Mental health: 15 days to receive services and other rights

This is the part of the Mental Health Act that says what you are owed, not how the system works. The law is long and has chapters on voluntary and involuntary admission, therapeutic restraint and seclusion, electroconvulsive therapy and minors; Chapter III is the one listing the adult’s rights and the one to use when you want to name what is yours. It applies at any level of care — outpatient, hospital, residential — and against any provider, direct or indirect: the law uses "indirect" to include whoever pays and administers the coverage, not only whoever treats you.

The adult who needs, requires and/or receives mental health services. The law writes all three situations on purpose: you do not have to already be in treatment to hold these rights, needing or requesting them suffices. And Article 3.04 expressly extends the reach: the rights apply to adults serving a sentence or held in penal or forensic psychiatric institutions when they do not conflict with the institution’s own security measures. This chapter is the adult one; minors are handled in other chapters of the law, which we did not read and do not describe here.

• Being an adult who needs, requires or receives mental health services. The law requires no prior diagnosis or procedure for the rights to apply.Verified against the official source
• For the 15-working-day obligation: having made the service request to a provider, direct or indirect, and it not being a psychiatric emergency.Verified against the official source

• The rights notice the institution must give you upon admission or as soon as possible after, together with the written institutional operating rules, which include the complaint procedure.
• If the admission is voluntary: the discharge request form, which the law orders be given to the adult, their legal guardian, a family member, or the person they designate.

1. 1

   Step 1: The fifteen working days and the ban on waiting lists

   This is the chapter’s most concrete right and the most ignored. The text says: every provider, direct or indirect, of mental health services has the obligation to provide the services within the first fifteen (15) working days of the request, provided it is not responding to a psychiatric emergency. And it continues: mental health providers, direct or indirect, are prohibited from having waiting lists to offer services to applicants that exceed the fifteen (15) working day limit. The law closes the exit: should the direct or indirect provider be unable to provide the services within this term, they are obliged to refer the person and coordinate the delivery of services. That is, "we have no appointment for three months" does not settle it: if they cannot, they must refer and coordinate. Note the date you made the request, because the term runs from there.

2. 2

   Step 2: You are presumed competent, and that changes who decides

   Article 3.03 establishes that every person is presumed mentally competent unless a court determination provides otherwise, and adds an important clarification: the judicial determination of incapacity under Article 703 of the Civil Code shall be distinct and separate from the judicial proceeding to determine whether the adult should be subject to involuntary admission. They are two different things: being involuntarily admitted is not the same as being declared incapacitated. The same article adds a second presumption: every person with mental or emotional disorders is presumed to have the potential for recovery or rehabilitation upon receiving services appropriate to their diagnosis and the severity of symptoms and signs. And 3.02 preserves the rest: you keep enjoying your constitutional and statutory rights, benefits and privileges while receiving services and during admission, transfer or discharge.

3. 3

   Step 3: Informed consent: the seven minimum elements

   Whenever an adult receives mental health services, at any level of care, their informed consent must be obtained, or their legal guardian’s if judicially declared incapacitated, and the information must be offered in language and tone the person can understand. The law lists the minimum information for consent to count as informed: (1) the diagnosis and clinical description of their health condition; (2) the recommended treatment; (3) the risks and consequences of accepting or refusing treatment; (4) other treatment alternatives that, though less indicated, are available; (5) benefits, risks and consequences of those alternatives; (6) the corresponding prognosis; and (7) the possibility of side effects and irreversible harm resulting from particular recommended treatments or medications. The exception is written in: in a medical, psychiatric or dental emergency, the services needed to stabilize the situation may be offered without informed consent, and the reason and emergency determination shall be recorded in the clinical file and reported as soon as possible to the closest relative or legal guardian.

4. 4

   Step 4: You can refuse treatment, and there is a line that is never crossed

   Any adult receiving services in a provider institution may, personally or through their legal guardian, exercise the right to refuse any type of service within their Treatment, Recovery and Rehabilitation Plan, and the law clarifies this refusal extends to medication. If you refuse, the services will not be provided; that said, it will be recorded in the clinical file. The Director or their representative will inform you of the alternative services and treatments available, the risks and consequences of refusing, and the prognosis of receiving them or not. There is an exception: if the services are needed to handle a psychiatric emergency, they will be administered, and the psychiatrist will record the emergency circumstances in the file; you will be notified as soon as you can understand the information, or your legal guardian will, and that notice is also recorded. And there is a prohibition with no exceptions, written this way in the law: under no circumstance shall an order be issued to receive or deny a service or to administer medication as a punishment or as a condition for the adult to be discharged.

5. 5

   Step 5: The treatment plan is made with you, not about you

   Every adult has the right to have an Individualized Treatment, Recovery and Rehabilitation Plan designed for them, inter- or multidisciplinary, safe and humane, in an environment as unrestrictive as possible given their condition. The law puts your participation in writing: the adult receiving services shall participate in formulating and reviewing the plan to the extent such participation is possible, and the closest relative’s participation shall also be required. The case manager is responsible for following up on the plan’s implementation, and the clinical file must contain the signature of all professionals who took part in preparing it and that of the adult or the relative representing them. A related right, item (ñ): when the inter- or multidisciplinary team is designated, you have the right to request the participation of any support group or person, who is then bound to keep your clinical information confidential.

