P.R. Laws tit. 24, § 6154e
All adults who need, require, or receive mental healthcare services shall be entitled to the following specific rights:
(a) Access to services. — All adults shall have access to mental healthcare services in accordance with the specialties and sub-specialties by stage of life, gender, disorder, age, and level of care, as per their diagnosis and the severity of symptoms and signs. Treatment services shall be rendered on an ongoing basis, in accordance with the level of intensity and the severity of the symptoms and signs, in order to achieve recovery in a reasonable level of functionality. To that effect, adults who receive mental healthcare services shall not be subject to discrimination or prejudice, and shall have access to said services, without distinction of diagnosis and severity of their mental disorder, except as provided for in this chapter. This right may not be constricted due to the existence of any physical condition or disability. There shall be no distinction between a mental disorder and any other medical condition in terms of the access that persons shall have to the services they need, except as provided for in this chapter.
No direct or indirect provider may establish distinctions as to the rendering, access, administration, or planning of mental healthcare services which might be discriminatory against this population.
The use of mental healthcare services at all levels of intensity, shall be determined by the inter- or multidisciplinary team, on the basis of the justified clinical need, which, in turn, shall be based on the diagnosis and the severity of symptoms and signs of the mental disorder, as defined in the disorder classification manual in effect at the time.
No direct or indirect provider may impose its medical criteria in the payment for mental healthcare services which have been found to be necessary by mental healthcare professionals, medical psychiatrists, and other practitioners duly qualified for such purposes, who are in charge of providing healthcare to the patient.
They shall also be entitled to receive pharmacotherapy services, as well as all kinds of therapy within the standards acceptable in the practice of psychiatry and psychology, including, but not limited to psychotherapy, support services, and others befitting their diagnosis and the severity of symptoms and signs, pursuant to optimal clinical parameters.
It is hereby provided that access to ambulance services shall be accorded by means of the 911 System and/or Medical Emergencies, whether this is a service under Commonwealth and/or health plan coverage, when an emergency arises which involves a person suffering from a mental disorder. Such services shall be rendered without discrimination or prejudice against persons suffering from mental disorders. These services shall be rendered upon the request of a mental healthcare professional or the person him/herself or any citizen who believes that the situation is potentially dangerous to a person’s life or to property.
All direct or indirect mental healthcare service providers shall be under the obligation to render services within the first fifteen (15) working days as of the date of being so requested, insofar as such a request does not issue from a psychiatric emergency. Direct or indirect mental healthcare service providers are hereby prohibited from keeping waiting lists to offer services to people who so request, which exceed the fifteen (15)-working-day limit established in this section. In the event that a direct or indirect provider is unable to provide services within such term, such provider shall be under the obligation to refer and to coordinate the services to be rendered.
(b) Right not to be identified as a mental health patient. — Any adult who receives mental healthcare services shall have the right not to be identified as a patient, or as a former patient, except when the person so requests or authorizes pursuant to the procedure established in this chapter for such purpose.
(c) Notification of rights; limitations. — Any adult who requests mental health services has the right to receive notification at the time of being admitted or hospitalized in the providing institution, or as soon as possible after the same, of the rights guaranteed pursuant to this chapter.
To that effect and in accordance with § 6153f of this title, the director of the institution or his/her representative shall advise the adult receiving the mental health services, the person designated by him/her, or his/her legal guardian in the case of those legally declared as mentally disabled. In the case of adults who request services voluntarily, the director of the institution or his/her representative shall expressly inform him/her of the right to be released from the institution within the shortest term possible. If the adult has been admitted voluntarily, he/she, or his/her legal guardian, family member or any other person so designated by the adult who receives mental health services shall receive a petition for release form.
Moreover, he/she shall receive a written document of the operating norms of the institution, which shall include, among others, the procedures to decide placement, to review said placement, and the claims and complaints procedures. In addition, during the process of admission or hospitalization, the person shall receive a detailed explanation of any limitations he/she may suffer while hospitalized, and the obligation that they result from a justified medical determination made by the inter or multidisciplinary team and are included in the clinical record. Admissible limitations shall also be notified to the closest family member, the legal guardian or the attorney, if any.
