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2013

REPORT on monitoring of the human rights situation in psycho-neurological institutions in the Republic of Moldova

Contents
ACKNOWLEDGMENTS ................................................................................................................................................ 3 SUMMARY....................................................................................................................................................................... 4 GLOSSARY. Notions and terms for the care of people with mental deficiencies ............................................................ 5 INTRODUCTION ............................................................................................................................................................ 6

DESCRIPTION OF THE PSYCHO-NEUROLOGICAL INSTITUTIONS UNDER THE JURISDICTION OF THE MINISTRY OF LABOR, SOCIAL PROTECTION AND FAMILY OF THE RM ......................................... 9 The Brinzeni psycho-neurological boarding house ............................................................................................................ 9 The Badiceni psycho-neurological boarding house ......................................................................................................... 11 The Coceiri psycho-neurological boarding house ........................................................................................................... 11 The Balti psycho-neurological boarding house ................................................................................................................ 11 The Orhei boarding school for children with mental deficiencies (boys) ......................................................................... 12 The Hincesti boarding school for children with mental deficiencies (girls) ..................................................................... 12

MEDICAL CARE AND SUPERVISION (Admission to the facility) ........................................................................ 16 The Brinzeni psycho-neurological boarding house .......................................................................................................... 16 The Badiceni psycho-neurological boarding house ......................................................................................................... 21 The Cocieri psycho-neurological boarding house ........................................................................................................... 30 The Balti psycho-neurological boarding house ................................................................................................................ 45 The Orhei boarding school ............................................................................................................................................... 56 The Hincesti boarding school ........................................................................................................................................... 65

CONCERNS AND RECOMMENDATIONS .............................................................................................................. 73 Concerns regarding the respect of the right to hosting conditions of persons with mental deficiencies in psychoneurological institutions ................................................................................................................................................... 73 Recommendations regarding the respect of the right to mental health of persons with mental deficiencies in boarding schools .............................................................................................................................................................................. 78 Recommendations regarding the respect of the right to mental health of persons with mental deficiencies in psychoneurological institutions ................................................................................................................................................... 80

REFERENCES. National and international legal regulations regarding mental health ............................................... 81

ACKNOWLEDGMENTS
This report benefited from the generous support and valuable contributions of many people and organizations, by giving feedback on discussions, making available basic documents or carrying out researches. We are extremely grateful to Civil Rights Defenders for the professional and financial support for the implementation of the Project Advocacy for institutional changes and human rights of the persons within psycho-neurological institutions in the Republic of Moldova. Finally, we thank the Ministry of Labor, Social Protection and Family of the Republic of Moldova for the provided general information and for permeation to access the psychiatric institutions, as well as to accompany the working group by the Center for Human Rights of Moldova representatives on monitoring visits.

SUMMARY
This Report is the result of activities carried out within the Project: Advocacy for institutional changes and human rights of the persons within psycho-neurological institutions in the Republic of Moldova, implemented by Moldovan Institute for Human Rights. About Moldovan Institute for Human Rights The Moldovan Institute for Human Rights (IDOM) is an independent, non-profit organization, founded in 2007 by a group of jurists and human rights defenders, which aims to protect the fundamental human rights and freedoms. The members of IDOM are experienced in monitoring respect for human rights and adherence to the obligations that the Republic of Moldova accepted before the OSCE, the United Nations, the Council of Europe and other international organizations. IDOM conducts advocacy and litigation, informs specific groups, as well as the entire society on the most severe violations of human rights, caused by the ignorance of superior values of individual freedoms, social justice, equity and non-discrimination. The members of IDOM have contributed to writing reports on various human rights violations, followed by the analysis of the situation, analysis of cases, comparative analysis of national and international human rights legislation, recommendations for improving the situation addressed to authorities, etc. Main purpose of the visits This Report presents the results of monitoring the human rights situation in the psycho-neurological institutions in the Republic of Moldova under the jurisdiction of the Ministry of Labor, Social Protection and Family. Information gathered from the examination of institutions, legality of admission and maintenance conditions, from the analysis of personal files of the patients with mental deficiencies, as well as from the discussions with the medical staff, included in this Report, reflect the unique position of the Moldovan Institute for Human Rights towards these institutions, towards the existing normative acts, towards the practice used and methods of admission and also a unique position towards the maintenance conditions of people, including their treatment during their stay in psycho-neurological institutions.

GLOSSARY. Notions and terms for the care of people with mental deficiencies
Deficiency lack or insufficiency of certain mental, intellectual capacities. Its main symptoms are the following: a) cease or slowing of the rhythm of evolution, especially of organic functions; and b) reduction of social competence. Causes of mental deficiency may be: a) individual etiological cases; and) mental deficiency is the effect of several causes, which acted simultaneously or successively during the development. If according to the old paradigm (medical model) disability was a disease (illness), a pathological state of a person, which, actually, represented the root of all the problems faced by him/her, now, according to the new paradigm, disability is a situation resulting from the interaction between persons with impairments and attitudinal and environmental barriers (social model). The expression mental deficiency is used alternatively with mental handicap, mental delay, mental retardation, mental disability, mental debility. The term of mental disability tends to replace the other terms. According to the UN Convention on the Rights of Persons with Disabilities, persons with disabilities must be provided with support in exercising their legal capacity [Art. 12 par.(3)], including in controlling their own financial affairs [Art. 12 par. (5)]. This means that the vicious and discriminatory practice of depriving persons of their legal capacity (an universal and fundamental human right) by establishment of guardianship, must be abolished and the decision making support system for persons in need, must be introduced without depriving them of legal capacity, irrespective of the severity of their disability. According to UN Convention on the Rights of Persons with Disabilities, persons with disabilities are those who have long-term physical, mental, intellectual or sensory impairments which in interaction with various barriers may hinder their full and effective participation in society on an equal basis with others. Social assistance element of the social protection system, represents the group of facilities and measures by which the state, local public administration authorities and civil society ensure the prevention, limitation or removal of temporary or permanent effects of situations that might cause marginalization or social exclusion of a person. Community services (protection of persons with disability) Services that allow to take care of the patient in his/her natural life.

