WRAP Compliance and Audit - sixsigma-tqm.in

WRAP Compliance and Audit is an excellent and crucial topic, especially in the healthcare and social services sectors. Let’s break down the “Rights of People” in the specific context of WRAP (Wellness Recovery Action Plan) compliance and auditing.

Understanding the Core Principle

At its heart, WRAP is a person-centered, empowerment model. It is built on the fundamental belief that the individual is the expert on their own life and wellness. Therefore, the “Rights of People” are not just an add-on; they are the very foundation of the entire WRAP process.

A WRAP audit, whether internal or external, will heavily scrutinize how an organization upholds these rights.

The Key Rights of People in a WRAP Context

These rights are derived from the values and ethics of the WRAP model, primarily focusing on self-determination, dignity, and respect.

1. The Right to Self-Direct and Lead the Process

This is the most critical right. The individual (often called the “WRAP facilitator” for their own plan) has the right to:

Create their own WRAP: It is their plan, based on their experiences, strengths, and goals.
Choose what to include: They decide the content of their Wellness Tools, Triggers, Early Warning Signs, and Crisis Plan.
Control the pace: They decide how quickly or slowly they develop their plan.
Decide who is involved: They choose who, if anyone, they want to share their WRAP with (peers, family, clinicians).

Audit Check: An auditor will look for evidence that the plan is written in the person’s own words and that staff/facilitators act as supporters, not directors.

2. The Right to Privacy and Confidentiality

The WRAP often contains highly sensitive and personal information.

Control Over Access: The individual has the sole right to decide who sees their WRAP. It is a personal document, not automatically a part of a clinical chart unless the person consents.
Informed Consent for Sharing: Any sharing of the WRAP with providers, family, or other agencies must be done with the explicit, informed, and voluntary consent of the individual.
Secure Storage: Organizations must have protocols for storing WRAPs securely, respecting their confidential nature.

Audit Check: An auditor will review consent forms, data storage policies, and interview staff and individuals about who has access to WRAPs and under what circumstances.

3. The Right to Make Informed Choices (Including “Risky” Ones)

WRAP is based on the principle of personal responsibility. This includes the right to make choices that others might perceive as unwise or risky, as long as they do not harm others.

Including Unconventional Wellness Tools: An individual has the right to list tools that work for them, even if they are not mainstream or clinically endorsed (e.g., “listening to a specific song,” “walking in the rain”).
Defining Their Own Crisis Plan: The individual defines what a “crisis” looks like for them and specifies what they do and do not want to happen (e.g., “I do not want to be taken to Hospital A,” “Please contact my sister first”).

Audit Check: An auditor will look for evidence that staff respect these choices, even when they disagree, and that the individual’s crisis plan is the primary guide during a difficult time.

4. The Right to Be Treated with Dignity and Respect

This right underpins all interactions.

Non-Coercion: Participation in creating or using a WRAP must be voluntary. It cannot be mandated as a condition for receiving services.
Person-First Language: Language used by staff and in documentation must be respectful and person-centered, avoiding labels and stigmatizing terms.
Valuing Lived Experience: The individual’s lived experience is valued as expertise.

Audit Check: Auditors will observe interactions, review communication policies, and interview individuals about how they are treated by staff.

5. The Right to Revoke or Change Their WRAP at Any Time

A WRAP is a living document. The individual has the right to:

Update it: Change their wellness tools, triggers, or crisis plan as their life and recovery evolve.
Revoke consent: Withdraw permission for someone to have access to their WRAP.
Stop using it: Decide they no longer wish to use the WRAP process.

Audit Check: An auditor will verify that processes are in place for individuals to easily update their plans and that revocations of consent are honored immediately.

WRAP Compliance and Audit: What is Being Measured?

A WRAP audit assesses whether an organization is implementing the WRAP model with fidelity to its core values, which are inseparable from the rights of people.

An organization is NOT in compliance if:

Staff write the WRAP for the person.
WRAPs are stored in the main clinical file without explicit consent.
The crisis plan is ignored during a crisis in favor of standard clinical protocol.
Participation is required for program eligibility.
Individuals are pressured to share their WRAP in team meetings.

