Clients Rights

POLICY: Lumin Wellness is committed to the delivering services in a safe, non-judgmental environment filled with warmth and care.  We respect the dignity of patients and staff members alike. Lumin Wellness believes that clients have definitive rights because of their affiliation with the organization. It is the policy of the organization that clients have their rights fully and clearly explained to them during their orientation for treatment, including but not limited to Privacy Rights. 

PROCEDURES: The following procedures apply: 

  1. The staff will discuss the client’s rights and responsibilities statement with clients when the client is admitted to treatment and annually for those clients who remain in treatment more than one year. Of critical importance, client rights and responsibilities will be explained in a way that is truly meaningful and understandable to the client, and in such a way as to respect the client’s developmental, language and mental abilities. Additionally, the client will receive a copy of the Client Orientation Handbook upon admission to Lumin Wellness which includes the client rights and responsibilities. 
  2. As part of the admission process to Lumin Wellness or during the first week in treatment, all clients will attend an orientation briefing that includes further discussion and emphasis of client rights and responsibilities and receive a client orientation booklet if not conducted at the time of admission. (Note: This policy recognizes that re-orientation may sometimes be required as clients may be cognitively impaired during the assessment process.) 
  3. A copy of the Client Rights and Responsibilities Statement will be posted in clinic so that it will be always readily available to all patients for review. A copy of the Client Rights and Responsibilities will be offered to all clients. 
  4. No later than December 31 of each year the Executive Director will formally review clinic operations and evaluate any restrictions placed on the rights or privileges of clients, methods to reinstate restricted or lost privileges or rights, if applicable, and the purpose or benefit of any type of restriction on rights or privileges. The Executive Director is responsible for documenting the results of the review and permanently maintaining it on file for review by accreditation surveyors and state/regulatory auditors. All staff members are responsible for conformance with this policy.  Executive Director is responsible for ensuring conformance with this policy and for periodic monitoring as may be necessary to ensure continued conformance. 

Client Rights

  • The right to have access to information and to release information, in an appropriate time frame to facilitate fully informed decision-making in support of your treatment and/or recovery. 
  • The right to have access to information about your treatment in sufficient time so that you can make the best-informed decision about your treatment. 
  • The right to informed consent, informed refusal and/or expression of your choice regarding service delivery (how we provide treatment services, the release of information about your treatment), concurrent services (services that you might also be receiving from another provider), composition and membership of your treatment team and involvement in research projects.  
  • The right to adherence to accepted research guidelines and practices and industry ethics if you choose to be involved in a research project being conducted at the clinic and/or by the clinic staff. 
  • The right to be fully involved as an active participant in all decisions pertaining to your treatment and to participate in all counseling/treatment modalities and activities offered by the clinic. 
  • The right to revoke a consent for treatment at any time (except for those clients in treatment because of a criminal justice system mandate). 
  • The right to have a primary counselor designated in writing who will direct and coordinate your treatment. 
  • The right to request a change in your primary counselor if you so desire. 
  • The right to receive individualized care and adequate dosing as part of your treatment. 
  • The right to receive services in an environment that is free of all forms of abuse, exploitation, and retaliation (including fiduciary/fiscal abuse), humiliation and neglect.  
  • The right to receive treatment services without fear of the use of seclusion and/or physical restraint. 
  • The right to the highest degree of privacy and to be treated with dignity and respect during medical examinations, physician consultations and/or intrusive procedures. 
  • The right to have information about your treatment and your confidentiality protected to the greatest extent allowed by federal and state confidentiality laws and regulations including 42 CFR Part 2 and the Health Insurance Portability and Accountability Act (HIPAA) of 1996. 
  • The right to access self-help and advocacy support services and, to obtain staff assistance, when necessary, to access those services. 
  • The right to access or referral to legal entities for appropriate representation as needed, and to obtain staff assistance, when necessary, to access those entities. 
  • The right to review and request copies of all protected health information, including all clinical documentation in your record. (For more information or to exercise this right, you should contact your counselor for specific details). 
  • The right to have family members, friends or others involved in your treatment and with your consent and approval. 
  • The right to receive services that comply with all applicable federal and state laws, rules, and regulations regarding methadone treatment. 
  • The right to file a grievance or complaint about the services you receive without fear of retaliation or reprisal of any sort, and to have the procedure for filing a grievance or complaint in a clear, understandable manner. 
  • The right to file a grievance with the responsible staff member, County, State licensing/regulatory authority if you feel that the organization has not satisfactorily addressed any concerns you have or does not adequately address any formal grievance you submit; and upon acceptance to another opioid treatment program, the right to transfer if approved by County Access, or Medicare, Self-pay. When you have notified your primary counselor in advance of your desired transfer date so that the Lumin Wellness staff can assist in a smooth transfer to the other program within designated timeframe. 
  • The right to have any violation of these rights investigated and appropriately resolved by an objective member of the clinical and/or managerial staff. 
  • If applicable, to expect that the staff will adhere to general accepted standards of research and ethics when such research involves you and/or other clients. 
  • It is emphasized that you may also have additional rights afforded to you and your primary counselor or the Executive Director can advise you of any additional rights that you may have. 