INTRODUCTION
Admission
The psycho-neurological boarding house is actually a specialized psychiatric institution for persons with chronic mental disorders. Therefore, the admission procedure must not differ from the procedure used by the Psychiatric Hospital. Considering their profound and severe mental disorders and that they are declared by courts incapable, the admission of beneficiaries in psychoneurological institutions is actually involuntary. Within the current procedure of involuntary admission, patients must undergo compulsory examination within 48 hours of their admission by a commission of psychiatrists of the facility. If the admission is founded, the commission of psychiatrists shall send, within 24 hours, appropriate notice to the court. The psychiatric inpatient admission request sent by the representative of the facility shall be examined by the judge within 3 days of its receiving. According to the Framework regulation for the functioning of boarding schools, approved by the Ministry of Labor, Social Protection and Family of the Republic of Moldova (2008), the boarding house is an institution for temporary or permanent placement, provider of social and medical services, for adults with mental disabilities. Beneficiaries of social services are persons who at one point may find themselves in a difficult situation generating marginalization or social exclusion when they have no support from their family or community and depend on third persons. The purpose of the boarding house is to ensure social protection to beneficiaries by providing recovery measures, maintenance of capacities and social (re)integration. The objectives of the boarding house are: to provide social and medical care to beneficiaries according to their special needs and characteristics of individual development; to help socialization and (re)socialization of beneficiaries in their extended biological family or in community. At the same time, according to the Instructions on accommodation of the patronized in social institutions under the jurisdiction of the Ministry of Labor, Social Protection and Family of the Republic of Moldova, approved by the same Ministry (No 61/227 of 16.02.2000) and Ministry of Health (No 06-34/188 of 16.03.2000), people with chronic mental disorders, people with disabilities and third age people who cannot take care of their own may be hosted temporarily or permanently in these social institutions.

Case referral to highly specialized social services


Case referral to highly specialized residential social services developed at a national level according to the Law on social services, Case referral mechanism in the social services system approved by the Order of the Ministry of Social Protection, Family and Child No 55 of 12.06.2009 (currently the Ministry of Labor, Social Protection and Family of the Republic of Moldova), is an activity carried out for a relatively low number of people with no legal tutor, residents of the Republic of Moldova under the law and it is usually accomplished by local structures at the suggestion of the community

social assistant only if there are valid reasons to believe that the medical and social services developed at the national level cannot satisfy the needs of the appliers. The case referred is accompanied by a set of documents according to the law which confirms the social status, health state and opportunity of intervention. The procedure of registration and record of persons referred is carried out in the ministry and in the local social assistance office. The accommodation letter of referral is issued depending on the beneficiarys health state and number of vacant places at the moment of service request. The scriptical evidence of beneficiaries is made by keeping records in the Registry of applicants for residential services, in the order of arrival of personal files and depending on the type of unit recommended by the Consulting Medical Commission under the Public Medical-Sanitary Facility.

Documents serving as legal basis for admission in the psycho-neurological boarding house: Minutes of the meeting of the Medico-pedagogical commission which recommends the admission in a specialized Institution for children with mental deficiencies, under the jurisdiction of the Ministry of Labor, Social Protection and Family of the Republic of Moldova. Medical observation sheet of the patronized. Welfare report of the person referred to admission, Court Decision which declares the incapacity of exercise of the patronized. Approval of the Ministry of Labor, Social Protection and Family of the Republic of Moldova. According to court decisions, people hosted in boarding houses have restrained capacity of exercise. But the direct admission to the boarding house and the term of admission does not depend on the court decision.

Range of services that should be provided by the psycho-neurological boarding house: accomodations, medical care, meals; services for the development of cognitive, communication and behavioral skills; recovery and rehabilitation services; support for educational inclusion; counseling of family members; and leisure activities.

Range of psychological, psycho-pedagogical and social interventions undertaken by psycho-neurological institutions


Adaptation to social needs and development of social habits are the quintessence of psycho-social interventions necessary for the institutionalized persons with severe mental deficiencies. Currently, the psycho-pedagogical specialists are using the following fields of psycho-social interventions to children with severe mental deficiency:

a) motor (general motility, fine motility and ocular-motor coordination, psychomotility). b) communication and language. c) cognitive (reading-writing-communication, mathematics, working with the concept of number). d) social-affective (personal and social autonomy, socio-affective maturity). Because of the lack of psycho-pedagogical specialists and crowding of the Hincesti boarding school with adults, the range of psycho-pedagogical interventions to children with severe mental disabilities are very limited. Also, they actually are reduced only to those elementary. It urges the Ministry of Labor, Social Protection and Family of the Republic of Moldova, responsible for the activity of the boarding school and psycho-neurological institutions, to develop national standards on Specialized medical assistance and Range of psycho-pedagogical, psychological and social interventions for the patronized with different stages of mental deficiency. Unfortunately, the range of interventions used for adaptation to social needs and development of social habits in the case of persons with severe deficiencies is very limited. This is caused by the health state itself, the mental deficiency and the lack of certain appropriate forms models of specialized interventions in such situations. Of the 315 persons hosted in the Hincesti boarding school for children with severe mental deficiencies, 310 had severe mental deficiency. Thus, the psycho-pedagogical interventions of the staff, medical assistants, educators and nurses are practically limited, according to the staff, only to: how to hold the spoon; how to use the toilet; how to wipe their mouths; how to stay at the table; how to listen to the staff.

The staff trained directly in medical assistance consists of: 7 doctors, paid by sponsors and 18 medical assistants paid from the budget; and in psycho-pedagogical interventions 19 persons, educators, paid from the budget. Considering the very low number of employees and the fect that the staff is trained in psychopedagogical interventions in two shifts, day-night, we can state that the psycho-pedagogical specialized support provided to those 315 persons hosted in the Hincesti boarding school is limited only to the supervision of beneficiaries and their physical care and nutrition. A part of the specialized equipment donated to the boarding house cannot be used for persons with severe deficiencies.

Legal rights to admission, medical care and release from psychoneurological institutions
Psycho-neurological institutions do not have an independent jurist to promote and protect the category of beneficiaries unable to exercise their capacity to act and defend their rights to admission to the boarding house, compulsory medical care in this facility, maintenance conditions; their rights to be involved in different educational psycho-social interventions and to be released from the boarding house. It is inconceivable that the facility does not have a jurist independent from its administration.

