[Federal Register Volume 59, Number 239 (Wednesday, December 14, 1994)]
[Unknown Section]
[Page 0]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 94-30411]


[[Page Unknown]]

[Federal Register: December 14, 1994]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Public Health Service
Substance Abuse and Mental Health Services Administration

42 CFR Part 51

RIN 0905-AD99

 

Requirements Applicable to Protection and Advocacy of Individuals 
With Mental Illness; Notice of Proposed Rulemaking

agency: Substance Abuse and Mental Health Services Administration, PHS, 
HHS.

action: Notice of proposed rulemaking.

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summary: The 1991 Protection and Advocacy for Individuals with Mental 
Illness (PAIMI) Act reauthorization stipulated that the Secretary shall 
promulgate regulations for the implementation of authorized activities 
of the Protection and Advocacy (P&A) Systems. Thus, this rule proposes 
regulations to implement Titles I and III of the PAIMI Act of 1986, as 
amended and will govern the authorized activities carried out by the 
Protection and Advocacy Systems to protect and advocate the rights of 
individuals with mental illness. Authorized activities include 
investigation of incidents of abuse and neglect and the pursuit of 
legal, administrative and other appropriate remedies to ensure the 
protection of the rights of individuals with mental illness in 
facilities providing care or treatment. In accordance with the 
provisions set forth, the system must be given access to records, 
facilities and individuals with mental illness. Each designated system 
must have a governing authority or board whose members broadly 
represent and are knowledgeable about the needs of its clients. In 
addition, the system must establish an advisory council to the PAIMI 
program. PAIMI program priorities are developed by the governing 
authority jointly with the advisory council.
    The proposed regulations are intended to provide basic definitions 
and to clarify the requirements of the PAIMI Act governing the 
authorized activities and provisions to be carried out by the P&A 
Systems to protect and advocate the rights of individuals with mental 
illness.
    The proposed regulations are not intended to preempt further 
regulation in the field by States. Consistent with the established 
principles of Constitutional law, the proposed Federal regulations will 
supersede State law to the extent that there is a conflict.

dates: To ensure consideration, comments must be submitted on or before 
February 13, 1995.

addresses: Please address comments to: Director, Center for Mental 
Health Services, 5600 Fishers Lane, Room 15-105, Rockville, Maryland 
20857.
    Two weeks after the close of the comment period, comments and 
letters addressing the proposed PAIMI program regulations, will be 
available for public inspection in the Office of Consumer, Family, and 
Public Information, 5600 Fishers Lane, Room 15-81, Rockville, Maryland 
20857.

FOR FURTHER INFORMATION CONTACT:
Ms. Natalie Reatig, Chief, Protection and Advocacy for Individuals with 
Mental Illness Program, (301) 443-3667 (Voice). This is not a toll-free 
number. This document is available in accessible formats (cassette 
tape, braille, large print or computer disk) upon request.

SUPPLEMENTARY INFORMATION:

Program History

    In 1975, the Department of Health and Human Services (the 
Department) established a program pursuant to Part C of the 
Developmental Disabilities Assistance and Bill of Rights Act (DD Act) 
[42 U.S.C. 6041, et seq.], providing formula grant support to the 
Protection and Advocacy System (system) designated by each State to 
protect and advocate the rights of persons with developmental 
disabilities. This program (PADD) is presently administered by the 
Administration on Developmental Disabilities (ADD).
    Since 1986, the Department has provided additional formula grant 
funds to the same State-designated systems to protect and advocate the 
rights of individuals with mental illness pursuant to the Protection 
and Advocacy for Individuals with Mental Illness (PAIMI) Act of 1986, 
as amended [42 U.S.C. 10801 et seq.]. This program is administered by 
the Center for Mental Health Service (CMHS) in the Substance Abuse and 
Mental Health Services Administration (SAMHSA).
    These proposed regulations govern activities carried out by the P&A 
systems under the PAIMI Act to protect and advocate the rights of 
individuals with mental illness. ADD will also be proposing to amend 
its regulations governing system operations under the DD Act to 
implement recent amendments and clarify certain requirements.

Description of PAIMI Program

    Formula grants are made to the system designated by the State under 
Part C of the DD Act to protect and advocate the rights of individuals 
with mental illness. The system must have the authority to investigate 
incidents of abuse and neglect and to pursue legal, administrative and 
other appropriate remedies to ensure the protection of the rights of 
individuals with mental illness in facilities providing care or 
treatment. In accordance with the provisions set forth, the system must 
be given access to records, facilities and individuals with mental 
illness.
    Each designated system must have a governing authority or board 
whose members broadly represent and are knowledgeable about the needs 
of its clients. In addition, the system must establish an advisory 
council to the PAIMI program. PAIMI program priorities are developed by 
the governing authority jointly with the advisory council.
    A section-by-section discussion of the proposed rule follows:

Part 51--Requirements Applicable to the Protection and Advocacy for 
Individuals With Mental Illness Program

Applicability
    Section 51.1, as proposed, indicates that requirements are 
applicable to State designated systems carrying out a protection and 
advocacy program for individuals with mental illness funded under the 
Act.
Definitions
    Section 51.2 proposes definitions for terms not defined in the Act. 
Definitions of ``ADD,'' ``Department,'' and ``Fiscal Year'' are the 
same as the definitions in ADD regulations governing protection and 
advocacy systems. The definitions of ``Governor'' and ``System'' have 
the exact meaning as the definition in ADD regulations and differ only 
slightly in phrasing. ``System'' refers to the P&A agency designated by 
the Governor under the Developmental Disabilities Assistance and Bill 
of Rights Act [42 U.S.C. 6041, 6042] which administers both DD and 
PAIMPI programs. ``Program,'' as used in the regulations, denotes 
activities involved with carrying out a protection and advocacy program 
for individuals with mental illness funded under the Act. ``Act,'' 
``Center'' and ``Director'' refer to the Protection and Advocacy for 
Individuals with Mental Illness Act, as amended, the Center for Mental 
Health Services and its Director, respectively.
    In keeping with Congressional intent, Senate Report (S. Rept.) 102-
114 on the Protection and Advocacy for Mentally Ill Individuals 
Amendments Act of 1991 at 8, the regulations propose a definition of 
``care or treatment.'' The proposed definition of ``care or treatment'' 
of an individual with mental illness is based on the survey format 
Mental Health Service System Reports, ``Data Standards for Mental 
Health Decision Support Systems,'' (``Data Standards'') used by the 
National Institute of Mental Health and the MCHS. It was developed 
through consensus in the mental health field. The definition of ``care 
or treatment,'' operating in conjunction with the term ``facilities,'' 
which includes homeless shelters, jails and prisons, provides a broad 
range of access for P&A systems to individuals with mental illness. 
Facilities that render care or treatment under Sec. 102(4) of the Act 
[42 U.S.C. 10802] are intended to mean those that provide overnight 
care accompanied by services to prevent, identify, reduce or stabilize 
mental illness or emotional impairment, (``Data Standards'' at 16).
    The proposed definitions of ``public entity'' and ``private 
entity'' distinguish between an organizational unit of a State or local 
government or a quasi-public organization exercising one or more 
governmental powers, and a nonprofit or for-profit corporation, 
partnership or other nongovernmental organization.
    The proposed definition of ``legal guardian, conservator, legal 
representative'' to include individuals appointed and regularly 
reviewed by a State court or agency empowered under State law to 
appoint and review such officers is widely used throughout the program. 
It originated in House Report (H. Rept.) 99-401 at 7 (accompanying H.R. 
3492 preliminary to passage of Pub.L. 99-319, Nov. 21, 1985). It is 
intended to include only those individuals who are given the legal 
authority to make all decisions on behalf of an individual with mental 
illness. Persons acting only as a representative payee or acting only 
to handle financial matters, attorneys or others acting on behalf of an 
individual with mental illness in individual legal matters, the State, 
or officials responsible for the provision of health or mental health 
services to the individual and other persons who are not legally 
appointed are not included.

