Primary Care Solutions Client Consent and Referral

Consent for Services

I agree to get the medical and mental health services suggested by the staff at Primary Care Solutions, like tests and counseling I agree to cooperate in the implementation of the services. I know that some information about my treatment will be shared with the insurance company to help keep track of care across the state.

 

Family Involvement Consent/Denial

I consent to have the family members listed below involved in the planning and delivery of the services that I shall be receiving during this period of service. I understand that, without this consent, the agency's employees will not be allowed to acknowledge to any family member that I am a consumer of their services.

It is the policy of Primary Care Solutions of Ohio to ensure that all verbal and written information of consumersserved is released in a manner that protects the individual's right to confidentiality and adheres to all HIPAArequirements. Information may not be released without the individual's written permission, except as the lawpermits or requires. Primary Care Solutions of Ohio will make reasonable efforts to limit the use, disclosure,and requests for private health information to the minimum necessary to accomplish the intend purpose.

Primary Care Solutions of Ohio ensure that all employees are aware of safety and liability issues related to
providing services. All programs comply with state and local fire, health, and safety codes.
Inspections and Compliance:
• Programs are inspected and approved annually by local and/or state fire, health, and safety agencies. Written
records of these inspections are maintained at each site.
• Any citations noted by fire and health authorities must be corrected, and documentation of these corrections
must be available at each location.
• Programs with existing sprinkler systems must have annual inspections conducted by licensed companies or
local fire authorities, with documentation retained at the site.
• A systematic pest control program will be implemented, with documentation maintained at each site.

• Scheduled fire equipment inspections will be conducted, which include:
o Annual inspections by an outside source (e.g., fire marshal, fire department representative) with a dated tag
on each unit.
o Monthly inspections by staff to verify equipment readiness, documented in a log or on the equipment.

Fire Extinguishers:
• Facilities will have operable 2A-108:C multi-purpose fire extinguishers in accessible locations. Maintenance
records must show that extinguishers are properly serviced and recharged as needed, at least once every six
years.
• Fire extinguishers that cannot be recharged must be replaced immediately.
Safety Equipment:
• Each facility is equipped with fire extinguishing equipment and alarms/detectors in areas where necessary
(e.g., flammable storage, kitchens, laundry rooms, garages).
• Carbon monoxide detectors are required in any building with natural gas or open flames, with at least one
detector per 1,000 square feet.
Emergency Exits:
• Clear diagrams of escape routes will be posted in visible locations throughout the facility, clearly indicating
exits.
• All exits will be adequately marked with lighted signs that remain visible at all times, with emergency lighting
equipped with battery backup.
• Windows that are part of the emergency exit must be operable from the inside without tools and provide a
minimum opening of 20 inches wide by 24 inches high.
Access and Safety Measures:
• No exit door will be locked when the building is occupied, unless an emergency system is in place that allows
it to unlock during emergencies.
• Exterior doors may have key-operated locks, provided a visible sign that states, "THIS DOOR MUST REMAIN UNLOCKED WHEN THE BUILDING IS OCCUPIED."

Facility Maintenance:

• The interior and exterior of each facility must be maintained safely and sanitarily, with furnishings kept clean
and in good repair.
• Facilities providing direct services will ensure operable hot water with temperatures set between 100- and
120-degrees Fahrenheit, measured quarterly.
• Emergency lighting systems will be tested monthly for at least 30 seconds and annually for 90 minutes, with
records of these tests maintained.
Utilities and Emergency Planning:
• Facilities will have operational utilities (water, sewer, air conditioning, heat, electricity) and must maintain a
written emergency action plan should utilities fail. This plan will be available for review.

GRIEVANCE PROCEDURES

1. Resolution of Issues:
Day-to-day concerns should be addressed informally between the consumer and their assigned staff member.
If the issue is not resolved satisfactorily, the Owners will follow the guidelines in this policy to facilitate access
to formal resolution procedures.

2. Contact Information:
If a client is uncomfortable discussing issues with PCS staff, they may call (888) 380-9990 for assistance.

3. Consumer Rights:
Consumers have the right to due process regarding grievances, and the organization will provide every
reasonable opportunity for informal and formal resolution.

4. Who Can File a Grievance:
Consumers who may file grievances include:
     o The individual receiving services
     o The guardian of the individual
     o An authorized attorney or representative from a rights protection or advocacy agency.

5. Protection Against Retaliation:
No individual will face disciplinary action or reprisal, including service denial or loss of privileges, because of
filing a grievance.

