Pennsylvania Code

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CHAPTER 5100. MENTAL HEALTH PROCEDURES

GENERAL PROVISIONS

Sec.

5100.1.    L= egal=20 base.
5100.2.    D= efinitions.=20
5100.3.    S= tatement=20 of policy.
5100.4.    S= cope.=20
TREATMENT

5100.11.    = Adequate=20 treatment.
5100.12.    = Treatment=20 facilities.
5100.13.    = Responsibility=20 for formulation and review of treatment plan.=20
5100.14.    = Appeal.=20
5100.15.    = Contents=20 of treatment plan.
5100.16.    = Review=20 and periodic reexamination.=20
MENTAL HEALTH REVIEW OFFICER AND=20 PROCEEDINGS

5100.21.    = Proceedings.=20
5100.22.    = Consultation=20 and education.
5100.23.    = Written=20 application, petitions, statements and certifications.=20
CONFIDENTIALITY OF MENTAL HEALTH=20 RECORDS

5100.31.    = Scope=20 and policy.
5100.32.    = Nonconsensual=20 release of information.
5100.33.    = Patient=92s=20 access to records and control over release of records.=20
5100.34.    = Consensual=20 release to third parties.
5100.35.    = Release=20 to courts.
5100.36.    = Departmental=20 access to records and data collection.=20
5100.37.    = Records=20 relating to drug and alcohol abuse or dependence.=20
5100.38.    = Child=20 or patient abuse.
5100.39.    = Release=20 of records.=20
FORMS

5100.41.    = Forms.=20
PATIENT = RIGHTS

5100.51.    = Preservation=20 of rights.
5100.52.    = Statement=20 of principle.
5100.53.    = Bill of=20 rights for patients.
5100.54.    = Manual=20 of rights for persons in treatment. =
5100.55.    = Notification=20 of rights.
5100.56.    = Existing=20 regulations.=20
CONTINUITY OF = CARE

5100.61.    = Continuity=20 of care.=20
VOLUNTARY=20 TREATMENT

5100.71.    = Voluntary=20 examination and treatment.
5100.72.    = Applications.=20
5100.73.    = Explanation=20 and consent to inpatient treatment. =
5100.74.    = Notice=20 to parents regarding voluntary inpatient treatment of minors.=20
5100.75.    = Physical=20 examination and formulation of individualized treatment plan.=20
5100.76.    = Notice=20 of withdrawal.
5100.77.    = Discharge=20 from voluntary inpatient treatment. =
5100.78.    = Transfer=20 of persons in voluntary treatment.=20
INVOLUNTARY=20 TREATMENT

5100.81.    = Involuntary=20 examination and treatment.
5100.82.    = Jurisdiction=20 and venue of legal proceedings. =
5100.83.    = Generally.=20
5100.84.    = Persons=20 who may be subject to involuntary emergency examination and = treatment.=20
5100.85.    = Standards.=20
5100.86.    = Involuntary=20 emergency examination and treatment not to exceed 120 hours.=20
5100.87.    = Extended=20 involuntary emergency treatment not to exceed 20 days.=20
5100.88.    = Court-ordered=20 involuntary treatment not to exceed 90 days.=20
5100.89.    = Additional=20 periods of court-ordered involuntary treatment not to exceed 180 = days.=20
5100.90.    = Transfers=20 of persons in involuntary treatment.=20
5100.90a.    State=20 mental hospital admission of involuntarily committed = individuals=97statement of=20 policy.=20
PERSONS CHARGED WITH A CRIME OR UNDER=20 SENTENCE

5100.91.    = General.=20
5100.92.    = Voluntary=20 examination and treatment of a person charged with a crime or serving = a=20 sentence.
5100.93.    = Costs=20 of treatment.=20

Authority

   The provisions of this Chapter 5100 issued under = sections=20 107=97116 of the Mental Health Procedures Act (50 P. S.=20 =A7 =A7  7107=977116); and the Mental Health and Mental = Retardation=20 Act of 1996 (50 P. S. =A7 =A7  4101=97 4704), unless = otherwise=20 noted.

Source

   The provisions of this Chapter 5100 adopted = January 26,=20 1979, effective January 27, 1979, 9 Pa.B. 315; amended October 12, = 1979,=20 effective October 13, 1979, 9 Pa.B. 3460.

Cross References

   This chapter cited in 55 Pa. Code = =A7  1151.31=20 (relating to participation requirements); 55 Pa. Code = =A7  5300.1=20 (relating to accreditation); 55 Pa. Code =A7  5300.2 = (relating to not=20 Nationally accredited or certified); and 55 Pa. Code = =A7  5320.22=20 (relating to governing body).

GENERAL PROVISIONS

=A7 5100.1. Legal base.

The legal base for this chapter is section 112 of the Mental = Health=20 Procedures Act (50 P. S. =A7  7112), section 201 of the = Mental Health=20 and Mental Retardation Act of 1966 (50 P. S. =A7  4201), and = section=20 1021 of the Public Welfare Code (62 P. S. =A7  1021). =
=A7 5100.2. Definitions.

The following words and terms, when used in this chapter, = shall have=20 the following meanings, unless the context clearly indicates = otherwise:=20

   Act=97The Mental Health Procedures = Act (50 P.=20 S. =A7 =A7  7101=977503).=20

   Administrator=97The person appointed = to carry=20 out the duties specified in section 305 of the Mental Health and = Mental=20 Retardation Act of 1966 (50 P. S. =A7  4305).=20

   Agency=97An instrumentality of the = United=20 States, its departments and agencies, including the Veterans=92 = Administration.=20

   Approved facility=97A facility as = defined by=20 section 103 of the act (50 P. S. =A7  7103) which meets the = standards=20 of this chapter and other applicable Department regulations or obtains = an=20 exemption in writing from the Department under section 105 of the act = (50 P.=20 S. =A7  7105).

   Behavorial = consent=97A=20 demonstrated willingness by the patient to remain voluntarily in the = facility=20 based upon a general understanding of the nature of the usual = treatment,=20 possible restraints upon free activity, and daily life within the = facility. A=20 general understanding may be shown by a finding that a person in = treatment has=20 participated in scheduled activities and does not protest continued=20 participation.

   County of = residence=97The county=20 wherein the person had a legal residence prior to being admitted or = committed=20 to an approved facility for treatment. =

   Designated=20 facility=97The approved facility named by the county administrator = as a=20 provider of one or more specific services. A facility so designated, = either on=20 a general basis or on a case by case basis must be identified in the = county=20 annual plan. The administrator shall address the public=92s need to = know where=20 and how they can obtain services under the act.=20

   Director=97The administrative head of = a=20 facility, including a superintendent or his designee.=20

   Director of treatment team=97A = physician or=20 licensed clinical psychologist designated by the facility director to = assure=20 that each patient receives treatment under the act and this chapter = and that=20 the facility=92s treatment responsibility to the patient, as defined = in this=20 chapter, the Mental Health/Mental Retardation Act of 1966 and the act, = are=20 discharged. The director of the treatment team is responsible for = implementing=20 and reviewing the individualized treatment plan, for participating in = the=20 coordination of service delivery between other service providers, and = for=20 insuring that the unique skills and knowledge of each team member are=20 utilized. The director of the treatment team is responsible for = encouraging=20 the person in treatment to become increasingly involved in decisions = regarding=20 the treatment planning process.

   Expert in = the=20 field of mental health=97A mental health professional whose = training,=20 experience and demonstrated achievements clearly exceed the minimum = standards=20 required for recognition as a professional in his discipline, and = whose=20 broad-based skills and knowledge in his specific areas of specialty = are=20 recognized by the members of his profession to be at the highest = level.=20

   Health professional in mental = health=97A person=20 who by years of education, training, and experience in mental health = settings=20 has achieved professional recognition and standing as defined by their = respective discipline, including, but not limited to medicine, social = work,=20 psychology, nursing, occupational therapy, recreational therapy, and=20 vocational rehabilitation; and who has obtained if applicable, = licensure,=20 registration, or certification.

   Inpatient = treatment=97All treatment that requires full-time or part-time = residence in=20 a facility as defined in section 103 of the act (50 P. S. = =A7  7103).=20

   Involuntary emergency = examination=97The=20 physical and mental evaluation by a physician of an individual taken = to a=20 facility under section 302 of the act (50 P. S. =A7  7302).=20

   Involutary emergency treatment=97The = treatment=20 provided to an individual taken to a facility under section 302 of the = act (50=20 P. S. =A7  7302). Such treatment in the absence of the = individual=92s=20 consent, shall be limited to that treatment which is necessary to = protect the=20 life or health, or both, of the individual or to control behavior by = the=20 individual which is likely to result in physical injury to others.=20

   Least restrictive alternate=97The = least=20 restrictive placement or status available and appropriate to meet the = needs of=20 the patient and includes both restrictions on personal liberty and the = proximity of the treatment facility to the person=92s natural = environment. This=20 concept stresses the importance of helping each person in need of = services to=20 seek those services voluntarily. The degree of restriction or the = degree of=20 separation from the natural environment is dependent upon both the = severity of=20 the person=92s dysfunction and his strengths and resources to function = in that=20 environment. The range of treatment alternatives, stemming from the = patient=92s=20 natural environment, through supportive services to 24-hour = hospitalization,=20 must be considered in light of the person=92s capability of handling = daily tasks=20 and stress and the need, if any, for varying degrees of support or=20 supervision.

   Licensed clinical = psychologist=97A=20 psychologist licensed under the act of March 23, 1972 (P. L. 136, No. = 52) (63=20 P. S. =A7 =A7  1201=971215) who holds a doctoral degree = from an=20 accredited university and is duly trained and experienced in the = delivery of=20 direct preventive assessment and therapeutic intervention services to=20 individuals whose growth, adjustment, or functioning is actually = impaired or=20 is demonstrably at risk of impairment. =

   Mental=20 illness=97Those disorders listed in the applicable APA Diagnostic = and=20 Statistical Manual; provided however, that mental retardation, = alcoholism,=20 drug dependence and senility do not, in and of themselves, constitute = mental=20 illness. The presence of these conditions however, does not preclude = mental=20 illness.

   Mental Health and Mental = Retardation Act=20 of 1966=97The act of October 20, 1966 (P. L. 96, No. 3) (50 P. S.=20 =A7 =A7  4101=974704). =

   Peace=20 officer=97Any person who by virtue of his office of public = employment is=20 vested by law with a duty to maintain public order, to make arrests = for=20 offenses, whether that duty extends to all offenses or is limited to = specific=20 offenses, or any person on active State duty under section 311 of The = Military=20 Code of 1949 (51 P. S. =A7  1-311). Prison wardens and = guards shall be=20 considered peace officers for purposes of the act.=20

   Physician=97A person licensed to = practice=20 medicine or osteopathy in this Commonwealth.=20

   Preliminary evaluation=97The initial = assessment=20 or evaluation of the physical and mental condition of an individual; = it may be=20 conducted without substantiation by formal testing procedures. The = evaluation=20 includes an assessment of the person=92s specific physical, = psychological,=20 developmental, familial, educational or vocational, social, and = environmental=20 needs in order to determine the adequacy, of the person=92s logic, = judgment,=20 insight, and self control to responsibly meet his needs.=20

   Qualified mental health personnel=97A = person=20 employed in the fields of mental health care, treatment or = rehabilitation=20 whose experience, training, and supervision is commensurate with his = assigned=20 tasks and who has not yet met the criteria of his own profession for=20 recognition as a health professional. Such persons shall work in = programs=20 which are under the direction of mental health professionals.=20

   Treatment plan=97An individualized = plan of=20 treatment as defined in section 107 of the act (50 P. S. = =A7  7107),=20 which imposes the least restrictive alternative consistent with = affording the=20 person adequate and appropriate treatment for his condition.=20

   Treatment team=97An interdisciplinary = team of=20 at least three persons appointed by the facility director, composed of = mental=20 health professionals, health professionals and other persons who may = be=20 relevant to the patient=92s treatment. At least one member of the team = shall be=20 a physician. The treatment team shall formulate and review an = individualized=20 treatment plan for every person who is in treatment under the act. The = treatment team shall consult with appropriate professionals regarding = the=20 inclusion in the treatment plan of specific modalities not within the = training=20 or experience of the members of the treatment team.