Subpart A--Basic Requirements

Formula for Determining Allotments
    Section 51.3, as proposed, states that funds shall be apportioned 
as prescribed by the Act.
Grants Administration Requirements
    Section 51.4, as proposed, lists parts of Title 45 CFR which apply 
to PAIMI programs funded under the Act.
Eligibility for Allotment
    Section 51.5, as proposed, requires systems designated by the 
Governor of a State under Part C of the DD Act [42 U.S.C. 6041, et 
seq.] to provide assurances of compliance with the PAIMI Act and 
regulations and to be operational in order to receive the State 
allotment for a PAIMI program. In addition, the Governor must give a 
written assurance that the allotment will be used to supplement and not 
to supplant the level of non-Federal funds available in the State to 
protect and advocate the rights of individuals with mental illness. If 
the Governor provides this assurance at the same time as he/she 
provides assurances to ADD under 45 CFR part 1386, the system shall 
submit a copy of the Governor's assurance as part of its application 
for PAIMI funds.
Use of Allotments
    Section 51.6, as proposed, delineates certain impermissible uses of 
grant funds. Allotments may not be used: (1) supplant the level of non-
Federal funds used for PAIMI activities; (2) support lobbying 
activities to influence proposed or pending Federal legislation or 
appropriations; or (3) produce or distribute written, audio or visual 
materials intended or designed to support or defeat any candidate for 
public office. However, program activities may include ``monitoring, 
evaluating and commenting upon the development and implementation of 
Federal, State, and local laws, regulations, State plans, budgets, 
policies, programs, hearings, levies and community action which will 
affect mentally ill persons [individuals with mental illness].'' [S. 
Rept. 99-109 on Protection and Advocacy for Mentally Ill Persons Act of 
1985 at 9 (July 25, 1985); see also, H. Rept. 99-401 at 9].
    Section 51.6(d), as proposed, also clarifies that the restriction 
in section 104(b)(1) of the Act [42 U.S.C. 10804(b)(1)], that a 
designated State system may use no more than five percent of the annual 
allotment for administrative expenses which includes State 
administrative and monitoring costs but does not include costs of 
training and technical assistance or the salaries, wages or benefits of 
program staff. This will assure that Federal funds for eligible systems 
will be used for protection and advocacy services, ``to the greatest 
extent possible,'' in keeping with the legislative intent (S. Rept. 99-
109 at 12). No funds may be used by the State for administrative costs 
where the eligible system is not a State agency (H. Rept. 99-401 at 9).
    Section 51.6(e), as proposed, also implements restrictions found in 
section 104(b)(2) of the Act [42 U.S.C. 10804(b)]. Under section 
104(b)(2) of the Act [42 U.S.C. 10804(b)(2)], no more than ten percent 
of an annual allotment may be used for providing technical assistance 
and training. This may include a portion of the salaries and 
administrative support of system or program staff who provide training 
or technical assistance to other staff, contractors, or members of the 
governing board or advisory council as a significant component of their 
responsibilities.
Eligibility for Services
    Under section 51.7, as proposed, protection and advocacy services 
funded under the Act must be provided in accordance with program 
priorities and policies established by the governing authority jointly 
with the mental health advisory council. Such protection and advocacy 
services may be provided to an individual with mental illness who is a 
resident or inpatient in a facility providing care or treatment; who is 
in the process of being admitted to a facility rendering care or 
treatment, including persons being transported to such a facility; or, 
who is involuntarily confined in a municipal detention facility for 
reasons other than serving a sentence resulting from conviction for a 
criminal offense. Federal funds may also be used to provide services to 
an otherwise eligible individual who is a resident in a Federal 
facility providing care or treatment, upon the request of that 
individual, or that individual's legal guardian, conservator, or other 
legal representative. Representatives of such individuals are accorded 
all the rights and authority accorded other representatives of 
residents of such activities pursuant to State and other Federal laws. 
Activities in federal facilities are subject to the system's 
appropriately established priorities and policies.
    Protection and advocacy services may be provided to individuals 
with regard to incidents which occurred while they were eligible under 
the Act, even though the incident is reported to the P&A system after 
their discharge from the facilities or after the expiration of their 
90-day post discharge eligibility. This reflects the legislative 
concern that appropriate discharge planning and placement take place in 
that attempts to withdraw mental health care or treatment services from 
individuals with mental illness without proper preparation can be as 
harmful as neglectful isolation or inappropriate treatment (H. Rept. 
99-401 at 8-9). This also reflects the legislative intent that the 
Act's restriction on periods of coverage is not a limitation on the 
time at which remedies may be sought nor a limitation on the time 
during which actions may extend. Other laws respecting statutes of 
limitations and requirements for settlement and adjudication are not 
altered by the Act (H. Rept. 99-401 at 9).
    In addition, allotments may be used to provide representation in 
civil commitment proceedings where this is the means used to appeal or 
otherwise challenge procedures which have subjected the individual to 
abuse or neglect or otherwise violated his or her rights.
Annual Reports
    Section 51.8, as proposed, describes the content and other 
specifications of the annual report required by section 105(a)(7) of 
the Act [42 U.S.C. 10805(a)(7)].
Financial Status Reports
    Section 51.9, as proposed, requires that a grantee shall submit a 
financial status report in accordance with 45 CFR 74.73
Remedial Actions
    Section 51.10, as proposed, provides that noncompliance with the 
provisions of the Act, regulations or other established grant policies 
and procedures, including reporting requirements, may be considered a 
material breach of the terms and conditions of the grant award which 
can result in remedial actions.

