P.R. Laws tit. 24, § 6158e
Any minor who receives mental healthcare services shall be entitled to the following specific rights:
(a) Access to services. — Every minor shall have access to mental healthcare services in accordance with the specialties and sub-specialties by stage of life, gender, age, and level of care, depending on his/her diagnosis and on the severity of his/her symptoms and signs. Services shall be rendered on an ongoing basis and befitting the level of intensity, in order to achieve recovery in a reasonable level of functionality.
No provider may establish distinctions in the rendering, access, administration, or planning of mental healthcare services which might be discriminatory against this population, except as provided for in this chapter.
The use of mental healthcare services shall be determined according to the justified clinical basis, which, in turn, shall be based upon the diagnosis and severity of symptoms and signs of the mental disorder, as defined in the classification manual in effect.
Minors shall also have the right to receive pharmacotherapy, psychotherapy, all kinds of therapy pursuant to standards in the practice of psychiatry and psychology, including, but not limited to psychotherapy, support and other services befitting their diagnosis and severity of symptoms and signs, pursuant to the best clinical parameters.
To that effect, minors who receive mental healthcare services shall not be subject to discrimination or prejudice, and shall have access to said services, regardless of their diagnosis and the severity of their mental disorders. This right may not be constricted due to the existence of any physical condition or disability. There shall be no distinction between a mental condition and a physical condition in terms of the access to the necessary services, except as provided for in this chapter.
In turn, all mental healthcare service providers shall address all requests for services not relative to an emergency within the first fifteen (15) calendar days as of the date of such request.
(b) Notification of right. — All minors identified as in need of mental healthcare services, as well as those who request and receive mental healthcare services, shall be offered guidance as to the rights set forth herein while being evaluated or at the time of intervention, when mentally capable of completing the information. The minor’s parent with legal or physical custody or legal guardian, as well as the minor if his/her mental capability so allows, shall be offered guidance and be given a copy of such minor’s rights.
No constriction shall apply between a minor and his/her attorney or the court, or between the former and another individual, when the communication addresses matters relative to administrative or judicial proceedings.
(c) Contingent autonomy to request counseling and treatment. — Every minor of fourteen (14) years of age or more, has the right to request counseling or psychotherapy and to receive mental healthcare treatment, up to a maximum of six (6) sessions, without his/her parents’ consent, pursuant to the provisions of § 6161 of this title. In those cases of counseling and treatment for substance-related disorders, the initial term shall not exceed seven (7) sessions.
(d) Individualized treatment, recovery and rehabilitation plan. — Every minor shall have the right to have a safe and humane individualized treatment, recovery and rehabilitation plan designed for him/her, within the less restrictive environment possible according to his/her condition.
The plan shall be based on a clinical evaluation of the strengths and needs of the minor and his/her family. In addition, the plan shall consider and, if needed, extend to home, school and community situations.
Any minor who receives the services shall participate in the preparation and revision of the plan to the degree said participation is possible. In addition, participation from his/her closest family member shall always be required, be it the parent with patria potestas or custody, his/her legal guardian or the person with provisional custody, for the design and revision of the individualized treatment, recovery and rehabilitation plan.
A mental health professional acting as case handler shall be responsible for giving follow-up to the implementation of the individualized treatment, recovery and rehabilitation plan, and for accessing all the services needed for the minor’s recovery. The name of said professional shall form part of the plan, which, in turn, shall form part of the minor’s clinical record. The clinical record shall contain the signature of all the professionals participating in the preparation of the plan, and that of the adult or family member who represent him/her during its preparation.
(e) Special considerations; minors. — All healthcare service providers shall address the special needs of children from birth up to twelve (12) years of age and of adolescents from thirteen (13) to eighteen (18) years of age, and the interconnection of signs and symptoms with the normal growing process and the development of mental disorders. Minors who receive mental healthcare services shall be serviced and treated at a different ward separate from adults who receive mental healthcare services.