Cross References

   This section cited in 55 Pa. Code = =A7  5100.71=20 (relating to voluntary examination and treatment). =
=A7 5100.3. Statement of = policy.

(a)  The act establishes procedures for the = treatment of=20 mentally ill persons. The procedures are to be applied consistently = with the=20 principles of due process to make voluntary and involuntary treatment=20 available where the need is great and where the absence of treatment = could=20 result in serious harm to the mentally ill person or to others. The = act and=20 the Mental Health and Mental Retardation Act of 1966, set forth the=20 Commonwealth=92s policy and procedures regarding the provision of = mental health=20 services. This chapter implements and supplements the act and the = Mental=20 Health and Mental Retardation Act of 1966, and are to be read together = with=20 the applicable provisions of the act and the Mental Health and Mental=20 Retardation Act of 1966.=20
(b)  It is the policy of the Commonwealth to seek = to assure=20 that adequate treatment is available with the least restrictions = necessary to=20 meet each client=92s needs. While this policy remains a shared = responsibility=20 between State, county, and facility personnel, the accountability for=20 recommending the transfer to the least restrictive alternatives = available=20 remains a responsibility of those directing treatment. Adequate = treatment=20 provided in an individual=92s own community or as close as possible to = his own=20 home shall be preferred.=20
(c)  Persons who are mentally retarded, senile, = alcoholic=20 or drug dependent shall be afforded mental health examination or = treatment if=20 they are also diagnosed as mentally ill, or if there is a reasonable=20 probability that upon examination such diagnosis will be established.=20
(d)  Persons in treatment under the act shall be = afforded=20 necessary diagnostic or treatment procedures as defined in their = treatment=20 plan for conditions of mental retardation, senility, alcohol, or drug = abuse=20 when it is determined that the absence of such procedures will be = detrimental=20 to the progress of the person accomplishing the goals of treatment. =
=A7 5100.4. Scope.

(a)  This chapter applies to all involuntary = treatment of=20 mentally ill persons, whether inpatient or outpatient, and for all = voluntary=20 inpatient treatment of mentally ill persons.=20
(b)  Persons 70 years of age or older who have been = continuously hospitalized in a State-operated facility for at least 10 = years=20 and who are chronically disabled shall not be subject to the = procedures of the=20 act.=20
   (1)  The Department extends the = protections of=20 =A7 =A7  5100.11, 5100.13=975100.16, 5100.31=975100.39 = and=20 5100.51=975100.56 to these persons.=20
   (2)  The Department may continue to = provide all=20 necessary treatment to such persons regardless of their ability to = freely give=20 rational informed consent except when such a person protests treatment = or=20 residence at a State operated facility.=20
   (3)  Persons described in this = subsection may=20 become subject to involuntary treatment when the person protests and = criteria=20 for involuntary treatment are met. =

TREATMENT

=A7 5100.11. Adequate = treatment.

(a)  Adequate treatment provided by an approved = facility=20 shall be designed on an individual basis under the relevant statutes,=20 regulations, and professional standards to promote the recovery from = mental=20 illness.=20
(b)  Treatment provided on an inpatient, outpatient = or=20 partial hospitalization basis shall reflect the needs of the = individual both=20 independently and in light of the community resources, family or = friends=20 available to lend support and assistance to the person while in = treatment.=20 These resources shall be considered in determining the adequacy of the = least=20 restrictive setting appropriate to his treatment.=20
(c)  The adequacy of an individual=92s treatment = may also be=20 reviewed through mechanisms of peer review and utilization review.=20
(d)  Involuntary treatment, voluntary outpatient = treatment=20 funded at least in part with public moneys or voluntary inpatient = treatment is=20 not adequate treatment unless it is provided in or at an approved = facility or=20 by an agency of the United States.

Cross References

   This section cited in 55 Pa. Code = =A7  5100.4=20 (relating to scope); and 55 Pa. Code =A7  5320.22 (relating = to=20 governing body).
=A7 5100.12. Treatment = facilities.

(a)  The Department, through the Deputy Secretary = of Mental=20 Health, will approve facilities under section 105 of the act (50 P. S. = =A7  7105). Designation of appropriate approved facilities = within the=20 county shall be made by the county administrator for those patients = using=20 mental health/mental retardation (MH/MR) funds. All other patients may = use any=20 approved facility.=20
(b)  All mental health facilities providing or = planning to=20 provide involuntary treatment or voluntary treatment shall be approved = annually by the Department by application to the Deputy Secretary of = Mental=20 Health.=20
(c)  Inpatient facilities treating persons who are = either=20 enrolled in or who are about to be enrolled in a county mental health = program=20 shall notify the appropriate administrator of the proposed discharge = plan as=20 early as possible. The facility shall encourage interagency = cooperation in=20 developing predischarge planning.=20
(d)  Chapters 4210 and 5300 (relating to = description of=20 services and service areas; and private psychiatric hospital) shall be = interpreted consistently with this chapter.=20
(e)  Facilities requesting an exemption from = approval=20 standards shall submit a written request to the Deputy Secretary of = Mental=20 Health. Each request shall state the compelling reasons why an = exemption=20 should be granted and the duration of such exemption.=20
(f)  The administrator shall publicly designate = which=20 approved facilities are available to provide involuntary emergency=20 examinations, involuntary treatment or voluntary treatment funded in = whole or=20 in part by MH/MR funds.
=A7 5100.13. Responsibility for = formulation=20 and review of treatment plan.

(a)  The director of the treatment team shall = assure that=20 staff trained and experienced in the use of the modalities proposed in = the=20 treatment plan participate in its development, implementation and = review.=20
(b)  The director of the treatment team shall be=20 responsible for:=20
   (1)  Insuring that the person in = treatment is=20 encouraged to become increasingly involved in the treatment planning = process.=20
   (2)  Implementing and reviewing the=20 individualized treatment plan and participating in the coordination of = service=20 delivery with other service providers.=20
   (3)  Insuring that the unique skills = and=20 knowledge of each team member are utilized and that specialty = consultants are=20 utilized when needed.=20
(c)  Although a treatment team must be under the = direction=20 of either a physician or a licensed clinical psychologist, specific = treatment=20 modalities may be under the direction of other mental health = professionals=20 when they are specifically trained to administer or direct such=20 modalities.

Cross References

   This section cited in 55 Pa. Code = =A7  5100.4=20 (relating to scope); and 55 Pa. Code =A7  5320.22 (relating = to=20 governing body).
=A7 5100.14. Appeal.

(a)  Each facility shall have a clearly defined = appeal=20 system through which any patient who wishes to voice objections = concerning his=20 treatment shall be heard and have objections determined.=20
(b)  Each facility shall monitor the appeal system = to see=20 that it works properly and records shall be maintained for review for=20 certification and licensure and for Departmental review in order to=20 investigate any complaint.=20
(c)  All patients shall be advised of such system = and be=20 encouraged to use it when they believe their treatment plan is not = necessary=20 or appropriate to their needs.

Cross References

   This section cited in 55 Pa. Code = =A7  5100.4=20 (relating to scope).
=A7 5100.15. Contents of = treatment plan.

(a)  A comprehensive individualized plan of = treatment=20 shall:=20
   (1)  Be formulated to the extent = feasible, with=20 the consultation of the patient. When appropriate to the patient=92s = age, or=20 with the patient=92s consent, his family, personal guardian, or = appropriate=20 other persons should be consulted about the plan.=20
   (2)  Be based upon diagnostic = evaluation which=20 includes examination of the medical, psychological, social, cultural,=20 behavorial, familial, educational, vocational, and developmental = aspects of=20 the patient=92s situation.=20
   (3)  Set forth treatment objectives and = prescribe an integrated program of therapies, activities, experiences, = and=20 appropriate education designed to meet these objectives.=20
   (4)  Result from the collaborative=20 recommendation of the patient=92s interdisciplinary treatment team.=20
   (5)  Be maintained and updated with = progress=20 notes, and be retained in the patient=92s medical record on a form = developed by=20 the facility and approved by the Deputy Secretary of Mental Health, as = part of=20 the licensing approval process.=20
(b)  The treatment plan shall indicate what less=20 restrictive alternatives were considered and why they were not = utilized. If=20 the plan provides for restraints, the basis for the necessity for such = restraints must be stated in the plan under Chapter 13 (relating to = use of=20 restraints in treating patients/residents).=20
(c)  Individual treatment plans shall be written in = terms=20 easily explainable to the lay person and a copy of the current = treatment plan=20 shall be available for review by the person in treatment.=20
(d)  When the most appropriate form of treatment = for the=20 individual is not available or is too expensive to be feasible, that = fact=20 shall be noted on the treatment plan form.

Cross References

   This section cited in 55 Pa. Code = =A7  5100.4=20 (relating to scope); and 55 Pa. Code =A7  5100.75 (relating = to=20 physical examination and formulation of individualized treatment = plan).
=A7 5100.16. Review and periodic=20 reexamination.

(a)  At least once every 30 days, every person in = treatment=20 under the act shall have his treatment plan reviewed. This review = shall be=20 based upon section 108(a) of the act (50 P. S. = =A7  7108(a)). A report=20 of the review and findings shall be summarized in the patient=92s = clinical=20 record.=20
(b)  The decisions and redisposition required by = section=20 108(b) of the act, based upon such reexamination and review, shall be = recorded=20 in the patient=92s clinical record as either a progress note or in any = other=20 appropriate form acceptable to the agency=92s records committee.=20
(c)  Such record shall include information required = by=20 section 108(c) of the act.

Cross References

   This section cited in 55 Pa. Code = =A7  5100.4=20 (relating to scope); and 55 Pa. Code =A7  5320.52 (relating = to review=20 and periodic reexamination).

MENTAL HEALTH REVIEW OFFICER AND = PROCEEDINGS

=A7 5100.21. Proceedings.

(a)  The county administrator shall inform the = Deputy=20 Secretary of Mental Health of the appointment of mental health review=20 officers. If no review officer is appointed, then the administrator = should=20 inform the Department of the judge who hears and determines = commitments under=20 the act. The Department will inform the mental health review officers = and=20 courts of new policies, procedures, and interpretations relating to = the act=20 and the provision of mental health services and will make available = training=20 to aid them in carrying out their duties.=20
(b)  A mental health review officer, unless = specifically=20 authorized by the court having jurisdiction over the person, shall not = reduce=20 the conditions of security of a person committed under section 401 of = the act=20 (50 P. S. =A7  7401).=20
(c)  The administrator=92s office shall assist = petitioners=20 with the preparation of the commitment petitions, applications, and = request=20 for certification for persons not already subject to involuntary = treatment.=20
(d)  The administrator shall designate = representatives to=20 issue warrants for involuntary emergency commitments.=20
(e)  The administrator shall coordinate, when = designated by=20 the court, all hearings and file all applications and certifications = under the=20 act.=20
(f)  Notwithstanding any other provision of the = act, no=20 judge or mental health review officer shall specify to the treatment = team the=20 adoption of any treatment technique, modality, or drug therapy. =
=A7 5100.22. Consultation and = education.