Accreditation of psycho-neurological institutions, public medico-social facilities


Psycho-neurological institutions are not subject to the accreditation applied to public medicalsanitary facilities under the jurisdiction of the Ministry of Health, which aims to establish their capacity to provide the population with appropriate medical assistance. Therewith, the institutions do not have clinical standards to provide medical services.

Descriptions of the psycho-neurological institutions under the jurisdiction of the Ministry of Labor, Social Protection and Family of the Republic of Moldova
The Brinzeni psycho-neurological boarding house is located in Brinzeni village, Edinet region, approximately 225 km from Chisinau. The boarding house is accessible by bus from Chisinau, Edinet, and some other neighboring localities. The road conditions to Brinzeni are poor and the traffic is slow. The institution has a kitchen with dining room, food storage, an animal farm, a greenhouse for vegetables as well as agricultural land and other unused auxiliary rooms. The majority of beneficiaries are former residents of orphanages for children with mental disabilities from the left bank of the river Nistru, who have been transferred to this institution after the start of the military conflict in 1992. Since 2004, the Brinzeni psycho-neurological boarding house hosts also chronic patients from psychiatric hospitals and the Orhei and Hincesti boarding schools . The official capacity of the Brinzeni psycho-neurological boarding house is 301, of whom, 79 had schizophrenia, 175 had mental disabilities and 47 had epilepsy. According to the doctors, 12 persons from the boarding house were placed in other facilities after being diagnosed with pulmonary tuberculosis. From 9 August 2013, the boarding house experienced a 12 -month tuberculosis outbreak. According to the statistical information presented by the administration of the Brinzeni psychoneurological boarding house, since 2 January.2013 there are 311 patients, of whom 183 are men and 128 are women.

Men : Age : 20 - 30 years 31 - 40 years 41 50 years 51 - 60 years 61 - 70 years over 70 years

No of persons : 22 36 51 52 4 4

Women : Age : 20 - 30 years 31 - 40 years 41 50 years 51 - 60 years 61 - 70 years over 70 years

No of persons : 16 34 24 34 12 8

From the total number-311 patients on 2 January 2013 Disabled people, I degree Disabled people, II degree Disabled people, III degree Bed-ridden

No 104 205 2 32

From the total number-311 patients on 2 January 2013 First-degree relatives Second-degree relatives Third-degree relatives

No 71 66 50

From the total number-311 patients on 2 January 2013 First-degree relatives Second-degree relatives Third-degree relatives Orphans (have no relatives)

No 71 66 50 124

From the total number-311 patients on 2 January 2013 Schizophrenia

No 81

10

Profound and severe mental retardation (total), Mild mental retardation Severe mental retardation Consequences of organic cerebral affections with dementia

177 20 157 20

63 of 311 patients do not have a Court decision. 248 of 311 patients do not have a legal representative. During 2012, from the total number of patients, 22 have been placed in the Psychiatric Hospital from Balti and 3 in the Phthisiology Hospital from Pavlovca, Briceni region. The Badiceni psycho-neurological boarding house is located 5 km from Badiceni village, in the Soroca region, covering12 hectares. The road to the institution is damaged and during winter, access is limited. The boarding house has an administrative building with a surface of 350 m2, built in 1957 and repaired in 2006; apartment building with two levels with a surface of 2100 m2, built in 1986 and partially repaired in 2005 (by changing the roof) and in 2010 (by changing the doors and windows); laundry room built in 1986; food storage built in 1985; boiler house built in 1986 and repaired in 2011. The electricity is delivered according to the agreement concluded with S.A. Red-Nord-Vest. The boarding house has an artesian well that provides drinking water and a coal boiler house. The sewer system is working, but it is old and needs to be reconstructed. The capacity of the Badiceni psycho-neurological boarding house is 460. On the visit day, in the Badiceni psycho-neurological boarding house there were 455 beneficiaries, of whom 241 men and 214 women. All the beneficiaries have identity cards, which are kept in personal files and have been paid from the budget of the institution. Depending on the nosological form, the beneficiaries are distributed: Schizophrenia Mental retardation Epilepsy with dementia Organic disorder with dementia No 117 277 25 36

The Coceiri psycho-neurological boarding house is located in Cocieri village, Dubasari region, 46 km from Chisinau. On the visit day, in the Cocieri psycho-neurological boarding house there were 346 beneficiaries, of whom 200 men and 146 women. The patients of the institution are from the age of 4 years and above and benefit from complete maintenance. The Balti psycho-neurological boarding house is located 3 km from the center of Balti, covering 45282,6 m2 , of which 8922,6 m2 are the total surface of the building and 36360 m2 the pertaining land. The patients of the institution are men and women of different ages who benefit from complete maintenance.

11

The Balti psycho-neurological boarding house began operating in August 1984. It has 4 apartment buildings for the hosted beneficiaries, outpatient department equipped with consulting rooms, treatment rooms, physical therapy, vaccination, massage rooms, clinical laboratory, dental departments, gynecological departments. The institution has a kitchen with dining room, food storage, events room, library, laundry room, autonomous heating system, houses for transportation units and other auxiliary rooms. The Orhei boarding school for children with mental deficiencies (boys) is a public institution of social assistance which provides placement services to children with mental disabilities towards their recovery, social and family rehabilitation and (re)integration. The Orhei boarding school is meant to be for children with mental disabilities from the age of 4 to 18 years. The capacity of the institution is 350. The boarding school is located in close proximity to Orhei and consists of a building with 4 levels and a building for hospitals boiler house. The Hincesti boarding school for children with mental deficiencies (girls) operates according to the Framework regulation for the functioning of boarding schools, approved by the Order of the Ministry of Labor, Social Protection and Family No 45 of 13.06.2008. The boarding school for children with mental deficiencies is a public institution of social assistance which provides placement services to children with mental disabilities towards their recovery, social and family rehabilitation and (re)integration. The Hincesti boarding school is meant for children with mental disabilities from the age of 4 to 18 years. From the total number of beneficiaries, 174 persons are over 18 years, respectively, 141 are underage. The youngest beneficiary is 4 years old and the oldest 52 years. On the visit day (11 January 2013) to the boarding school for children with mental deficiencies (girls) we found out that according to documents there were 315 patients, of whom only 141 were children (46 being bed-ridden) and 174 were adults (48 being bed-ridden). From the 94 bed-ridden persons, 68 were suffering from convulsions. Depending on the nosological form, from the total number of 221 No children and adults, persons not bed-ridden are distributed: Mild mental retardation Profound mental retardation Severe mental retardation Statistical dynamics from the last 3 years of beneficiaries presence in the boarding school, on the visit day is the following: 2011 2012 Hosted primarily 13 9 2 3 216

