent

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The member must give Consent to

• Receive treatment and Have confidential information about them released to others.

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In order to give consent:

• The member must:
• Be told about risks, benefits and available alternatives to treatment or medication
• Be able to understand risks, benefits and consequences
• Not be forced or pressured into a decision
• Give consent in writing and the forms be signed by the member and/or legal representative

(Can be given verbally if witnessed by someone who is not treating them at the time).

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Person Centered Planning

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“Person – Centered Planning” means a process for planning and supporting the individual receiving services that builds upon the individual’s capacity to engage in activities that promote community life and that honors the individual’s preferences, choices and abilities

Individual Plan of Service

The Responsible Mental Health agency (RMHA) assures a person-centered planning process (PCP) shall be used to develop an Individual Plan of Service (IPOS).

• The purpose of the PCP process is for an individual to define the life that he/she wants and what components need to be in place.
• When a person centered process is used it means the member has choice about:
• the goals included in their plan,
• the services included in their plan,
• how, when and where those services are delivered,
• with which mental health professionals they choose to work

• Evidence of the member having choice can be found in their record.
• The wording in the IPOS clearly represents the member’s wishes and goals when it is in their own words
• There is a form signed by the member placed and in the record that states the member has had the PCP process explained to them and they understand their right to express their choices.

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The Preliminary Plan must be developed within 7 days of the start of outpatient services and address the immediate needs of the member.

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• The comprehensive IPOS must be:
• Developed within 30 days of the start of outpatient services.
• Address desired or required needs for nutrition, housing, clothing, health care, employment opportunities, educational opportunities, legal services, transportation, socialization and recreation
• Describe the roles and responsibilities of the member, supports coordinator or case manager, the allies (friends, family, others), and providers
• Distributed to member and guardian within 15 business days after the meeting.

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Individual Plan of Service (cont.)

The IPOS must clearly identify:

• The amount of service (number of units).
• Scope of service: parameters within which the services will be provided.
• Who will provide the service (i.e., professional, Assertive Community Treatment team, etc.).
• How the service will be rendered (i.e., face-to-face, telephone, group, individual, etc.).
• How frequently the service will be provided (i.e. weekly, monthly, etc.).
• Where the service will be rendered (i.e., community setting, office, home, etc.).
• Duration of service: the length of time (i.e., 3 weeks, 6 months, etc.) it is expected that an identified service will be provided.
• All current physical health conditions.
• The specific health care practitioners who are treating any physical health conditions.
• Any assistance: (e.g., referral, coordination, transportation) that the individual needs in accessing health care practitioners.

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The IPOS must also:

* Establish meaningful and measurable goals.

* Be formally renewed at least annually and modified when needed or requested by the member.

* Include any limitations placed on the member.

* Include the name of the person in charge of implementing and monitoring the plan.

* Be read, understood and followed by all staff providing services listed in the plan.

If a member is not satisfied with his/her plan, they may make a request for review to the individual in charge of implementing the plan. The review shall be completed within 30 days and approved by the appropriate treatment team.

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Suitable Services

Services included in the IPOS must:

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• Be suited to the member’s condition.

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• The services agreed to in the plan must meet the physical and mental health needs of that individual member. Diets and menu plans as well as programs and personal activities should not be designed for the benefit and convenience of the home, provider, or staff. The services must be individualized to each member’s personal circumstances.

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• Be provided in the least restrictive environment which is appropriate and available.

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• It is not acceptable to force one member to live a more restricted life style because of the needs and conditions of another member in the same home. It is not acceptable to force a member to travel to a doctor’s appointment for another member due to staffing limitations.

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• Allow for movement throughout the home and in the community and should be restricted only as necessary to prevent injury or property damage and to protect the rights of other members.

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The right to receive services in a safe, sanitary, humane environment.

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• Members receiving services in a licensed residential setting have the right to live in a place that is clean and safe and comfortable.

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• Management must follow State and local laws and the MHC when maintaining their business. The licensing rules apply to how an environment in an AFC home should be.

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• There should be:
• Proper lighting
• Proper heating and cooling
• Hot and cold running water
• Bathrooms with privacy
• Sufficient personal storage space
• Freedom from unpleasant smells, insects, or other irritants

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• The building should be in good repair
• Yards are free of trash and debris
• Walkways safe (Cleared of snow or other obstructions)
• Ramps, railings and porches meet state requirements and are free from weathering or rot
• Passes all fire safety requirements
• Appliances are functional (refrigerators, washer and dryer, etc)
• Furniture is clean, structurally sound and appropriate for the individuals residing at that location.

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Physical and Mental Exams

Within 24 hrs after admission into a hospital, a member shall receive a comprehensive physical and mental exams.

