1.K.a-i

The organization implements policies promoting the following rights of the persons served:

1. Confidentiality of information.
2. Privacy.
3. Freedom from:
   1. Abuse.
   2. Financial or other exploitation.
   3. Retaliation.
   4. Humiliation.
   5. Neglect.
4. Access to:
   1. Information pertinent to the person served in sufficient time to facilitate his or her decision making.
   2. Their own records.
5. Informed consent or refusal or expression of choice regarding:
   1. Service delivery.
   2. Release of information.
   3. Concurrent services.
   4. Composition of the service delivery team.
   5. Involvement in research projects, if applicable.
6. Access or referral to:
   1. Legal entities for appropriate representation.
   2. Self-help support services.
   3. Advocacy support services.
7. Adherence to research guidelines and ethics when persons served are involved, if applicable.
8. Investigation and resolution of alleged infringement of rights.
9. Other legal rights.

• ???

---

1.K.2.a-b

The rights of the persons served are:

1. Communicated to the persons served:
   1. In a way that is understandable.
   2. Prior to the beginning of service delivery or at initiation of service delivery.
   3. At least annually for persons served in a program longer than one year.
2. Available at all times for:
   1. Review.
   2. Clarification.

• ???

---

1.K.3.a-c

The organization:

1. Implements a policy and written procedure by which persons served may formally complain to the organization that specifies:
   1. Its definition of a formal complaint.
   2. That the action will not result in retaliation or barrier to services.
   3. How efforts will be made to resolve the complaint.
   4. Levels of review, which include availability of external review.
   5. Time frames that:
      1. Are adequate for prompt consideration.
      2. Result in timely decisions for the person served.
   6. Procedures for written notifications regarding the actions to be taken to address the complaint.
   7. The rights of each party.
   8. The responsibilities of each party.
   9. The availability of advocates or other assistance.
2. Makes complaint procedures and, if applicable, forms:
   1. Readily available to the persons served.
   2. Understandable to the persons served.
3. Documents formal complaints received.

• ???

---

1.K.4

An analysis of all formal complaints:

1. Is conducted at least annually.
2. Is documented, including:
   1. Whether formal complaints were received.
   2. Trends.
   3. Areas needing performance improvement.
   4. Actions to be taken to address the improvements needed.
   5. Actions taken or changes made to improve performance.

• ???

 

---