2013 7

12

From home From other facilities Released To relatives In other facilities Deceased

5 8 8 3 5 3

6 3 26 2 22 2

1 6 13 1 12 0

Financing of psycho-neurological institutions


The Brinzeni psycho-neurological boarding house: Total budget for facility 14834,8 thousand lei, of which 14834,8 thousand lei : 365 days =40,6 thousand lei. One day per person hosted in the boarding house: 311 beneficiaries = 1300 thousand lei (somatic1305,0). The Badiceni psycho-neurological boarding house: On 30 September 2013, the execution of the State budget was: according to the plan mentioned for the management period - 11697.8 thousand lei, financed 11532.8 thousand lei, effective costs 11707.1 thousand lei. The Hincesti boarding school: Plan mentioned for the year 2013:

lei

From the Budget Executed for 9 months, 2013 Effective costs for 9 months, 2013 Plan mentioned for the year 2013:

15268,6 thousand 10631,5 thousand 10770,7 thousand lei

Special means Executed for 9 months, 2013 Effective costs for 9 months, 2013 Humanitarian aid: Received for 9 months, 2013 Including: Food Medicines soft inventory

923,4 thousand 613,3 thousand 471,7 thousand 55,9 thousand 20,3 thousand 231,3 thousand

13

household materials and objects Spent Including: Food Medicines soft inventory household materials and objects

164,2 thousand 319,1 thousand 84,0 thousand Comparative characteristics. 26,1 thousand 67,9 thousand 141,1 thousand

From the discussions held with the management, the institution has received financing according to the established terms, the main source being the state budget and donors. No delays in salary payments have been noticed. Currently, the staff of this institution is worried about low salaries and insufficient staff members. There is no periodical independent monitoring on the expenditure of money and material resources (from the budget and donors) received by the boarding school. Therefore, it is impossible to monitor the expenditure of money and material resources for each beneficiary.

Maintenance costs of patients:

lei

Food according to the budget de facto Medicines according to the budget de facto Total per person/day: according to the budget de facto

32,10 32,70 5,94 6,96 10770,7 thousand 153,71 142,00

Staff of psycho-neurological institutions

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No

Insurance of boarding schools with health care staff Orhei Hincesti Unity According Occupied According Occupied with to staff with to staff natural persons scheme natural scheme persons Head doctor Therapist Psychiatrist Neurologist Dentist Pediatrician Gyneacologist 1.0 1.0 1.0 1.0 4.0 1 0.5 0.25 1.75 0.25 1.0 0.5 1.0 1.0 0.5 4.25 0.25 1 0.5 external parttime employment 0.5 external parttime employment 9 (8 sponsorships) 0.5 external parttime employment 11.75 (8 sponsors)

Professional doctors 1. 2. 3. 4. 5. 6. 7. TOTAL

Medium medical staff 1. Chief medical assistant 2. Medical assistant 3. 4. TOTAL Low medical staff 1. 2. Procedure medical assistant Medical assistant - masseur

1.0 17.0 1.0 3.0 22.0

1 11 1 3 15 2 96.5

1.0 18.0 1.0 1.0 21.0 108.0 20+2 (sponsorships) 1 1 24

Medical assistant Nurse

2.0 113.0

TOTAL 115.0 98.5 108.0 Other employees involved directly in the health care of beneficiaries 1. Speech therapist 1.0 1 2. Educators 8.0 9 19.0 3. Social assistants 3.0 2 1.0 TOTAL 12.0 12 20.0

186 (+78, parttime employment) 186 19 1 20

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MEDICAL CARE AND SUPERVISION (Admission to the facility)


The Brinzeni psycho-neurological boarding house
Living conditions: The boarding house has 3 apartment buildings with 2 levels. On each level there are a number of rooms/bedrooms, 1 rest room, 1 sanitary unit and 1 storage place for clothes and shoes, some of them have been donated and others have been bought by the institution. During the day and night, patients in each group are supervised by one nurse. The source of artificial light in each room is provided by bulbs, mounted on the ceiling, the light quality being satisfactory. Also, the windows are large enough to let the natural light come in during the day (in picture).

The boarding house is completely connected to an autonomous heating system, which has been broken for at least half of a year. They patients suffer from the cold and sleep two to a bed in order to stay warm. The electric heaters are also broken and beneficiaries have to wash themselves with cold water. According to what we have been told, the renovation of the heating system may take

16

Currently, the boarding house is in quarantine because of the tuberculosis outbreak. The institution does not have sufficient electric heaters to warm the rooms and the use of several electrical heaters overloads the electrical system. During the discussions with the staff, we found out that in certain groups there are no: Additional quilts; Bedside tables for personal belongings; The halls of the institution are moldy and there is a strong smell of cigarette smoke everywhere, because patients (especially men) smoke in halls and rooms (in picture).

17

Personal hygiene: The sanitary conditions in each unit were satisfactory (in picture).

18

19

The bathroom and sanitary unit are divided in two rooms. In one of the rooms there are two or three toilets (many of them broken) and one sink. In the other room there are one or two showers, which, according to certain nurses have not been used by patients for quite a long time, because the heating system does not work and there is no hot water. Many sanitary units of the institutions are broken and are not connected to the centralized sewer system. The floor is wet or there are large surfaces of water. The working group saw how a patient with locomotor disability had to go to the toilet through these surfaces of water and her clothes got wet eventually. According to the staff, all the beneficiaries have a face towel, soap and toothbrush. Dietary: Patients have meals four times a day, at preset hours (in picture-menu). We have to mention that, according to the chef, patients with special dietary needs have a separate menu, depending on their health state. The institution has a dining room for all the beneficiaries from the 3 buildings and to avoid overcrowding, they eat in groups, i.e., according to the building they are placed in (in picture).

