PERIODIC INTERNAL REVIEW

PERIODIC INTERNAL REVIEW

The Ship Group Community Services governing body shall ensure, no less than every three years, to conduct a compliance review in the agencies regarding the implementation of Client Rights Rules as specified in 10A NCAC 27C, 27D, 27E, and 27F. The review will assure compliance with the following:

• There is compliance with applicable provisions of the federal law governing advocacy services to the mentally ill, as specified in the Protection and Advocacy for Mentally Ill Individuals Act of 1986 (Public Law 99-319) and amended by Public Law 100-509 (1988); and ;

• There is compliance with applicable provisions of the federal laws governing advocacy services to the developmentally disabled, the Developmental Disabilities Assistance and Bill of Rights Act, 42 U.S.C. 6000 et seq.

The Quality Management Director and Clinical Director shall maintain the three most recent written reports of the findings of such reviews.

INFORMING CLIENTS

The Program Director or Qualified Professional will ensure that the client and his legally responsible person receive a written summary of client’s rights upon admission to the agencies. The summary will be in a manner that is consistent with the consumer/legally responsible person’s level of comprehension. The information provided to the client or the legally responsible person will include:

• Procedure for obtaining a copy of the client’s person-centered plan

• 4. His/her right to contact the Governor’s Advocacy Council for Persons with Disabilities (GACPD), the statewide agency designated under federal and State law to protect and advocate the rights of persons with disabilities.

*Note: North Carolina Governor's Advocacy Council for Persons with Disabilities was the Protection & Advocacy System for North Carolina until the Protection & Advocacy System was re-designated to Carolina Legal Assistance (CLA), effective July 1, 2007.

1314 Mail Service Center

Raleigh, North Carolina 27699-1314

Telephone: 800-821-6922

TT: 888-268-5535

Fax: 919-733-9173

Web: http://www.gacpd.com/

Email: GACPD@ncmail.net.

• Each client is informed regarding the issues specified in Paragraph (d) and, if applicable in Paragraph (e), of this Rule, upon admission or entry into a service, or

• In an program where a day/night or periodic service is provided, within three visits, explanation shall be in a manner consistent with the client’s or legally responsible person’s level of comprehension.

In each office, the information provided to the client or legally responsible person includes;

▪ 1. The rules that the client is expected to follow and possible penalties for violations of the rules;

▪ The client’s protections regarding disclosure of confidential information, as delineated in GS 122C-52 through GS 122C-56; Prior to obtaining a consent for release of confidential information, the Qualified Professional or his designee, must inform the client or his legally responsible person that the provision of services is not contingent upon such release. 5. The client or legally responsible person shall give consent voluntarily.

Governing body policy regarding:

• Grievance policy and procedure including the individual to contact and a description of assistance the client will be provided;

• Suspension and expulsion policy and procedure

• Fee schedule and collection practices

• Client’s records are protected through state and federal government confidentiality guidelines. Also informed of the circumstances under which release can be made without consent

• Search and seizure is used only if there is deemed a real and imminent risk of danger

• Purpose, goals, and reinforcement structure of any behavior management system that is allowed

• Potential restrictions or the potential use of restrictive interventions.

• Notification provisions regarding emergency use of restrictive intervention procedures.

• Legally responsible person of a minor may request notification after any occurrence of the use of restrictive interventions/that the component adult client may designate an individual to receive notification, in accordance with GS 122C-53 (a), after any occurrence of the use of restrictive intervention

• Of notification provisions regarding the restriction of client rights as specified in GS 122 C-62 (e)

There will be documentation in the client’s record that the client rights have been explained.

INFORMING STAFF

All staff are informed at the time of employment and annually thereafter, of rights of clients as specified in 122C, Article 3 and are expected to be familiar with policies. Documentation of receipt of information is signed by each staff member and maintained by The Ship Group Community Services Care.

SOCIAL INTERGRATION

Each client in a day/night, periodic service is encouraged to participate in appropriate and generally acceptable social interactions and activities with other clients and non-client members of the community. A client is not prohibited from such social interactions unless restricted in writing in the client record in accordance with GS 122C-62 (e).

CLIENT SELF-GOVERNANCE

The Ship Group Community Services Care’s governing body encourages client input into program governance and the development of the client’s self-governance group (in a day/night, periodic service). This is primarily achieved through weekly clinical meetings with the QP or Clinical Director. Additionally, consumers are encouraged to provide feedback through suggestion boxes located at each office.

PROTECTION FROM HARM, ABUSE, NEGLECT, OR EXPLOITATION

Employees will protect the clients from harm, abuse, neglect, or exploitation in accordance with GS 122C-66. All instances of alleged or suspected abuse, neglect, or exploitation of clients are reported to the County Department of Social Services.

Employees will not subject a client to any sort of abuse or neglect, as defined in 10A NCAC 27C .0102 of this Chapter.

Goods or services shall not be sold to or purchased from a client except through established governing body policy. This means unless the client is engaged in a fund-raising activity in which case, employees may at their discretion purchase items from the consumer. If all consumers are raising funds, the employee must purchase items from every client if you choose to purchase from one consumer.

Employees shall use only the degree of force necessary to repel or secure a violent and aggressive client and which governing body policy permits. The degree of force that is necessary depends upon the individual characteristics of the client (such as age, size, physical, and mental health) and the degree of aggressiveness displayed by the client. Use of intervention procedures shall be in compliance with Subchapter 10A NCAC 27E of this chapter.

Any violation by an employee of Paragraphs (a) through (d) of this Rule shall be grounds for dismissal of the employee. Employees suspected of abuse, neglect, harm, or exploitation will be reported to the Health Care Registry and the Local Department of Social Services.

LEAST RESTRICTIVE ALTERNATIVE

A. Each program shall provide services/supports that promote a safe and respectful environment. These include:

1. using the least restrictive and most appropriate settings and methods;

2. promoting coping and engagement skills that are alternatives to injurious behavior to self or others;

3. providing choices of activities meaningful to the clients served/supported; and

4. sharing of control over decisions with the client/legally responsible person and staff.

B. The use of a restrictive intervention procedure designed to reduce a behavior shall always be accompanied by actions designed to insure dignity and respect during and after the intervention. These include:

1. using the intervention as a last resort; and

2. employing the intervention by people trained in its use.