(f) Lesser-intensity, greater-autonomy level of care. — All mental healthcare service providers shall consider as most beneficial to keep children and adolescents with severe mental disorders together with their families, or in similar settings, or in the community, before considering hospitalization, which leads to separation from the family unit.
(g) Hospitalization services and segregated care for children and adolescents. — Children from zero (0) to twelve (12) years of age shall be provided with services befitting their age and gender, with individualized therapy separate from the treatment provided to adolescents and adults.
Hospital services may be shared between the child and the adolescent population, contingent upon strict supervision. Treatment services for children and adolescents shall never be intermingled with services for adults.
(h) Informed consent of the minor or parent with patria potestas or custody, the legal guardian or the person with provisional custody. — Every minor admitted, his/her parent with patria potestas or custody, legal guardian or person with provisional custody shall have the right to know everything related to the services and treatment proposed in the individualized treatment, recovery and rehabilitation plan, inter- or multidisciplinary, designed by an institution that provides mental health services, before consenting to it.
Every service offered to the minor shall be explained in such a way, that all related information may be understood. The clinical record shall include a summary of the explanation and, that according to the judgment of the professional in charge, the explanation given was understood.
When a minor receives mental health services, it shall be required that his/her parent with patria potestas or custody, or legal guardian or person with provisional custody, give a written and informed consent so that the minor may receive said service with the exceptions established in this chapter.
The minimum information required for consent to be considered as duly informed shall be the following:
(1) The diagnosis and clinical description of the health condition.
(2) The recommended treatment.
(3) The risks and consequences of accepting or rejecting the treatment.
(4) Other available alternatives for treatment, even if 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 treatment or the use of certain medications recommended.
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 minor or his/her parent with patria potestas or custody, legal guardian or person with provisional custody. The reason and determination of an emergency shall be included in the minor’s clinical record. It is herein provided that consent from parent with patria potestas or custody, legal guardian or person with provisional custody shall be obtained as soon as possible.
(i) Refusal of treatment. — The minor’s parent with legal or physical custody, legal guardian, or surrogate parent may refuse services for such minor from an institutional provider. This refusal includes medications and any other kind of service or therapeutic modality. Such refusal shall be stated and entered in the clinical record. However, the healthcare professional may use the procedures established in this chapter to provide medical treatment to the minor if he/she deems it to be clinically compelling to prevent such minor from inflicting harm upon him or herself or others of from damaging property.
The director or his/her representative shall inform the parent with legal or physical custody, the legal guardian or the surrogate parent of alternate services and treatments available, the risks and consequences that said minor may suffer by refusing such services, and the prognosis of receiving or refusing such services. However, in the event that the services or treatment required under the minor’s inter- or multidisciplinary treatment, recovery and rehabilitation plan are necessary in order to prevent a psychiatric or medical emergency situation whereby such minor may inflict immediate harm upon him/herself or others or damage property, or when such services have been ordered by the court, these shall be administered. The psychiatrist shall enter in the clinical record the emergency circumstances under which it was necessary to order said service or treatment. The minor shall be notified of said decision as soon as he/she is able to understand the information, as well as his/her parent with legal or physical custody or his/her legal guardian. This notification shall be entered in the clinical record.
Under no circumstance shall an order to provide or refuse to provide services or to administer medications shall be issued as punishment or as a condition to discharge the minor.
(j) Freedom of communication. — Every minor who receives services at an institutional provider shall have the right to communicate in private, with no censorship or impairment, with any person he/she chooses, save for persons who are the inflictors of physical, psychological, or sexual abuse upon the minor, and when it is determined by the intervening therapeutic team that said communication would bring about a declension in the minor’s condition.