20

From the discussions held with certain patients, we found out that the food and drinks (tea) are practically always cold, especially for the last group. The kitchen staff ensured us that the diabetics have a separate menu. According to certain beneficiaries, we found out that often the food is not enough or has no salt or sugar. Other occupational activities: The beneficiaries of the institution have the possibility to be involved only in the household activity (almost 10% of the patients).

The Badiceni psycho-neurological boarding house


Living conditions: The boarding house has 3 buildings with 2 levels. Two of them are apartment buildings: Building A and G and Building B is medical. Each group has a bedroom, sanitary unit and restroom equipped with a TV set, chairs and a table. The beneficiaries are eating here, because there is no dining room (in pictures).

21

During the day and night, patients in each group are supervised by one nurse and one medical assistant for six groups. The source of artificial light in each room is provided by bulbs, mounted on the ceiling, the light quality is being satisfactory, but unfortunately, in most of the groups, only 4 of the 8 bulbs are on, the others are pulled out or broken. Also, the windows are large enough to let the natural light come in during the day, but also to air the room, so there is no odor. During the cold time of the year, the facility is completely heated, having for that purpose a boiler house (in picture). The rooms temperature is relatively good and varies between 21-23C.

22

Clothes, shoes and bed linens are kept in wardrobes (in pictures). Some of the beneficiaries have personal bedside tables, which can be fastened with a lock in order to protect their personal belongings.

23

Most of the groups are clean. There are carpets on the walls and the floors are covered (in pictures).

24

25

Personal hygiene: The sanitary conditions in each unit were satisfactory. The humidity is high and varies between 71-76%. The walls and ceilings of certain rooms are moldy (in pictures).

26

27

The bathroom is separated from the sanitary unit by a concrete wall. In these rooms there are two toilets, one bath and two sinks. Each sanitary unit has hot water. Patients have the possibility to use the bathroom everyday for personal hygiene. Here were found large quantities of sodium chloride, which stood at hand patients (in pictures).

28

Dietary: Patients have meals three times a day, at preset hours. The facility has also special food storage: for meat, dairy products, berries, tins, fruits and vegetables. Other occupational activities: The beneficiaries of the institution have the possibility to be involved in tailoring and auxiliary household activities.

29

The Cocieri psycho-neurological boarding house


Apartment building: During the night, patients in each unit are supervised by 2 nurses and during the day by 1 nurse. The source of artificial light in each room is provided by bulbs, mounted on the ceiling, the light quality is being satisfactory during the night. Also, each room has windows which let the natural light come in during the day. There is no ventilation system, so the rooms are aired by opening the windows. The institution is completely connected to autonomous heating system. Bed linens were clean. They are changed once in 10 days. Most of the rooms on the 3rd floor are equipped only with beds, thus there are no individual bedside tables and wardrobes for clothes or other personal belongings (in pictures).

30

Whereas on the 1st and 2nd floor, we have noticed at least one bedside table or wardrobe in each room, where there between two and four beneficiaries (in pictures).

31

32

33

Each unit has a restroom for the patients. This is equipped with chairs or couches and a TV set (in pictures).

34

35

The institution has also a library, which is on the 2nd floor. It has Romanian and Russian literature: books, newspapers and magazines. Recently, the Adevarul Holding made a donation: several collections of universal literature, novels and fiction. According to the librarian, beneficiaries come often to the library. Dietary: Regarding the dining room, patients have meals three times a day and according to the director of this facility, the average daily spending for patients food is of 35,50 lei. We have to mention that, according to the chef, patients with special dietary needs (50 persons) have a separate menu, depending on their health state. The institution has also food storage. Storage and preparation of food is poor (in pictures).

36

37

According to the beneficiaries, some of them are satisfied with the food offered here, but some do not like it and say that it is not enough and they are often hungry. Others told us that they are periodically visited by their relatives who bring them food supplies. Personal hygiene: According to the nurse, patients take a bath twice a week: on Tuesdays and Fridays. The sanitary conditions were unsatisfactory on the 2nd and 3rd floor (in picture). Thus, these places need major repair and endowment with all the necessary.

38

39

40

41

The sanitary conditions were satisfactory on the 1st floor.

42

The sanitary unit has: 3rd floor, Group 3V and 3G: 2 toilets, 1 sink and 1 shower. 3rd floor, Group 3B: 2 toilets, 1 sink and 1 bath. 2nd floor, Group 2V: 2 toilets, 2 sinks and 2 showers. 2nd floor, Group 2 B i 2G: 2 toilets, 1 sink and 3 baths. 1st floor, Group 1V i 1 B: 2 toilets, 2 sinks and 2 showers. Patients receive shoes and clothes from their relatives or periodically from donations. The dirty clothes are collected in a room, where there is also the laundry. The clothes are washed, dried here and put in separate rooms, on separate shelves. According to the responsible person, in the morning some of them are dressed with clothes chosen at random, by size and others recognize and wear only their clothes (in pictures).

43

Here was found the existence of a detention place. The low qualified staff decides who is detained and for how long (in pictures).

44

The Balti psycho-neurological boarding house


Apartment building No 2 On the 4th floor there is the Unit for women. On the 3rd floor there is the Unit for men. On the 2nd floor there is the Unit for men and women. The most difficult unit regarding the provision of care services and medical assistance is the one which has almost 200 persons with severe mental disabilities: mental retardation, senile dementia etc., who are under a closer supervision in the Building No 2 (so-called secure care unit). Beneficiaries from this category are hosted in a separate building, with 4 levels and are under continuous supervision. There are 50-70 beneficiaries on each floor, supervised by 3 nurses: 1 man and 2 women. The beneficiaries are distributed depending on the severity of disability: on the 1 st floor there are hosted

45

persons with locomotor disabilities, on the 3rd and 4th floor persons in severe conditions and persons transferred from other units due to the deterioration of their mental health. The access doors to the units located on the 3rd and 4th floor are locked 24 hours a day. The majority of doors are open and the handles are removed. But certain doors have hanging locks, fastened on the visit day (in picture).