An organization IS in compliance if it can demonstrate:

Policies and Procedures: Written policies that explicitly protect the rights outlined above (confidentiality, self-direction, informed consent).
Staff Training and Competency: Evidence that all staff (not just WRAP facilitators) are trained on the ethics and values of WRAP and understand their role in upholding individuals’ rights.
Documentation: Clean, clear consent forms, WRAPs written in the individual’s own words, and records of plan reviews and updates initiated by the individual.
Individual Feedback and Outcomes: Surveys, interviews, and feedback mechanisms that show individuals feel in control of their WRAP and that their rights are respected. Positive outcomes related to increased self-efficacy and hope are strong indicators of compliance.

Summary Table: Rights vs. Audit Evidence

Right of the Person	What an Auditor Will Look For (Evidence of Compliance)
Self-Direction	WRAPs in person’s own handwriting/words; staff training records on person-centered facilitation; individual testimonials.
Privacy & Confidentiality	Secure storage systems; signed consent forms for sharing; policies on information governance.
Informed Choice	Crisis plans that include “do nots”; documentation showing staff respected a person’s choice even when concerned.
Dignity & Respect	Person-first language in notes; absence of mandates for WRAP participation; observation of respectful interactions.
Revoke/Change	Processes for easy plan updates; logs showing plans are reviewed; evidence consent was revoked and honored.

In conclusion, ensuring the “Rights of People” is the definitive measure of true WRAP compliance. An audit is not just a check-box exercise; it is a deep dive into the culture of an organization to ensure it is truly empowering individuals on their recovery journey.

What is Required WRAP Compliance and Audit

Courtesy: GCL International Ltd

The Core Shift: From Philosophy to Mandatory Practice

The “Required Rights” are the non-negotiable, operationalized principles that an organization must uphold to be certified as providing WRAP with fidelity. An audit will test for concrete evidence of each right.

The Required Rights & The Audit Evidence

For each right, there are specific, auditable actions and documents that prove compliance.

1. The Right to Self-Direction and Ownership

Requirement: The individual must be the undisputed author and owner of their WRAP. It is their personal property and plan for their life.
Audit Evidence:
- Document Inspection: The WRAP document itself is written in the first person (“I,” “my,” “me”) and in the individual’s own words (or transcribed verbatim). It does not sound like a clinical assessment.
- Staff/Individual Interviews: Auditors will interview individuals and ask: “Who decided what went into your WRAP?” The answer must indicate the individual led the process. Staff must describe their role as a “facilitator” or “supporter,” not a “director” or “creator.”
- Policy Review: Organizational policies must state that WRAPs are person-directed and owned by the individual.

2. The Right to Voluntary Participation and Freedom from Coercion

Requirement: Creating or using a WRAP cannot be mandated as a condition for receiving services, housing, or any other benefit.
Audit Evidence:
- Policy and Procedure Review: The organization’s official WRAP policy must explicitly state that participation is voluntary.
- Individual Interviews: Auditors will ask individuals if they felt pressured or required to create a WRAP. A single “yes” can trigger a deep dive and potentially a compliance failure.
- Program Materials: Brochures and intake materials must describe WRAP as an “option” or “available tool,” not a “program requirement.”

Requirement: The individual must provide explicit, informed, and revocable consent for anyone to view or use their WRAP.
Audit Evidence:
- Signed Consent Forms: The auditor will inspect consent forms. These forms must be specific, detailing:
  - Who can see the WRAP (e.g., “my case manager, Dr. Smith,” “the crisis team”).
  - What parts can be shared (e.g., “only the Crisis Plan”).
  - For what purpose (e.g., “to guide your response if I am in crisis”).
  - An expiration date or a clear process for revocation.
- Data Security Protocols: Evidence of secure storage for WRAP documents (e.g., locked cabinet, encrypted digital file) separate from the main clinical record unless consent is given for inclusion.
- Demonstration of Revocation: The organization must have a process for instantly honoring a request to revoke consent, and staff must be able to describe it.

4. The Right to Define Personal Wellness and Crisis

Requirement: The individual’s definitions of their Wellness Tools, Triggers, Early Warning Signs, and what constitutes a crisis are definitive and must be respected.
Audit Evidence:
- Crisis Plan Adherence: This is a critical audit point. The auditor will review crisis incident reports and compare them to the individual’s WRAP Crisis Plan. They will check:
  - Were the listed supporters contacted?
  - Were the stated do not do actions avoided? (e.g., “Did they call the police when the plan said ‘Do not call the police’?”)
  - Was the plan used as the primary guide?
- Content of WRAP: The WRAP contains personalized, sometimes non-clinical, wellness tools (e.g., “play with my dog,” “watch comedy movies”). Staff cannot dismiss these.

