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Assurance of Civil Rights



ODMH 5122-2-1-02; 5122-26-18

ODJFS 5101:2-5-35; 5101:2-5-13 (A) (35)


ODMRDD 5123.62




This policy clarifies and establishes procedures for the protection of the civil rights of all clients and families served by Anthony’s Villa and apply to all facilities, programs, and contractors providing services to clients.


For Compliance with OAC 5101:2-5-13(A)(25):

Pursuant to the Ohio Civil Rights commission, protection of a child’s civil rights means the protection of the child against unlawful discrimination because of the race, color, religion, sex, military status, national origin, disability, age, or ancestry.



  1. It is the expectation of all ANTHONY’S VILLA employees and contractors that the rights of clients and families be recognized and protected.  A review of client rights and grievance procedure will be a mandatory part of each employee’s orientation.  ANTHONY’S VILLA acknowledges clients rights per Sections 5101:2-5-35 (foster care, respite, adoption), 5122:2-1-02 (mental health treatment),     and 5123.62 (MR/DD services) of the Ohio Revised Code, and those as outlined by COA under Rights of Persons Served.


Specific client rights and grievance procedures are addressed with the client, following all provisions within these standards as applicable to the service provided to the client.


The rights of the person served will be communicated:

  1. In a manner appropriate to the age and understanding of the client;    

  2. Prior to the beginning of service delivery or at the initiation of service delivery;

  3. Annually for persons served longer than one year.


  1. A list of client rights and grievance procedures will be given and explained to each new client upon admission to services or within the next subsequent appointment. Efforts will be made to assure that the client receives a list of client rights and grievance procedure within five (5) days of service admission/placement whenever possible. Client rights will include, but not limited to thetitle, location, hours of availability and telephone number of the designated Client Rights Officer (CRO).  Client rights will be also explained and provided as appropriate in the case of emergency referral. 


  1. When informing clients about their rights, staff will assure that the client has the capacity to understand the material needed.  Information will be reviewed with the client, read as necessary; with the provision of an interpreter should the client not have English as his/her primary language or have special communication needs, such as a hearing impairment.


  1. The grievance procedure will clarify the role of the CRO, to include a statement of that person’s responsibilities to accept and oversee the process of any grievance filed by a client or other person or agency on behalf of a client.  All staff will receive an orientation on Client Rights as part of the agency orientation and will be expected to be able to explain any and all aspects of client rights and the grievance procedure upon request.


  1. In the event of a crisis or emergency situation, the client will be verbally advised of their immediately pertinent rights, including the right to consent to or refuse the offered treatment and the consequences of that consent and/or refusal.  A written copy of client rights and grievance procedure will be provided no later than the next subsequent meeting.


  1. Should ANTHONY’S VILLA provide “community services” to clients (to include information and referral, consultation, mental health education, prevention and/or training service), clients may receive a copy and explanation of the client rights policy upon request.


  1. Each office operated by the agency will have posted in a conspicuous location the client rights policy.  Staff will immediately advise any client about how to access the Client Rights Officer and the right to file a grievance when concerns or questions arise.


  1. The agency CRO will assure the keeping of records of grievances received, the subject matter of grievances and the resolution of the grievances.  Grievances should contain all required information as indicated by the Ohio Administrative Code, to include the date, time, description of the situation and the names of the individuals involved. Agency records will be made available to regulating bodies as required by the Ohio Revised Code.  Per reporting requirements, ANTHONY’S VILLA will submit annual summary reports to mental health boards, detailing the number of grievances received, the type of grievance and the resolution status of grievances. 


  1. In the event that the client rights complaint is against the CRO, the Executive Director or designee will be responsible for assisting the client and addressing the grievance.


  1. The agency will maintain for two (2) years the records of written grievances to include  a copy of the grievance (signed and dated by the client), documentation of the grievance resolution and a copy of the letter to the grievant reflecting the resolution. All client information is to be maintained within the requirements of client confidentiality standards.




