Free Client Rights Limitation or Denial Documentation - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Long Term Care Division of Mental Health and Substance Abuse Services F-26100 (07/2008)

STATE OF WISCONSIN Wisconsin Statutes 51.61(2) HFS 94.05 Admin. Rules

CLIENT RIGHTS LIMITATION OR DENIAL DOCUMENTATION
Signature of client is voluntary. If not signed, the staff will witness and document refusal. This record is filed in the client's record and is accessible to all authorized users

INSTRUCTIONS for completion of this form are on the back side of the last ply or on page 2 if a single ply. Name ­ County 51.42 Board which Authorized Placement Name ­ Client (Last, First MI)

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Name ­ Agency / Institution / Facility Client Right to be Affected Describe Specific, Individualized Limitation / Denial Living Unit Date Limitation/Denial Begins Reason for Limitation / Denial Safety / Security Treatment Explain Specific Reason for Limitation / Denial Attach Relevant Documentation

Condition for Restoring Right(s) ­ If unknown, who will provide information and when?

Does the Client Want an Informal Hearing / Meeting? Yes No If YES, Date Hearing/Meeting Requested: SIGNATURE ­ Person Completing Form

If NO, SIGNATURE ­ Client "I waive my right to a hearing/meeting." Title / Position

Date ­ Hearing Conducted / Meeting Held Hearing / Meeting Outcome Right Restored Right / Limitation / Denial Continued Right / Limitation / Denial Modified as Follows:

Client's Comments at Hearing / Meeting or Give Location Where Comments are Documented.

SIGNATURE ­ Person Conducting Hearing / Decision Maker

Title / Position

This limitation/denial shall be reviewed Daily Annually Weekly Other: Monthly Quarterly REVIEW DATE

REVIEW SCHEDULE Reasons for Choosing this Review Schedule

OUTCOME

STAFF SIGNATURE

DISTRIBUTION: ORIGINAL ­ Client's record COPY 1 ­ Client Rights Specialist COPY 2 ­ County Client Rights Specialist; for state facilities, Client Rights Office COPY 3 ­ Client or guardian at time of Limitation / Denial

CLIENT RIGHTS LIMITATION OR DENIAL DOCUMENTATION INSTRUCTIONS
Items that are banned per policy, such as weapons, do not have to be reviewed and it is not necessary to complete this form.

Which client rights may be limited or denied? In accordance with s.51.61(2) Stats., ONLY the "patient rights" in s.51.61(1)(p) through (t) Stats., may be limited or denied "for cause" when "medically or therapeutically contraindicated." These are the rights: to make telephone calls; to wear one's own clothing and use one's own personal possessions; to have access to secure storage space; to have privacy in toileting and bathing; and to see visitors daily. What is "good cause" for a limitation or denial? "Good cause of denial or limitation of a right exists only when the director or designee of the treatment facility has reason to believe the exercise of the right would create a security problem, adversely affect the patient's treatment, or seriously interfere with the right or safety of others." HFS 94.05(2)(a), Wis. Admin. Code. The "good cause" rationale must be specifically and individually documented on this form. Limitation vs. denial "Denial of a right may only be made when there are documented reasons to believe there is not a less restrictive way of protecting the threatened security, treatment, or management interests." HFS 94.05(2)(b). "No right may be denied when a limitation can accomplish the purpose and no limitation may be more stringent than necessary to accomplish the purpose." HFS 94.05(2)(c), Wis. Admin. Code. Consideration of less restrictive alternatives MUST be documented, either on this form or on an attachment. Procedure To limit or deny one of the rights enumerated above, complete Page 1 of this form. A copy must be given to the client or guardian at the time of the limitation or denial, HFS 94.05(3). Filling out the form completely will ensure that the client or guardian will be given all the information required under HFS 94.05(3)(a) through (d), Wis. Admin. Code. Note, if the limitation or denial is based on a specific incident that occurred and there is an "incident report" or similar documentation required to be filed by internal policy, a copy should be attached. What is an informal hearing or meeting with decision maker? Within 3 calendar days of the limitation or denial, the client has a right to an "informal hearing" or a "meeting with the person who made the decision to limit or deny the right." HFS 94.05(5), Wis. Admin. Code. "Informal hearings" and "meetings" are equivalent; the only difference being who conducts it. The "informal hearing" is conducted by the director or designee and the "meeting" is conducted by the person who made the initial decision to limit or deny the right or if it was a team decision, appropriate representative of the treatment team. The hearing or meeting consists of presenting the individualized, specific reasons for the limitation or denial to the client and the client being given the opportunity to dispute facts or to explain his or her position about the matter. The client's comments at the hearing/meeting must either be documented on the copy of this form, which is kept in the client's records or it must be noted on this form where in the record those comments can be found. The outcome of the hearing or meeting must also be documented on this form. What if a limitation of some other right is considered? Some other rights may be limited or denied for individual treatment, security, or safety reasons. DO NOT USE THIS FORM for those purposes. Please refer to specific statutes, s.51.61 or s.51.30, Stats., or rules, HFS 94 or HSS 92, Wis. Admin. Code, about these rights for procedural and documentation requirements. Note that some rights, such as the right to send or receive mail or to refuse treatment or medications, may not be limited or denied unless a court order is first obtained. What is an appropriate review schedule? Rights limitations or denials must be reviewed on a reasonable schedule to decide if they are still necessary. JCAHO requires of its accredited facilities that limits on telephone calls or visitors be reviewed weekly. Given this professional standard, it is recommended that other facilities also review such limitations weekly. It is further suggested that all other limitations or denials should be reviewed at least monthly. Exceptions to monthly review may be made where the limitation or denial is part of a client's treatment program and there is a regular review schedule, such as quarterly, for the program. The schedule for review must be noted on this form. Rare cases, such as a limitation on access to a possession, which may be deemed counter-therapeutic to the individual, may be reviewed annually. In no case should a review schedule be longer than annually. Who gets copies of this form? The original should be kept in the client's records. A copy must be given to the client or guardian at the time of the limitation or denial. The other copies should be distributed in accordance with the list at the bottom of the preceding page.