5. The Right to Revise and Update

Requirement: The individual must be able to easily change their WRAP at any time as their recovery evolves.
Audit Evidence:
- Dated Versions: The organization has a process for maintaining and dating different versions of a WRAP, showing it is a “living document.”
- Process Description: Staff can describe a simple, accessible process for individuals to request and make updates to their plan.
- Individual Interviews: Individuals confirm they know they can change their plan and have been assisted in doing so.

Summary: The Auditor’s Checklist for “Required Rights”

An auditor will use a tool to verify the following. “No” answers to these questions indicate non-compliance:

Audit Question	Evidence of Compliance
1. Is the WRAP written in the first person, reflecting the individual’s own language and choices?	Yes, the document is clearly self-authored.
2. Do organizational policies and staff confirm participation is voluntary and not mandated?	Yes, policies and interviews confirm no coercion.
3. Is there a signed, specific, and informed consent form for sharing the WRAP?	Yes, a valid consent form is present and detailed.
4. Is the WRAP stored securely, and is access controlled by the individual?	Yes, with logs or procedures proving controlled access.
5. During a crisis, was the individual’s WRAP Crisis Plan followed as the primary guide?	Yes, incident reports align with the crisis plan.
6. Can staff and individuals describe the process for updating the WRAP or revoking consent?	Yes, both parties accurately describe the simple process.
7. Is the culture one of respect for lived experience and person-first language?	Yes, observed in interactions and documentation.

In essence, WRAP Compliance is not about whether people have a WRAP; it’s about whether the culture, policies, and practices of the organization consistently protect and promote the rights of the individual as the director of their own recovery journey. The audit is the objective verification of this commitment.

Who is Required WRAP Compliance and Audit

The phrase “Required Rights of People” refers to the rights held by specific individuals, which in turn create obligations for specific organizations and auditors.

Here is a breakdown of who is involved and what their role is concerning these rights.

1. The Rights-Holder: The Individual (Consumer, Participant, Service User)

This is the most important “who.” The entire WRAP model exists for this person.

Who They Are: Any person who is creating, has created, or is using a Wellness Recovery Action Plan. They are often referred to as the “WRAP facilitator” for their own life.
Their Role in Compliance & Audit:
- They hold all the rights we’ve discussed (self-direction, confidentiality, etc.).
- They are the source of truth for whether their rights are being respected.
- During an audit, they are interviewed to provide direct testimony about their experience.
- They are the direct beneficiary of a compliant system and the primary victim of a non-compliant one.

In short: They are the subject of the rights and the key informant for an audit.

2. The Duty-Bearer: The Organization (Provider Agency, Hospital, System)

This is the entity required to respect, protect, and fulfill the rights of the individual. They are the ones being audited.

Who They Are: Any organization that facilitates, uses, or stores WRAPs as part of its service delivery. This includes mental health centers, peer-run organizations, hospitals, housing providers, etc.
Their Role in Compliance & Audit:
- Legal and Ethical Responsibility: They have a duty to build systems and a culture that upholds WRAP rights.
- Implement Policies: They must create and enforce policies on confidentiality, voluntary participation, and self-direction.
- Train Staff: They are responsible for training all relevant staff (from facilitators to crisis responders to front-desk personnel) on WRAP ethics and the “Required Rights of People.”
- Provide Evidence: During an audit, they must provide documentation, demonstrate procedures, and make staff available for interviews to prove their compliance.

In short: They are accountable for compliance and are the primary target of the audit.

3. The Enforcers & Validators: The Auditors (Certification Bodies, Fidelity Reviewers)

These are the independent parties who verify whether the Duty-Bearer (the organization) is upholding the rights of the Rights-Holder (the individual).