  1. Per CARF, ANTHONY’S VILLA will specify to all behavioral health clients their rights as follows:


  1. Confidentiality of information

  2. Privacy

  3. Freedom from:

    1. Abuse: physical or emotional harm

    2. Financial or other exploitation: someone taking advantage of you by trying to take money or valuables from you

    3. Retaliation: someone trying to get back at you in any way for telling that your rights are being violated or complaining about how you are being treated

    4. Humiliation: being made to feel ashamed or degraded

    5. Neglect: not having your emotional or physical needs meet.


Additional Rights Include:

  1.  Access to information pertinent to person served in sufficient time to facilitate his or her decision making.

  2. Informed consent or refusal or expression of choice regarding:

  1. Service delivery: the type of services you are getting from ANTHONY’S VILLA, how you are getting them and preferences you may have

  2. Release of information

  3. Concurrent services

  4. Composition of the service team

  5. Involvement in research projects

    1. Access or referral to legal entities for appropriated representation

    2. Access to self-help and advocacy support groups

    3. Adherence to research guidelines and ethics when persons served are involved as applied

    4. Investigation and resolution of alleged infringements of right

    5. Other Legal Rights


  1. Per Ohio Revised Code, 5101:2-5-35 (Foster care, Respite, Adoption), ANTHONY’S VILLA will specify to clients their rights as follows:


(1)      The right to enjoy freedom of thought, conscience, and religion or to abstain from the practice of religion.


(2)      The right to reasonable enjoyment of privacy.


(3)      The right to have his or her opinions heard and be included, to the greatest extent possible, when any decisions are being made affecting his life.


(4)      The right to receive appropriate and reasonable adult guidance, support, and supervision.


(5)      The right to be free from physical abuse and inhumane treatment.


(6)      The right to be protected from all forms of sexual exploitation.


(7)      The right to receive adequate and appropriate medical care.


(8)      The right to receive adequate and appropriate food, clothing, and housing.


(9)      The right to his own money and personal property in accordance with the child's service or case plan.


(10)    The right to live in clean, safe surroundings.


(11)    The right to participate in an appropriate educational program.


(12)    The right to communicate with family, friends and "significant others"

from whom he is living apart, in accordance with the child's service or case plan.


(13)    The right to be taught to fulfill appropriate responsibilities to himself and to others.


  1. Per Ohio Revised Code, 5122:2-1-02 (mental health treatment), ANTHONY’S VILLA will specify to clients their rights as follows:



“Client” means a person asking for or receiving mental health services from an agency. For a minor, this includes a parent/guardian acting in behalf of the youth.


All who access mental health services are informed of these rights:


(a) The right to be informed of the rights described in this rule prior to consent to proceed with services, and the right to request a written copy of these rights;


(b) The right to receive information in language and terms appropriate for the person’s understanding; and


(c) The right to be fully informed of the cost of services.


(2) Services are appropriate and respectful of personal liberty:


(a) The right to be treated with consideration, respect for personal dignity, autonomy, and privacy, and within the parameters of relevant sections of the Ohio Revised Code and the Ohio Administrative Code;


(b) The right to receive humane services;


(c) The right to participate in any appropriate and available service that is consistent with an individual service plan (ISP), regardless of the refusal of any other service, unless that service is a necessity for clear treatment reasons and requires the person’s participation;


(d) The right to reasonable assistance, in the least restrictive setting; and


(e) The right to reasonable protection from physical, sexual and emotional abuse, inhumane treatment, assault, or battery by any other person.


(3) Development of service plans:


(a) The right to a current ISP that addresses the needs and responsibilities of an individual that specifies the provision of appropriate and adequate services, as available, either directly or by referral; and


(b) The right to actively participate in periodic ISP reviews with the staff including services necessary upon discharge.