No limitation shall apply when the communication is between an adult, his/her representative, legal tutor, attorney or the court, or between the adult and another individual on matters related to administrative or legal procedures.
(d) Individualized treatment, recovery and rehabilitation plan. — Every adult shall have the right to have an inter or multidisciplinary, safe and human individualized treatment, recovery and rehabilitation plan designed for him/her, within the least restrictive environment possible, according to his/her condition.
Any adult who receives the services shall participate in the preparation and revision of the plan to the degree to which said participation is possible. In addition, the participation from his/her closest family member shall be required. The case handler shall be responsible for giving follow-up to the implementation of the inter or multidisciplinary individualized treatment, recovery and rehabilitation plan. The clinical record shall contain the signature of all the professionals participating in the elaboration of the plan, and that of the adult or family member who represents him/her during its preparation.
(e) Informed consent. — Every adult shall have the right to know everything related to the services or treatments proposed by his/her inter or multidisciplinary individualized treatment, recovery and rehabilitation plan, for mental health services, before consenting to it. Every time an adult receives mental health services, regardless of the level of care, his/her informed consent shall be obtained, or that of his/her legal guardian, in the case of an adult who has not been legally declared disabled. The information and orientation shall be offered in a language and tone that the person can understand.
The minimum required information that the adult shall receive for his/her consent to be considered as being duly informed, shall be the following:
(1) The diagnosis and clinical description of his/her health condition.
(2) The recommended treatment.
(3) The risks and consequences of accepting or rejecting the treatment.
(4) Other alternatives for treatment available, even though they are less indicated.
(5) Benefits, risks and consequences of the alternatives for treatment.
(6) The corresponding prognosis.
(7) The possibility of side effects and irreversible damages caused by the treatments or use of certain recommended medications.
As an exception, in case of a medical, psychiatric or dental emergency, the treatments necessary to stabilize the emergency situation may be offered without prior informed consent from the adult. The reason and determination of an emergency shall be included in the adult’s clinical record, and shall be notified as soon as possible to the closest family member or his/her legal guardian, as the case may be.
(f) Refusal to receive treatment. — Any adult who receives services at an institutional provider may, pro se or through his/her legal guardian, exercise the right to refuse any kind of service within his/her treatment, recovery and rehabilitation plan. This refusal applies to medications and to any other kind of service within his/her treatment, recovery and rehabilitation plan. If the adult refuses to receive such services, these shall not be rendered; however, this shall be so entered in the clinical record.
The director or his/her representative shall inform the adult or legal guardian of alternate services and treatments available, the risks and consequences that said adult may suffer when refusing to receive said services, and the prognosis of receiving or refusing to receive the same. However, if the services or treatments required by the adult’s treatment and rehabilitation plan are necessary to handle a psychiatric emergency situation, these shall be provided. The psychiatrist shall enter in the clinical record the emergency circumstances in which it was necessary to order said service or treatment. The adult shall be notified of said decision as soon as he/she can understand the information, or his/her legal guardian. This notification shall be entered in the clinical record.
Under no circumstance shall an order be issued to receive or refuse a service or to administer medications as a punishment or as a condition for the adult’s discharge.
(g) Freedom of communication. — Every adult who receives services at an institutional provider shall, after being institutionalized, have the right to communicate in private, with no censorship or impairment, with any person he/she chooses. This communication may be accomplished by telephone, mail or visits, as described below:
(1) Correspondence. — The director of the providing institution shall make sure that the correspondence is received and deposited in the mail. He/She shall also provide writing materials and stamps when the adult who receives mental health services does not have the means to obtain them. All the letters, regardless of the addressee, shall be sent to thereto, without being examined by the authorities of the institution that provides mental health services. [The responses to the adult’s letters shall be handed over, regardless of the addressee and without being examined by the authorities of the mental health institution. In case that the adult does not know how to read or write and upon the adults request, he/she shall be assisted when desiring to exercise his/her right to communicate in writing.]
(2) Telephone. — The director of the institution that provides mental health services shall make sure that telephones are accessible and shall establish in writing the places and times for their reasonable use. Any adult who does not have the means to obtain one, shall receive funds for the reasonable use of the telephone, be it for local calls or long distance.