The administrator shall, in discharging his duties under the = Mental=20 Health and Mental Retardation Act of 1966, provide the court or mental = health=20 review officer with:=20
   (1)  Education and training regarding=20 principles and practices of mental health services.=20
   (2)  Administrative consultation = regarding the=20 nature and availability of approved and designated mental health = facilities=20 and services.=20
   (3)  Case consultation if so ordered by = the=20 court or mental health review officer. =
=A7 5100.23. Written application, = petitions,=20 statements and certifications.

(a)  Written application, petitions, statements and = certifications required under this chapter shall be made upon forms = issued or=20 approved by the Department.=20
(b)  The forms listed in =A7  5100.41 = (relating to=20 forms) have been issued by the Department, and their use is mandated. = No=20 substitute for such forms is permitted without prior written = authorization of=20 the Deputy Secretary of Mental Health.=20
(c)  Other forms required under this chapter may be = developed by the administrator or the facility, but are subject to the = approval of the Department.=20
(d)  Unsworn falsification=97all statements written = under all=20 applications, petitions and certifications required under the act on=20 Departmentally issued or approved forms MH 781, 783, 784, 785, 786 and = 787,=20 shall contain the following notice=97old forms may be utilized until = the supply=20 is exhausted:=20
  ANY PERSON WHO KNOWINGLY PROVIDES ANY FALSE INFORMATION = WHEN=20 COMPLETING THIS FORM MAY BE SUBJECT TO PROSECUTION.=20
(e)  When a person is admitted for voluntary = treatment and=20 only when no part of his treatment is provided with public funds, the = new=20 voluntary admission Form MH-788 may be used. This form will be = identical to=20 Form MH-781 with the exception that the notice concerning the penalty = for=20 giving false information will be deleted. Until form MH-788 is printed = and=20 distributed, existing Form MH-781 may be utilized for this group of = persons.=20 Each facility may make the necessary deletion on Form MH-781 to = conform with=20 section 110(c) of the act (50 P. S. =A7  7110(c)).=20
(f)  Submission to county administrator:=20
   (1)  Except as set forth in paragraphs = (2)=97(5),=20 Forms MH 781, 783, 784, 785, 786 and 787, shall be provided to the=20 administrator under section 110 of the act (50 P. S. = =A7  7110).=20
   (2)  No Form MH-788 need be provided to = the=20 administrator on behalf of a patient admitted for voluntary treatment = when=20 reimbursement for treatment provided the patient will not include = public=20 monies. This shall not affect in any way the applicability to such = patients of=20 the rights and procedures afforded voluntary patients by the act and = this=20 chapter. For admission to a State facility forms must be provided to = the=20 administrator.=20
   (3)  The administrator shall review all = applications, petitions, statements and certifications provided to the = administrator=92s office to determine whether the services needed are = available=20 and to assure a continuity of care.=20
   (4)  The administrator may designate a = place=20 other than his office for filing of the forms mentioned in this = section.=20
   (5)  Mental health facilities shall = file such=20 statistical reports of activities and services required by the act and = the=20 Mental Health and Mental Retardation Act of 1966 as the Department = from time=20 to time may require, so long as the data does not identify individual=20 patients.

CONFIDENTIALITY OF MENTAL HEALTH RECORDS

=A7 5100.31. Scope and = policy.

(a)  This chapter applies to records of persons = seeking,=20 receiving or having received mental health services from any facility = as=20 defined in section 103 of the act (50 P. S. =A7  7103).=20
(b)  Persons seeking or receiving services from a = mental=20 health facility are entitled to do so with the expectation that = information=20 about them will be treated with respect and confidentiality by those = providing=20 services. Confidentiality between providers of services and their = clients is=20 necessary to develop the trust and confidence important for = therapeutic=20 intervention. While full confidentiality cannot be guaranteed to = everyone as a=20 result of Federal and State statutes which require disclosure of = information=20 for specific purposes, it remains incumbent upon service providers to = inform=20 each current client/patient of the specific limits upon = confidentiality which=20 affect his treatment when these limits become applicable. When = facilities are=20 required by Federal or State statutes or by order of a court to = release=20 information regarding a discharged patient, a good faith effort shall = be made=20 to notify the person by certified mail to the last known address.=20
(c)  As used in this chapter, =91=91records=92=92 = includes, but is=20 not limited to, all written clinical information, observations and = reports or=20 fiscal documents, relating to a prospective, present or past, client = or=20 patient, which are required or authorized to be prepared by the act or = by the=20 Mental Health and Mental Retardation Act of 1966. This includes any = central=20 file of client/patient records and reports which are required to be = maintained=20 by the Department=92s regulations or other statutes and regulations = regarding=20 service content for mental health programs. Every therapist who = reports=20 objective findings must carefully consider the impact of placing in = the=20 records statements made privately in therapy sessions.=20
(d)  Nothing in this chapter shall limit the = facility=92s=20 obligation to attempt to obtain social history and other records = necessary to=20 properly treat an involuntarily committed patient, or to obtain = information on=20 financial resources or insurance coverage necessary to determine the = liability=20 for services rendered.=20
(e)  This section applies to all records regarding = present=20 or former patients of mental health facilities, including records = relating to=20 services provided under previous mental health acts.=20
(f)  Records of a person receiving mental health = services=20 are the property of the hospital or facility in which the person is or = has=20 received services. The person who is or was receiving services shall = exercise=20 control over the release of information contained in his record except = as=20 limited by =A7  5100.32 (relating to nonconsensual release = of=20 information), and be provided with access to the records except to the = limitations under =A7  5100.33 (relating to patient=92s = access to=20 records and control over release of records).=20
(g)  The presence or absence of a person currently=20 involuntarily committed at a mental health facility is not to be = considered a=20 record within the meaning of subsection (c) and such information may = be=20 released at the discretion of the director of a facility in response = to=20 legitimate inquiries from governmental agencies or when it is clearly = in the=20 patient=92s best interest to do so.=20
(h)  No document which was a public record prior to = the=20 person=92s treatment shall become confidential by its inclusion in the = facility=92s records.=20
(i)  When information and observations regarding = clients or=20 patients are not made part of a record, there remains a duty and = obligation=20 for staff to respect the patient=92s privacy and confidentiality by = acting=20 ethically and responsibly in using or discussing such information.

Cross References

   This section cited in 55 Pa. Code = =A7  3800.20=20 (relating to confidentiality of records); 55 Pa. Code = =A7  5100.4=20 (relating to scope); 55 Pa. Code =A7  5100.33 (relating to = patient=92s=20 access to records and control over release of records); 55 Pa. Code=20 =A7  5200.47 (relating to other applicable regulations); 55 = Pa. Code=20 =A7  5210.26 (relating to records); 55 Pa. Code = =A7  5210.56=20 (relating to other applicable regulations); 55 Pa. Code = =A7  5221.52=20 (relating to notice of confidentiality and nondiscrimination); and 55 = Pa. Code=20 =A7  5320.26 (relating to confidentiality). =
=A7 5100.32. Nonconsensual = release of=20 information.

(a)  Records concerning persons receiving or having = received treatment shall be kept confidential and shall not be = released nor=20 their content disclosed without the consent of a person given under=20 =A7  5100.34 (relating to consensual release to third = parties), except=20 that relevant portions or summaries may be released or copied as = follows:=20
   (1)  To those actively engaged in = treating the=20 individual, or to persons at other facilities, including professional=20 treatment staff of State Correctional Institutions and county prisons, = when=20 the person is being referred to that facility and a summary or portion = of the=20 record is necessary to provide for continuity of proper care and = treatment.=20
   (2)  To third party payors, both those = operated=20 and financed in whole or in part by any governmental agency and their = agents=20 or intermediaries, or those who are identified as payor or copayor for = services and who require information to verify that services were = actually=20 provided. Information to be released without consent or court order = under this=20 subsection is limited to the staff names, the dates, types and costs = of=20 therapies or services, and a short description of the general purpose = of each=20 treatment session or service.=20
   (3)  To reviewers and inspectors, = including the=20 Joint Commission on the Accreditation of Hospitals (JCAH) and = Commonwealth=20 licensure or certification, when necessary to obtain certification as = an=20 eligible provider of services.=20
   (4)  To those participating in PSRO or=20 Utilization Reviews.=20
   (5)  To the administrator, under his = duties=20 under applicable statutes and regulations.=20
   (6)  To a court or mental health review = officer, in the course of legal proceedings authorized by the act or = this=20 chapter.=20
   (7)  In response to a court order, when = production of the documents is ordered by a court under=20 =A7  5100.35(b) (relating to release to courts).=20
   (8)  To appropriate Departmental = personnel=20 =A7  5100.38 (relating to child or patient abuse).=20
   (9)  In response to an emergency = medical=20 situation when release of information is necessary to prevent serious = risk of=20 bodily harm or death. Only specific information pertinent to the = relief of the=20 emergency may be released on a nonconsensual basis.=20
   (10)  To parents or guardians and = others when=20 necessary to obtain consent to medical treatment.=20
   (11)  To attorneys assigned to = represent the=20 subject of a commitment hearing.=20
(b)  Current patients or clients or the parents of = patients=20 under the age of 14 shall be notified of the specific conditions under = which=20 information may be released without their consent.=20
(c)  Information made available under this section = shall be=20 limited to that information relevant and necessary to the purpose for = which=20 the information is sought. The information may not, without the = patient=92s=20 consent, be released to additional persons or entities, or used for = additional=20 purposes. Requests for information and the action taken should be = recorded in=20 the patient=92s records.

Notes of Decisions

   Duty to Report=20
   Mental healthcare workers do not have an = affirmative duty=20 to investigate and report possible crimes involving their patients.=20 Hennessy v. Santiago, 708 A.2d 1269 (Pa. Super. 1998).=20
   Release of Information in Response to Medical=20 Emergency=20
   Regulations which provide for the nonconsensual = release=20 of confidential information when release is necessary to prevent harm = or death=20 in response to medical emergency may include situations wherein a = psychiatric=20 patient=92s threats to harm a third party are disclosed. Ms. B. v. = Montgomery=20 County Emergency Service, 799 F.Supp. 534 (E.D. Pa. 1992), = affirmed, 989=20 F.2d 488 (3d Cir. Pa. 1993); cert. denied, 510 U. S. 860, 126 L. Ed. = 2d 133,=20 114 S. Ct. 174 (1993).

Cross References

   This section cited in 55 Pa. Code = =A7  3800.20=20 (relating to confidentiality of records); 55 Pa. Code = =A7  5100.4=20 (relating to scope); 55 Pa. Code =A7  5100.31 (relating to = scope and=20 policy); 55 Pa. Code =A7  5100.34 (relating to consensual = release to=20 third parties); 55 Pa. Code =A7  5100.90a (relating to State = mental=20 hospital admission of involuntarily committed individuals=97statement = of=20 policy); 55 Pa. Code =A7  5200.41 (relating to records); 55 = Pa. Code=20 =A7  5200.47 (relating to other applicable regulations); 55 = Pa. Code=20 =A7  5210.26 (relating to records); 55 Pa. Code = =A7  5210.56=20 (relating to other applicable regulations); 55 Pa. Code = =A7  5221.52=20 (relating to notice of confidentiality and nondiscrimination); and 55 = Pa. Code=20 =A7  5320.26 (relating to confidentiality). =
=A7 5100.33. Patient=92s access = to records and=20 control over release of records.