6. Grievance Process:
     o Notices explaining the right to due process and how to file grievances will be available at each facility.
     o Each individual will be informed of their right to file a grievance and to receive assistance from a
representative of their choice in an understandable manner.

7. Formal Grievance Rights:
During a formal grievance procedure, the individual has the right to:
     o Assistance from their chosen representative
     o Review information used in the grievance process, except information violating confidentiality
     o Present evidence and witness testimony relevant to the grievance
     o Receive complete findings and recommendations, except those violating confidentiality.

8. Burden of Proof:
The organization must demonstrate compliance with policies and procedures protecting consumer rights.

9. Filing and Responding to a Grievance:
     o Formal grievances must be submitted in writing to the supervisor or director of the relevant service unit or program.
     o The grievance will also be forwarded to the administrative head.
o The supervisor will meet with the grievant and/or their representative to discuss potential resolutions
promptly.
     o A formal written response will be provided within five working days, excluding weekends and holidays.

10. Grievance Details:
Each grievance must include:
• The date
• The approximate time of the incident
• A description of the incident and the names of individuals involved

11. Appealing a Grievance Decision:
If a grievant is not satisfied with the response, they may appeal to the Owner/CEO within five days, excluding
weekends and holidays. The Owner/CEO will respond within the same time frame.

12. Referral to Third Parties:
If the grievant remains unsatisfied with the findings, they may be referred to external organizations for
advocacy, such as protective services or professional licensing boards.

13. Training and Confidentiality:
All staff will receive training on these procedures during orientation and ongoing training as needed.
Grievances related to staff actions will follow personnel rules and contract provisions.

A Grievance Log will be maintained to record the nature of complaints, the investigation process, and
outcomes, ensuring participant confidentiality.

Record Retention:
All grievances will be kept for a minimum of two years, including:
1. A copy of the original grievance.
2. Documentation of the process and resolution.
3. Documentation of any circumstances extending resolution beyond 21 days.

DISCHARGE INFORMATION

We encourage discussions about your discharge to begin as early as possible. It is important for you to be
actively involved in this process and to understand the timeframe of the services provided.

You will be scheduled for an assessment appointment. Based on your needs following the assessment, you
may receive one or more of the following services:
1. Therapy
2. Case Management
3. Substance Abuse Treatment
4. Other:
Typically, you will be engaged in services for at least 3 months, but it may extend beyond 18 months,
depending on your progress in achieving your goals.
If you choose not to continue services or if you transition out of services and need assistance during a crisis,
please refer to the information below for additional services or contact your Primary Care Physician.

Nearest Local Hospital: The Christ Hospital - 2139 Auburn Ave, Cincinnati OH 45219

Nearest Local Crisis Center: Hamilton County Mental Health and Recovery Services – Mobile Crisis Team - 513-
584-5098 University of Cincinnati Medical Center Psych Emergency Room - 3188 Bellevue Ave, Cincinnati, OH
45219

Authorization to Disclose Information to Primary Care Physician

Effective communication between those who care for your mental health and those who care for your physical health (Primary Care Physician) is essential.

By signing this form, you are giving Primary Care Solutions (PCS) permission to share information related to your mental health services and treatment with your primary care physician. This information may include your diagnosis, treatment plan, and progress.

We will not release any information without your written consent.

I authorize Primary Care Solutions to release and/or communicate with the physician listed below regarding
my treatment:

Client Rights

You may revoke this authorization (permission to use or disclose information) at any time by contacting PCS. If you request to end this authorization, it will not affect any information that has already been used or disclosed based on your prior consent.

Signing this form is not a requirement for treatment, enrollment, or eligibility for benefits.

Please be aware that the information disclosed because of this authorization may be re-disclosed by the recipient and may no longer be protected by law.

Patient Authorization:

I, the undersigned, understand that I may revoke this consent at any time, except to the extent that action has already been taken based on it. This consent will expire one year from the date of signature unless another date is specified. I have read and understand the information provided above and give my authorization.

CLIENT CHOICE OF SERVICES AND PROVIDERS

Primary Care Solutions is committed to ensuring that consumers have the right to choose the services they qualify for and to select their preferred providers.

By signing this form, you acknowledge that you, as a consumer, have the right to choose relevant services and which provider delivers those services. You also confirm that no employees of Primary Care Solutions have influenced your choice of services or providers in any way.

Our services have been explained in clear, non-technical language, including the risks, benefits, and alternatives to the proposed treatment. My signature below indicates my consent to treatment for services provided.

Chosen Provider: Primary Care Solutions of Ohio

I understand that Primary Care Solutions has not influenced my decision in any way.