Sections 51.11-51.20  Reserved

Subpart B--Program Administration and Priorities

Contracts for Program Operations
    Section 51.21(a), as proposed, permits a system to contract with 
one or more public or private nonprofit organizations to carry out all 
or a portion of the program's protection and advocacy services as long 
as the system institutes oversight and monitoring procedures. The 
system and the provider must enter into a written agreement which 
specifies the protection and advocacy services to be performed and 
evidences that the provider can meet the terms and conditions of the 
grant.
    Eligible systems are encouraged under section 104(a)(2) of the Act 
[42 U.S.C. 10804(a)(2)] to enter into program contracts with groups run 
by individuals who are receiving or have received mental health 
services or by family members of such individuals, as well as with 
other organizations with relevant expertise. Such arrangements build on 
the experience of these groups and foster cooperative efforts (S. Rept. 
99-109 at 9-10).
Governing Authority
    Section 51.22, as proposed, describes the composition of the 
governing authority and its program oversight responsibilities. Under 
section 105(c) of the Act [42 U.S.C. 10805(c)], a single governing 
authority oversees both PAIMI and DD activities. Members of any multi-
member governing board which functions as the governing authority must 
``broadly represent or [be] * * * knowledgeable about the needs of the 
clients served by the system.'' To ensure this, the Act specifies that 
members who are broadly representative include individuals who have 
received or are receiving mental health services and family members of 
such individuals. [See section 105(c)(1)(B) of the Act [42 U.S.C. 
10805(c)(1)(B)]].
    Further, the proposed regulation specifies that an individual or 
family member who serves on a system's governing board in a 
representative capacity must have direct experience with the needs of 
clients served by the system. And, if the governing authority is a 
nonprofit entity, the chairperson of the program's advisory council 
must be a member. Other advisory council members are also eligible to 
serve on the governing board. In addition, each system is required to 
establish its own policies and procedures for the selection and service 
of governing board members. These requirements implement 1988 
amendments, found in section 105(c)(1)(B) of the Act [42 U.S.C. 
10805(c)(1)(B)]. They are intended to ``ensure that protection and 
advocacy systems, which historically served persons with developmental 
disabilities, have added to their governing boards representatives of 
the mental health community who are knowledgeable about the special 
advocacy needs of mental ill individuals, including individuals who 
have received or are receiving mental health services and family 
members of such individuals.'' [S. Rept. 100-454 on Protection and 
Advocacy for Mentally Ill Individuals Amendments Act of 1988, at 8 
(Aug. 5, 1988)]. Finally, continuing efforts should be made to increase 
the involvement of ethnic and racial minorities in program governance 
and administration to assure that the program addresses the needs of 
minority individuals with mental illness (H. Rept. 102-319 of the 
Protection and Advocacy for Mentally Ill Individuals Amendments Act of 
1991 at 8; S. Rept. 102-114 at 7).
Advisory Council
    Section 51.23, as proposed, implements requirements, found in 
section 105(a)(6) of the Act [42 U.S.C. 10805(a)(6)], for an advisory 
council to advise the system on policies and priorities governing 
protection and advocacy activities for individuals with mental illness. 
The council membership should be broadly representative of persons and 
groups who are knowledgeable about mental illness and the needs of the 
clients served by the system (S. Rept. 99-109 at p. 10-11). At least 60 
percent of the council members, including the chairperson, must be 
individuals who have received or are receiving mental health services, 
or family members of such individuals. Such persons, have a ``valuable 
perspective on the advocacy needs of individuals with mental illness, 
as well as on potential priority areas for the system'' (S. Rept. 100-
454 at 9).
    The statutorily-based requirement that such persons constitute 
three/fifths of the council membership is designed to assure that their 
experience and knowledge will inform program priorities and policies. 
In addition, continuing efforts should be made to increase the 
involvement of ethnic and racial minorities in program governance and 
administration to assure that the program addresses the needs of 
minority individuals with mental illness (H. Rept. 102-319 at 8; S. 
Rept. 102-114 at 7).
    Each system shall, at least annually, provide the advisory council 
with reports, materials and fiscal data to assist the members in 
carrying out their responsibilities. It shall also establish policies 
and procedures for reimbursing expenses incurred by council members, 
including travel costs and costs of caring for family members with 
mental illness or developmental disabilities during the activity 
period, so as to enable those with limited financial resources to 
participate fully in council activities.
Program Priorities
    Section 51.24, as proposed, implements requirements, found in 
sections 105(a)(6)(A) and 105(c)(2)(B) of the Act [42 U.S.C. 
10805(a)(6)(A) and 10805(c)(2)(B)], mandating that the policies and 
priorities which will govern the program be established by the 
governing authority jointly with the advisory council. The governing 
authority should engage the full and active participation of the 
advisory council in this process (S. Rept. 100-454 at 8).
    The annual priorities must specify the short-term goals and 
objectives of the program and have measurable outcomes, as is done in 
setting priorities for DD programs. Case selection criteria and the 
availability of staff and monetary resources must be considered. 
Attention should also be focused on the special problems and cultural 
barriers that individuals with mental illness who have multiple 
handicaps or who are members of racial or ethnic minorities, face in 
obtaining mental health care and treatment.
    Priorities are to be reviewed annually by the governing authority 
and the advisory council and revised as necessary. Public comment is an 
important part of this annual review. In each system, procedures should 
be established which afford persons with mental illness and family 
members or their representatives, as well as other interested persons, 
a chance to comment, in writing or in person, on existing and proposed 
priorities and policies prior to adoption or reconfirmation each year. 
The annual program performance report shall include a statement of the 
priorities and shall address any comments received from the public. 
These requirements are similar to those established for DD programs (S. 
Rept. 100-454 at 10).
Grievance Procedure
    Section 51.25, as proposed, implements requirements, found in 
section 105(a)(9) of the Act [42 U.S.C. 10805(a)(9)], for grievance 
procedures that will address two classes of complaints: (1) complaints 
of clients or prospective clients directed to whether or not eligible 
individuals with mental illness in the State have full access to the 
services of the system; (2) complaints of individuals who have received 
or are receiving mental health services, their family members or 
representatives of such individuals or family members directed to 
whether or not the eligible system is operating in compliance with the 
Act.
    Each system is responsible for structuring procedures which satisfy 
the statutory objectives of each class of complaint. Some systems have 
established a bifurcated process; others have a single process with 
some steps applying only to certain types of complaints. These or other 
procedures may be developed as long as the process includes for each 
class of complaint (1) an appeal to the governing authority from any 
final staff review or determination; (2) annual, or more frequent 
reports to the governing authority and the mental health advisory 
council describing the content of the complaints received, the 
grievances processed and the resolution; (3) identification of 
individuals responsible for review; (4) a timetable to assure prompt 
resolution; (5) a written response to the grievant; and (6) protection 
of client confidentiality. Measures designed to protect client 
confidentiality should ensure that a complaining client or family 
member will not be entitled to confidential information concerning any 
client without that client's consent, or, if the client is legally 
incompetent or a minor, without the consent of the legal guardian or 
representative.
Conflicts of Interest
    Section 51.26, as proposed, recommends that each system establish 
policies and procedures to avoid actual or apparent conflict of 
interest involving clients, employees, contractors and subcontractors, 
and members of the governing authority and advisory council. Those 
policies and procedures should prohibit the participation of employees 
and members of the governing authority or advisory council in matters 
affecting particular contracts and subcontracts, reimbursement and 
expenses and the employment or termination of staff if the covered 
person or a relative could benefit financially or suffer a financial 
loss. Public Health Service (PHS) Grants Policy Statement 8-18 lists 
additional matters that should be covered by such policies.
Training
    Section 51.27, as proposed, requires each system to provide 
training for program staff and permits training of contractors, 
governing board and advisory council members to enhance the development 
and implementation of effective P&A services. A system may utilize 
individuals who have received or are receiving mental health services 
or family members to provide such training. Training should include 
advocacy techniques such as negotiation and mediation which, when 
appropriately used, avoid costly and time-consuming procedures (H. 
Rept. 99-401 at 11; S. Rept. 99-109 at 12).
    At a minimum, program staff should be trained to work with family 
members of clients served by the program where the individual with 
mental illness is a minor, legally competent and chooses to involve the 
family member, or legally incompetent and the legal guardian, 
conservator or other legal representative is a family member. In 
addition, each system should also provide training to ensure that the 
program works effectively with individuals with mental illness who are 
members of racial and ethnic minorities. This training should enhance 
cultural sensitivity and understanding on the part of staff, governing 
authority and advisory council members (H. Rept. 102-319 at 8; Rept. 
102-114 at 7).
    A system may use its Federal allotment to support training, 
including related travel expenses, for individuals with mental illness, 
family members of such individuals, and other persons who are not 
program staff, contractors, or board or council members, to increase 
knowledge about protection and advocacy issues, to enhance leadership 
capabilities, or to promote Federal-State and inter-State cooperation 
on matters related to mental health system improvements. Decisions 
concerning the selection of individuals to receive such training shall 
be made in accordance with established policies, procedures and 
priorities of the system. Expenditures for such training are subject to 
the 10 percent limitation cited in section 51.6(e).

Section 51.28-Section 51.30  Reserved

Subpart C--Protection and Advocacy Services

Conduct of Protection and Advocacy Activities
    Section 51.31, as proposed, directs each system to establish its 
own policies and procedures to govern its advocacy activities. Many 
programs have already developed such procedures and policies following 
standards issued by the National Association of Protection and Advocacy 
Systems (NAPAS).
    Program advocacy policies and procedures should encourage staff to 
maintain a presence in mental health care facilities. An on-site 
presence allows staff to interact with current or potential recipients 
of protection and advocacy services on a regular basis and enhances the 
ability to communicate with facility personnel providing mental health 
care and treatment as well as to obtain information and to review 
records. Program policies should also encourage system advocates to 
work with family members, social and community system workers and 
others who provide care and treatment for potential and present 
clients.

Resolving Disputes

    Section 51.32, as proposed, clarifies that a system may pursue all 
appropriate remedies on behalf of its clients consistent with Federal 
and State law and the canons of professional ethics. Negotiation, 
mediation, conciliation, and other administrative procedures, should be 
developed and employed where such approaches offer the prospect of 
prompt and economical resolution of disputes. Disputes between 
individuals with mental illness and treatment professionals respecting 
a particular course of treatment may be singularly suitable for 
resolution through nonadversarial techniques--especially where these 
methods facilitate the appropriate involvement of family members (S. 
Rept. 102-114 at 6). However, although systems are encouraged to use 
nonadversarial methods where feasible, the Act does not restrict client 
rights to legal remedies otherwise available under Federal and State 
laws (S. Rept. 99-109 at 11).