Some rooms had no bulbs (in picture).

46

The windows are grated. On average, there are 5-7 beneficiaries hosted in each room bulbs (in picture).

We have measured four rooms chosen at random on each floor: 3rd floor room with 9 beds measured 31,34 m2 (although there were 11 persons in this room); 4th floor room with 7 beds measured 30,76 m2 and room with 6 beds measured 17,42 m2;

47

2nd floor room with 4 beds measured 18,84 m2 According to the staff, enhanced security measures are necessary because the beneficiaries are very aggressive. On the 4th and 3rd floor the hosting conditions are unsatisfactory: there is a strong smell of urine, cigarette smoke, beds are old, some beds do not have mattresses or linens and the hall is dirty, the minimal necessary furniture is missing (bedside tables, chairs, wardrobes), in certain rooms switches are not running, the bulbs are missing and the concrete floor is full of holes and poses a threat to life and that is why it must be repaired as soon as possible (in pictures).

48

49

During the night, the clothes of beneficiaries are kept in separate rooms. In the morning they are dressed with clothes chosen at random, by size (in pictures).

There is no ventilation system, so the rooms are aired by opening the windows.

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On the 2nd floor the hosting conditions are better comparing to the other floors, because linens are clean, there are wardrobes and bedside tables, the floor is in good condition and in some rooms the floors are covered with carpets in good condition (in pictures).

The source of artificial light in each room is provided by a bulb, mounted on the ceiling, the light quality being satisfactory during the night (in pictures).

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The institution is completely connected to autonomous heating system. It is cold in the halls, since there are no heaters. Are not well warmed up either. During the visit, we have noticed that in the so-called Secure care unit there are periodically transferred not only persons with disturbances or deteriorated mental health, but also persons who

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consumed alcohol in excess, fought or aggressed other beneficiaries, who didnt listen to the staff or tried to escape from the facility. Apartment building No 3 On the 1st floor there are hosted persons with locomotor disabilities, but the elevators do not work and patients have difficulty in moving without help. On a whole, the hosting conditions are satisfactory. The windows are not grated. There are 1-2 beneficiaries hosted in a room, 4 at most. They are allowed to decorate their sace at their own will. They are allowed to put a telephone line in their room at their expense, to decorate the room with personal belongings (additional furniture, TV set, Microsystems etc.), lock their rooms. Beneficiaries from this building are allowed to choose their roommates and form couples. During the day, beneficiaries are not involved in recovery/resocialization and maintenance of capacities activities; their only occupation is to take care of the living spaces and to nurse bedridden beneficiaries. They go for a walk, play cards, watch television, talk. Dietary: Patients have meals three times a day, at preset hours. The 2nd, 3rd and 4th floor from Building No 2 (Secure care unit) has its own dining rooms, located on the same floor, but the conditions are unsatisfactory (in pictures).

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The facility has also a dining room for patients from the open care unit, who have meals in two turns, the average daily spending for patients food being of 30,40 lei. We have to mention that, according to the chef, patients with special dietary needs have a separate menu, depending on their health state. Bed-ridden patients have meals directly in their rooms. The facility has also a storage place for food supplies, food samples and for food preparation. Personal hygiene: The sanitary conditions in each unit were satisfactory (in pictures).

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The bathroom and sanitary unit are divided in three rooms. In one of the rooms there are 4 hands and foot wash sinks. In another room there are 4 shower units, isolated from each other by a special wooden wall. In the 3rd room there are 4 toilets. According to certain patients, they have a bath only once a week. According to beneficiaries: During the visit, we have discussed with more patients, who expressed their opinion regarding the life in the facility and the attitude of the staff towards them. Some of them are happy that they have a place to sleep and eat. Others want to go home, but their relatives do not have possibilities to take care of them.

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The Orhei boarding school


Apartment building: During the day and night, patients are supervised by a nurse, educator and medical assistant. The source of artificial light in each room is provided by a bulb, mounted on the ceiling, the light quality being satisfactory during the night. Also, each room has windows which let the natural light come in during the day. There is no ventilation system, so the rooms are aired by opening the windows. The institution is completely connected to autonomous heating system. It is clean here, thus the conditions are satisfactory. Each group from the 2nd floor has: rest room with a TV set, chairs and tables (in pictures 1, 2, 3, 4, 5, 6, 7); wardrobe for clothes and shoes (in pictures 8, 9, 10); bathroom equipped with 3 baths (in pictures 11, 12, 13); activity room (in pictures 14, 15); bedroom (in pictures 16, 17, 18); sanitary unit equipped with 4 toilets and 4 sinks, small compartments for towels, soaps and tooth paste (in pictures 19, 20, 21, 22). 1.

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Dietary: Patients have meals three times a day, at preset hours. The average daily spending for patients food is of 33 lei and it is completed, on need.

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We have to mention that, according to the chef, patients with special dietary needs have a separate menu, depending on their health state. The facility has also satisfactory food storage: for meat, dairy products, berries, tins, fruits and vegetables (in pictures).

Other occupational activities: The facility has an events room, a gym and a pool. There are often sporting and cultural competitions.

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The Hincesti boarding school


Sanitary conditions: According to the director, currently there are 92 bed-ridden girls, who always use wheelchairs. On the territory there are enough ramps to allow them to move. To this end, the director told us that they need some new wheelchairs (size 21-22), because a few of the existing have already broken. Living conditions: The beneficiaries are divided into 17 groups of 16-20 people and placed according to age and diagnosis, of which 1 group consists of 8 girls with the most severe mental and physical complications. The boarding school has 3 apartment buildings with 2 levels. Here persist orders (in pictures).

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During the night, patients in each group are supervised by 2 nurses and during the day by 1 medical assistant and 2 nurses. Clothes, shoes and bed linens are kept in separate wardrobes. Thus, each patient has her shelf with necessary clothes and shoes (in pictures).

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Personal hygiene: The sanitary conditions in each unit were satisfactory (in pictures).