(a)  When a client/patient, 14 years of age or = older,=20 understands the nature of documents to be released and the purpose of=20 releasing them, he shall control release of his records. For a client = who=20 lacks this understanding, any person chosen by the patient may = exercise this=20 right if found by the director to be acting in the patient=92s best = interest. In=20 the event that the client/patient is deceased, control over release of = records=20 may be exercised by the client=92s/patient=92s chosen executor, = administrator or=20 other personal representative of his estate, or, if there is no chosen = personal representative, by a person otherwise empowered by court = order to=20 exercise control over the records. In the event that the = client/patient is=20 less than 14 years of age or has been adjudicated legally incompetent, = control=20 over release of the client=92s/patient=92s records may be exercised by = a parent or=20 guardian of the client/patient respectively.=20
(b)  The term =91=91access=92=92 when used in this = section refers=20 to physical examination of the record, but does not include nor imply = physical=20 possession of the records themselves or a copy thereof except as = provided in=20 this chapter.=20
(c)  A person who has received or is receiving = treatment=20 may request access to his record, and shall be denied such access to = limited=20 portions of the record only:=20
   (1)  Upon documentation by the = treatment team=20 leader, it is determined by the director that disclosure of specific=20 information concerning treatment will constitute a substantial = detriment to=20 the patient=92s treatment.=20
   (2)  When disclosure of specific = information=20 will reveal the identity of persons or breach the trust or = confidentiality of=20 persons who have provided information upon an agreement to maintain = their=20 confidentiality.=20
(d)  A patient may obtain access to his records = through the=20 facility, or in the case of those records kept by the county = administrator,=20 through the physician or mental health professional designated by the=20 administrator. Any third parties who are granted access to records may = discuss=20 this information with the patient only insofar as necessary to = represent the=20 patient in legal proceedings or other matters for which records have = been=20 released. Discussion of records with patients should be part of the=20 therapeutic process and is not to be undertaken by other than mental = health=20 professionals.=20
(e)  The limitations in subsection (c) are = applicable to=20 parents, guardians, and others who may control access over records as=20 described in subsection (a) except that the possibility of substantial = detriment to the parent, guardian, or other person may also be = considered.=20
(f)  If a person wishes to enter a written reaction = qualifying or rebutting information in their records which they = believe to be=20 erroneous or misleading, they shall have the right to prepare such = statement=20 for inclusion as part of their record. The patient=92s written = reaction shall=20 accompany all released records.=20
(g)  The director of the treatment team or the = facility=20 director may require that a mental health professional, who is a = member of the=20 treatment team, and who has reviewed the record in advance, be present = when=20 the patient or other person examines the record to aid in the = interpretation=20 of documents in the record. If the records pertain to a former = patient, an=20 appropriate mental health professional may be designated by the = facility=20 director.=20
(h)  Access to presentence reports, which may be = part of=20 the persons=92 records, is governed Pa.R.Crim.P. No. 1404 (relating to = disclosure of reports), and the patient may have access to these = records only=20 upon order of the sentencing judge. Any conditions of confidentiality = imposed=20 by the sentencing judge must be complied with. Similarily, parole and=20 probation reports shall be released or access to them given only in = accordance=20 with 37 Pa. Code Part II (relating to Board of Probation and Parole).=20
(i)  If a person is denied access to all or part of = his=20 record, this fact and the basis for the denial shall be noted in the = person=92s=20 record.=20
(j)  When records or information have been = forwarded from=20 one agency to another agency, the receiving agency may not refuse the = client=20 or patient access to the records received except in accordance with = subsection=20 (c). Records received from other agencies become part of the = client/patient=92s=20 active record and are subject to the controls exercised over them by = the=20 client, patient, or those with authority over records as defined in=20 =A7  5100.31 (relating to scope and policy).

Notes of Decisions

   Patient access to whatever record was made of = commitment=20 hearing, in the form it exists, is a minimal requirement to comport = with=20 procedural due process. In re S.O., 492 A.2d 727 (Pa. Super. = 1985).

Cross References

   This section cited in 55 Pa. Code = =A7  3800.20=20 (relating to confidentiality of records); 55 Pa. Code = =A7  5100.4=20 (relating to scope); 55 Pa. Code =A7  5100.31 (relating to = scope and=20 policy); 55 Pa. Code =A7  5100.34 (relating to consensual = release to=20 third parties); 55 Pa. Code =A7  5200.41 (relating to = records); 55 Pa.=20 Code =A7  5200.47 (relating to other applicable = regulations); 55 Pa.=20 Code =A7  5210.26 (relating to records); 55 Pa. Code=20 =A7  5210.56 (relating to other applicable regulations); 55 = Pa. Code=20 =A7  5221.52 (relating to notice of confidentiality and=20 nondiscrimination); and 55 Pa. Code =A7  5320.26 (relating = to=20 confidentiality).
=A7 5100.34. Consensual release = to third=20 parties.

(a)  Access to records, as defined in=20 =A7  5100.33(b) (relating to patient=92s access to records = and control=20 over release of records) will be granted to persons other than the = patient=20 upon written consent of the client/patient. With the consent, copies = of=20 excerpts or a summary of a record may be provided to specific persons = at the=20 discretion of the director. If copies of excerpts or summaries are = provided, a=20 charge may be made against the patient or person receiving the record = for the=20 cost of making the copies. The facility may require payment for the = copies in=20 advance.=20
(b)  When a patient designates a third party as = either a=20 payor or copayor for mental health services, this designation carries = with it=20 his consent to release information to representatives of that payor = which is=20 necessary to establish reimbursement eligibility. Unless otherwise = consented=20 to by the patient, information released to the third-party payors = shall be=20 limited to that necessary to establish the claims for which = reimbursement is=20 sought.=20
(c)  Clients, patients, or other persons consenting = to=20 release of records are to be informed of their right, subject to=20 =A7  5100.33 to inspect material to be released.=20
(d)  When records are released or disclosed under=20 =A7  5100.32 (relating to nonconsenual release of = information) or=20 subsections (a) and (b) the written or oral disclosure shall be = accompanied by=20 a written statement which reads as follows:=20
=91=91This information has been disclosed to you from records = whose=20 confidentiality is protected by State statute. State regulations limit = your=20 right to make any further disclosure of this information without prior = written=20 consent of the person to whom it pertains.=92=92=20
(e)  The limitation in subsection (d) does not = prohibit the=20 re-release of information in accordance with =A7  5100.32.=20
(f)  Each facility shall prepare a form for use in = the=20 voluntary release of records which shall meet the following = requirements:=20
   (1)  A time limit on its validity which = shows=20 starting and ending dates.=20
   (2)  Identification of the agency or = person to=20 whom the records are to be released.=20
   (3)  A statement of the specific = purposes for=20 which the released records are to be used.=20
   (4)  A statement identifying the = specific=20 relevant and timely information to be released.=20
   (5)  A place for the signature of the=20 client/patient or parent or guardian and the date, following a = statement that=20 the person understands the nature of his release.=20
   (6)  A place for the signature of a = staff=20 person obtaining the consent of the client/patient or parent or = guardian and=20 the date.=20
   (7)  A place to record a verbal consent = to=20 release of information given by a person physically unable to provide = a=20 signature and a place for the signatures of two responsible persons = who=20 witnessed that the person understood the nature of the release and = freely gave=20 his verbal consent.=20
   (8)  Indication that the consent is = revocable=20 at the written request of the person giving consent, or oral request = as in=20 paragraph (7).=20
(g)  A mental health facility receiving a request = for=20 information from a governmental agency may accept that agency=92s = release of=20 information form if signed by the patient/client or the person legally = responsible for the control of information unless the patient has = specifically=20 expressed opposition to that agency receiving information.

Cross References

   This section cited in 55 Pa. Code = =A7  3800.20=20 (relating to confidentiality of records); 55 Pa. Code = =A7  5100.4=20 (relating to scope); 55 Pa. Code =A7  5100.32 (relating to=20 nonconsensual release of information); 55 Pa. Code = =A7  5200.41=20 (relating to records); 55 Pa. Code =A7  5200.47 (relating to = other=20 applicable regulations); 55 Pa. Code =A7  5210.26 (relating = to=20 records); 55 Pa. Code =A7  5210.56 (relating to other = applicable=20 regulations); 55 Pa. Code =A7  5221.52 (relating to notice = of=20 confidentiality and nondiscrimination); and 55 Pa. Code = =A7  5320.26=20 (relating to confidentiality).
=A7 5100.35. Release to = courts.

(a)  Each facility director shall designate one or = more=20 persons as a records officer, who shall maintain the confidentiality = of=20 client/patient records in accordance with this chapter.=20
(b)  Records shall comply with the following:=20
   (1)  Whenever a client/patient=92s = records are=20 subpoenaed or otherwise made subject to discovery proceedings in a = court=20 proceeding, other than proceedings authorized by the act, and the=20 patient/client has not consented or does not consent to release of the = records, no records should be released in the absence of an additional = order=20 of court.=20
   (2)  The records officer, or his = designee, is=20 to inform the court either in writing or in person that, under statute = and=20 regulations, the records are confidential and cannot be released = without an=20 order of the court. Neither the records officer nor the facility = director has=20 any further duty to oppose a subpoena beyond stating to the the court = that the=20 records are confidential and cannot be released without an order of = the court;=20 however, nothing in this section shall be construed as authorizing = such a=20 court order.=20
   (3)  If it is known that a patient has = a=20 current attorney of record for the given proceedings, that attorney = shall be=20 informed of the request of subpoena, if not already served with a = copy, and=20 shall be expected to represent and protect the client/patient=92s = interests in=20 the confidentiality of the records. The person whose record has been=20 subpoenaed shall be notified of such action if they are currently = receiving=20 services and their whereabouts are known, unless served with a copy of = the=20 subpoena. Those currently in treatment shall also be advised that they = may=20 wish to obtain an attorney to represent their interests. In the case = of=20 persons no longer receiving services, the facility shall send this=20 notification by certified mail to the last known address.=20
(c)  If a present or former patient sues a person = or=20 organization providing services subject to the act in connection with = said=20 patient=92s care, custody, evaluation or treatment, or in connection = with an=20 incident related thereto, defense counsel for said service provider = shall have=20 such access to the present or former patient=92s records as such = counsel deems=20 necessary in preparing a defense. Counsel receiving such records shall = maintain their confidentiality and shall limit the disclosure of the = contents=20 thereof to those items they deem necessary to allow counsel to prepare = and=20 present a proper defense.=20
(d)  All employes of a facility shall be informed = of the=20 rules and regulations regarding confidentiality of records and shall = also be=20 informed that violation of them could potentially subject them to = civil or=20 criminal liability. Training for employes regarding confidentiality = remains=20 the responsibility of the facility director.

Notes of Decisions

   Release Appropriate=20
   Information in defendant=92s treatment records = which had=20 been the subject of earlier newspaper articles and had been discussed = without=20 objection in deposition was a rational and admissible source for the = jury to=20 consider in determining the harm caused to plaintiff=92s reputation = which was=20 brought about by the emotional and mental stress under which defendant = wrote=20 articles with underlying hatred for plaintiff and plaintiff=92s = pursuit of=20 prosecution of defendant for wiretapping. It was beyond argument that=20 defendant=92s mental and emotional problems had become so familiar in = the public=20 domain that the additional notice of certain medical records had no = impact and=20 was harmless evidence in this case. Sprague v. Walter, 656 A.2d = 890=20 (Pa. Super. 1995).