(4) Declining or consenting to services:


(a) The right to give full informed consent to any service including medication prior to commencement and the right to decline services including medication absent an emergency;


(b) The right to be advised of and refuse observation by techniques such as one-way vision mirrors, tape recorders, televisions, movies, or photographs, or other audio and visual technology. This right does not prohibit an agency from using closed-circuit monitoring to observe seclusion rooms or common areas, which does not include bathrooms; and


(c) The right to decline any hazardous procedures.


(5) Restraint, seclusion or intrusive procedures: The right to be free from restraint or seclusion unless there is imminent risk of physical harm to self or others.


(6) Privacy: The right to reasonable privacy and freedom from excessive intrusion by visitors, guests and non agency surveyors, contractors, construction crews or others.


(7) Confidentiality:


(a) The right to confidentiality unless a release or exchange of information is authorized and the right to request to restrict treatment information being shared; and


(b) The right to be informed of the circumstances under which an agency is authorized or intends to release, or has released, confidential information without written consent for the purposes of continuity of care as permitted by division (A) of section 5122.31 of the Revised Code.


(8) Grievances: The right to have the grievance procedure explained orally and in writing, the right to file a grievance, with assistance if requested; and the right to have a grievance reviewed through a grievance process, including the right to appeal a decision.


(9) Non-discrimination: The right to receive services and participate in activities free of discrimination on the basis of race, ethnicity, age, color, religion, gender, national origin, sexual orientation, physical or mental handicap, developmental disability, genetic information, human immunodeficiency virus status, or in any manner prohibited by local, state or federal laws.


(10) No reprisal for exercising rights: The right to exercise rights without reprisal in any form including the ability to continue services with uncompromised access. No right extends so far as to supersede health and safety considerations.


(11) Outside opinions: The right to have the opportunity to consult with independent specialists or legal counsel, at one’s own expense.


(12) No conflicts of interest: No agency employee may be a person’s guardian or representative if the person is currently receiving services from said facility.


(13) The right to have access to one’s own psychiatric, medical or other treatment records, unless access to particular identified items of information is specifically restricted for that individual client for clear treatment reasons in the client’s treatment plan. If access is restricted, the treatment plan shall also include a goal to remove the restriction.


(14) The right to be informed in advance of the reason (s) for discontinuance of service provision, and to be involved in planning for the consequences of that event.


(15) The right to receive an explanation of the reasons for denial of service.



  1. Per Ohio Revised Code, 5123.62 (MR/DD services), ANTHONY’S VILLA will specify to clients their rights as follows:

(A) The right to be treated at all times with courtesy and respect and with full recognition of their dignity and individuality;


(B) The right to an appropriate, safe, and sanitary living environment that complies with local, state, and federal standards and recognizes the persons’ need for privacy and independence;


(C) The right to food adequate to meet accepted standards of nutrition;


(D) The right to practice the religion of their choice or to abstain from the practice of religion;


(E) The right of timely access to appropriate medical or dental treatment;


(F) The right of access to necessary ancillary services, including, but not limited to, occupational therapy, physical therapy, speech therapy, and behavior modification and other psychological services;


(G) The right to receive appropriate care and treatment in the least intrusive manner;


(H) The right to privacy, including both periods of privacy and places of privacy;


(I) The right to communicate freely with persons of their choice in any reasonable manner they choose;


(J) The right to ownership and use of personal possessions so as to maintain individuality and personal dignity;


(K) The right to social interaction with members of either sex;


(L) The right of access to opportunities that enable individuals to develop their full human potential;


(M) The right to pursue vocational opportunities that will promote and enhance economic independence;


(N) The right to be treated equally as citizens under the law;


(O) The right to be free from emotional, psychological, and physical abuse;


(P) The right to participate in appropriate programs of education, training, social development, and habilitation and in programs of reasonable recreation;


(Q) The right to participate in decisions that affect their lives;


(R) The right to select a parent or advocate to act on their behalf;


(S) The right to manage their personal financial affairs, based on individual ability to do so;


(T) The right to confidential treatment of all information in their personal and medical records, except to the extent that disclosure or release of records is permitted under sections 5123.89 and 5126.044 of the Revised Code;


(U) The right to voice grievances and recommend changes in policies and services without restraint, interference, coercion, discrimination, or reprisal;


(V) The right to be free from unnecessary chemical or physical restraints;


(W) The right to participate in the political process;


(X) The right to refuse to participate in medical, psychological, or other research or experiments.