(3) Visits. — The director of the providing institution shall be responsible for guaranteeing the existence of an adequate place so that adults subject to hospitalization may receive visitors. To that effect, he/she shall make public the schedule and place for said visits.
The institutional provider shall establish the rules for communication through other media, such as fax machines, email or courier service.
The foregoing notwithstanding, written communication, use of the telephone and visits to adults shall be reasonably constricted by the director of the institutional provider or his/her representative when there exists a clinical determination that so warrants, insofar as said constriction has the purpose of protecting the adult or third parties from being harmed, persecuted, harassed or intimidated. The decision to constrict this right shall be taken into consideration by the inter- or multidisciplinary team, and entered in the clinical record, duly warranted and notified to the adult. The person’s family member, legal guardian or attorney, if any, shall be also notified. As to forensic psychiatric institutions, the appropriate restrictions shall apply to conform to the nature of the services being rendered.
No constriction whatsoever shall apply between the adult and his/her representative, legal guardian, or attorney, or the court, or between the adult and another person, when the communication is about matters associated with administrative or judicial proceedings.
(h) Personal effects. — Every adult who receives mental health services in a providing institution may possess, use and keep his/her personal effects in an assigned and safe place provided for such purposes.
Possession and use of certain types of personal property may be limited by the director of the providing institution or his/her representative when necessary in order to protect the adult or others from any physical injury. When the adult is released, all of his/her personal property shall be returned.
(i) Money and deposits. — Every adult shall have the right to manage his/her own assets, including his/her valuable belongings while receiving services in a mental health institution. The hospital or residential providing institution shall establish the necessary rules and procedures according to the regulations promulgated to that effect by the Administration to ensure that the money of the adults who receive services therein are protected against theft, loss or illegal appropriation. To that effect, the rules and procedures shall include the following:
(1) Any person who receives services in these institutions may use his/her money as he/she wishes. However, no adult who has been prohibited from using his/her money by court order may do so;
(2) no personnel of the hospital or residential institution shall be designated to receive money from social security, pensions, annuities, trusts or any other direct form of payment or assistance of the adults hospitalized in institutions that provide mental health services, except in those cases in which a court order designates the personnel as custodian of said money. In addition, a designation may occur by virtue of a law or regulation related to the disposition of rights from social security, pension or any other benefit, and
(3) any adult in a hospital or residential institution that provides mental health services may request the deposit of any funds pertaining to it in any financial institution in Puerto Rico.
(j) Labor or work. — Any adult under treatment at an institutional provider may voluntarily agree to engage in labor or work for the institution. However, the adult may not be forced to engage in such labor or work. It is hereby provided that when the work or labor is not a part of the treatment, recovery and rehabilitation plan at the institution and the same yields financial benefits for said institution, the adult shall receive wages and benefits in proportion with the work carried out, pursuant to the applicable federal and Commonwealth laws. In those cases in which adults are confined at an institutional provider by a court order, such adults shall be subject to the terms of the sentence imposed by the court.
It is hereby provided as an exception that it may be required that the adult carry out maintenance duties or tasks in his/her room, and any other duty or task as part of his/her treatment, recovery and rehabilitation plan with no compensation. The assignment of these tasks or duties shall be entered in the clinical record as part of the treatment, recovery and rehabilitation plan.
Such duties may not infringe upon the dignity and physical integrity of program participants, nor be contrary to the constitutional clause that prohibits involuntary servitude.
The foregoing notwithstanding, under no circumstance may any adult be required to carry out duties or tasks of any kind as retaliation or punishment.
(k) Claims and complaints. — Any adult may, per se or through his/her legal guardian, exercise his/her right to present claims or complaints in relation to any violation to the rights described in this chapter. The providing institution shall have the obligation to warn the adult who receives mental health services and his legal guardian of the right he/she has for his/her claim or complaint to be solved in an impartial proceeding, in a fair and timely manner. When the petitioner does not agree with the determination made, he/she may seek remedy at the Court of First Instance.