(1) Correspondence. — The director of the providing institution shall make sure that the correspondence is received and deposited in the mail. Minors shall receive writing materials and stamps when they do not have the means to obtain them. All the letters regardless of the addressee shall be sent thereto without being examined by the authorities of the institution that provides mental health services. Minors shall receive answers to said letters, regardless of the sender and without being examined by the authorities of the institution that provides mental health services. If the minor does not know how to read or write, and upon his/her request, he/she shall be assisted whenever he/she wishes to exercise the 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 minor 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 minors subject to hospitalization may receive visitors. To that effect, he/she shall make public the schedule and place for said visits.
Institutions shall establish the rules for communication through other media, such as fax machines, email or courier service.
As pertains to forensic psychiatric institutions or institutions relative with the criminal justice system which provide mental healthcare services, the appropriate restrictions shall apply to conform to the nature of the services provided.
The foregoing notwithstanding, written communication, the use of the telephone, and visits to minors may be reasonably constricted by the director of the institution or his/her representative when there is a clinical finding that so warrants, insofar as said constriction has the purpose of protecting the minor 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, entered in the clinical record, duly justified, and notified to the minor, his/her parent with legal or physical custody or legal guardian, and his/her attorney, if any.
No constriction whatsoever shall apply between the minor and his/her father or mother, representative, legal guardian, or attorney, or the court, or between the minor and another person, when the communication is about matters relative to administrative or judicial proceedings.
(k) Personal effects. — Every minor 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 minor or others from any physical injury. When the minor is released, all of his/her personal property shall be returned.
(l) Money and deposits. — Every minor, his/her father or mother, representative or legal guardian, shall have the right to manage his/her 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 ensure that the money of the minors 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 minor who receives services in these institutions may use his/her money as the parent with patria potestas, legal guardian or authorized representative wishes him/her to 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 minors 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 parent with patria potestas, legal guardian or representative of a minor 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.
(m) Labor or work. — Any minor under treatment at an institutional provider may voluntarily agree to engage in labor or work for the institution. However, the minor may not be forced to engage in such labor or work.
It is hereby provided that the minor may be required to carry out maintenance duties or tasks in his/her room, or any other duty or task that is a part of his/her treatment, recovery, and rehabilitation plan, insofar as it inures to the minor’s benefit. The assignment of said tasks or duties shall be entered in the clinical record as part of the treatment, recovery and rehabilitation plan.
For-profit or nonprofit community-based organizations may request, as part of their community treatment and rehabilitation methodology, that participants of said programs carry out duties with no financial compensation, insofar as these are part of their treatment, recovery and rehabilitation plan and inure to the benefit of the minor. The assignment of such tasks or duties shall be entered in the clinical record as part of the treatment, recovery and rehabilitation plan, insofar as participants and their guardians have voluntarily agreed. However, said duties may not infringe upon the dignity and physical integrity of participants of any program, nor be contrary to the constitutional clause that prohibits involuntary servitude.
The foregoing notwithstanding, under no circumstance may any minor be required to carry out any duty or task as retaliation or punishment, or for the institution’s exclusive benefit.
(n) Grievances and complaints. — Any minor may, pro se or through his/her parent with legal or physical custody, legal guardian or surrogate parent, exercise his/her right to lodge grievances or complaints in relation to any violation of the rights described in this chapter. Furthermore, notice shall be given of the right to an impartial proceeding whereby such grievances or complaints are to be considered and elucidated fairly and expediently. When the petitioner does not agree with the determination made, he/she may resort to the Court of First Instance.
All institutional providers institution shall establish a system to manage grievances and complaints relative to the treatment and services being offered pursuant to this chapter. The procedure established to lodge grievances and complaints shall be disclosed to the minor who receives mental healthcare services, his/her father or mother, legal guardian, family members, visitors and the personnel that works at the institution.
All grievances and complaints shall be addressed and elucidated within a term of twenty (20) days. The minor, his/her parent with patria potestas, and/or legal guardian shall be notified in writing of the final determination made on the minor’s complaint even after having been discharged.