Section 51.33-Section 51.40  Reserved

Subpart D--Access to Records, Facilities and Individuals Access to 
Records

    Section 51.41, as proposed, implements section 105(a)(4) of the Act 
[42 U.S.C. 10805(a)(4)] which affords a system access to all records of 
an individual with mental illness when authorized by that individual or 
his or her representative. A system also has the right to records when 
it has probable cause to believe that an eligible individual has been 
subject to abuse or neglect, and is mentally or physically unable to 
provide authorization, and has no legal guardian, conservator or other 
legal representative or the individual's guardian is the State. 
Further, in accordance with section 105(a)(4)(C)(i) of the Act [42 
U.S.C. 10805(a)(4)(C)(i)], the system also has the right to records if 
the system has probable cause to believe that the individual's health 
or safety is in serious and immediate jeopardy or with respect to whom 
a complaint has been received, provided the individual's representative 
has been contacted, offered assistance, and failed or refused to act. A 
facility must cooperate by promptly furnishing the system the records 
or the name and address of an individual's representative or otherwise 
comply with section 51.43.
    Authority to access records is essential to enable systems to 
``effectively carry out their protection and advocacy and investigatory 
responsibilities'' (S. Rept. 100-454 at 9); Mississippi Protection & 
Advocacy System, Inc. v. Cotten, 929 F.2d 1054 (5th Cir. 1991). A 
system must be given access to records based either on a complaint or 
based on information obtained ``as a result of monitoring or other 
activities (either of which result from a complaint or other 
evidence).'' Section 105(a)(4)(B)(iii) of the Act [42 U.S.C. 
10805(a)(4)(B)(iii)]. Monitoring or other investigate activity may be 
initiated either based on a complaint from an allegedly abused or 
neglected individual or from other persons, or based on other evidence 
such as observations by system personnel, review of reports, newspaper 
accounts, or ``hot-line'' calls. The definition of ``probable cause'' 
is modeled on the California statute, implementing the Act, California 
Welfare & Institutions Code, Div. 4.7, section 4900(g). This prototype, 
enacted in January 1992, follows conventional legal principles 
measuring probable cause in terms of reasonable judgments made by 
system personnel drawing, where appropriate, upon their training and 
experience.
    Section 51.41(c), as proposed, identifies some of the kinds of 
information and records which shall be made available to a system under 
this requirement. Such information includes: access to records obtained 
in the course of providing intake, assessment, evaluation, care or 
treatment services [paragraph (c)(1)]; to investigative reports of 
incidents of abuse, neglect or injury occurring at the facility 
[paragraph (c)(2)]; to discharge planning records [(c)(3)], as 
specifically mandated under section 106(b)(3)(A) of the Act [42 U.S.C. 
10806(b)(3)(A)]; and to safety standards and demographic and 
statistical information [pargaraph (c)(5)].
    In addition, both the Senate and House committee reports discussed 
access to records of medical care evaluation and peer review committees 
during their consideration of the 1991 amendments, and indicated that 
the Act was not intended to preempt State law regarding disclosure of 
peer review or medical review records (S. Rept. 102-114 at 5; H. Rept. 
102-319 at 6). However, Congress recognizes that systems must have 
access to ``supporting documents'' in order to ``carry out their 
protection and advocacy and investigatory responsibilities'' (S. Rept. 
100-454 at 9).
    The proposed descriptions of information and records subject to 
access requirements are largely modeled on access agreements negotiated 
by various systems or imposed under court order. Provision for 
inspection and copying of records at reasonable times and places, 
subject to reimbursement of reasonable duplicating costs, [paragraph 
(d)], is an essential element of any access requirement.
Access to Facilities and Residents
    Section 51.42, as proposed, implements section 105(a) of the Act 
[42 U.S.C. 10805(a)(3)] which affords systems access to facilities in 
the State rendering care and treatment for individuals with mental 
illness so that they can meet their investigatory, monitoring and 
advocacy responsiblities. It is modeled on section 4902(b) of the 
California statute referenced above. Provision is made for access at 
all times necessary to investigate incidents of abuse or neglect when 
an incident is reported to the system or when a system determines that 
there is probable cause to believe an incident occurred or that there 
is imminent danger of serious abuse or neglect.
    Access to facilities and residents at reasonable times and 
circumstances for other protection and advocacy services, such as 
information and training (described in paragraph (b)) accords with the 
legislative intent (S. Rept. 100-454 at 11). It largely follows the 
California model and provisions in negotiated agreements and in court 
orders.
Denial of Access
    Section 51.43, as proposed, facilitates the speedy resolution of 
disputes regarding access by requiring facilities to provide a written 
statement of the reasons for a denial as well as the name and address 
of any person whose authorization is allegedly required.
Access to Federal Facilities and Records
    Section 51.44, as proposed, implements section 104(c) of the Act 
[42 U.S.C. 10804(c)] which requires that systems be accorded the same 
rights and authority accorded to other representatives of residents of 
Federal facilities pursuant to State and Federal law.
Confidentiality of P&A System Client Records
    Section 51.45, as proposed, establishes procedures to ensure the 
protection of the system's client records and for access by authorized 
Federal officials. The requirements in paragraph (a) are similar to 
those in CMHS PAIMI policy guidelines implementing section 106(a) of 
the Act [42 U.S.C. 10806(a)] and ADD regulations. Paragraph (b), 
modeled on section 4903(d) of the California statute, makes it clear 
that confidentiality restrictions do not impede a system from issuing 
public reports that do not identify individuals or from reporting 
information to cognizant investigative and enforcement agencies.
Disclosing Information Obtained From a Provider of Mental Health 
Services
    Section 51.46, as proposed, implements sections 106(b) (1) and (2) 
of the Act [42 U.S.C. 10806(b) (1) and (2)] which spells out the steps 
to be taken to resolve disputes about disclosure of material in records 
to which the system has access under the act to the individual who 
received the mental health services. The proposed regulation tracks the 
statutorily mandated procedures for resolution of such disputes by 
another mental health professional to be selected either by the 
individual, by the individual's legal guardian, conservator or other 
legal representative or by the system acting on behalf of an individual 
whose guardian is the State or whose legal representative has not 
selected a mental health professional to review the information within 
a reasonable period of time after the denial of access. The legislative 
objective is ``to restrict informed consent of clients/patients as 
little as possible'' (H. Rept. 99-401 at 10).

Impact Analysis

Executive Order 12866

    Executive Order 12866 requires that all regulations reflect 
consideration of the costs and benefits they may generate, and that 
they meet certain standards, such as avoiding unnecessary burden. 
Regulations which are ``significant'' because of cost, adverse impacts 
on the economy, inconsistency with other federal agency action, effects 
on the federal budget, or their raising of novel legal or policy 
issues, require special analysis. The Secretary has determined that 
this proposal does not meet the Order's significance criteria.

Regulatory Flexibility Act of 1980

    The proposed regulations have been reviewed in accordance with the 
requirements of the Regulatory Flexibility Act of 1980 [5 U.S.C. 
Chapter 6]. The Department has determined that compliance with the 
proposed regulations would not have a significant economic impact on a 
substantial number of small entities and, therefore, a Regulatory 
Flexibility Analysis is not required.

Federal Supremacy

    These proposed regulations are not intended to preempt further 
regulation in the field by States. However, we are aware of at least 
one State that has enacted legislation implementing the PAIMI Act. 
Consistent with the established principles of Constitutional law, the 
proposed Federal regulations will supersede State law to the extent 
that there is a conflict.