Who They Are:
- Advanced Level WRAP Facilitators who are trained to conduct fidelity reviews.
- Representatives from the Copeland Center (or other certifying bodies) who set the standards for WRAP.
- Internal QA/QI Staff within the organization conducting internal audits.
Their Role in Compliance & Audit:
- Objective Assessment: They use standardized tools and checklists to measure the organization’s adherence to the required rights.
- Gather Evidence: They review documents, observe practices, and interview both staff and individuals.
- Issue Findings: They determine a level of compliance (e.g., “in fidelity,” “out of fidelity”) and provide a report detailing strengths and areas for corrective action.

In short: They are the independent judges of whether the required rights are being met.

4. The Supporters & Advocates: WRAP Facilitators and Peer Staff

This group has a unique, dual role. They are employees of the Organization (Duty-Bearer) but are also ethically bound to serve the Individual (Rights-Holder).

Who They Are: Staff members, often with lived experience, who are trained to facilitate WRAP groups and support individuals in creating their plans.
Their Role in Compliance & Audit:
- Primary Implementers: They are on the front lines of ensuring the individual’s right to self-direction is realized during the creation of the WRAP.
- Ethical Bridge: They must constantly navigate their role, ensuring they facilitate without directing and support without taking over.
- Key Interviewees: During an audit, they are crucial for explaining how they uphold individuals’ rights in practice.
- Cultural Champions: They help create and maintain the person-centered culture required for true compliance.

In short: They are the practical guardians of the individual’s rights within the organization.

Summary Table: “Who’s Who” in WRAP Rights & Compliance

Stakeholder	Primary Role in “Required Rights”	Key Responsibility in an Audit
The Individual	Rights-Holder	To provide truthful testimony about their experience of having their rights respected.
The Organization	Duty-Bearer	To prove, through policies, practices, and staff behavior, that it systematically upholds these rights.
The Auditor	Validator/Enforcer	To objectively gather evidence from all parties and judge the level of compliance with the required rights.
The Facilitator/Staff	Implementer/Advocate	To demonstrate in practice how they support the individual’s rights and adhere to organizational policy.

Conclusion:

When you ask “Who is Required Rights of People – WRAP Compliance and Audit,” the answer is not a single person. It is a dynamic relationship between these four groups. The system only works when all parties understand and fulfill their specific roles in protecting the fundamental rights of the individual at the center of the WRAP process.

When is Required WRAP Compliance and Audit

The commitment to these rights is not a one-time event but a continuous process, with specific moments of heightened focus and formal assessment.

Here is a breakdown of “When” these rights are critically applied and audited.

1. Continuously: The “Always-On” Principle

The foundation is that the Required Rights of People must be upheld at all times. Respect for self-direction, dignity, and confidentiality is a non-negotiable standard for daily practice in a WRAP-based environment.

When: Every single day, during every interaction related to a person’s wellness and recovery.
Examples:
- A staff member speaks to an individual with respect.
- A facilitator reminds a group that each person is the expert on their own life.
- A WRAP document is stored securely after a session.
- An individual decides to add a new wellness tool to their plan.

2. At Key Milestones in the WRAP Journey (Proactive Compliance)

These are critical moments where the risk of violating these rights is highest, and therefore, compliance must be demonstrably front-and-center.

When	Rights in Focus	Compliance Action
During WRAP Facilitation (Creation)	Right to Self-Direction, Voluntary Participation	The facilitator must act as a supporter, not an instructor. The individual’s choices are final.
When Storing the WRAP	Right to Privacy & Confidentiality	The document must be placed in a secure, access-controlled location, separate from the clinical record unless consented.
When Sharing the WRAP	Right to Informed Consent	A specific, signed consent form must be obtained before sharing with anyone (family, other providers, crisis teams).
During a Wellness Setback or Crisis	Right to Define Crisis & Direct Care	The individual’s Crisis Plan must be the primary guide. Their “What to Do/What NOT to Do” instructions must be followed.
When Updating the WRAP	Right to Revise	The individual must be able to easily change their plan at any time. Processes must support this.

3. During Formal Audits and Reviews (Reactive Verification)

This is when an official, structured evaluation occurs to verify that the “always-on” principle and proactive compliance are actually happening.