  1. Clients have the right to file a grievance with Anthony's Villa by submitting a written complaint to the client advocate or their assigned therapist.

  2. The client advocate or assigned therapist will assist the client in completing the written complaint.

  3. The written complaint must include the date, approximate time, description of the incident, and names of individuals involved in the incident or situation being grieved.

  4. The written complaint must be dated and signed by the client or have an attestation by the client advocate or assigned therapist that the written complaint is a true and accurate representation of the client's grievance.

  5. The client advocate or assigned therapist will provide a written acknowledgement of receipt of the grievance to the client within three business days of receipt of the grievance.

  6. The client's grievance will be reviewed and investigated by the appropriate staff member(s).

  7. A resolution decision on the grievance will be made by Anthony's Villa within twenty business days of receipt of the grievance. If extenuating circumstances indicate that this time period will need to be extended, a written notification will be given to the client.

  8. The client will be informed of the resolution decision in writing, which will include a summary of the investigation and decision reached.

  9. Clients have the option to file a grievance with outside organizations, including but not limited to the applicable board of alcohol, drug addiction, and mental health services, Ohio department of mental health and addiction services, Disability Rights Ohio, or the U.S. department of health and human services, civil rights regional office in Chicago.

  10. Internal reporting of grievances will be to:

    1. Executive Director or Compliance Officer

    2. Via email at

    3. Via mail at: Anthony’s Villa c/o Grievances PO Box 337, Sandusky, OH 44871

    4. Via website at:

    5. In person with Compliance officer, CEO, or board of directors


Client Advocate:

  1. Anthony's Villa will designate a client advocate to assist clients with filing grievances and ensuring their rights are protected.

  2. The client advocate's name, title, location, hours of availability, and telephone number will be included with the posting of client rights.

  3. The client advocate will be available to assist clients in filing grievances and preparing written complaints.

  4. The client advocate will ensure that clients receive written acknowledgement of receipt of their grievances and are informed of the resolution decision.



The outside organization may be one of the following:


Ohio Department of Jobs and Family Services

899 East Broad St., 4th Floor

Columbus, Ohio 43205

      (614) 466-2738

     Ohio Legal Rights Service
    50 West Broad Street, Suite 1400
    Columbus, Ohio 43215-5923
    Phone: 614-466-7264 or 1-800-282-9181

     TTY: 614-728-2553 or 1-800-858-3542


U.S. Dept of Health and Human Services

Office for Civil Rights-Region
      233 N. Michigan Ave., Suite 240
      Chicago, IL 60601
      Voice Phone (312)886-2359; FAX (312)886-1807; TDD (312)353-5693


Ohio Department of Mental Health

30 East Broad Street, 8th Floor

Columbus, OH 43266-0414

614-466-2333; fax: 614-466-1571

Toll-free: 1-877-275-6364;

TTY: 1-888-636-4889


Licking County Mental Health Services Board

Or you may contact the Mental Health Board

representing your local community or county of original residence (in cases of foster care

placements out of county)


Counselor, Social Worker, Marriage and

Family Therapist Board

50 W. Broad St. Suite 1075

Columbus, OH 43215-5919

Tel: (614) 466-0912; (fax) (614)728-7790


    Attorney General’s Office  

        Medicaid Fraud Control Unit

30 E. Broad Street., 14th Floor

Columbus, Ohio 43215

1-800-282-0515 or 614-466-2986


State of Ohio, Department of Developmental Disabilities
30 East Broad Street, 13th Floor

Columbus, Ohio 43215


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