Choice of Physician / MHP

A member shall be given a choice of physicians or mental health professionals in accordance with the policies of the CMH service program, hospitals or providers under contract to the CMH system.

Clinical Status

A member shall be informed orally and in writing of their clinical status and progress at reasonable intervals as established in the IPOS.

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Mental Health Professional

If a member is able to secure the services of a mental health professional they shall be allowed to see them at reasonable times.

Spiritual Treatment

A provider shall permit a member to have access to treatment by spiritual means upon request.

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The member has the right to access their own record.

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Adult members, who do not have a guardian, have the right to see their own record. They may read or get a copy of all or part of their record. (Effective after 3/28/1996)

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For members who do have a guardian and for those under the age of 18, information that may be harmful to the member must be redacted from the record by the responsible physician before it is made available to the member.

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Once a request to see the record is made the physician has up to 30 days to provide access to the record.

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Information will not be removed from the record at the member’s request but the member can add information to the file to dispute or elaborate on any information they feel necessary.

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The member has the right to NOT be fingerprinted, photographed, audio taped or videotaped or viewed through the use of one-way glass without giving consent.

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Photographs or recordings taken with the member’s consent must be held in a

confidential manner or returned to the member or destroyed when they are no longer needed.

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COMMUNICATION

* Mail * Visits * Entertainment * Information * News

All members are entitled to unimpeded, private, uncensored communication with others by mail, phone or with visitors of their choice. The provider must not prevent a member from exercising this right.

Access to mail, phones, computers and visitors can be limited.

When communication rights are limited, the limitation must be noted in the IPOS or Behavioral Treatment Plan.

Providers must establish written policies and procedures that provide for programming restrictions .

Communication should not be limited if it is between the member and their attorney or court or involves legal matters.

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FAMILY PLANNING

The individual in charge of the member’s written plan of service shall provide the member, their guardians, and the parents of minor members with notice of the availability of family planning and health information services and, upon request, provide referral assistance to providers of such services. The notice shall include a statement that receiving mental health services does not depend in any way on requesting or receiving family planning or health information services.

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Knowing about Federal, State, CMH system laws, contracts, policies and medical best practice guidelines will help you protect the member’s rights, prevent discrimination and prevent you from being named in a rights complaint.

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As staff, you are responsible for protecting all of the rights of all of the members. The Office of Recipient Rights (ORR) is available to assist you in resolving any questions or concerns you may have about protecting the rights of the members who receive our services. Call us at 1(888)339-5595 Toll Free.

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No one may directly or indirectly prevent you from contacting the rights office. You may do so anytime you choose. At other times it is mandatory that you contact the ORR and must be done as the law and policy requires. Failing to call the ORR when required is a rights violation.

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Directly or indirectly preventing others from contacting the ORR

is a rights violation.

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Whistleblower’s Act (of 1980): If you are being discharged, threatened, or otherwise discriminated against regarding your compensation, terms conditions, locations, or privileges of employment because you take part in a public hearing, investigation, inquiry, or court action you may bring a civil action within 90 days of the alleged violation.

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Sec 755 (1) (b) of the Michigan Mental Health Code: Complainants, staff of state office of recipient rights, and any staff acting on behalf of a recipient will be protected from harassment or retaliation resulting from recipient rights activities.

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Bullard-Plawecki Employee Right To Know Act 397 of 1978: Provides and employee with a right to review and request copies of documents contained in the personnel record. If there is a disagreement regarding information, removal or correction may be mutually agreed upon between the employee and the employer.

EMPLOYEE PROTECTION LAWS

Dignity and Respect

 Dignity is:

• The quality or state of being worthy, honored, or esteemed.

Respect is:

• Having a high or special regard for someone and their beliefs about how they want to live.
• To treat someone with esteem.

Treatment with Dignity and Respect means:

• treat the member as someone who is worthy of your special regard.
• value and honor who they are just the way they are and the way they are not
• respect their cultural ways of being, religious beliefs, the choices they make for their life.

Being a member of mental health services does not make them a lesser person who can be treated with disregard.

Treating someone with dignity and respect shows up in the way you speak to the member.

• use the name they want used
• be mindful of the words used or the tone of voice.
• watch your body mannerisms, facial expressions, how you touch or don’t touch someone.

If you think someone is not worthy or not as valuable as you:

• you may make decisions that disregard their feelings
• what is important to them
• or ignore their beliefs and rules for how people should treat each other.

Not all cultures have the same beliefs about how people should interact. We must consider the differences.

Ultimately, treatment with dignity and respect is defined from the member’s view.

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Family Rights

Family members also have the right to be treated with dignity and respect.

They should be allowed to:

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• Request and receive general information.