Every providing institution shall establish a system to handle claims and complaints related to the treatment and service being offered pursuant to this chapter. The proceeding established to present claims and complaints shall be informed to the adult who receives mental health services, his/her legal guardian, family members, visitors and personnel who work in the institution.
Every claim and complaint shall be handled and solved within a term of thirty (30) days after having been duly presented. The adult or his/her legal guardian shall be notified in writing of the final determination made on his/her claim even after having been released.
The services manuals stipulated in §§ 6157b and 6161c of this title, respectively, shall include a section titled Proceedings for the Presentation and Solution of Claims and Complaints, which shall consist of a description, in simple words, of the steps to be followed by adults, minors and their families who need to use these mechanisms.
(l) Experimental or exploratory procedures. — No adult shall be submitted to experimental or exploratory procedures that are not approved by the corresponding federal and state organisms. To participate in the same, the adult or his/her legal guardian, as the case may be, shall give written and legally effective informed consent.
The minimum information that shall be offered to a participant of these procedures shall be made in comprehensible and non-coercive language, and shall consist of:
(1) A document stating that the procedure constitutes a scientific experiment or investigation; its purposes, the duration of the patient’s participation in the procedure; a description of the procedures to be used and which parts of them are experimental;
(2) the risks and nuisances that may be reasonably foreseen;
(3) a description of the benefits that may be reasonably expected by the participant or others;
(4) disclosure of alternate procedures or treatments that may benefit or have more advantageous results for the participant than the experimental or exploratory procedure;
(5) a document stating the scope and degree of confidentiality under which the adult’s identity shall be kept;
(6) in investigations that involve risks, it shall be informed if compensation or medical treatment shall be offered for damages resulting from the procedure, and the full extent of the treatments, in addition to the place in which to obtain additional information about them;
(7) an explanation with respect to the persons to be notified, in case the participant has any questions or suspects to any damages related to the procedure;
(8) a document stating that participation in the procedure is voluntary and refusal to participate or to discontinue at any moment does not involve penalty or loss of any benefit to which the participant may be entitled. The adult subject to any experimental or exploratory procedure shall be notified in writing at least seventy-two (72) hours before beginning the procedure, excluding Saturdays, Sundays and holidays, and
(9) any other criteria established through regulation by the Administrator.
The adult has the right to end his/her participation in the experimental procedure, before or during the procedure.
(m) Scientific research. — Any petition to conduct scientific research related to an adult who receives mental health services in public or private institutions shall be directed to the Administrator or the director of the institution that provides these services, respectively, who shall request the approval from the evaluating committee of the requesting institution, in order to evaluate the proposals submitted for investigation according to its recommendations. The preceding shall be carried out pursuant to the standards established by the federal and State Government for scientific investigation processes. The committee shall issue its recommendation within fifteen (15) days after its receipt. Afterwards, the Administrator or the director of the providing institution shall notify to the interested party its determination on the investigation.
No adult shall be submitted to any scientific investigation without having first obtained his/her authorization or that of his/her legal guardian, as the case may be, through a written and legally effective informed consent.
The basic information that shall be offered to the person or his/her legal guardian in a comprehensible and non-coercive language and shall consist of:
(1) A document stating that the procedure constitutes a scientific investigation; its purposes, the duration of the patient’s participation in the procedure; a description of the procedures to be used and which parts of them are experimental;
(2) the risks and nuisances that may be reasonably foreseen;
(3) a description of the benefits that may be reasonably expected by the participant or others;
(4) disclosure of alternate procedures or treatments that may benefit or have more advantageous results for the participant than the scientific investigation procedure;
(5) a document stating that adult’s identity shall be kept in strict confidentiality;
(6) in investigations that involve risks, it shall be informed if compensation or medical treatment shall be offered for damages resulting from the procedure, and the full extent of the treatments, in addition to the place in which to obtain additional information about them;
(7) an explanation with respect to the persons to be notified, in case the participant or his/her legal guardian has any question or suspects any damages related to the procedure;
(8) a document stating that participation in the procedure is voluntary and that refusal to participate, or to discontinue it at any time does not involve a penalty or loss of benefits of any kind to which the participant may be entitled, and
(9) any other criteria established through regulation by the Administrator.