Cross References

   This section cited in 55 Pa. Code = =A7  3800.20=20 (relating to confidentiality of records); 55 Pa. Code = =A7  5100.4=20 (relating to scope); 55 Pa. Code =A7  5100.32 (relating to=20 nonconsensual release of information); 55 Pa. Code = =A7  5200.41=20 (relating to records); 55 Pa. Code =A7  5200.47 (relating to = other=20 applicable regulations); 55 Pa. Code =A7  5210.26 (relating = to=20 records); 55 Pa. Code =A7  5210.56 (relating to other = applicable=20 regulations); 55 Pa. Code =A7  5221.52 (relating to notice = of=20 confidentiality and nondiscrimination); and 55 Pa. Code = =A7  5320.26=20 (relating to confidentiality).
=A7 5100.36. Departmental access = to records=20 and data collection.

(a)  Notwithstanding any part of this chapter to = the=20 contrary, employes of the Department shall not be denied access to any = patient=20 records where such access is necessary and appropriate for the = employe=92s=20 proper performance of his duties. The facility director shall make = such=20 decision, and shall be responsible for limiting access to those = portions which=20 are relevant to the request.=20
(b)  Any conflict as to access by an employe to = patient=20 records at State hospitals shall be resolved by the Regional = Commissioner of=20 Mental Health.=20
(c)  Collection and analysis of clinical or = statistical=20 data by the Department, the administrator, or the facility for = administrative=20 or research purposes may be undertaken as long as the report or paper = prepared=20 from the data does not identify any individual patient without his=20 consent.

Cross References

   This section cited in 55 Pa. Code = =A7  3800.20=20 (relating to confidentiality of records); 55 Pa. Code = =A7  5100.4=20 (relating to scope); 55 Pa. Code =A7  5200.41 (relating to = records);=20 55 Pa. Code =A7  5200.47 (relating to other applicable = regulations);=20 55 Pa. Code =A7  5210.26 (relating to records); 55 Pa. Code=20 =A7  5210.56 (relating to other applicable regulations); 55 = Pa. Code=20 =A7  5221.52 (relating to notice of confidentiality and=20 nondiscrimination); and 55 Pa. Code =A7  5320.26 (relating = to=20 confidentiality).
=A7 5100.37. Records relating to = drug and=20 alcohol abuse or dependence.

Whenever information in a patient=92s records relates to drug = or=20 alcohol abuse or dependency, as defined in 71 P. S. = =A7  1690.102,=20 those specific portions of the patient=92s records are subject to the=20 confidentiality provisions of section 8(c) of the Pennsylvania Drug = and=20 Alcohol Abuse Control Act (71 P. S. =A7  1690.108(c)), and = the=20 regulations promulgated thereunder, 4 Pa. Code =A7  255.5 = (relating to=20 projects and coordinating bodies: disclosure of client-oriented=20 information).

Cross References

   This section cited in 55 Pa. Code = =A7  3800.20=20 (relating to confidentiality of records); 55 Pa. Code = =A7  5100.4=20 (relating to scope); 55 Pa. Code =A7  5200.41 (relating to = records);=20 55 Pa. Code =A7  5200.47 (relating to other applicable = regulations);=20 55 Pa. Code =A7  5210.26 (relating to records); 55 Pa. Code=20 =A7  5210.56 (relating to other applicable regulations); 55 = Pa. Code=20 =A7  5221.52 (relating to notice of confidentiality and=20 nondiscrimination); and 55 Pa. Code =A7  5320.26 (relating = to=20 confidentiality).
=A7 5100.38. Child or patient = abuse.

Nothing in this chapter shall conflict with the mandatory = statutory=20 or regulatory requirements of reporting suspected or discovered child = abuse or=20 patient abuse. Whenever a conflict exists between the reporting = requirements=20 of the Child Protective Services Act (11 P. S. = =A7 =A7  2201=972224),=20 and the confidentiality of mental health records, the reporting = requirements=20 shall govern.

Cross References

   This section cited in 55 Pa. Code = =A7  3800.20=20 (relating to confidentiality of records); 55 Pa. Code = =A7  5100.4=20 (relating to scope); 55 Pa. Code =A7  5100.32 (relating to=20 nonconsensual release of information); 55 Pa. Code = =A7  5200.41=20 (relating to records); 55 Pa. Code =A7  5200.47 (relating to = other=20 applicable regulations); 55 Pa. Code =A7  5210.26 (relating = to=20 records); 55 Pa. Code =A7  5210.56 (relating to other = applicable=20 regulations); 55 Pa. Code =A7  5221.52 (relating to notice = of=20 confidentiality and nondiscrimination); and 55 Pa. Code = =A7  5320.26=20 (relating to confidentiality).
=A7 5100.39. Release of = records.

Under 42 Pa.C.S. =A7 =A7  8721=978725 = (relating to=20 availability of otherwise confidential information), records which are = otherwise confidential may be made available to certain investigating = bodies=20 upon order of a judge of the Commonwealth Court.

Cross References

   This section cited in 55 Pa. Code = =A7  3800.20=20 (relating to confidentiality of records); 55 Pa. Code = =A7  5100.4=20 (relating to scope); 55 Pa. Code =A7  5200.41 (relating to = records);=20 55 Pa. Code =A7  5200.47 (relating to other applicable = regulations);=20 55 Pa. Code =A7  5210.26 (relating to records); 55 Pa. Code=20 =A7  5210.56 (relating to other applicable regulations); 55 = Pa. Code=20 =A7  5221.52 (relating to notice of confidentiality and=20 nondiscrimination); and 55 Pa. Code =A7  5320.26 (relating = to=20 confidentiality).

FORMS

=A7 5100.41. Forms.

(a)  Reference. All references to article or = section=20 numbers in the title of the forms issued by the Department refer to = articles=20 or section numbers of the act.=20
(b)  Forms. Forms adopted by the Department = as=20 published in prior regulations may be amended to conform with the act = by pen=20 and ink changes until new forms are available:=20
   MH 781. Consent for Voluntary Inpatient = Treatment=20 (Article II).=20
     MH 781-A. Initial Evaluation.=20
     MH 781-B. Explanation of = Voluntary=20 Admission Rights (Adult).=20
     MH 781-C. Explanation of = Voluntary=20 Admission Rights (Minor between 14 and 18 years of age).=20
     MH 781-D. Explanation of = Voluntary=20 Admission Rights (Minor under 14 years of age.=20
     MH 781-E. Notification of = Admission of=20 Child (For parents or guardians of minor 14-18 years old).=20
     MH 781-F. Request to Withdraw = from=20 Treatment.=20
     MH 781-X. Request for Voluntary=20 Admission of Person Charged with Crime or Serving Sentence.=20
     MH 781-Y. Consent for Voluntary=20 In-patient Treatment of Person Charged With Crime or Serving Sentence. =
     MH 781-Z. Explanation of = Admission of=20 Person Charged With Crime or Serving Sentence.=20
   MH 782. Patient=92s Bill of Rights.=20
   MH 783. Application for Involuntary = Emergency=20 Examination and Treatment.=20
     MH 783-A. Explanation of Rights = under=20 Emergency Involuntary Treatment.=20
     MH 783-B. Explanation of = Warrant.=20
   MH 784. Application for Extended Involuntary = Treatment (section 303).=20
     MH 784-A. Notice of Intent to = File or=20 Petition for Extended Involuntary Treatment and Explanation of Rights. =
   MH 785. Petition for Involuntary Treatment.=20
     MH 785-A. Notice of Intent to = File a=20 Petition for Extended Involuntary Treatment and Explanation of Rights. =
     MH 785-B. Notice of a Hearing on = Petition for Involuntary Treatment and Explanation of Rights.=20
   MH 786. Petition for Involuntary = Treatment=97Through=20 the Criminal Justice System.=20
     MH 786-A. Notice of Intent to = File a=20 Petition for (Extended) Involuntary Treatment at a Mental Health = Facility and=20 Explanation of Rights.=20
   MH 787. Petition for Commitment for = Involuntary=20 Treatment After Finding of Incompetence to Stand Trial Where Severe = Mental=20 Disability is Not Present.=20
   MH/MR 50. Patient Consent to Transfer.=20
(c)  Forms amended in this chapter include:=20
   MH-781-X=20
   MH-788

Cross References

   This section cited in 55 Pa. Code = =A7  5100.23=20 (relating to written application, petitions, statements and = certifications).

PATIENT RIGHTS

=A7 5100.51. Preservation of = rights.

Persons subject to treatment under this chapter shall retain = all=20 civil rights that have not been specifically curtailed by separate = judicial or=20 administrative determination by the appropriate legal authority.

Cross References

   This section cited in 55 Pa. Code = =A7  5100.4=20 (relating to scope); 55 Pa. Code =A7  5200.47 (relating to = other=20 applicable regulations); 55 Pa. Code =A7  5210.56 (relating = to other=20 applicable regulations); 55 Pa. Code =A7  5320.22 (relating = to=20 governing body); and 55 Pa. Code =A7  5320.45 (relating to = staff=20 orientation and training).
=A7 5100.52. Statement of = principle.

(a)  Facilities. Upon voluntary or = involuntary=20 admission to an inpatient facility, each patient shall be given a copy = of the=20 summary statement of the Bill of Rights, contained in = =A7  5100.53=20 (relating to bill of rights for patients), Form MH-782, or the patient = rights=20 pamphlet (PWPE # 605), published by the Department entitled You = Have a=20 Right to be Treated with Dignity and Respect. Appended to each of = these=20 documents shall be the names, addresses, and telephone numbers of = legal and=20 other available advocacy services. Assistance in contacting a legal or = other=20 advocate shall be provided by the facility to each patient upon = request. The=20 rights contained therein shall be explained to the extent feasible to = persons=20 who cannot read or understand them. Within 72 hours of admission, the = Manual=20 of Rights, set forth in =A7  5100.54 (relating to manual of = rights for=20 persons in treatment), or the Patient Rights Handbook (PWPE # 606), = entitled=20 Your Rights Are Assured, shall be made available or given to = each=20 patient, and the rights contained therein shall be explained to the = extent=20 feasible to persons who cannot read or understand them. Additionally, = a copy=20 of either the Manual of Rights or the Patient Rights Handbook (PWPE # = 606)=20 entitled Your Rights Are Assured, shall be made available for = each=20 patient access in each patient living area.=20
(b)  Current patients. All current patients = shall be=20 given a copy of either the Manual of Rights, or Patient Rights = Handbook=20 entitled Your Rights Are Assured (PWPE # 606), as in subsection = (a).=20 Existing supplies of previously printed forms and manuals may be = utilized.=20
(c)  Manual of rights. Upon request, a = complete copy=20 of the Manual of Rights shall be made available to the family, = guardian,=20 attorney, and other interested parties.

Cross References

   This section cited in 55 Pa. Code = =A7  5100.4=20 (relating to scope); 55 Pa. Code =A7  5200.47 (relating to = other=20 applicable regulations); 55 Pa. Code =A7  5210.56 (relating = to other=20 applicable regulations); 55 Pa. Code =A7  5320.22 (relating = to=20 governing body); 55 Pa. Code =A7  5320.33 (relating to=20 resident/provider contract; information on resident rights); and 55 = Pa. Code=20 =A7  5320.45 (relating to staff orientation and training). =
=A7 5100.53. Bill of rights for=20 patients.