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• Family members who are not the guardian cannot be given confidential information about the member’s medical condition or treatment information unless the member or guardian has given consent. They can be given general information including booklets and handouts about certain types of diagnosis, and the location of advocacy and support groups .

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• Provide information to treating professionals.

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• The psychiatrists and other treating professionals should make time to learn what family members want to share about their family member.

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The family is an integral part of the member’s life.

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Abuse & Neglect and other actions

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Abuse is:

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• a. A non-accidental act or urging of another to act, b. by a staff, which c. caused or contributed to
• Death
• Sexual Abuse
• Serious physical harm
• Non-serious physical harm
• Economic harm
• Exploitation
• Emotional harm
• Degrade, threaten, or sexually harass

….. d. harm to e. a member.

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• The staff may or may not have meant to cause the harm. The definition does not include the idea that the staff wanted to or meant to harm the member. It states simply that staff did something on purpose and the end result was that the member was harmed.

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Abuse

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We have ZERO tolerance regarding abuse and neglect

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Abuse and Dignity and Respect

A member’s right to be free from Abuse and treatment with Dignity and Respect is very closely related.

• To treat someone as worthy, valuable and with high regard leads to not allowing any harm to come to them.

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• Harm can occur at many different levels. The most extreme harm is considered a Abuse I. This is when the action of the staff causes or contributes to the death, permanent disfigurement or dismemberment or involves sexual abuse of, or serious physical injury to a member.

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• Abuse II takes many forms. Actions taken by staff that result in non-serious physical harm is Level II Abuse. This may include the use of unreasonable force with or without apparent harm as well as treating the member as if they are incompetent, or when the member is exploited.

• Abuse III is when language (or other means of communication including body language) is used to degrade, threaten, or sexually harass a member. Anything that causes or contributes to emotional harm is an Abuse III

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The difference between Abuse Level III and Dignity and Respect?

Being Threatening.

• Cursing in front of members is Dignity and Respect
• Cursing at or about members is Abuse III

NEGLECT

• The act of commission (doing something that was not approved to do) or omission (failing to do something that was supposed to be done) by an employee…that result from a noncompliance with a standard of care or treatment required by law/rules, polices, guidelines, written directive, procedures, or IPOS and causes or contributes to some level of harm.

• Neglect I - “Serious Physical harm” … results in death, impairment of bodily functions, or permanent disfigurement.
• Neglect II- “Non-Serious Physical harm” or emotional harm is done to the member.
• Neglect III- What staff did or did not do placed or could have placed a member at risk of physical harm or sexual abuse.

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Neglect continued…

Neglect is also:

• Failure to report any known or suspected incident of abuse or neglect
• The MHC requires that all events of Abuse and Neglect be reported directly to the ORR. This is a standard of care that allows for immediate and appropriate response by the ORR to the member. Failure to report Abuse or Neglect then become a non-compliance with a standard of care and puts the member at further risk of harm so it is an act of Neglect and therefore a rights violation.

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Neglect and Suitable Services

Neglect and suitable services are closely related protected rights.

• Suitable services are determined by the member’s physical and mental health condition. Approved standards (rules) of care for managing the member’s condition(s) must be established and written in their IPOS and/or found in house or program rules.
• Following the standard of care is what ensures the member receives the services suited to their condition.
• Failing to follow the standards of care means the member is NOT receiving services suited to their condition and that would be a rights violation.

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If failing to provide suitable service happens because staff do not follow the standards of care and the incident rises to the level of harming the member or putting the member at risk of harm, then the violation rises to the level of Neglect.

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Physical Restraints & Seclusion

DWIHN’s has ELIMINATED the use of restraints (restricting movement) or seclusion (temporary confinement to a place) as a physical management technique in ANY TREATMENT SETTING except hospitals and child caring institutions (CCI).

Prone immobilization of a member for the purpose of Behavioral Control is PROHIBITED!

Specific criteria apply based upon the age of the member and treatment setting. See policy for details and other guidelines.

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DOCUMENTATION IS CRITICAL

AT ALL STEPS OF THE PROCESS.

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Abuse & Neglect Reporting Requirements

Reporting Abuse and Neglect is

required by State civil law and by the Mental Health Code.

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IT IS NOT OPTIONAL

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What the law requires:

• Each staff of the CMH system
• Must report all known or even just suspected acts of Abuse or Neglect
• Abuse and Neglect (as defined by both the MHC and other state law)
• It must be verbally reported (within minutes of your knowing)
• To all 3 of the following organizations:
• The Office of Recipient Rights at: 1 888 339 5595
• Child or Adult Protective Services: 1 855 444 3911
• The Police Department that has jurisdiction. (You must discover this number as it is based on where the member was when the event occurred).