Retention and Destruction of Records 

POLICY: It is the policy of Lumin Wellness that all records will be maintained in accordance with applicable federal and state laws or, for a period of seven years after the last entry or documented event, whichever is shorter. Further, it is the policy of the organization that the only acceptable ways to destroy records is through shredding and/or burning. 

PROCEDURE: The following procedures apply to the retention and destruction of records: 

  1.  Security Provision 

All records, whether active or inactive, will be filed, stored, or locked in a cabinet, vault, or secure room to prevent unauthorized access and inadvertent loss or compromise if not stored using an approved Electronic Medical Records Software. This policy specifically authorizes the secure storage or client records overnight in the clinic medical or counselor’s offices if they are afforded an adequate degree of protection as provided elsewhere in this policy. 

  1.  Off-Site Storage of Inactive/Archived Records 

In the event a clinic lacks adequate room to store inactive (archived) records, such records may be transferred to a secure, off-site commercial facility. A complete listing of records transferred to the off-site storage facility will be prepared by designated clinic staff and will include, at a minimum: client name; client number; date admitted to treatment; and date last seen.  

  1.  Destruction of Records 

As previously stated, client records can be destroyed through burning or shredding. In either event, the Executive Director will ensure that a Certificate of Records Destruction will be completed to accurately document those records destroyed. The document of destruction form will be completed in its entirety and each form will bear the signatures of the staff members (Executive Director, name of person destroying the records, staff witness to the destruction) involved in the destruction process. Destruction forms will be maintained on file in accordance with regulatory requirements for compliance purposes and will be afforded the same degree and extent of confidentiality protection as client records. Prior to the  

destruction of any client records, the Executive Director will approve or disapprove the proposed destruction in writing. 

  1.  Stopping Destruction If a Legal Process is initiated 

If the staff is involved in the destruction of records and a legal process is initiated against the organization, all such destruction will be terminated immediately upon discovery of the legal process. For the purposes of this policy, legal process is defined as the presentation of an appropriately signed and sworn subpoena, warrant or search warrant by a duly sworn member of a local, state, or federal law enforcement agency. Upon discovery that a legal process is pending, the staff member who is initially notified or contacted or, who is first alerted to or discovers the existence of the process, will immediately notify the Program/Executive Director. The Executive Director will in turn notify the Corporate Compliance Officer. The Corporate Compliance Officer will ensure that all essential staff is notified so that any destruction of records, if ongoing, can be immediately terminated if required as a condition of the legal process. Executive/Program Director is responsible for the implementation of this policy and will ensure that all retention policies and procedures at the clinic are consistent with those mandated by law and/or regulatory agency policy. 

Client Grievances 

PURPOSE: To establish the official position of Lumin Wellness on client grievances, the procedures by which a client may file a formal complaint or grievance, or appeal a decision made by the organization’s staff members or treatment team and to assign specific responsibility for implementation of the policy. 