The following is the bill of rights for patients:

BILL OF RIGHTS

YOU HAVE A RIGHT TO BE TREATED WITH DIGNITY=20 AND
RESPECT

YOU SHALL RETAIN ALL CIVIL RIGHTS THAT HAVE NOT = BEEN
SPECIFICALLY=20 CURTAILED BY ORDER OF COURT

You have the right to unrestricted and private communication = inside=20 and outside this facility including the following rights:=20
   a. To a peaceful assembly and to join with = other=20 patients to organize a body of or participate in patient government = when=20 patient government has been determined to be feasible by the facility. =
   b. To be assisted by any advocate of your = choice in=20 the assertion of your rights and to see a lawyer in private at any = time.=20
   c. To make complaints and to have your = complaints=20 heard and adjudicated promptly.=20
   d. To receive visitors of your own choice at = reasonable hours unless your treatment team has determined in advance = that a=20 visitor or visitors would seriously interfere with your or others=92 = treatment=20 or welfare.=20
   e. To receive and send unopened letters and = to have=20 outgoing letters stamped and mailed. Incoming mail may be examined for = good=20 reason in your presence for contraband. Contraband means specific = property=20 which entails a threat to your health and welfare or to the hospital=20 community.=20
   f. To have access to telephone designated = for=20 patient use.=20
2. You have the right to practice the religion of your = choice or=20 to abstain from religious practices.=20
3. You have the right to keep and to use personal = possessions,=20 unless it has been determined that specific personal property is = contraband.=20 The reasons for imposing any limitation and its scope must be clearly = defined,=20 recorded and explained to you. You have the right to sell any personal = article=20 you made and keep the proceeds from its sale.=20
4. You have the right to handle your personal affairs = including=20 making contracts, holding a driver=92s license or professional = license,=20 marrying, or obtaining a divorce and writing a will.=20
5. You have the right to participate in the development = and=20 review of your treatment plan.=20
6. You have the right to receive treatment in the least=20 restrictive setting within the facility necessary to accomplish the = treatment=20 goals.=20
7. You have the right to be discharged from the facility = as soon=20 as you no longer need care and treatment.=20
8. You have the right not to be subjected to any harsh = or=20 unusual treatment.=20
9. If you have been involuntarily committed in = accordance with=20 civil court proceedings, and you are not receiving treatment, and you = are not=20 dangerous to yourself or others, and you can survive safely in the = community,=20 you have the right to be discharged from the facility.=20
10. You have a right to be paid for any work you do = which=20 benefits the operation and maintenance of the facility in accordance = with=20 existing Federal wage and hour regulations.

Cross References

   This section cited in 55 Pa. Code = =A7  5100.4=20 (relating to scope); 55 Pa. Code =A7  5100.52 (relating to = statement=20 of principle); 55 Pa. Code =A7  5200.47 (relating to other = applicable=20 regulations); 55 Pa. Code =A7  5210.56 (relating to other = applicable=20 regulations); 55 Pa. Code =A7  5320.22 (relating to = governing body);=20 and 55 Pa. Code =A7  5320.45 (relating to staff orientation = and=20 training).
=A7 5100.54. Manual of rights for = persons in=20 treatment.

The following is the manual of rights for persons in = treatment:=20
Article I: The Right to Communicate

Statement of Principle

   1. Right to Information=20
   2. Right to Assistance=20
   3. Right to an Attorney=20
   4. Right to Have Visitors=20
   5. Right to Send and Receive Letters=20
   6. Right to Use Telephones=20
Article II: The Right of Religious Freedom

Statement of Principle

   1. Right to Refuse Medication=20
   2. Right to Diets Based on Religious or = Ethical=20 Consideration=20
   3. Right to Abstain from Religious Practices =
Article III: The Right to Handle Your Personal Affairs =
Article IV: The Right to a Humane Physical and = Psychological=20 Environment=20
Article V: The Right to Treatment

Statement of Principle

   1. Individualized Treatment Plan=20
   2. Discharge=20
Article VI: Permissible, Restricted and Prohibited = Treatment=20 Procedures

Statement of Principle

   1. Permissible Procedures=20
   2. Restricted Procedures=20
   3. Prohibited Procedures=20
Article VII: Grievance and Appeal Procedures

Statement of Principle

   1. Grievance Procedures=20
   2. First Level Appeal=20
   3. Second Level Appeal

ARTICLE I
THE RIGHT TO=20 COMMUNICATE

Statement = of=20 Principle.

(a)  Every patient has the right and shall be = encouraged to=20 communicate freely and privately with others within the facility and = in the=20 community at large, as described below. This is based upon the firm = belief=20 that meaningful communications are essential to a successful course of = treatment. These rights may be suspended or restricted for a limited = period by=20 the treating physician only when reasonable cause exists to believe = that=20 failure to suspend communications will result in a substantial risk of = serious=20 and immediate harm to the patient or others, or that a crime is being=20 committed. The physician shall fully explain any suspensions or = restrictions=20 of these rights to the patient and document the reasons for the = restriction in=20 the patient=92s record. Suspension or restrictions shall be reviewed = and=20 documented every 48 hours until the risk of serious and immediate harm = is=20 reduced.=20
(b)  Every patient shall have the right to make = complaints=20 and offer suggestions to the director, or his designee, regarding the=20 operation of the facility, and may meet with other patients to discuss = their=20 concerns with facility administrators. Complaints and suggestions = shall be=20 heard and decided promptly.
1. Right to Information.=20
(a)  Every patient has the right to be informed of = his=20 rights and responsibilities while in treatment, and those house rules = and=20 regulations of the facility which affect his treatment.=20
(b)  Every patient has the right to be informed of=20 diagnostic and treatment procedures, their risks and their costs, that = are=20 available to him and which would aid in his recovery from mental = illness.=20 Patients have the right to be informed of the reasons and factors = involved in=20 recommending a procedure of choice.=20
(c)  Every patient has the right to be informed of = the=20 nature of material about to be released to others (or obtained) when = he is=20 requested to sign a release of information.
2. Right to = Assistance.=20
(a)  Every patient shall have the right to the = assistance=20 of an independent person not a member of his treatment team to resolve = a=20 problem raised by the patient.=20
(b)  Each non-State facility shall designate one or = more=20 persons either on a volunteer or staff basis as needed to help = patients in=20 this manner.=20
(c)  State facilities shall designate one or more = staff to=20 aid patients, and these persons shall be accessible during regular = working=20 hours.=20
(d)  Every State facility shall advise and educate = all=20 patients about the availability and services of this program.=20
(e)  These persons will be responsible for = assisting or=20 supporting the patient in meeting with the appropriate person to = discuss the=20 problem and possible solution. They shall maintain a confidential file = of=20 requests for service and subsequent actions taken. The file shall be = open to=20 review only by the facility director or the patient=92s Attorney and = shall be=20 filed with the patient=92s clinical record upon discharge. They have = no=20 authority to directly resolve problems but may report his or her = findings=20 directly to the facility director.
3. Right to an Attorney.=20
(a)  Every patient has the right to retain an = attorney of=20 his choice to assist the patient in asserting his rights to treatment = or=20 release or to aid the patient in any other matter.=20
(b)  The facility will provide patients with = referral=20 information and other non-monetary assistance to enable patients to = implement=20 this right. The names, addresses and telephone numbers of legal = services and=20 other available advocates in this area shall be given to all patients. =
(c)  Every patient has the right to see or = telephone his=20 attorney in private at any reasonable time, regardless of visiting = hours.=20
4. Right to Have Visitors.=20
(a)  Every patient has the right to receive = visitors of his=20 own choice daily, within established visiting hours, in a setting of=20 reasonable privacy conducive to free and open conversation unless a = visitor or=20 visitors are determined to seriously interfere with a patient=92s = treatment or=20 welfare.=20
(b)  Established visiting hours shall attempt to = meet the=20 needs of individual patients and visitors, and may be waived to the = extent=20 feasible to accommodate special circumstances or the needs of = individual=20 patients.
5. Right to Send and Receive Letters.=20
(a)  Every patient has the right to send unopened = mail.=20 Reasonable amounts of such mail shall be stamped free of charge if = sufficient=20 personal funds are not available.=20
(b)  Writing materials shall be made available to = patients=20 on a daily basis and an opportunity provided for writing letters and = other=20 communications. Reasonable assistance shall be provided upon request, = if=20 feasible.=20
(c)  Incoming mail may be opened only when there is = reason=20 to suspect it contains contraband, and in the presence of the patient = unless=20 dangerous or infeasible in the light of the patient=92s condition. = Contraband is=20 specific property, the possession or use of which is illegal or = entails a=20 substantial threat to the health and welfare of the patient or the = hospital=20 community.=20
(d)  Whenever mail is opened on suspicion of = contraband, an=20 identification of the person opening the mail, a statement of the = facts=20 constituting good cause, and the results of the opening including = disposition=20 shall be noted in the patient=92s record.=20
(e)  A patient=92s mail, whether incoming or = outgoing, shall=20 not be read under any circumstances, unless at the patient=92s = request.=20
6. Right to Use Telephones.=20
(a)  Every patient has the right to make telephone = calls at=20 his own expense, at reasonable times, using telephones designated for = patient=20 or public use. The facility shall take steps to provide sufficient = telephones.=20
(b)  In cases of personal emergency, when = alternative=20 methods of communication are impractical, every patient shall have the = right=20 to make reasonable local and long distance phone calls, free of = charge. These=20 calls shall be subject to reimbursement if the patient has sufficient = funds to=20 pay for the call. The director of the facility, or his delegate, shall = determine what constitutes personal emergency.

ARTICLE II
THE RIGHT TO=20 RELIGIOUS
FREEDOM

Statement of=20 Principle.

Every patient has the right to follow and practice his = religion.=20 Substantiated ethical convictions held independently of a belief in = any=20 religion shall be accorded the same respect as religious belief. The = facilty=20 shall provide reasonable assistance to enable a patient to effect this = right.=20
The exercise of these rights may be limited only if it poses = a=20 serious threat to the freedom or welfare of others, or a serious = danger to the=20 patient.
1. Right to Refuse Medication.=20
Any patient who holds a substantiated belief in the power of=20 spiritual healing shall not be compelled to take medication, provided = the=20 patient is intellectually capable of understanding the impact of such = refusal=20 and of deciding to refuse medication.
2. Right to Diets Based = on=20 Religious Considerations.=20
The patient=92s right to independently comply with his or her = dietary=20 regimen shall not be interfered with by the facility unless unfeasible = or=20 unless there is serious danger to a person=92s health. =
3. Right to=20 Abstain from Religious Practices.=20
No patient shall be required to be pressured directly or = indirectly=20 to participate in religious practices. No patient shall be compelled = to accept=20 visitation from a clergyman or minister of any religion.

ARTICLE III
THE RIGHT TO HANDLE
YOUR PERSONAL=20 AFFAIRS

Statement of Principle.

Every patient retains all civil rights not specifically = curtailed by=20 an order of a court or other body empowered to take such action.=20
(a)  Every patient has the right to handle his = personal=20 affairs. Admission or commitment to a mental health facility does not = by=20 itself, prevent a patient from holding a driver=92s license or = professional=20 license, from marrying or obtaining a divorce, from voting or writing = a will,=20 or exercising other civil and personal rights; nor is the patient = guaranteed=20 the ability to exercise any of these rights.=20
(b)  Every patient has the right to purchase, keep, = and use=20 personal possessions. This right may be limited only when the = possession or=20 use of specific property is illegal or creates a substantial threat to = the=20 health or welfare of the patient or others. The reasons for imposing = any=20 limitations on the exercise of this right and the scope of such = limitation=20 shall be clearly explained to the patient and placed in the = patient=92s record.=20
(c)  Every patient has the right to sell or retain = any=20 product or crop he makes, or grows on facility property. Money = received from=20 these activities shall not be used to pay the costs of any patient=92s = care and=20 treatment.=20
(d)  A patient shall not be deemed incompetent to = manage=20 his own affairs solely by reason of admission or commitment to a = mental health=20 facility.=20
A court finding of incompetency may not be extended beyond = the=20 specific scope of the court order.