(o) Scientific research. — Any petition to conduct scientific research related to the minor 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 Governments 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 minor shall be submitted to any scientific investigation without having first obtained from his/her parent with patria potestas or custody, legal guardian, as the case may be, a written and legally effective informed consent.
The minimum information that shall be offered to the minor’s parent with patria potestas or custody, or legal guardian shall be made in 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 minor’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 describing that minor’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 minor or his/her parent with patria potestas or custody, or 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 confidentiality of the information of the minors who receive mental health services in relation to any type of scientific or exploratory investigations.
(p) Language. — Every minor 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 [minor] 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 [minor], 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 [minor] so determines it.
All written documentation furnished to the minor, the parent with patria potesta or custody, legal guardian or person with provisional custody, shall be issued in the language he/she understands. In those cases in which any of them 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 he/she was asked to read. The provisions of this section shall be included in the clinical record of the minor.
In these cases, the facts that generate the report or entry and the name of the issuer shall be clearly written into the record.
(q) 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 group or person. 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.
(r) Right to support from father, mother, guardian, and minors’ protective or assistance agencies upon discharge. — All minors institutionalized in a facility shall have the right to receive support from their parents, family members, and significant persons. Protective agencies with the obligation to provide shelter and care at the proper level shall provide these services as well as personnel trained to adequately serve minors with mental disorders at the lesser intensity setting with the greatest autonomy.
(s) Transportation. — Every minor shall have the right to transportation in an adequate vehicle, including ambulances certified by the Public Service Commission and the Department of Health when the severity of the symptoms and signs so requires it, to transport him/her to the facility where he/she will receive treatment.
If the minor, his/her parent with patria potestas or custody, legal guardian or person with provisional custody has the economic means, such as health coverage to pay for transportation expenses, these shall be paid by said coverage. In the case of persons who receive mental health services or interventions under the Health Reform, the entity contracted to handle and coordinate health services shall be responsible for covering the transportation expenses.
(t) Responsibility of the parent with patria potestas or custody, legal guardian or provisional guardian of the minor who receives mental health services. — It is hereby established that the above-mentioned persons who have a minor receiving mental health services shall comply with the following responsibilities:
(1) Assume responsibility for his/her recovery and promote that the minor assumes this responsibility according to his/her capacities.
(2) Participate in the self-sufficiency and community support activities and programs.
(3) Assume the responsibility of taking the minor to his/her treatments, participating in activities recommended, counseling and family therapies.
(4) As their income allows and whenever possible, contribute toward the payment for the services, according to the criteria established by Medicaid or the co-payment amounts established by medical health plans.
(u) Right to receive 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 minor 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 minor with a mental disorder can participate in the services directed toward his/her recovery, according to his/her level of capacity.
(v) Legal representation upon involuntary admission. — Any minor involuntarily admitted shall have the right to be represented by an attorney. If the minor is indigent, his/her parent with patria potestas or custody, legal guardian or provisional guardian has not been able to hire an attorney, the court shall designate one to represent him/her during the hearing.
(w) Less intensive level of care with greater autonomy. — Every minor 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.
(ñ) Experimental or exploratory procedures. — No minor 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 minor’s parent with patria potestas or legal guardian, as the case may be, shall give written and legally effective informed consent.
The minimum information that shall be offered to the minor’s parent with patria potestas or custody, or legal guardian 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 the minor’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 result for the participant than the experimental or exploratory procedure;
(5) a document stating that the minor’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 minor or his/her parent with patria potestas or custody, or legal guardian has any questions or suspects 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 minor subject to any experimental or exploratory procedure shall be notified in writing, though his/her parent with patria potestas or custody, legal guardian or person with provisional custody, 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 minor, as well as his/her parent with patria potestas or custody, legal guardian or person with provisional custody, has the right to end his/her participation in the experimental procedure, before or during the procedure.
History —Oct. 2, 2000, No. 408, § 7.06; Aug. 6, 2008, No. 183, § 37.