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• The Orange and White Poster must be located at all contracted locations.

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Circumstances Which Require the use of an Incident Reports

• Suspected or known acts of Abuse (physical, verbal or sexual) or Neglect of a member by anyone.
• Exploitation
• Any Explained or Unexplained injury of a member.
• An Unusual or first time medically related occurrence such as: seizures, stomach aches, headaches, rashes, etc.
• Environmental Emergencies or incidents that could place member(s) at risk
• Problem behaviors not addressed in the Individual Plan of Service
• Displays of serious hostility or significant/serious member destruction of property
• Serious challenging behaviors like attacking people, or setting fires, hurting themselves…
• Inappropriate Sexual Acts (Excessive Masturbation, Inappropriate Touching of Others).
• Medication Errors or Medication Refusals, unless already addressed in the Individual Plan of Service.
• Suspected Criminal Offenses committed by or against a member.
• Any situation requiring the use of Physical intervention or Time out techniques.
• The Involvement of other agencies (Police, Jail, Hospital, Fire, etc).
• Any unauthorized leave of absence of a member.
• The death of a member.
• Any incident that could include a Recipient Rights violation.

Remember

Writing a progress note does not take the place of completing an IR or

mandatory reporting of Abuse and Neglect

​

A Quality Critical/Sentinel Event entry in MH Win is not a substitute for writing an Incident Report.

​

EVERY IR MUST BE FAXED TO THE ORR 313-833-2043

WITHIN 24 HOURS OF THE INCIDENT

Incident Reports

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Completing the Incident Report

​

< Give the complete name and address of the location sending the IR.

​

< Give the complete name, DOB and MH-WIN member ID# for the primary member named in the IR.

​

< Write everything you know, saw, heard, were told. If there is not enough room to write all you have to say, add another page.

​

< Tell us what rules or regulations you were following.

​

< Others may contribute to this document.

​

< Do not leave any blanks. If the question does not apply fill the space with “NA”.

​

<Each staff that witnessed, or has knowledge of the incident should complete their own separate IR.

​

< Each person who wrote on this form must sign it

A Quality Critical/Sentinel Event entry in MH Win is not a substitute for writing an Incident Report.

Detroit Wayne Integrated Health Network

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A complaint is:

An allegation of a member’s rights being violated

and a legal request to have an investigation opened.

(Not mandatory for staff to file but can be done by any staff without punishment)

(See chapter 7A of the MHC).

​

A report is: Mandatory

The documenting and delivery of essential information as required by law, contract and policies.

​

The most common reports are:

• Abuse and Neglect reporting (phone call + IR)
• Use of Incident Reports (written IRs).

​

​

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Complaint Resolution

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Chapter 7A

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Filing a Rights Complaint

• If you believe that any right listed in the Mental Health Code has or may have been violated then you or someone must inform the Office of Recipient Rights on behalf of the member.
• A complaint can be filed by:
• calling it in
• visiting the ORR
• Or by
• completing a rights complaint form and faxing or mailing it in.

​

Filing a rights complaint

does not replace reporting Abuse and Neglect

and you must still write an Incident Report.

​

Filing a Rights Complaint

• The person who files a rights complaint is known as the complainant.
• The complainant can choose to be anonymous.
• The complainant can be anyone.
• The member
• Staff
• Family
• Neighbors
• Total strangers
• The ORR
• When a complaint is filed, ORR will determine if there is a code-protected right involved.
• When a complaint is opened the ORR has up to 90 days to complete the investigation.
• If the complainant is not anonymous they will receive notification of the progress of the investigation every 30 days until the investigation is completed.
• The complainant, the member or their guardian can appeal the final conclusion if:
• The findings are not consistent with fact, law, rules, policies, or guidelines.
• The remedial action was inadequate
• The investigation took more than 90 days.

​

​

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Chapter 7A

Dispute Resolution

In picture form

​

What to do When…

Answering phones so as to not disclose confidential information:

State, “I can neither confirm nor deny that the person resides here. However, if you’d like to leave your contact information, you can.”

​

​

Agency protocol for police interaction

Know DWIHN and your company’s confidentiality policy regarding this and

Know when those rights can be limited.

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Thank You

for

taking care of

our community!

�PLEASE READ CAREFULLY!�Quiz Submissions�

We are aware that some organizations require outside organizations to have an account and password to open encrypted emails. As a result, we are offering the following options to send your quiz for grading.

• Submit the quiz from your personal email address
• Take a photo of your answers and submit it through your phone
• Reply to the training email with your answers no later than 3pm.

​

• Email address: Orr.training@dwihn.org

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CLOSING INSTRUCTIONS…

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