POLICY: Lumin Wellness recognizes that all clients have a fundamental right to file a formal complaint or grievance in relation to services received at Lumin Wellness clinic. Further, the agency recognizes its ethical and moral obligation to be fair, honest, and ethical in all matters pertaining to client services. Therefore, it is the policy Lumin Wellness that formal grievance procedures shall be implemented for use by clients and will be explained to clients as part of their initial orientation to the program; and, that the staff will render assistance to any client who desires to submit a grievance. Further, this policy specifically prohibits any reprisal, retaliation or change in service delivery or the imposition of any barriers for any client who chooses to file a grievance under the provisions of this policy. At the heart of this policy is the expectation that every client and every staff member will attempt to resolve grievances at the lowest possible level within the agency; and, that the grievance process will not be used to resolve trivial matters that could otherwise be resolved in the normal course of case management and service delivery. A fundamental part of this policy is the expectation that communications with clients during the grievance process will be honest, clear, concise, and more critically, expressed in terms that are understandable and appropriate to the client’s individual needs. 

PROCEDURES: The following procedures will also guide the organization, its clients and staff in handling and processing client grievances: 

  1. As part of new client orientation, the procedures for filing a complaint, grievance or appeal will be thoroughly explained and done so in a manner that is understandable to the client. When applicable, this explanation will also be provided to family members who may be involved in the client’s treatment. Grievance forms will be available for all stakeholders that utilize Lumin Wellness facility. 
  2. Program/Executive Director will ensure that grievance forms are readily available to all clients and are provided on demand to any client who desires to file/submit a written grievance or complaint. 
  3. Primary counselors will always attempt to resolve complaints/issues before recommending that the matter be addressed with the Clinical Director. 
  4. If the Clinical Director cannot resolve the matter to the satisfaction of the client within two (2) working days, the client must be informed by the Clinical Director of his/her right to discuss the matter with the Program/Executive Director. Additionally, the Clinical Director will arrange a mutually agreeable time and date for the client and Executive Director to meet and discuss the grievance and the client’s concerns. 
  5. Executive Director shall have three (3) working days to resolve the matter and provide a verbal explanation/resolution to the client. If the client is not satisfied with the Executive Director’s decision and/or explanation, the client must be informed by the Executive Director of his/her right to address the matter in writing or verbally with the Macomb County the Office of Substance Abuse (MCOSA), Department of Community Mental Health. The Executive Director or his/her designee will assist the client, if required and necessary, in drafting a written grievance to be forwarded to Macomb County the Office of Substance Abuse (MCOSA)/ Department of Community Mental Health Lansing, MI. 
  6. If the client chooses to exercise the option, the Executive Director shall ensure that the client is provided with the name, address and phone number of the County, and State licensing/regulatory authority.  
  7. All clients shall be afforded the opportunity, upon request and at their own expense, to use the services of professional advocates or others in seeking redress for grievances. To the greatest extent possible and practical, staff members will assist the client, if required, in accessing professional advocacy services. 
  8. If any procedure stated herein conflicts with rules or regulations published by the County, State licensing/regulatory authority, the rules or regulations issued by the County, State licensing/regulatory authority will override this policy and shall prevail in the handling and processing of client grievances. 
  9. Lumin Wellness’ goal is to resolve client grievances in the favor of the client whenever possible but in full compliance with County, State, and Federal laws, and regulations. 
  10. Program/Executive Director is encouraged to consult or discuss client complaints with the Program/Executive Director for resolution at any point in the process. In many instances, variances, exceptions, or alterations in treatment direction are possible within the scope of County, State and Federal regulations and/or corporate policy. 
  11. All grievances will be logged in a file/record and maintained by the Executive Director. At least annually, and as a part of the organization’s end of year data collection effort, Executive Directors will forward a synopsis of all grievances filed to the County/State to assist in the identification of any significant trends and identify areas of performance improvement. 
  1. Grievance procedures will be explained to all clients in an understandable manner as part of the new client orientation process. 

