301.1 Each MH provider shall establish and adhere to a Consumer Rights Policy. The MH provider's Consumer Rights Policy must be approved by the MH provider's governing authority and DMH, and contain, at a minimum, the following:

(a) A Consumer Rights Statement published by DMH;

(b) A copy of the MH provider's Grievance Procedure established in accordance with § 306;

(c) The telephone number for any independent peer advocacy programs established in accordance with § 302.1; and

(d) The following statement: "You may also have the option to initiate a grievance with any or all of several outside entities, including but not limited to the Office of Administrative Review and Appeals at the Department of Human Services, the U.S. Department of Health and Human Services, and the District of Columbia's program for the protection and advocacy for persons with mental illness. For further information, contact the Department of Mental Health's Access Hotline or its web site."

301.2 Within one hundred eighty (180) days of the effective date of these rules, each MH provider shall submit to DMH its written Consumer Rights Policy, including the MH Provider Grievance Procedure, for approval. DMH must approve the Consumer Rights Policy of each MH provider in order for the MH provider to be certified and licensed by DMH.

(a) A MH provider shall submit subsequent substantive changes to its Consumer Rights Policy or MH Provider Grievance Procedure to DMH for approval before implementation of the changes by the MH provider.

(b) A MH provider may continue to utilize existing consumer grievance policies approved by DMH in the certification process for MH providers, until the MH provider adopts a new procedure consistent with §§ 304 through 306 and approved by DMH as required by this section 301.2.

301.3 Each MH provider shall disseminate its Consumer Rights Policy in ways designed to foster consumer understanding, including, at a minimum:

(a) A MH provider shall provide a copy of its Consumer Rights Policy to each consumer at his or her initial appointment with the provider or at the next appointment. At the same time the MH provider shall also

offer a verbal explanation of the Policy to the consumer and provide such explanation upon request.

1. (b) The consumer, and his or her legal guardian if present, shall sign a DMH-approved form acknowledging receipt of the Policy and any verbal explanation. The receipt form shall be placed in the consumer's clinical record.
2. (c) If the consumer elects not to sign the receipt form, the reasons given for not signing shall be recorded on the form.
3. (d) In the event of a crisis or other emergency at the initial or next appointment that prevents a written and verbal explanation of the Consumer Rights Policy, the consumer shall be verbally advised of, at a minimum, the consumer's immediately pertinent rights and protections, such as the right to consent to or to refuse the offered treatment and the consequences of that consent or refusal. In such cases, distribution and explanation of the Consumer Rights Policy shall be accomplished at the consumer's next appointment and the reason for the delay shall be documented on the receipt form.
4. (e) Each MH provider shall post a copy of the Consumer Rights Policy in strategic and conspicuous locations in each building operated by the provider, and shall make additional copies of the Consumer Rights Policy available to consumers, parents, guardians, family, designated personal representatives and staff upon request.
5. (f) Each MH provider shall ensure that every current staff member, including administrative, clerical, and support staff, is knowledgeable about its Consumer Rights Policy when its grievance procedure goes into effect. Each MH provider shall also establish a means of ensuring that all new staff members who are hired in the future are knowledgeable about its Consumer Rights Policy.

SOURCE: Final Rulemaking published at 50 DCR 8480 (October 10, 2003).