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Dietary: Patients have meals four times a day, at preset hours. Sanitary conditions in the kitchen were satisfactory (in pictures).

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We have to mention that, according to the chef, patients with special dietary needs have a separate menu, depending on their health state. The facility has also food storage: for meat, dairy products, berries, tins, fruits and vegetables. Expired products have been found (51 milk packets and several candy boxes), (in picture).

Other occupational activities: The beneficiaries of the facility have the possibility to be involved in different activities, such as: embroidery, crocheting, drawing, music and dance. In the auxiliary household therhhhe are involved 10-15 girls. Other 10 girls learn to cook and set the table.

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The facility has also: An events room with capacity of 100 seats. Here, children organize concerts and various exhibitions. An equipped classroom. Here, children are taught necessary subjects, such as: Romanian, mathematics, history, geography, biology etc. A gym and a massage room.

Each year on 1 June, the international childrens day, meetings with patients parents and relatives are taking place. According to the director, we found out that shortly an Irish institution will provide financial support for the construction of a house in Hincesti for 12 girls from the boarding school, who will live there, cook by themselves, clear up etc. in order to reintegrate in society. Thus, their competences will be periodically monitored and analyzed to know if they have registered any progress to that effect.

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CONCERNS AND RECOMMENDATIONS


Concerns regarding the respect of the right to hosting conditions of persons with mental deficiencies in psycho-neurological institutions: The Brinzeni psycho-neurological boarding house
1. The maintenance conditions are unstable. The heating system is repaired in the middle of December, considering that the boarding house is in quarantine because of the tuberculosis outbreak. 2. Persons hosted in the boarding house do not benefit of legal support for the protection of their rights. We saw persons with visible bodily injuries (in picture). To that effect, there are no clear procedures regarding the recording of these injuries.

3. Bed-ridden beneficiaries are placed at the upper floors of the apartment building. 4. There is no independent person to monitor the distribution of goods, food, clothes, donations etc. to patronize. 5. The status of the staff, especially of the staff involved in education and treatment (doctors) is not empowered by the competent state institutions. 6. The boarding house keeps a large quantity of medicines, including anticonvulsant and psychotropic and there is no independent person to monitor their use. 7. The legacy of the therapeutic activity of doctors paid by donors is not clear. 8. Referral and detention in the boarding house does not have a LEGAL support.

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9. Contrary to national and international provisions, the Republic of Moldova ignores the creation of an independent national institution for the protection and promotion of the rights of persons with mental disorders and intellectual deficiencies hosted in psycho-neurological institutions. 10. IDOM is opened to competent national authorities to establish the violations of the rights of persons with mental disorders and intellectual deficiencies and to remove them from the existing normative acts and current practice.

The Badiceni psycho-neurological boarding house


1. During the visit, in the group No 10, a medical container for the storage of pills labeled (tizertsin psychotropic substances) was found in the bedside table of the nurse on guard. It contained 34 pills of different sizes, which have been taken away and transmitted to police officers who came on the scene at the request of the director of the boarding house (in picture).

Furthermore, a 500 ml container which contained a yellow liquid, with alcohol odor, was taken away from the same bedside table (in picture).

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2. In three groups there were insufficient beds for beneficiaries and in other groups the number of tableware (cups and spoons) was insufficient. 3. Beneficiaries in group No 18 had insufficient linen, thus, there were only 12 pairs of spare socks and 3 pairs of underwear for 21 patients. 4. In certain groups, patients are having meals in their bedrooms. Also, the dishes are washed here. 5. In certain sanitary units there were uncovered containers with sodium chloride, at the disposal of patients. 6. There was high humidity (71-77%) in certain wards and sanitary units. 7. Beneficiaries do not have spare individual clothes and shoes. 8. Nurses take away the pensions of certain beneficiaries.

The Cocieri psycho-neurological boarding house


1. During the visit we found out the following: - unsatisfactory conditions in the sanitary units, as well as the lack of hygiene products freely available to beneficiaries (soap, shampoo, toilet paper, tooth paste and toothbrush); - lack of appropriate accommodation for persons with physical disabilities, in wheelchairs, who do not have the possibility to go for a walk; - lack of bulbs, but also the broken source of artificial light; - existence of a detention place. The low qualified staff decides who is detained and for how long; - unsatisfactory conditions in the kitchen. 2. Persons hosted in the boarding house do not benefit of legal support for the protection of their rights. We saw persons with visible bodily injuries (in picture). To that effect, there are no clear procedures regarding the recording of these injuries.

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3. During the visit, beneficiaries complained about the use of physical force by the staff of the boarding house who hit with sticks and other tools (in pictures).

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The Balti psycho-neurological boarding house


1. During the visit we found out the following: - certain beneficiaries did not have identity cards; - two persons in one bed, but also female beneficiaries hosted with male beneficiaries in the same ward; - beneficiaries were engaged in physical work outside the boarding house; - certain beneficiaries take away the pensions of other beneficiaries; - expired medicines at medical workplaces; - the restroom was not equipped with special furniture and the beneficiaries were staying on the floor; - the electrical system was broken; - the floor was full of holes and posed a threat to life; - lack of mattresses and their replacement with pieces of sponge (in pictures).

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Recommendations regarding the respect of the right to mental health of persons with mental deficiencies in boarding schools:
1. No standards of professional care, general medical, psychiatric, psychological and social care of the patronized in the boarding schools in the Republic of Moldova have been developed and approved. 2. State institutions from this field approved, adhered and developed Laws, Government Decisions and Ministerial Orders in compliance with international practices. 3. By default of the standards of work, the medical staff, including the auxiliary one, trained in the care of the patronized limit their tactics, forms and range of care, taking into account life experience and advices from other colleagues. 4. The lack of medical and auxiliary professionals with elementary, middle and high education in the field, the worrying low number of employees, reduce their role only to the following activities: for persons with moderate mental deficiencies: - their supervision; - exclusion of the possibility of escape from facility; - prevention, in as far as possible, of aggressive incidents between the patronized; - other occupational activities are casual. for persons with severe mental deficiencies: - their supervision; - their food and dressing; - their escorting in and out the facility. persons with relapsed mental disorders and aggressive behavior: The Hincesti and Orhei boarding schools do not have the possibility to provide psychiatric care to beneficiaries. The number of employees is worryingly low and inadequately trained in psychiatric and psychosocial care of persons with mental disorders and aggressive behavior. 5. Also, there are no unique standards for completion of various registers with medical, psychosocial and other interventions used in relation to beneficiaries. Each institution completes the registries differently. Even the patronized are named differently etc. 6. The psycho-pharmacological treatment is used occasionally. The medical staff, especially the low and medium, applies sometimes this treatment voluntarily. 7. There is no independent institution in the Republic of Moldova to monitor the respect of beneficiaries right to health, use of medicines and food received from donations and sponsorships. Thus, the risk of violation of fundamental rights and freedoms of persons under long-term hospitalization is obvious. 8. Completion of medical and social acts, letter of referral to the boarding house from the place of residence or from other similar facility, is often superficial and does not contain details regarding the mental state and range of social skills of the beneficiary.