As part of the organization’s year end data collection and analysis effort, the organization will prepare a written summary of all formal grievances received during the year. This summary will include the identification of: 

  1. Any identified trends 
  2. Any changes that need to be made to operating procedures 
  3. Any revisions to written policies 
  4. Specific recommendations for quality improvement at either the clinic or corporate level. 
  5. Grievances will be evaluated quarterly as part of Lumin Wellness’ Performance Improvement Plan. 

Confidentiality and Control of Client Records 

POLICY: Lumin Wellness is firmly committed to the protection of all client-related information and data and recognizes its responsibility to comply with 42 CFR Part 2 and the Health Insurance Portability and Accountability Act (HIPAA) of 1996 regarding confidential client information. This policy recognizes that clients are afforded confidentiality protection from the time they initially seek services and into perpetuity. The organization also recognizes that the protection of client confidentiality represents a moral and ethical obligation for the organization and all its employees. Therefore, it is the policy of Lumin Wellness that client confidentiality and its protection will be of paramount concern; and the organization will make every attempt through both policy development and service delivery to afford the highest degree of protection to all records and files that contain any client-related data.  

PROCEDURE: The following procedures pertain to confidentiality of client information and are provided in support of the organization’s policy on this matter: 

Physical Safeguards to Protect client Records, Files and Charts 

This policy recognizes that the physical safeguards an organization takes to protect confidentiality are the cornerstone for protecting client information and data. Therefore, the Executive Director will ensure a system is in place to provide for the positive control of all client records. Implied in the term positive control is the requirement for: 

  1. The organization of the records in a systematic manner so that clinic staff will always know the location of those records. 
  2. The Executive Director has specific responsibility for controlling the records and implementing the policies and procedures pertaining to all organizational records. 
  3. Procedures to limit access to clinical and administrative records (including any electronically generated records such as email, fax) to those authorized staff members with a legitimate need to know. 
  4. Procedures for securing all records in a way that always provides maximum protection of client confidentiality and reasonable protection against fire, water damage and other hazards. 
  5. Procedures for the routine back-up of data files in all computer/electronic systems. 
  6. A separate policy on the retention and destruction of client records. 
  1. Identifies the procedures for paper and/or electronic record keeping. 
    1. Specifies the provisions for stopping the destruction of records if a legal process is initiated against the organization. 
    1. Complies with all applicable state and federal laws. 

Inherent in the term positive control is the practice that client records are always locked up or in the immediate control and/or possession of an employee with a legitimate need to know. (It should be noted that Lumin Wellness has a separate policy on Retention and Destruction of Records that immediately follows in this manual. That policy provides more specific guidelines regarding retention and destruction of records and includes the required provisions for stopping destruction if the organization is served with legal notice of any kind.) 

At the discretion of the Executive Director, client records may be filed and maintained in counselors’ offices, provided that the records are returned to and locked in a metal filing cabinet at the end of each working day. Under no circumstances will records be left unsecured in counselor offices after normal working hours. However, during normal working hours, records may be kept in staff offices but do not have to be locked in the same cabinets used for overnight storage; they must be always protected from inadvertent disclosure/compromise. Specifically, a staff member must be physically present in the office so that he/she has personal custody and control of the records; alternatively, the door to the office must be locked during those times that the staff member may need to leave the office for short periods of time. For clarification, this policy does not require that client records be returned to the metal filing cabinet each time that a staff member leaves his/her office during the day; it does, however, require that office doors be locked each time that a staff member leaves her/his office temporarily during the workday. 

Client Check-in/Check-out forms will be used consistently by each staff member who has custodial responsibility for client records. Check-in/Check-out forms must be completed each time that a client’s record is physically moved from the staff member’s office; all forms must clearly identify where the record was moved to, the date it was moved and the date it was returned to the primary custodian. 

Each clinic is protected by a dual electronic alarm and/or intrusion system. One half of the system protects the clinic proper and clinic perimeter. The other half protects the nursing and safe(s). Most employees are given a security code to enter the clinic. Only the Executive Director and licensed medical personnel have the security code for the nursing dispensing station. Additionally, the Program Director shall have access to the security code to the nursing station should it be deemed necessary by the Executive Director. The security system is checked quarterly to ensure its continued safe/effective operation. 