6. 6

   Step 6: Private, uncensored communication, at no cost if you lack means

   While admitted you have the right to communicate privately, without censorship and without impediment, with the people of your choosing, by phone, mail or visits. The law details all three. Mail: the Director shall ensure it is received and deposited in the mail, and shall also provide writing material and postage stamps when you lack the means to obtain them; all letters, regardless of addressee, shall be sent without being examined by the institution’s authorities, and replies are delivered without prior examination. If you cannot read or write and ask for help, you shall be assisted. Phone: telephones must be accessible, with places and hours set in writing for reasonable use, and funds shall be provided for reasonable use — local or long distance — to anyone lacking means. Visits: the Director must guarantee an adequate place and publish the schedule. These three may be reasonably limited by the director when a clinical determination justifies it and for the purpose of protecting the adult or third parties from harm, persecution, harassment or intimidation; the decision is considered by the team, recorded with justification in the file, and reported to you, as well as to the relative, guardian or attorney. But there is one communication never limited: that between the adult and their representative, legal guardian, attorney or the Court, or between the adult and another individual, when it concerns matters related to administrative or judicial proceedings.

7. 7

   Step 7: The complaint: thirty days and a written answer even after discharge

   Every adult may, personally or through their legal guardian, exercise the right to file complaints regarding the violation of the rights described in this law. The provider institution has the duty to advise you — and your legal guardian — of your right to have your complaint resolved in an impartial proceeding, fairly and promptly. Every provider institution shall establish a system for handling complaints about the treatment and service it offers, and the procedure must be reported to the adult, their legal guardian, their relatives, the institution’s visitors and the staff. The term is firm: every complaint shall be addressed and resolved within thirty (30) days from its proper filing, and the final determination shall be reported in writing to the adult or their legal guardian even if they have already been discharged. And if you are not satisfied with the determination, the law gives you the exit: when the petitioner is not satisfied, they may go before the Court of First Instance. The Service Manuals must include a section titled "Procedures for Filing and Resolving Complaints" describing the steps in plain language.

8. 8

   Step 8: Ambulance, transportation and the police-car prohibition

   The law provides access to ambulance services through the 911 System and/or Medical Emergencies, whether state service and/or using the health plan, when an emergency befalls a person with a mental disorder, and orders it be provided without discrimination or prejudice. The service is provided upon request of a mental health professional, of the person themselves, or of any citizen who believes the situation is potentially dangerous to a person’s life and/or to property. The transportation item adds its own: every person going through a psychiatric emergency has the right to transportation in an adequate vehicle, including ambulances certified by the Public Service Commission and the Department of Health, to be moved to the facility where they will receive treatment. If they have health coverage, it must bear the transportation costs in medical emergencies; under the Health Reform, the entity contracted to manage and coordinate services is responsible for covering them. And the prohibition: no mental health patient may be transported in a Puerto Rico Police vehicle, unless it is a situation where a crime has been committed, in which case the intervening officer answers according to law.

9. 9

   Step 9: The other rights the chapter lists

   Worth knowing because they are written down and can be cited. Not being identified as a patient or former patient, except when the person so requests or authorizes. Possessing, using and keeping your personal effects in an assigned, secure place, with all your personal property returned on discharge. Managing your assets: you may use your money as you see fit unless a court forbids it, hospital staff shall not be designated to receive your social security, pension or annuity absent a court order or legal provision, and you may request your funds be deposited in any financial institution in Puerto Rico. On labor or work: you may voluntarily consent to it, you cannot be compelled, and if the work is not part of your plan and brings economic benefit to the institution, you shall receive wages and benefits proportionate to the work under applicable law; you may be required to maintain your room and other tasks that are part of your plan, without compensation; and under no circumstance may any labor be required as retaliation or punishment. Not being subjected to experimental or exploratory procedures not approved by the pertinent federal and state bodies, with written informed consent, written notice at least seventy-two (72) hours before it begins — excluding Saturdays, Sundays and holidays — and the right to end your participation before or during. Language: if you do not know or understand the language used to explain things, the institution must provide you a translator or interpreter, and that includes hearing or speech limitations; a relative may serve as interpreter if you so decide; if you have visual limitations, the institution must advise you of your right to have documents read aloud by a person of your choosing. Legal representation: every adult admitted involuntarily has the right to be represented by an attorney, and if indigent and unable to retain one, the court shall appoint one for the hearing. And level of care: hospitalization must be for the shortest time possible until you are able to move to a level of lower intensity and greater autonomy.

The first counterpart is the provider institution itself: the law requires it to set up the complaint system, inform you of the procedure, and resolve within thirty days with written notice. If you are not satisfied with the determination, the law expressly gives you the route to the Court of First Instance. The Mental Health and Anti-Addiction Services Administration (ASSMCA) is the agency the law charges with regulation in this area; within Chapter III itself it appears, for example, as the one issuing the regulation on handling the money of admitted persons and as a recipient, alongside the institution’s director, of requests to conduct scientific research. What we do not publish: an ASSMCA phone number or form to file complaints under this law, because Chapter III does not name one and we will not assume it.

• Accepting a months-long waiting list: the law expressly prohibits those exceeding fifteen working days and requires referral and coordination if the provider cannot comply.
• Not noting the date of the service request, which is when the term starts running.
• Believing an involuntary admission equals a declaration of incapacity: Article 3.03 says they are distinct and separate proceedings.
• Signing a consent without the seven elements, especially the 7th: the possibility of side effects and irreversible harm.
• Accepting discharge being conditioned on taking a medication: the law prohibits it under any circumstance.
• Accepting having your mail examined: the law orders it sent and delivered without prior examination by the institution’s authorities.
• Dropping a claim after discharge: the complaint’s final determination is reported in writing even if you have been discharged.
• Not asking for an interpreter when you do not understand the language, or when the limitation is hearing or speech: the institution is obliged to provide one.

These are the government pages this guide is based on.

• Administración de Servicios de Salud Mental y Contra la Adicción (ASSMCA)

  ASSMCA

  bvirtualogp.pr.gov

• ASSMCA — Mental Health and Anti-Addiction Services Administration

  ASSMCA

  www.assmca.pr.gov