The persons in charge of conducting the investigation shall comply with the rules of confidentiality established in this chapter. The director of the institution shall safeguard the confidentiality of the information of the adult who receives mental health services in relation to any type of scientific or exploratory investigations.
(n) Language. — Every adult who receives mental health services has the right to know and be informed about everything related to his/her evaluation, treatment, recovery and rehabilitation, and therefore, when there is a need to give an explanation to the adult who receives mental health services and he/she does not know or understand the language in which it is offered, the institution shall be bound to provide to the adult, or his/her legal guardian, the translator or interpreter necessary to achieve an effective communication. This provision includes those cases in which the nature of the limitation is auditory or of speech. For the purposes of this provision, family members of the person who receives mental health services are not banned from serving as interpreters, provided the adult so determines it.
All written documentation furnished to the adult shall be issued in the language he/she understands. Everything possible shall be done for an effective communication. In those cases in which the adult has visual limitations, the institution shall be bound to advise him/her of the right to have the documents read out loud by the person of his/her choice, who shall also sign each and all the documents that have been read, pursuant to the adult’s petition and determination. The provisions of this section shall be included in the clinical record of the adult who receives mental health services.
(ñ) Right to request participation of support groups or persons. — Upon designation of the inter- or multidisciplinary team, the patient shall have the right to request the participation of any support person or group. Any persons who serve in such a capacity shall be under the obligation to keep the clinical information of the person receiving mental healthcare services confidential, pursuant to the provisions on this matter contained in this chapter. Noncompliance with this provision shall entail the imposition of penalties, as provided for in this chapter.
(o) Right to receive support from the patient’s mother, father, guardian and protection or assistance agencies for the person at the time of release. — Every person admitted to a facility shall have the right to receive support from his/her parents, family members, significant others and agencies with protection services and the obligation to provide shelter and the adequate level of care, as well as the personnel trained to adequately serve persons with mental disorders in a less restrictive environment with greater autonomy.
(p) Transportation. — All persons on a state of psychiatric emergency shall have the right to transportation in an adequate vehicle, including ambulances certified by the Public Service Commission and the Department of Health, to take them to the facility where they will receive treatment.
In they should have the financial means, such as health coverage to pay for transportation expenses in cases of medical emergency, such expenses shall be paid by such coverage. In the case of persons who receive mental healthcare services or interventions under the Health Reform, the entity contracted to manage and coordinate healthcare services shall be responsible for covering the transportation expenses in cases of medical emergency. No mental health patient may be transported in a vehicle of the Puerto Rico Police, unless the situation involves the commission of a crime, in which case, the police officer who intervenes shall respond pursuant to the law. When placement of a patient is ordered by a court, the court shall make the necessary arrangements for the patient’s transportation as provided.
(q) Right to support when there is a moral responsibility. — Any adult person who, for reason of consanguinity or moral obligation, be it because he/she has benefited financially or received any other benefit from the person who [suffers from mental disorders], or that needs or receives mental health services, shall be bound to provide the necessary support and shall make sure that the person with a mental disorder can participate in the services directed toward his/her recovery, according to his/her level of capacity.
(r) Legal representation upon involuntary admission. — Any adult involuntarily admitted shall have the right to be represented by an attorney. If the person is indigent and has not been able to hire an attorney, the court shall appoint one to represent him/her during the hearing.
(s) Less intensive level of care with greater autonomy. — Every person has the right to receive adequate treatment, according to his/her diagnosis and level of care, and therefore his/her hospitalization shall be for the shortest period possible, until he/she can be transferred to a less intensive level of care.
(t) Responsibility of persons who receive mental healthcare services in Puerto Rico. — It is hereby established that persons who receive mental healthcare services shall discharge the following responsibilities:
(1) Assume responsibility for his/her recovery according to his/her abilities;
(2) participate in self-sufficiency and community support activities and programs, and
(3) The guardians or caregivers of the person who receives mental healthcare services shall have the responsibility of taking the person to his/her treatment sessions and participating in activities, counseling and family therapy sessions recommended for the progress of the person with mental disorders.
History —Oct. 2, 2000, No. 408, § 3.06; Aug. 6, 2008, No. 183, § 21.