Release of Client-Related Data and Protected Health Information 

The release of client-related data/information is specifically prohibited without the express, written consent/permission of the client, or unless specifically allowed by applicable legal guidelines. For emphasis, the other exemptions from the general prohibition against the release of client-related information include: 

  1. Internal program communications 
  2. Communications that do not disclose the identity of the client 
  3. Communications during medical emergencies 
  4. Court-ordered disclosures 
  5. Communication with law enforcement officials regarding crimes committed by clients on clinic premises or against Lumin Wellness employees 
  6. Communications in conjunction with research, audit, or evaluation and that do not disclose the client’s identity 
  7. Reporting of child abuse and neglect 
  8. Communications as part of a qualified service organization agreement 

The following guidelines will be strictly followed when preparing Consent for Release of Confidential Information Forms for client signature: 

  1. Clients will be asked to sign a consent form only when there is a legitimate need to communicate with/release information to another individual, entity or organization. UNDER NO CIRCUMSTANCES WILL A CLIENT BE ASKED TO SIGN A BLANK RELEASE FORM. For emphasis, consent forms must be prepared and signed in response to a specific need and not simply as a matter of convenience or expediency for the staff. 
  2. All consent forms must include the following: 
  3. Client name 
  4. Lumin Wellness clinic name 
  5. Name of the organization and/or person to who information will be released 
  6. A completed description of the specific information to be released 
  7. The intended purpose for which information will be released 
  8. The specific date, event, or condition upon which the client’s consent will expire. UNDER NO CIRCUMSTANCES WILL THE EXPIRATION DATE BE LONGER THAN ONE YEAR FROM THE DATE THE CLIENT SIGNS THE CONSENT FORM. 
  9. Information to describe the circumstances, events, or incidents under which the authorization can be revoked. For clarification, authorizations may be revoked orally or in writing by the client. 
  10. The date the release is signed by the client 
  11. The signature of the client or the signature of the client’s legal guardian or authorized representative, as applicable. 
  12. The name and signature of the staff member witnessing the client’s signature. 

In all cases in which the organization releases confidential client information, a statement will be included to specifically advise/warn the recipient that the information cannot be re-released or re-disclosed to a third party. 

The originals of all signed consent forms will be maintained in the client’s chart/record; a copy will be forwarded to the receiving entity along with the requested information. This policy and procedure recognizes that County/State regulatory authorities may require the use of different release forms as a condition for compliance or licensure. In such cases, Lumin Wellness will utilize such forms as may be required by County/State regulatory/licensing agencies. 

If a client desires to view his or her record or any part thereof, the request should be submitted in writing to the Executive Director. For clarification, this does not require that the client sign Consent for Release of Confidential Information Form. The Executive Director will schedule an appointment with the client as soon as possible. Additional information relative to a client’s right to review his or her record is contained in the organization’s Notice of Privacy Practices under HIPAA and under the organization’s policy on HIPAA conformance. 

In all cases, access to and the release of client-related information will be accomplished in sufficient time for the patient to make fully informed decisions about his/her treatment. In some cases, the organization receives requests for client records and/or client-related information from attorneys involved in lawsuits and/or other legal action against Lumin Wellness. In such cases, no records will be released without a properly executed consent form signed by the involved client and prior approval from the Corporate Compliance Officer or Executive Director. It is reasonable that the organization would want to review any client record that might ultimately be used in legal action against the organization and therefore, management approval must be obtained as a condition for release. 

On occasion, Lumin Wellness may be presented with court orders, search warrants and other legal demands for documents or for the arrest of clients receiving services at Lumin Wellness clinics. In such cases, law enforcement officers should be afforded every courtesy and consideration and given free and unencumbered access to the clinic. However, federal confidentiality laws prohibit the staff from assisting in the actual identification of any client enrolled at the clinic. For clarification, this also includes any act or statement that would confirm that a client is receiving services at the clinic. If a search warrant is presented, a copy of the warrant should be made and retained by the Executive Director. Additional guidelines for responding to subpoenas, search warrants, investigations, inquiries, and other legal actions are contained in the organization’s policy on corporate compliance. Additionally, the Executive Director should contact the Corporate Compliance Officer prior to releasing any information to ensure that Lumin Wellness complies with all legal requirements and demands. The following are examples of disclosures that require additional exploration and discussion prior to release. 