ARTICLE IV
RIGHT TO A HUMANE PHYSICAL
AND PSYCHOLOGICAL=20 ENVIRONMENT

Statement of Principle.

Every patient has the right to reside and be treated in a = setting=20 which preserves and promotes his physical and psychological dignity.=20
(a)  Every patient has the right to be treated = humanely and=20 with consideration by all staff members. Any grossly negligent or = intentional=20 conduct of staff which causes or may cause emotional or physical harm = to a=20 patient is a violation of this right.=20
(b)  Every patient has the right to assistance in=20 developing a physical appearance which promotes a positive self image. = This=20 includes the following:=20
   (1)  The right to keep and wear his own = clothing, unless there are reasonable grounds to believe such clothing = or=20 specific items constitute a substantial threat to the health or safety = of the=20 patient or others.=20
   (2)  Clothing provided by the facility = shall be=20 neat, clean, appropriate to the season and to the extent possible, = consistent=20 with the patient=92s personal preference. This clothing shall enable = the patient=20 to make a customary appearance within the community.=20
   (3)  The right to purchase, keep, and = use=20 customary cosmetic, hygiene, and grooming articles or services unless = there=20 are reasonable grounds to believe specific articles constitute a = substantial=20 threat to the health or safety of the patient or others.=20
   (4)  Basic customary cosmetic, hygiene, = and=20 grooming articles or services shall be provided by the facility for = patients=20 who need them but cannot afford them. Patients shall be given = reasonable=20 assistance as needed in utilizing cosmetic, hygiene, and grooming = articles and=20 services.=20
(c)  Every residential patient shall be furnished = with a=20 comfortable bed and bedding, adequate change of linen, a closet or = locker for=20 personal belongings, and a bedside cabinet. Every patient, at his or = her own=20 risk, shall be allowed to keep and display appropriate personal = belongings and=20 to add personal touches to his room or living area.=20
(d)  Every patient has the right to a nutritionally = adequate diet and every patient has the right to eat or to be fed = under=20 supervision, in the dining room or area in the relaxed atmosphere, and = to use=20 normal eating implements, unless contra-indicated by the patient=92s = conduct or=20 course of treatment.=20
(e)  Every patient has the right to bathroom = facilities=20 which provide privacy for personal hygiene and meet Departmental = standards for=20 health, safety, and cleanliness.=20
(f)  Every patient has the right to therapeutic and = daily=20 living activities held in settings that approximate noninstitutional = living.=20 Dining, recreational, vocational, and other activities shall where = possible=20 and appropriate be conducted on a basis which provides interaction = between=20 male and female patients.

ARTICLE V
RIGHT TO = TREATMENT

Statement of=20 Principle.

Every patient has the right to receive treatment designed to = aid and=20 promote his recovery from mental illness. This treatment shall, = whenever=20 possible, be in or near the patient=92s home community, and shall be = in the=20 least restrictive setting available to provide adequate treatment or = to meet=20 the conditions of security imposed by a court.
1. Individual=20 Treatment Plan.=20
(a)  Every patient has the right to an = individualized=20 treatment plan, appropriate to his needs, setting forth the = objectives, goals,=20 activities, experiences, and therapies designed to promote recovery.=20
(b)  The plan shall be developed within 72 hours of = admission or commitment. It shall be revised whenever necessary and = reviewed=20 at least every 30 days.=20
(c)  Every patient has the right to participate to = the=20 extent feasible in the development of his treatment plan. The plan = shall be=20 written in terms understandable by lay persons and shall be explained = to the=20 patient. A copy of the treatment plan shall be made available for the=20 patient=92s review.
2. Discharge.=20
Every patient has the right to be discharged as soon as care = and=20 treatment is no longer necessary. Every patient has the right to all = of the=20 available treatment modalties appropriate to his or her needs which = promote=20 recovery and discharge. Treatment shall also include the appropriate=20 post-discharge rehabilitative services available in the community. =

ARTICLE VI
PERMISSIBLE SPECIALIZED AND
PROHIBITED = TREATMENT=20 PROCEDURES

Statement of Principle.

Every patient shall only receive approved treatment = procedures in=20 accordance with Departmental regulations. This treatment shall be = described in=20 his individual treatment plan and shall be explained to the patient.=20
1. Permissible Procedures.=20
(a)  All patients may in an emergency, be required = to=20 accept the minimal sufficient diagnostic procedures and treatment = necessary to=20 alleviate the emergency.=20
(b)  Patients committed pursuant to sections 303, = 304 or=20 305 of the act (50 P. S. =A7 =A7  4303, 4304, and = 4305), may also=20 be required to accept routine medical, psychiatric, psychological, and = educational programs conforming to departmental regulations and the = patient=92s=20 individualized treatment plan.=20
(c)  Any patient committed for examination by court = may be=20 required to accept the minimal diagnostic procedures necessary to = determine=20 the patient=92s mental condition.=20
(d)  Any patient in treatment on a voluntary basis = may=20 agree to participate in any and all approved treatment methods as = described in=20 his individualized treatment plan. Any voluntary patient may also = refuse to=20 participate in any aspect of his individualized treatment plan and may = request=20 a review of the proposed treatment. Refusal to accept a reviewed and = approved=20 treatment may be cause for discharge.
2. Specialized = Procedures.=20
(a)  No patient shall be subject to the withholding = of=20 privileges, nor to any system of rewards, except as part of an = individualized=20 treatment plan.=20
(b)  Electro-convulsive or other therapy, = experimental=20 treatments involving any risk to the patient, or aversion therapy = shall not be=20 prescribed unless:=20
   (1)  The patient=92s treatment team has = documented in the patient=92s record that all reasonable and less = intensive=20 treatment modalities have been considered; that the treatment = represents the=20 most effective therapy for the patient at that time; and that the = patient has=20 been given a full explanation of the nature and duration of the = proposed=20 treatment and why the treatment team is recommending the treatment; = and that=20 the patient has been told that he or she has the right to accept or = refuse the=20 proposed treatment and that if he consents, has the right to revoke = his=20 consent for any reason at any time prior to or between treatments.=20
   (2)  The treatment was recommended by = qualified=20 staff members trained and experienced in the treatment procedure and = has been=20 approved by the facility administrator if an M.D. or, if not, by the = clinical=20 director after review by the appropriate committee.=20
   (3)  The patient has given written = informed=20 consent to the specific proposed treatment. In the alternative, oral = informed=20 consent is sufficient where that consent is witnessed by two persons = not part=20 of the patient=92s treatment team. In either case, such consent shall = be limited=20 to a specified number of maximum treatments over a specific period of = time and=20 shall be revocable at any time before or between treatments. Such = withdrawal=20 of consent may be immediately effective.=20
   (4)  If a patient=92s treatment team = determines=20 that the patient could benefit from one of those specified treatments = but also=20 believes that the patient does not have the capacity to give informed = consent=20 to the treatment, a court order shall be obtained authorizing the = recommended=20 treatment before such treatment may be administered to the patient.=20
(c)  No patient shall be subject to chemical, = physical, or=20 psychological restraints, including seclusion, other than in = accordance to the=20 Department=92s regulations applicable to State Mental Health = Facilities or, in=20 case of community facilities, the policy and procedures for seclusion = and=20 restraint approved by its medical staff and governing body. A copy of = the=20 applicable regulations shall be made available to patients upon = request.=20
(d)  No patient shall be the subject of any = research,=20 unless conducted in strict compliance with Federal regulations on the=20 protection of human subjects. Patients considered for research = approved by the=20 facility shall receive and understand a full explanation of the nature = of the=20 research, the expected benefit, and the potential risk involved. = Copies of the=20 Federal regulations shall be made available to patients involved in, = or=20 considering becoming involved in, research or their advocates. Patient = research conducted in State facilities or funded by State monies = requires=20 prior approval of the Deputy Secretary of Mental Health.=20
3. Prohibited Procedures.=20
Psychosurgery, removal of organs for the purpose of = transplantation,=20 and sterilization, shall not be performed at a State-operated mental = hospital.=20

ARTICLE VII
GRIEVANCE AND=20 APPEAL
PROCEDURES

Statement of Principle.

To insure that these rights are safeguarded and that disputes = concerning their rights and others are resolved promptly and fairly, = patients=20 must have the right to lodge grievances and appeals when informal = methods of=20 resolving disputes are unsuccessful. Each facility shall have a = grievance and=20 appeal system in effect. Every patient shall be informed of the = grievance and=20 appeal system and shall be encouraged to utilize it when informal = methods of=20 resolving complaints are unsuccessful.
1. Grievance = Procedure.=20
(a)  Any patient, or those helping him, may = initiate a=20 complaint orally or in writing, concerning the exercise of these = rights or the=20 quality of services and treatment at the facility. The complaint shall = be=20 presented as soon as possible to the treatment team leader or other=20 appropriate person.=20
(b)  Every patient shall have the right to the = assistance=20 of an independent person and witnesses in presenting his complaint.=20
(c)  The treatment team leader, administrative = supervisor,=20 or their designees receiving the complaint shall investigate the = complaint and=20 make every effort to resolve it. Based upon this investigation, a = decision=20 shall be rendered in writing as soon as possible but within 48 hours = after the=20 filing of the complaint. Complaints shall be decided by persons not = directly=20 involved in the circumstances leading to the grievance.=20
(d)  The patient shall be given a copy of the = complaint and=20 final decision and a copy shall be filed in the patient=92s record.=20
2. First Level Appeal.=20
(a)  Any patient, or those helping him, may appeal = the=20 grievance decision within 10 working days of the decision. = State-operated=20 facilities shall follow the procedures set forth in this part. = Non-State=20 operated facilities shall have in effect a fair and impartial appeal=20 procedure, which shall be reviewed by the county administrator.=20
(b)  In a State-operated facility, standing Rights = Review=20 Committee composed equally of facility staff and persons from the = community=20 not affiliated with the facility shall hear the appeal and render a = written=20 decision within 10 working days of the date of the appeal. Staff = members shall=20 be appointed by the facility director. Until such time as the = committee is in=20 effect, the appeal shall be heard by a hearing examiner appointed by = the=20 regional deputy secretary. If the grievance requires immediate action, = the=20 appeal shall be heard and decided as soon as possible.=20
(c)  The patient shall be given prompt notice of = the date=20 set for the appeal and shall be informed of his right to be = represented by=20 counsel.=20
(d)  Hearings shall be informal, without strict = adherence=20 to the rules of evidence. A sufficient record of the hearing shall be = made.=20
(e)  A copy of the decision shall be given to the = patient,=20 the facility director, and filed in the patient=92s chart. =
3. Second=20 Level Appeal.=20
(a)  Any patient in a State facility, those helping = him, or=20 the facility director, may appeal the decision of the hearing examiner = or=20 Rights Review Committee within 10 working days of the decision. The = appeal=20 must set forth the specific objections to the decision.=20
(b)  The Secretary of Public Welfare shall = establish a=20 standing Rights Appeal Committee composed equally of Department and = community=20 personnel. Within 5 working days of receipt of a second level request, = the=20 Committee shall review the decision of the Rights Review Committee and = may=20 seek any additional information it deems necessary.=20
(c)  The patient shall be given prompt notice of = the date=20 set for the appeal and shall be informed of his or her right to be = represented=20 by counsel.=20
(d)  Reviews shall be informal. A sufficient record = of the=20 hearing shall be made.=20
(e)  The Committee shall submit a recommendation to = the=20 Secretary of Public Welfare within 10 working days of its receipt of = the=20 second level appeal request. The Secretary will review the findings = and=20 recommendations by the Committee and will issue a decision.=20
(f)  Nothing in this section shall be construed as=20 precluding a patient from instituting appropriate legal = proceedings.