Paperwork Reduction Act

    The proposed rule contains information collection requirements 
which are subject to review and approval by the Office of Management 
and Budget (OMB) under the Paperwork Reduction Act of 1980. The form 
and manner of information collection specified in Sec. 51.8 (Annual 
Reports) have been previously reported to and approved by OMB under OMB 
Approval No. 0930-0169. The title, description, and respondent 
description of the information collection requirements are presented 
below with an estimate of the annual reporting burden. Included in the 
estimate is the time for reviewing instructions, searching existing 
data sources, gathering and maintaining the data needed, and completing 
and reviewing the collection of information.
    Title: Protection and Advocacy of Individuals with Mental Illness--
42 CFR 51--NPRM
    Description: Recipients of formula grants to provide protection and 
advocacy services to individuals with mental illness are required by 
law to report their activities and accomplishments annually, including 
the number and types of persons served, the types of facilities 
covered, and the manner in which the activities were undertaken. The 
Advisory Council is required to submit a description of activities and 
an assessment of the operations of the protection and advocacy system.
    Description of Respondents: State or local governments, Non-profit 
institutions.
    Estimated Annual Reporting Burden:

----------------------------------------------------------------------------------------------------------------
                                                                                                        Annual  
             Section                   Annual No. of respondents         Annual     Average burden      burden  
                                                                       frequency     per response       hours   
----------------------------------------------------------------------------------------------------------------
51.8(2)&(4)......................  56--Program Performance Report...            1  35 hours........        1,960
51.8(3)..........................  56--Advisory Council Report......            1  10 hours........          560
    Total........................  .................................  ...........  ................       2,520*
----------------------------------------------------------------------------------------------------------------
*Burden hours are approved under OMB Approval No. 0930-0169                                                     

    We have submitted a copy of this proposed rule to OMB for its 
review of these information collections. Individuals or organizations 
wishing to submit comments on the information requirements, estimated 
burden or any other aspect of this collection of information should 
direct such comments to the agency official designated for this purpose 
whose name appears in this preamble, and to the Office of Information 
and Regulatory Affairs, OMB, New Executive Office Building (Room 
10235), 725 17th Street N.W., Washington, DC 20503 ATTN: SAMHSA Desk 
Officer.

Smoke Free Workplace

    Public Law 103-229 enacted on March 31, 1994 prohibits smoking in 
certain facilities in which minors will be present. The Department of 
Health and Human Services is now preparing to implement the provisions 
of the law. Until those implementation plans are in place, PHS 
continues to strongly encourage all grant recipients to provide a 
smoke-free workplace and promote the non-use of all tobacco products.

List of Subjects in 42 CFR Part 51

    Administrative practice and procedure, Grant programs--health 
programs, Grant programs--social programs, Health records, Mental 
health programs, Privacy, Reporting and recordkeeping requirements.

Catalogue of Federal Domestic Assistance

    Catalogue of Federal Domestic Assistance (CFDA) number programs 
affected by this proposed rule are: 93.138 Protection and Advocacy for 
Individuals with Mental Illness.

    Dated: September 16, 1994.
Philip R. Lee,
Assistant Secretary for Health.

    Approved: December 5, 1994.
Donna E. Shalala,
Secretary.
    Accordingly, it is proposed to add part 51 to title 42 of the Code 
of Federal Regulations to read as set forth below.

PART 51--REQUIREMENTS APPLICABLE TO THE PROTECTION AND ADVOCACY FOR 
INDIVIDUALS WITH MENTAL ILLNESS PROGRAM

Sec.
51.1  Applicability.
51.2  Definitions.

Subpart A--Basic Requirements

51.3  Formula for determining allotments.
51.4  Grants administration requirements.
51.5  Eligibility for allotment.
51.6  Use of allotments.
51.7  Eligibility for protection and advocacy services.
51.8  Annual reports.
51.9  Financial status reports.
51.10  Remedial actions.
51.11-51.20  [Reserved]

Subpart B--Program Administration and Priorities

51.21  Contracts for program operations.
51.22  Governing authority.
51.23  Advisory council.
51.24  Program priorities.
51.25  Grievance procedure.
51.26  Conflicts of interest.
51.27  Training.
51.28-51.30  [Reserved]

Subpart C--Protection and Advocacy Services

51.31  Conduct of protection and advocacy activities.
51.32  Resolving disputes.
51.33-51.40  [Reserved]

Subpart D--Access to Records, Facilities and Individuals

51.41  Access to records.
51.42  Access to facilities and residents.
51.43  Denial of access.
51.44  Access to Federal facilities and records.
51.45  Confidentiality of protection and advocacy system client 
records.
51.46  Disclosing information obtained from a provider of mental 
health services.

    Authority: Protection and Advocacy for Individuals with Mental 
Illness Act of 1986, as amended 42 U.S.C. Sec. 10801 et seq.


Sec. 51.1  Applicability.

    The provisions of this part apply to recipients of Federal 
assistance under the Protection and Advocacy for Individuals with 
Mental Illness Act of 1986, as amended [42 U.S.C. 10801 et seq.].


Sec. 51.2  Definitions.

    In addition to the definitions in section 102 of the Act, as 
amended [42 U.S.C. 10802] the following definitions apply:
    Act means the Protection and Advocacy for Individuals with Mental 
Illness Act of 1986, as amended [42 U.S.C. 10801 et seq.].
    ADD means the Administration on Developmental Disabilities within 
the Administration for Children and Families.
    Care or Treatment means services provided to prevent, identify, 
reduce or stabilize mental illness or emotional impairment such as 
mental health screening, evaluation, counseling, biomedical, behavioral 
and psycho-therapies, supportive or other adjunctive therapies, 
medication supervision, special education and rehabilitation.
    Center or CMHS means the Center for Mental Health Services in the 
Substance Abuse and Mental Health Services Administration.
    Department or HHS means the U.S. Department of Health and Human 
Services.
    Director means the Director of the Center for Mental Health 
Services, Substance Abuse and Mental Health Services Administration, or 
his or her designee.
    Fiscal Year means the Federal fiscal year (October 1--September 30) 
unless other specified.
    Governor means the chief executive officer of the State or 
Territory, or his or her designee, who has been formally designated to 
act for the Governor in carrying out the requirements of the Act and 
these regulations.
    Legal guardian, conservator, and legal representative all mean 
individuals appointed and regularly reviewed by a State court or agency 
empowered under State law to appoint and review such officers. It does 
not include persons acting only as a representative payee, persons 
acting only to handle financial payments, attorneys or persons acting 
on behalf of an individual with mental illness only in individual legal 
matters, the State, or officials responsible for the provision of 
health or mental health services to an individual with mental illness.
    Private Entity means a nonprofit or for-profit corporation, 
partnership or other non-governmental organization.
    Program means a program for protection and advocacy for individuals 
with mental illness that meets the requirements of the Act.
    Public Entity means an organizational unit of a State or local 
government or a quasi-governmental entity with one or more governmental 
powers.
    System means the organization or agency designated in a State to 
administer and operate advocacy programs to protect and advocate the 
rights of persons with developmental disabilities under Part C of the 
Developmental Disabilities Assistance and Bill of Rights Act [42 U.S.C. 
6041, 6042] and thereby eligible to receive allotments from the 
Secretary under the Act to administer a program.

Subpart A--Basic Requirements


Sec. 51.3  Formula for determining allotments.

    The Secretary shall make allotments to eligible systems from 
amounts apportioned each year under the Act on the basis of a formula 
prescribed by the Secretary in accordance with the requirements of 
sections 112 and 113 of the Act [42 U.S.C. 10822 and 10823].


Sec. 51.4  Grants administration requirements.

    The following parts of title 45 CFR apply to grants funded under 
this part.