When	Type of Audit	Focus on “Rights of People”
Scheduled/Periodic Audit	Recertification Fidelity Review	A comprehensive audit, typically every 1-3 years, to renew an organization’s certification to provide WRAP. This is a deep dive into all rights.
Initial Certification Audit	First-Time Fidelity Review	Conducted when an organization first applies to become a certified WRAP provider. It sets the baseline for their compliance with rights.
Internal QA/QI Check	Internal Audit (Self-Assessment)	The organization regularly checks its own practices (e.g., quarterly, biannually) against the rights-based fidelity measures to catch issues early.
Triggered by an Event	For-Cause or Incident-Based Audit	Initiated after a specific event, such as a complaint, a crisis where the plan was ignored, or a data breach. Heavily focuses on the specific right that was potentially violated.

Summary: The “When” Timeline

You can think of the timeline for “Required Rights of People” as follows:

ALWAYS: The Underlying Ethos – The culture of the organization must constantly respect these rights.
AT KEY MOMENTS: Applied Practice – Every time a WRAP is created, stored, shared, or used in a crisis, the rights must be actively operationalized.
PERIODICALLY: Formal Verification – Scheduled audits (e.g., annually for internal, every 2 years for external) provide a structured check on the system.
AFTER A PROBLEM: Reactive Investigation – An unscheduled audit occurs when there is a suspicion or evidence that a right has been violated.

In essence, the “Required Rights of People” are relevant before a WRAP is even started (in organizational policy and staff training), during its creation and use, and after it’s been implemented (through ongoing audits and reviews). There is no time when these rights are not in effect.

Where is Required WRAP Compliance and Audit

The “Where” is Multidimensional

The rights are not confined to a single document or room. They must be present and demonstrable across the following domains:

1. In Physical and Digital Spaces (The Tangible “Where”)

This is about where the evidence of these rights resides and where the practices happen.

In the WRAP Document Itself: The primary physical location of self-direction. The plan must be written in the first person (“I,” “me,” “my”), proving it is owned by the individual.
In Secure Storage Locations:
- A locked file cabinet in a private office, accessible only to authorized staff.
- A password-protected, encrypted digital file on a secure server, not automatically in the main electronic health record (EHR) unless specific consent is given.
In Meeting and Group Rooms: Where WRAP is facilitated. The physical environment should feel safe, respectful, and conducive to personal sharing, not institutional or clinical.
In Crisis Settings: This is a critical “where.” The rights must be present in the person’s home, in an emergency room, or in a community setting during a crisis. The Crisis Plan must be physically with the individual or immediately accessible to the crisis team to guide actions.
In Administrative Offices: Where policies are written, staff are trained, and consent forms are filed.

2. In Organizational Systems and Documents (The Structural “Where”)

This is where the framework for protecting rights is established.

In Official Policies and Procedures: The organization’s written mandates on confidentiality, informed consent, and voluntary participation must explicitly reference WRAP.
In Employee Training Materials and Records: Documentation proving that all staff (not just facilitators) have been trained on the ethics and rights inherent in the WRAP model.
In Consent Forms: Specific, signed documents that detail who, what, when, and why a WRAP can be shared. This is a primary piece of audit evidence.
In Incident Reports and Crisis Debriefs: Documentation showing that during a real-world event, the individual’s WRAP was consulted and followed, respecting their right to direct their care.

3. In Culture and Interactions (The Intangible “Where”)

This is the most crucial yet hardest-to-measure dimension. It’s about the “environment” or “culture.”

In the Language Used by Staff: Respectful, person-first language that validates the individual’s expertise. It’s heard in conversations, team meetings, and clinical notes.
In the Attitudes and Beliefs of the Workforce: A shared, genuine belief among staff that the individual is in charge of their recovery journey. This is observed in their demeanor and approach.
In the Power Dynamics: A environment where the individual feels empowered to say “no,” to revoke consent, or to disagree with a suggestion without fear of losing services or respect.

4. In the Audit Process Itself (The Evaluative “Where”)

Finally, the “where” is also the context of the audit or fidelity review.

In the Auditor’s Tool/Checklist: The specific criteria and questions used to measure compliance are where the rights are formally assessed.
In the Interview Rooms: During conversations between the auditor and:
- Individuals served by the organization.
- WRAP Facilitators and frontline staff.
- Clinical and Administrative Leadership.
In the Final Audit Report: The formal document that states where (in which domains, policies, or practices) the organization is compliant or non-compliant with upholding these rights.