  1. Deceased Client disclosures 
  2. On-site and off-site correspondence 
  3. Telephone correspondence (Documenting telephone calls) 
  4. Face-to-face correspondence (Documenting meetings) 
  5. Written correspondence 

 The Executive Director is responsible for the implementation of this policy. 

Health Insurance Portability and Accountability Act 

POLICY: It is the policy of Lumin Wellness that it will operate and conduct its business in compliance with all applicable laws, regulations, and rules, including HIPAA. 

PROCEDURE: 

  • The Corporate Compliance Officer will serve as the organization’s HIPAA Privacy Officer. The HIPAA Privacy Officer will ensure that Lumin Wellness clinic operates in accordance with HIPAA at all times. The Privacy Officer will serve as the organization’s primary point of contact for all matters pertaining to HIPAA and client requests for protected health information as defined by the Act. The Privacy Officer will prepare and present an annual report to the Executive Director on the organization’s ongoing compliance with HIPAA. 
  • A copy of the organization’s Notice of Privacy Practices will be posted in the clinic. Additionally, a copy of the notice will be provided to each client as part of the new client orientation process. 
  • Staff will ensure that each client signs an acknowledgement that they have received a copy of the Notice of Privacy Practices. 
  • No protected health information will be released in response to a client request under this Act without the consent and approval of the Privacy Officer. For clarification, clients may also request copies of their records and/or authorize the release of their information from their records under 42 CFR Part 2 by signing and executing a release form; such releases do not have to be approved by the organization’s Privacy Officer. 

Handling of Legal Documents 

PURPOSE: To establish and specify systematic steps for the handling of claims reporting and legal documents received for or by any member, subsidiary of Lumin Wellness 

POLICY:  It is the policy of Lumin Wellness to analyze and resolve actual (corrective action) or potential (preventive action) problems stemming from the presentation of legal correspondence to create a permanent solution that prevents mishandling of legal documents, minimizes losses, and protects the legal interests of Lumin Wellness, its employees, and customers. 

PROCEDURE: This procedure applies to any claim or legal document that is received by or addressed to Lumin Wellness whether such delivery is made by mail (certified, registered, overnight, or regular delivery), fax, hand-delivered, or served by either a law enforcement officer or private process server.  

  1. For the purposes of this policy, the term “legal documents” would be defined as, but not limited to, any unemployment paperwork, any level of a court claim filed against any variance of our company name (e.g., Lumin Wellness, including any misspellings or mislabeling of any of the legal names, etc.), any form of litigation; civil court appearances such as a notice to appear; notices of court hearings; subpoenas; police, fire or law enforcement reports; zoning, code or building violations, fines or tickets; certified or non- certified mail from any agency or person requesting information; restraining orders; public hearings or announcements, requests for information or depositions, etc. 
  2. This process also applies to reporting of incidents resulting in employee or client injury on or off property that the clinic has direct knowledge of, and any incident involving injury or death that a Lumin Wellness client may have been involved in, caused, or witnessed. 
  3. Lumin Wellness has designated “Management Representatives” as the corporate contact on all legal documentation. For the purposes of this policy, the term “Management Representatives” is defined as the Executive Director or Program Director

Informing the Management 

  1. All Lumin Wellness employees are responsible for immediate delivery or transmittal of any legal document to the Executive Director or direct supervisor within 24 hours of receipt. There are no exceptions to this procedure.  
  2. Executive Director/Program Director will evaluate each document and determine the most effective course of action. 
  3. Executive Director/Program Director will process the document to internal or external counsel.  If the issue can be handled at the clinic level, the Executive/Program Director will alert the appropriate employees as to the expected course of action.