    45 CFR part 16--Procedures of the Departmental Grant Appeal 
Board.
    45 CFR part 74--Administration of Grants.
    45 CFR part 75--Informal Grant Appeals Procedures.
    45 CFR part 76--Government-wide Debarment and Suspension 
(NonProcurement) and Government-wide Requirements for Drug-Free 
Workplace.
    45 CFR part 80--Nondiscrimination under Programs Receiving 
Federal Assistance through the Department of Health and Human 
Services--Effectuation of Title VI of the Civil Rights Act of 1964.
    45 CFR part 81--Practice and Procedure for Hearings under part 
80 of this title.
    45 CFR part 84--Nondiscrimination on the Basis of Handicap in 
Programs and Activities Receiving or Benefiting from Federal 
Financial Assistance.
    45 CFR part 86--Nondiscrimination on the Basis of Sex in 
Education Programs and Activities Receiving Federal Financial 
Assistance.
    45 CFR part 91--Nondiscrimination on the Basis of Age in 
Education Programs and Activities Receiving Federal Financial 
Assistance from HHS.
    45 CFR part 92--Uniform Administrative Requirements for Grants 
and Cooperative Agreements to State and Local Governments.
    45 CFR part 93--New Restrictions on Lobbying.
    45 CFR part 1386, Subpart A.


Sec. 51.5  Eligibility for allotment.

    (a) Federal financial assistance for protection and advocacy 
activities for individuals with mental illness will be given only to a 
system that has been established under part C of the Development 
Disabilities Assistance and Bill of Rights [42 U.S.C. 6041, 6042] and 
designated in accordance with 45 CFR part 1386, subpart B.
    (b) The system must meet the requirements of sections 105 and 111 
of the Act [42 U.S.C. 10805 and 10821] and that system must be 
operational.
    (c) Written assurances of compliance with sections 105 and 111 of 
the Act [42 U.S.C. 10805 and 10821] and other requirements of the Act 
and the regulations shall be submitted by the system in the format 
designated by the Director. These assurances will remain in effect for 
the period specified in the application for funds unless changes occur 
within the State which will affect the functioning of the system, in 
which case an amendment is required 30 days prior to the effective date 
of the change.
    (d) The Governor's written assurance that the allotments made 
available under the Act will be used to supplement and not to supplant 
the level of non-Federal funds available in the State to protect and 
advocate the rights of individuals with mental illness shall be 
submitted by the system. The Governor may provide this assurance along 
with the assurances provided at ADD under 45 CFR part 1386.


Sec. 51.6  Use of allotments.

    (a) Allotments must be used to supplement and not to supplant the 
level of non-Federal funds available in the State to protect and 
advocate the rights of individuals with mental illness.
    (b) Allotments may not be used to support lobbying activities to 
influence proposed or pending Federal legislation or appropriations. 
This restriction does not affect the right of any system, organization 
or individual to petition Congress or any other government body or 
official using resources. A system may monitor, evaluate and comment on 
the development and implementation of Federal, State and local laws, 
regulations, plans, budgets, levies, projects, policies and hearings 
affecting individuals with mental illness as a part of federally-funded 
advocacy activities.
    (c) Allotments may not be used to produce or distribute written, 
audio or visual materials or publicity intended or designed to support 
or defeat any candidate for public office.
    (d) If an eligible system is a public entity, the system shall not 
be required by the State to obligate more than five percent of its 
annual allotment for administrative expenses such as costs of internal 
or external evaluations, monitoring or auditing. This restriction does 
not include:
    (1) Salaries, wages and benefits of program staff;
    (2) Costs associated with attending governing board or advisory 
council meetings; or
    (3) Expenses associated with the provision of training or technical 
assistance for staff, contractors, members of the governing board or 
advisory council.
    (e) No more than ten percent of each annual allotment may be used 
for providing technical assistance and training, including travel 
expenses, for staff, contractors, or members of the governing board or 
advisory council.


Sec. 51.7  Eligibility for protection and advocacy services.

    In accordance with section 105(a)(1)(C) of the Act [42 U.S.C. 
10805(a)(1)(C)] and the priorities established by the system's 
governing authority together with the mental health advisory council 
pursuant to section 105(c)(2)(B) of the Act [42 U.S.C. 10805(c)(2)(B)], 
allotments may be used:
    (a) To provide protection and advocacy services for:
    (1) Individuals with mental illness as defined in 42 U.S.C. 
10802(4) and 10805(a)(C), including, persons who report matters which 
occurred while they were individuals with mental illness;
    (2) Individuals with mental illness in Federal facilities rendering 
care or treatment who request representation by the eligible system. 
Representation may be requested by an individual with mental illness, 
or by a legal guardian, conservator or legal representative.
    (b) To provide representation of clients in civil commitment 
proceedings if the system is acting on behalf of an eligible individual 
to obtain judicial review of his/her commitment in order to appeal or 
otherwise challenge procedures which have subjected the individual to 
abuse or neglect or otherwise violated his/her rights. This restriction 
does not prevent a system from representing clients in commitment or 
recommitment proceedings using other resources so long as this 
representation does not conflict with responsibilities under the Act.


Sec. 51.8  Annual reports.

    By January 1 of each year, a report shall be submitted, pursuant to 
section 105(a)(7) of the Act [42 U.S.C. 10805(a)(7)], to the Secretary 
which:
    (a) Is in the format designated by the Secretary;
    (b) Describes the activities, accomplishments, and expenditures of 
the system on behalf of individuals with mental illness during the 
previous fiscal year;
    (c) Includes a section prepared by the mental health advisory 
council describing its activities during the previous fiscal year and 
its assessment of the program's progress in addressing the priorities, 
goals and objectives established for the previous fiscal year; and
    (d) Includes a statement of the program priorities established and 
shall also address any comments received through public comment.


Sec. 51.9  Financial status reports.

    A grantee shall submit a Financial Status Report in accordance with 
45 CFR 74.73.


Sec. 51.10  Remedial actions.

    Failure to submit an annual report in the designated format on time 
or to satisfy any other requirement of the Act, the regulations, or 
other requirements may be considered a breach of the terms and 
conditions of the grant award and may require remedial action such as 
the suspension or termination of an active grant, withholding of 
payments or converting to a reimbursement method of payment.


Secs. 51.11-51.20  [Reserved]

Subpart B--Program Administration and Priorities


Sec. 51.21  Contracts for program operations.

    (a) An eligible system should work cooperatively with existing 
advocacy agencies and groups and, where appropriate, should consider 
entering into contracts for protection and advocacy services with 
organizations already working on behalf of individuals with mental 
illness. Special consideration should be given to contracting for the 
services of groups run by individuals who have received or are 
receiving mental health services or by family members of such 
individuals.
    (b) An eligible system may contract for the operation of all or 
part of its program with another pubic or private nonprofit 
organization provided that:
    (1) Any organization that will operate the full program meets the 
requirements of sections 104(a)(1), 105 and 111 of the Act [42 U.S.C. 
10804(a)(1), 10805 and 10821] and has the capacity to perform 
protection and advocacy activities throughout the State;
    (2) The eligible system institutes oversight and monitoring 
procedures which ensure that all applicable terms, conditions and 
obligations of the Federal grant are met;
    (3) The eligible system and the contractor organization enter into 
a written agreement that includes at least the following:
    (i) A description of the protection and advocacy services to be 
provided;
    (ii) The type of personnel, their qualifications and training;
    (iii) The methods to be used;
    (iv) A timetable for performance;
    (v) A budget;
    (vi) Assurances that the contractor will meet all applicable terms 
and conditions of the grant;
    (vii) Assurances that the contractor has adequate management and 
fiscal systems in place, including insurance coverage, if appropriate;
    (viii) Assurances that the contractor's staff is trained to provide 
advocacy services to individuals with mental illness; and
    (ix) Assurances that the contractor staff is trained to work with 
family members of clients served by the system where the clients are:
    (A) Minors;
    (B) Legally competent and choose to involve the family member; or,
    (C) Legally incompetent and the legal guardians, conservators or 
other legal representatives are family members.


Sec. 51.22  Governing authority.