Summary Table: The Locations of WRAP Rights

Dimension	“Where” It Is Located	Key for Audit
Physical/Digital	The WRAP document, secure filing cabinets, encrypted servers, group rooms.	Evidence is inspected in these physical and digital locations.
Structural/Documentary	Policy manuals, training records, signed consent forms, crisis reports.	The paper trail and formal systems are reviewed.
Cultural/Behavioral	In conversations, staff attitudes, and the overall feeling of empowerment and respect.	Observed by the auditor and reported by individuals in interviews.
Evaluative	The audit checklist, interview notes, and the final compliance report.	The context where compliance is officially judged.

Conclusion:

The “Required Rights of People” in WRAP Compliance and Audit are not located in one place. They must be embedded everywhere:

On paper (the WRAP itself, policies, consents).
In systems (storage, training, crisis response).
In people (the culture, language, and beliefs of both staff and individuals).
In the process (the audit that verifies it all).

An organization is truly compliant only when these rights are alive and verifiable across all these dimensions simultaneously.

How is Required WRAP Compliance and Audit

How the “Required Rights” Are Implemented and Enforced

The process can be broken down into two main parts: 1) How an organization operationalizes the rights, and 2) How an auditor verifies it.

Part 1: How an Organization Ensures Compliance (The “How” of Implementation)

This is what an organization must do to uphold the Required Rights of People.

Right	How It is Implemented (Operational Actions)
Self-Direction	1. Facilitator Training: Staff are trained to use open-ended questions (“What works for you?”) and to avoid directives. 2. First-Person Documentation: Providing templates and tools that encourage the individual to write in “I” statements. 3. Individual Control: The physical or digital copy of the WRAP is given to the individual; the organization keeps a copy only with consent.
Voluntary Participation	1. Clear Messaging: Brochures and intake processes state WRAP is “an option” or “a tool you can choose.” 2. Policy Mandate: A written policy explicitly prohibits mandating WRAP for service eligibility. 3. Staff Accountability: Supervisors monitor that no one is pressured to participate.
Privacy & Confidentiality	1. Secure Systems: Using locked cabinets or encrypted digital folders with strict access controls. 2. Informed Consent Forms: Creating and using detailed consent forms that specify who, what, when, and why for sharing. 3. Access Logs: Maintaining records of who has accessed a digital WRAP to ensure it aligns with consent.
Informed Choice in Crisis	1. Crisis Plan Accessibility: Ensuring the crisis plan is easily accessible to the individual and their designated supporters. 2. Staff Drills & Training: Training crisis response teams on the imperative to read and follow the individual’s crisis plan, especially the “What I Do Not Want” section. 3. Debriefing Process: After any crisis, reviewing with the individual whether their plan was followed and how it could be improved.
Ability to Revoke/Change	1. Simple Processes: Having a clear, simple way for an individual to request changes or withdraw consent. 2. Immediate Action: Policies requiring that revoked consent is honored immediately (e.g., within 24 hours). 3. Version Control: Dating new versions of the WRAP to show it is a living document.

Part 2: How an Auditor Verifies Compliance (The “How” of Audit)

This is the methodology an auditor uses to test whether the implementation is effective.

How the Auditor Checks	What Specific Action They Take
Document Review	• Examines WRAPs: Looks for first-person language and personalized content. • Reviews Policies: Checks for explicit statements on voluntariness and confidentiality. • Inspects Consent Forms: Ensures they are specific, signed, and up-to-date. • Analyzes Crisis Reports: Cross-references incident reports with the individual’s Crisis Plan to see if it was followed.
Structured Interviews	• Asks Individuals: “Who decided what went into your plan?” “Did you feel pressured?” “What happens if you want to change your plan?” • Questions Staff: “How do you ensure the person leads the process?” “What is your first step in a crisis?” “What do you do if a client revokes consent?” • Interviews Leaders: “How do you train staff on these rights?” “How do you monitor fidelity?”
Direct Observation	• Observes a WRAP Group: Watches facilitator-individual interactions to see if the facilitator is guiding vs. directing. • Tours Facilities: Checks the physical security where WRAPs are stored. • Reviews Data Systems: Tests the digital access controls for WRAP files.
Culture Assessment	• Listens to Language: Notes whether staff use person-first and respectful language. • Assesses Power Dynamics: Observes whether individuals seem empowered to speak up and disagree with staff.