Cross References

   This section cited in 55 Pa. Code = =A7  5100.4=20 (relating to scope); 55 Pa. Code =A7  5100.52 (relating to = statement=20 of principle); 55 Pa. Code =A7  5200.47 (relating to other = applicable=20 regulations); 55 Pa. Code =A7  5210.56 (relating to other = applicable=20 regulations); 55 Pa. Code =A7  5320.22 (relating to = governing body);=20 and 55 Pa. Code =A7  5320.45 (relating to staff orientation = and=20 training).
=A7 5100.55. Notification of = rights.

Upon receipt of a person for treatment the facility shall = advise the=20 individual of his rights, and obtain when feasible a written = acknowledgement=20 by the person that his rights affecting their treatment were = explained. In the=20 event that conditions prevent such acknowledgement or understanding, = the=20 process of notification shall be recorded by the person designated and = confirmed by a witness.

Cross References

   This section cited in 55 Pa. Code = =A7  5100.4=20 (relating to scope); 55 Pa. Code =A7  5200.47 (relating to = other=20 applicable regulations); 55 Pa. Code =A7  5210.56 (relating = to other=20 applicable regulations); 55 Pa. Code =A7  5320.22 (relating = to=20 governing body); and 55 Pa. Code =A7  5320.45 (relating to = staff=20 orientation and training).
=A7 5100.56. Existing = regulations.

(a)  Existing regulations regarding treatment = facilities=20 and procedures continue in force to guide facilities and providers in=20 protecting the rights of persons in treatment.=20
(b)  It shall be the responsibility of the = administrator in=20 utilizing facilities to assure that procedures for affecting and = protecting=20 the rights of persons in treatment are developed and followed.

Cross References

   This section cited in 55 Pa. Code = =A7  5100.4=20 (relating to scope); 55 Pa. Code =A7  5200.47 (relating to = other=20 applicable regulations); 55 Pa. Code =A7  5210.56 (relating = to other=20 applicable regulations); 55 Pa. Code =A7  5320.22 (relating = to=20 governing body); and 55 Pa. Code =A7  5320.45 (relating to = staff=20 orientation and training).

CONTINUITY OF CARE

=A7 5100.61. Continuity of = care.

(a)  When a person in treatment under the act moves = into or=20 out of a State-operated mental health facility, the county = administrator=20 responsible for the person=92s continuity of care shall take such = actions to=20 ensure that the person receives available services as needed. In = taking such=20 actions, the administrator shall consider the person=92s plans to = utilize=20 private resources.=20
(b)  Whenever a person is considered for discharge = from=20 treatment at a State facility, the director shall take steps to assure = that=20 the appropriate county administrator=92s office is involved in = predischarge=20 planning before the discharge. The degree of involvement by the county = may be=20 based upon the person=92s plans to utilize private resources.=20
(c)  Upon discharge, the county administrator = receiving the=20 referral shall take the necessary steps to arrange for the available = mental=20 health treatment services as defined in application statutes.=20
(d)  When a person referred for service refuses to=20 cooperate with the county administrator after discharge, such person = shall be=20 evaluated for alternative services before the case can be closed. Such = evaluations should be as clinically thorough as possible. There should = be=20 documentation of repeated efforts at reinvolving the person in = voluntary=20 treatment if treatment has been recommended and of the decisions = regarding the=20 appropriateness of commitment proceedings. =

VOLUNTARY TREATMENT

=A7 5100.71. Voluntary = examination and=20 treatment.

(a)  Persons 14 years of age or older may seek = voluntary=20 inpatient treatment if they substantially understand the nature of = such=20 treatment and the treatment setting. Parents or guardians who decide = to seek=20 voluntary inpatient treatment for persons under 14 years of age may do = so only=20 in accordance with the act and applications regulations.=20
(b)  The test of a person=92s substantial = understanding for=20 inpatient treatment is met if the person gives consent to the = information and=20 explanations outlined in section 203 of the act (50 P. S. = =A7  4203).=20
(c)  Behavorial consent, as defined in = =A7  5100.2=20 (relating to definitions) shall be sufficient consent for persons = presently=20 receiving treatment at a facility to remain at that facility and to=20 participate in treatment which is explained to him. Behavioral consent = shall=20 be documented under =A7  5100.73 (relating to explanation = and consent=20 to inpatient treatment). Behavorial consent shall not be relied upon = for=20 admission to or transfer from a facility.=20
=A7 5100.72. Applications.

(a)  Written application for voluntary inpatient = treatment=20 shall be made upon Form MH-781, issued by the Department.=20
(b)  A State-operated facility shall not accept an=20 application for voluntary inpatient treatment for persons not = currently in the=20 facility unless:=20
   (1)  There is concurrence on an = individual case=20 basis given by the administrator.=20
   (2)  There is a preexisting agreement = of waiver=20 approved by the Deputy Secretary of Mental Health between the State = facility=20 and the Administrator which designates that facility as the only = provider of=20 inpatient services of the county program.=20
   (3)  There is a preexisting letter of = agreement=20 approved by the Deputy Secretary of Mental Health between the State = facility=20 and the Administrator which designates the State facility as:=20
     (i)   A substitute = provider of=20 inpatient services on a temporary basis when an emergency need arises = and=20 there are no other appropriate approved facilities available; or=20
     (ii)   A provider of=20 specialized forensic inpatient services when a need for security = arises.=20
   (4)  Such letter of agreement shall = define the=20 nature of security to be available and the responsibilities of both = the State=20 facility and the administrator.=20
(c)  When application is made to an approved = facility, the=20 director of the facility shall:=20
   (1)  Be responsible for insuring that a = preliminary evaluation of the applicant is conducted in order to = establish the=20 necessity and appropriateness of outpatient services or partial=20 hospitalization or inpatient hospitalization service for the = individual=20 applicant. The preliminary evaluation shall be done in the least = restrictive=20 setting possible. The results of the preliminary evaluation shall be = set forth=20 on Form MH-781-A issued by the Department.=20
   (2)  Promptly notify the administrator = if the=20 applicant=92s treatment will involve mental health/mental retardation = (MH/MR)=20 funding.=20
(d)  When application is made to the administrator: =
   (1)  The administrator shall designate = an=20 approved facility which shall conduct a preliminary evaluation of the=20 applicant in order to establish the necessity and appropriateness of=20 outpatient services or partial hospitalization service or inpatient=20 hospitalization for the individual applicant.=20
   (2)  The designated facility shall = immediately=20 upon its completion of the preliminary evaluation, notify the = administrator of=20 its finding and recommendations.=20
   (3)  Upon receipt of the report, the=20 administrator shall review the report and when necessary, designate an = approved appropriate facility for the recommended treatment of the = individual=20 applicant.
=A7 5100.73. Explanation and = consent to=20 inpatient treatment.

(a)  In order to assure that a person substantially = understands the nature of voluntary inpatient treatment, an = explanation shall=20 be made to him of the findings of the preliminary evaluation and the = proposed=20 treatment and goals. An explanation of planned diagnostic and = treatment=20 procedures, including the medications, restraints or restrictions = which may be=20 utilized shall be given in terms understandable by the person seeking=20 services.=20
(b)  Each applicant shall be provided with a copy = of the=20 Patient=92s Bill of Rights. Form MH-782 or the Patient=92s Rights = Pamphlet, PWPE=20 #605 entitled You Have a Right To Be Treated With Dignity and = Respect.=20 Consent shall be obtained by use of Form MH-781 B, C or D.=20
(c)  In the event that the consent of the applicant = is=20 given but cannot be obtained in writing, a statement o

CHAPTER 5100. MENTAL HEALTH PROCEDURES

GENERAL PROVISIONS

TREATMENT

MENTAL HEALTH REVIEW OFFICER AND=20 PROCEEDINGS

CONFIDENTIALITY OF MENTAL HEALTH=20 RECORDS

FORMS

PATIENT = RIGHTS

CONTINUITY OF = CARE

VOLUNTARY=20 TREATMENT

INVOLUNTARY=20 TREATMENT

PERSONS CHARGED WITH A CRIME OR UNDER=20 SENTENCE

GENERAL PROVISIONS

=A7 5100.1. Legal base.

TREATMENT

=A7 5100.11. Adequate = treatment.

MENTAL HEALTH REVIEW OFFICER AND = PROCEEDINGS

=A7 5100.21. Proceedings.

=A7 5100.23. Written application, = petitions,=20 statements and certifications.

CONFIDENTIALITY OF MENTAL HEALTH RECORDS

=A7 5100.31. Scope and = policy.

=A7 5100.35. Release to = courts.

=A7 5100.36. Departmental access = to records=20 and data collection.

=A7 5100.39. Release of = records.

FORMS

=A7 5100.41. Forms.

PATIENT RIGHTS

=A7 5100.51. Preservation of = rights.

=A7 5100.52. Statement of = principle.

BILL OF RIGHTS

YOU HAVE A RIGHT TO BE TREATED WITH DIGNITY=20 ANDRESPECT

YOU SHALL RETAIN ALL CIVIL RIGHTS THAT HAVE NOT = BEENSPECIFICALLY=20 CURTAILED BY ORDER OF COURT

Statement of Principle

Statement of Principle

Statement of Principle

Statement of Principle

Statement of Principle

ARTICLE ITHE RIGHT TO=20 COMMUNICATE

ARTICLE IITHE RIGHT TO=20 RELIGIOUSFREEDOM

ARTICLE IIITHE RIGHT TO HANDLEYOUR PERSONAL=20 AFFAIRS

ARTICLE IVRIGHT TO A HUMANE PHYSICALAND PSYCHOLOGICAL=20 ENVIRONMENT

ARTICLE VRIGHT TO = TREATMENT

ARTICLE VIPERMISSIBLE SPECIALIZED ANDPROHIBITED = TREATMENT=20 PROCEDURES

ARTICLE VIIGRIEVANCE AND=20 APPEALPROCEDURES

=A7 5100.56. Existing = regulations.

CONTINUITY OF CARE

=A7 5100.61. Continuity of = care.

VOLUNTARY TREATMENT

=A7 5100.71. Voluntary = examination and=20 treatment.

YOU HAVE A RIGHT TO BE TREATED WITH DIGNITY=20 AND
RESPECT

YOU SHALL RETAIN ALL CIVIL RIGHTS THAT HAVE NOT = BEEN
SPECIFICALLY=20 CURTAILED BY ORDER OF COURT

ARTICLE I
THE RIGHT TO=20 COMMUNICATE

ARTICLE II
THE RIGHT TO=20 RELIGIOUS
FREEDOM

ARTICLE III
THE RIGHT TO HANDLE
YOUR PERSONAL=20 AFFAIRS

ARTICLE IV
RIGHT TO A HUMANE PHYSICAL
AND PSYCHOLOGICAL=20 ENVIRONMENT

ARTICLE V
RIGHT TO = TREATMENT

ARTICLE VI
PERMISSIBLE SPECIALIZED AND
PROHIBITED = TREATMENT=20 PROCEDURES

ARTICLE VII
GRIEVANCE AND=20 APPEAL
PROCEDURES