    (a) Each system shall have a governing authority responsible for 
planning, design, implementation and functioning.
    (b) If the system is organized with a multi-member governing board:
    (1) Each system shall establish policies and procedures for the 
selection of its governing board members, and their terms;
    (2) The board shall be composed of members who broadly represent or 
are knowledgeable about the needs of the clients served by the system;
    (3) If the governing authority is organized as a private nonprofit 
entity, the chairperson of the mental health advisory council shall be 
a member of the governing board.
    (c) Continuing efforts shall be made to include members of racial 
and ethnic minority groups as board members.
    (d) A member of the advisory council may also serve on the 
governing board.


Sec. 51.23  Advisory council.

    (a) Each system shall establish an advisory council to advise on 
program policies and priorities.
    (b) Members of the council shall include attorneys, mental health 
professionals, individuals from the public who are knowledgeable about 
mental illness, a provider of mental health services, individuals who 
have received or are receiving mental health services and family 
members of such individuals. Continuing efforts shall be made to 
include members of racial and ethnic minority groups on the advisory 
council.
    (1) At least 60 percent of the membership (including the chair) of 
the advisory council shall be comprised of individuals who have 
received or are receiving mental health services or who are family 
members of such individuals;
    (2) The council shall be chaired by an individual who has received 
or is receiving mental health services or who is a family member of 
such an individual;
    (c) Each system shall provide its advisory council with reports, 
materials and fiscal data to enable review of existing program policies 
and priorities. Such submissions shall be made at least annually and 
shall report expenditures for the past two fiscal years, as well as 
projected expenses for the next fiscal year, identified by budget 
categories (e.g., salaries and wages, contracts for services, 
administrative expenses).
    (d) Reimbursement of expenses. (1) Allotments may be used to pay 
for all or a part of the expenses incurred by members of the advisory 
council in order to participate in its activities. Expenses may include 
transportation costs, parking, meals, hotel costs, per diem expenses, 
stipends or subsistence allowances, and the cost of day care (or its 
equivalent for travel and subsistence expenses) for their dependents 
with mental illness or developmental disabilities.
    (2) Each system shall establish its own policies and procedures for 
reimbursement of expenses of council members, taking into account the 
needs of individual council members, available resources, and 
applicable restrictions on use of grant funds, including the 
restrictions in sections 51.4, 51.6(e) and 51.27(b).


Sec. 51.24  Program priorities.

    (a) Program priorities and policies shall be established annually 
by the governing authority, jointly with the advisory council. 
Priorities shall specify short-term program goals and objectives, with 
measurable outcomes, which implement established priorities. In 
developing priorities, consideration shall be given to, at a minimum, 
case selection criteria, the availability and monetary resources, and 
special problems and cultural barriers faced by individuals with mental 
illness who are multiply handicapped or who are members of racial or 
ethnic minorities in obtaining protection of their rights.
    (b) Members of the public shall be given an opportunity, on an 
annual basis, to comment on the priorities established by, and the 
activities of, the system. Procedures for public comment must provide 
for notice in a format accessible to individuals with mental illness, 
including such individuals who are in residential facilities, to family 
members and representatives of such individuals and to other 
individuals with disabilities. Procedures for public comment must 
provide for receipt of comments in writing or in person.


Sec. 51.25  Grievance procedure.

    (a) The system shall establish grievance procedures to address 
complaints from:
    (1) clients or prospective clients of the system to assure that 
individuals with mental illness have full access to the services of the 
program; and
    (2) individuals who have received or are receiving mental health 
services in the State, family members of such individuals, or 
representatives of such individuals or family members to assure that 
the eligible system is operating in compliance with the Act.
    (b) At a minimum, the grievance procedures shall provide for:
    (1) an appeal to the governing authority for any final staff review 
and/or determination;
    (2) reports, at least annually, to the governing authority and the 
mental health advisory council describing the complaints received, the 
grievances processed and the resolution;
    (3) identification individuals responsible for review;
    (4) a timetable to ensure prompt resolution;
    (5) a written response to the grievant; and
    (6) protection of client confidentiality.


Sec. 51.26  Conflicts of interest.

    The system should develop appropriate policies and procedures to 
avoid actual or apparent conflict of interest involving clients, 
employees, contractors and subcontractors, and members of the governing 
authority and advisory council, particularly with respect to matters 
affecting client services, particular contracts and subcontracts, 
grievance review procedures, reimbursements and expenses, and the 
employment or termination of staff.


Sec. 51.27  Training.

    (a) A system shall provide training for program staff, and may also 
provide training for contractors, governing board and advisory council 
members to enhance the development and implementation of effective 
protection and advocacy services for individuals with mental illness, 
including at a minimum:
    (1) Training of program staff to work with family members of 
clients served by the program where the individual with mental illness 
is:
    (i) A minor,
    (ii) Legally competent and chooses to involve the family member; or
    (iii) Legally incompetent and the legal guardian, conservator or 
other legal representative is a family member.

This training may be provided by individuals who have received or are 
receiving mental health services and family members of such 
individuals.
    (2) Training to enhance sensitivity to and understanding of 
individuals with mental illness who are members of racial or ethnic 
minorities and to develop strategies for outreach to those populations.
    (b) A system may support or provide training, including related 
travel expenses, for individuals with mental illness, family members of 
such individuals, and other persons who are not program staff, 
contractors, board or council members, to increase knowledge about 
protection and advocacy issues, to enhance leadership capabilities, or 
to promote Federal-State and inter-State cooperation on matters related 
to mental health system improvement. Decisions concerning the selection 
of individuals to receive such training shall be made in accordance 
with established policies, procedures and priorities of the system.


Sec. 51.28-51.30  [Reserved]

Subpart C--Protection and Advocacy Services


Sec. 51.31  Conduct of protection and advocacy activities.

    (a) A system shall establish policies and procedures to guide and 
coordinate advocacy activities.
    (b) Wherever possible, the program should establish an ongoing 
presence in residential mental health care or treatment facilities, and 
relevant hospital units.
    (c) Program activities should be carried out in a manner which 
allows program staff to:
    (1) Interact regularly with those individuals who are current or 
potential recipients of protection and advocacy services;
    (2) Interact regularly with staff providing care or treatment;
    (3) Obtain information and review records; and
    (4) Communicate with family members, social and community service 
workers and others involved in providing care or treatment.


Sec. 51.32  Resolving disputes.

    (a) Consistent with State and Federal law and the canons of 
professional ethics, a system may use any appropriate technique and 
pursue administrative, legal or other appropriate remedies to protect 
and advocate on behalf of individuals with mental illness. However, 
each system is encouraged to develop and employ techniques such as 
those involving negotiation, conciliation and mediation to resolve 
disputes early in the protection and advocacy process.
    (b) Disputes, including disputes between an individual with mental 
illness and treatment professionals as to a particular course of 
recommended treatment, should be resolved whenever possible through 
nonadversarial processes involving negotiation, mediation and 
conciliation. Consistent with State and Federal laws and canons of 
professional responsibility, family members should be involved in this 
process as appropriate where the individual with mental illness is:
    (1) A minor,
    (2) Legally competent and chooses to involve the family member, or
    (3) Legally incompetent and the legal guardian, conservator or 
other legal representative is a family member.
    (c) A system must exhaust in a timely manner all administrative 
remedies, where appropriate, prior to initiating legal action. However, 
if in pursuing administrative remedies, the system determines that any 
matter with respect to an individual with mental illness will not be 
resolved within a reasonable time, the system may pursue alternative 
remedies, including initiating legal action.
    (d) Paragraph (c) of this section does not apply to any legal 
action instituted to prevent or eliminate imminent serious harm to an 
individual with mental illness.
    (e) The Act imposes no additional burden respecting exhaustion of 
remedies.


Sec. 51.33-51.40  [Reserved]

Subpart D--Access to Records, Facilities and Individuals


Sec. 51.41  Access to records.