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9. Often the letter of referral to the boarding house of a person is based on the social factor and ignores the mental and social possibilities of the beneficiary to adapt or integrate partially in the community. 10. There is no effective mechanism of monitoring the respect of patrimonial rights of the patronized in boarding houses. Thus, the cases of beneficiaries expropriation are not excluded. 11. The nosological characteristics of the patronized in boarding houses reveals that most of the persons hosted in facilities have mental disabilities. Thus, according to international practices, the treatment, maintenance and release of persons hosted in the Hincesti and Orhei boarding houses are the same as those practiced by Psychiatric Hospitals. Thus, the standards of maintenance and of the staff must comply with these practices. The medical staff from the boarding schools paid from the State budget cannot practically ensure the minimal medical assistance. Comparative analysis depending on the nosological form of the beneficiaries from boarding houses: No Nosological form Boarding house Orhei Boarding house Hincesti Total Children Adults Total Children Adults Epilepsy 72 20 52 1. Schizophrenia 5 2 3 2. Mental retardation 136 43 93 315 141 174 3. Asthma 2 2 4. Blindness 14 9 5 5. Deafness 7 7 6. TOTAL - 551 236 76 160 315 141 174

12. Beneficiaries in boarding houses without a Court Decision regarding their capacity of exercise: The Hincesti Social Assistance and Family Protection Department, as guardianship authority, confirms that the Director of the Hincesti Boarding House is considered STATE GUARDIAN of the orphans and children left without parental care in the Hincesti boarding house for children with intellectual deficiencies. Medical acts of persons placed in boarding houses are officially sent to Court by ignoring the legislation in force regarding the judicial procedure of adopting court decisions on the establishment of guardianship. The case is not examined before sending to court the medical acts of beneficiaries, as required by law. 13. Furthermore, there is no regulation on the establishment of guardianship of the patronized. 14. Furthermore, it is also worrying the situation regarding the low medical staff, which, ultimately, ensures the personal care of persons with severe mental deficiencies, including of those bed-ridden. Of the 186 nurses of the Hincesti boarding house, 86 are paid by donors. Thus, the situation can get out of control and become disastrous if donors will stop paying the medical staff.

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Recommendations regarding the respect of the right to mental health of persons with mental deficiencies in psycho-neurological institutions:
1. According to the nosological structure of patronized, psycho-neurological institutions in the Republic of Moldova are psychiatric facilities for patients with chronic mental deficiencies. Thus, the qualified staff, trained in the attendance of beneficiaries must have knowledge and professional skills for the residential care of persons with chronic mental deficiencies. Thus, the necessary psychiatric assistance, including psychotropic and the services of psychological, psychotherapeutic and psycho-social intervention cannot be ensured by the current structure and number of qualified staff. No standards of work with persons with mental deficiencies placed in psycho-neurological institutions have been developed and implemented in the Republic of Moldova. Admission, medical care and release of patients from psycho-neurological institutions must be the same as from psychiatric facilities. Mental health reformin the Republic of Moldova must be completed with the role and needs of the psycho-neurological institutions under the jurisdiction of the Ministry of Labor, Social Protection and Family of the Republic of Moldova. Cooperation with the Department of psychiatry of the University of Medicine and Pedagogical University Ion Creanga would allow the Ministry of Labor, Social Protection and Family of the Republic of Moldova to develop standards of good practices in its subordinated facilities. The living conditions of patients should be adjusted to European standards.

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REFERENCES
National and international legal regulations regarding mental health:
Helsinki Declaration on Human Rights, 12-15 January 2005. UN Convention on the Rights of Persons with Disabilities (CDPD) adopted in New York by the UN General Assembly on 13 December 2006 and signed by the Republic of Moldova on 30 March 2007, ratified by the Law No 166/09.07.2010. The Republic of Moldova adopted the European Declaration on the Health of Children and Young People with Intellectual Disabilities and their Families: Better health, better lives: children and young people with intellectual disabilities and their families. Law on social inclusion of persons with disabilities No 169 of 09.07.2010. Strategy on social inclusion of persons with disabilities (2010-2013). Law No 60 of 30.03.2012 on social inclusion of persons with disabilities. National Program regarding the creation of an integrated system of social services (Government Decision No 1512 of 31.12.2008), by the Order No 353 of 15.12.2011 of the Ministry of Labor, Social Protection and Family of the Republic of Moldova. Law No 169 of 09.07.2010 for the approval of the Strategy on social inclusion of persons with disabilities (20102013). Law on mental health No 1402 din 16.12.1997. Government Decision No 1500 of 31.12.2004 for the approval of the Standard Regulation on functioning of the social residential institutions destined for elderly and persons with disabilities. Government Decision No 506 of 11.05.2006 for the approval of the natural norms for maintenance of persons hosted in social institutions. Government Decision No 520 of 15.05.2006 for the approval of the expenditure norms for maintenance of persons hosted in social institutions. Government Decision No 1025 of 28.12.2012 for the approval of the National Mental Health Program for the years 2012-2016. Framework regulation for the functioning of boarding schools. Instructions on accommodation of the patronized in social institutions under the jurisdiction of the Ministry of Labor, Social Protection and Family No 06-34/188 of 16.03.2000.

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