    (a) A system shall have access to the records of any of the 
following individuals with mental illness:
    (1) An individual who is a client of the system if authorized by 
that individual or the legal guardian, conservator or other legal 
representative.
    (2) An individual, including an individual who has died or whose 
whereabouts is unknown, to whom all of the following conditions apply:
    (i) The individual, due to his or her mental or physical condition, 
is unable to authorize the system to have access;
    (ii) The individual does not have a legal guardian, conservator or 
other legal representative, or the individual's guardian is the State; 
and
    (iii) A complaint has been received by the system or, as a result 
of monitoring or other activities, the system has probable cause to 
believe that the individual has been subject to abuse or neglect.
    (3)An individual who has a legal guardian, conservator, or other 
legal representative, with respect to whom a complaint has been 
received by the system or with respect to whom the system has 
determined that there is probable cause to believe that the health or 
safety of the individual is in serious and immediate jeopardy, whenever 
all of the following conditions exist:
    (i) The representative has been contacted by the system upon 
receipt of the representative's name and address;
    (ii) The system has offered assistance to the representative to 
resolve the situation; and
    (iii) The representative has failed or refused to act on behalf of 
the individual.
    (b) ``Probable Cause'' to believe that an individual has been or is 
in danger of being subject to abuse and neglect exists when the system 
determines that a reasonable person in a like position, drawing when 
appropriate upon his or her training and experience, would suspect 
abuse or neglect.
    (c) Information and records which shall be available to the system 
under the Act shall include, but not be limited to:
    (1) Information and records obtained in the course of providing 
intake, assessment, evaluation and other services, including medical 
records, financial records, and reports prepared or received by a 
member of the staff of a facility or program rendering care or 
treatment.
    (2) Reports prepared by an agency charged with investigating 
reports of abuse, neglect and injury occurring at a facility/hospital 
rendering care or treatment, or by or for the facility/hospital itself, 
that describe any or all of the following:
    (i) Abuse, neglect, and injury occurring at the facility;
    (ii) The steps taken to investigate the incidents; or,
    (iii) Reports and records, including personnel records, prepared or 
maintained by the facility in connection with such reports of 
incidents.
    (3) Discharge planning records.
    (4) Reports prepared by individuals and entities performing 
certification or licensure reviews, or by professional accreditation 
organizations, as well as related assessments prepared for the facility 
by its staff, contractors or related entities, except that nothing in 
this section is intended to preempt State law protecting records 
produced by medical care evaluation or peer review committees.
    (5) Professional, performance, building or other safety standards, 
demographic and statistical information relating to the facility.
    (d) A system shall be permitted to inspect and copy records, 
subject to a reasonable charge to offset duplicating costs.


Sec. 51.42  Access to facilities and residents.

    (a) A system shall have reasonable access to public and private 
facilities and programs in the State which render care or treatment for 
individuals with mental illness and reasonable access to residents/
patients at all times necessary to investigate an incident of abuse or 
neglect. Such access shall be afforded upon request by the system when:
    (1) An incident is reported to the system;
    (2) The system determines there is probable cause to believe that 
an incident occurred; or
    (3) The system determines that there is or may be imminent danger 
of serious abuse or neglect of an individual with mental illness.

This authority shall include reasonable access and authority to examine 
all relevant records and interview any facility/hospital service 
recipient, employee, or other person who might have knowledge of the 
alleged abuse or neglect.
    (b) In addition to access as prescribed in paragraph (a) of this 
section, a system shall have access to facilities and programs and 
their residents/patients at reasonable times, which at a minimum shall 
include normal working hours and visiting hours, for the purpose of:
    (1) Providing information and training on, and referral to, 
programs addressing the needs of individuals with mental illness, 
including information and training about individual rights and the 
protection and advocacy services available from the system;
    (2) Monitoring compliance with respect to the rights and safety of 
residents/patients, and
    (3) Inspecting, viewing and photographing all areas of the 
facility/hospital which are used by residents/patients or are 
accessible to residents/patients.

Such activities shall be conducted so as to minimize interference with 
facility/hospital programs, respect residents/patient's, privacy 
interests, and honor a resident's/patient's request to terminate an 
interview.
    (c) Access shall be extended to all authorized agents of a system, 
including advocates, appropriately supervised trainees, health/mental 
health care providers, legal and accounting personnel, and program 
contractors.
    (d) Access to residents/patients shall include the opportunity to 
meet and communicate with an individual regularly, both formally and 
informally, by telephone, mail and in person.


Sec. 51.43  Denial of access.

    If a facility proposes to deny access to facilities/hospitals, 
residents/patients or records, it shall promptly provide the system 
with a written statement of reasons, including, in the case of a denial 
for alleged lack of authorization, the name and address of the legal 
guardian, conservator, or other legal representative of an individual 
with mental illness.


Sec. 51.44  Access to federal facilities and records.

    A system providing representation to individuals with mental 
illness in Federal facilities shall be accorded all the rights and 
authority accorded other representatives of residents of such 
facilities pursuant to State and Federal laws.


Sec. 51.45  Confidentiality of protection and advocacy system client 
records.

    (a) Client records are the property of the system which must 
protect records from loss, damage, tampering or use by unauthorized 
individuals. The system must:
    (1) To the same extent as is required by a provider of mental 
health services, keep confidential all information contained in client 
records, including information contained in an automated electronic 
data system, except as provided elsewhere in this section. This 
requirement does not restrict access by the Department or other 
authorized Federal officials to client records or other records of the 
system for audit purposes and for monitoring system compliance with 
applicable Federal law and regulations. Subject to the restrictions and 
procedures set out in this section, implementing section 106 (a) and 
(b) of the Act [42 U.S.C. 10806 (a) and (b)], this regulation does not 
limit access by a legal guardian, conservator, or other legal 
representative of an individual with mental illness, unless prohibited 
by State or Federal law, court order or the attorney-client privilege.
    (2) Have written policies governing access to, duplication and 
release of information from client records; and
    (3) Obtain written consent from the client, if competent, or from 
his or her legal representative before releasing information to 
individuals not otherwise authorized to receive it.
    (b) Nothing in this subpart shall prevent the system from doing any 
of the following:
    (1) Issuing a public report of the results of an investigation 
which maintains the confidentiality of individual service recipients; 
or,
    (2) Reporting the results of an investigation to responsible 
investigative or enforcement agencies should an investigation reveal 
information concerning the facility/hospital, its staff, or employees 
warranting possible sanctions or corrective action. This information 
may be reported to agencies responsible for facility licensing or 
accreditation, employee discipline, employee licensing or 
certification, or criminal prosecution.


Sec. 51.46  Disclosing information obtained from a provider of mental 
health services.

    (a) Except as provided in paragraph (b) of this section, if a 
system has access to records pursuant to section 105(a)(4) of the Act 
[42 U.S.C. 10805(a)(4)] which under Federal or State law are required 
to be maintained in a confidential manner by a provider of mental 
health services, it may not disclose information from such records to 
the individual who is the subject of the information if the mental 
health professional responsible for supervising the provision of mental 
health services to that individual has given the system a written 
determination that disclosure of such information to the individual 
would be detrimental to the individual's health. The provider shall be 
responsible for giving any such written determination to the system at 
the same time as access to the records containing the information is 
denied.
    (b) If disclosure of information has been denied under paragraph 
(a) of this section to:
    (1) An individual;
    (2) The legal guardian, conservator, or other legal representative 
of the individual; or
    (3) An eligible system, acting on behalf of an individual:
    (i) Whose legal guardian is the State; or
    (ii) Whose legal guardian, conservator, or other legal 
representative has not, within a reasonable time after the denial of 
access to information under paragraph (a) of this section, selected a 
mental health professional to review the information,

then such individuals or the system may select another mental health 
professional to review the information and to determine if disclosure 
of the information would be detrimental to the individual's health. If 
such mental health professional determines, based on professional 
judgment, that disclosure of the information would not be detrimental 
to the health of the individual, the system may disclose such 
information to the individual.
    (c) This restriction does not affect the system's right to obtain 
access to the records.

[FR Doc. 94-30411 Filed 12-13-94; 8:45 am]
BILLING CODE 4160-20-M