The “How” in Practice: A Step-by-Step Flow

For the Organization:

Policy Creation: Write policies that codify the Required Rights.
Staff Training: Train all staff on these policies and the “how” of upholding rights in daily practice.
Implementation: Provide the tools (templates, secure storage, consent forms) to make it happen.
Internal Monitoring: Conduct regular internal audits to self-correct before an external audit.

For the Auditor:

Pre-Audit Review: Study the organization’s policies and procedures.
On-Site Investigation: Use the triad of Document Review, Interviews, and Observation to gather evidence.
Evidence Triangulation: Compare what the policy says, what the staff say they do, and what the individuals report experiencing. Consistency across all three is key.
Scoring & Reporting: Use a standardized fidelity scale to score compliance and produce a report detailing findings.

Summary: The Ultimate “How”

The “How” of Required Rights of People in WRAP Compliance and Audit is a cycle of:

Embedding rights into policies and training.
Demonstrating rights through daily actions and documentation.
Verifying rights through systematic and multi-method auditing.
Improving practices based on audit feedback.

It is not a passive state but an active, ongoing process of implementation and verification that ensures the individual’s voice and choices remain at the very center of their own recovery journey.

Case Study on WRAP Compliance and Audit

The Crestwood Recovery Center Audit

Background:
Crestwood Recovery Center is a community mental health organization that began offering WRAP (Wellness Recovery Action Plan) programs two years ago. They are now undergoing their first formal external fidelity audit to maintain their certification. The auditor, Maria, is an Advanced Level WRAP Facilitator.

The Characters:

Alex: A individual who uses services at Crestwood and has created a WRAP.
Sarah: A well-intentioned but busy clinical coordinator at Crestwood who helps facilitate WRAP.
David: The Director of Programs at Crestwood.
Maria: The External Auditor.

The Pre-Audit Situation: A Rights Violation in the Making

Scene 1: WRAP Creation
Alex, who has anxiety and depression, works with Sarah to create his WRAP. Sarah is pressed for time.

Action: Sarah uses a template and says, “Most people put ‘exercise’ and ‘healthy eating’ here for their wellness tools.” Alex, wanting to please, agrees, even though his most effective tool is actually “sketching in his nature journal.”
Right Violated: Self-Direction. The plan is not fully authored by Alex.

Scene 2: Crisis Plan Development
Alex specifies in his Crisis Plan that if he is in crisis, his supporter should not call the police under any circumstances, as this escalates his anxiety. He requests they contact his sister first.

Action: Sarah files the WRAP in Alex’s main clinical electronic health record (EHR) without a specific separate consent form for this action. She tells him, “This is so everyone on the team can see it if they need to.”
Right Violated: Informed Consent & Confidentiality. Alex did not provide explicit, informed consent for his WRAP to be placed in his general EHR, accessible to all staff.

Scene 3: A Crisis Event
Alex experiences a severe depressive episode and calls the crisis line. The on-call worker, who has not been trained on WRAP, sees the note in the EHR but doesn’t read the details. They dispatch a mobile crisis team, who, upon finding Alex unresponsive, calls the police for a wellness check, as per standard protocol.

Action: The police arrive, which terrifies Alex and worsens the situation. His explicit instruction in his WRAP was ignored.
Right Violated: The Right to Direct Their Own Crisis Care. The most critical part of his self-directed plan was overridden.

The Audit: Uncovering the Gaps

Scene 4: The Auditor Arrives
Maria, the auditor, begins her review.

Document Review:
- She pulls Alex’s WRAP. She notes the language is generic (“exercise,” “eat well”) and lacks personal voice.
- She finds no standalone, signed consent form authorizing the WRAP’s placement in the EHR or for specific crisis procedures.
- Auditor’s Note: “Evidence suggests self-direction and informed consent procedures are not being followed.”
Staff Interview with Sarah:
- Maria asks Sarah, “How do you ensure the WRAP belongs to the individual?”
- Sarah replies, “We guide them to clinically sound wellness tools.”
- Maria asks, “What is your process for sharing the WRAP with the crisis team?”
- Sarah says, “It’s in the EHR, so they all have it.”
- Auditor’s Note: “Staff understanding is focused on clinical integration, not on individual rights and control. Confusion between ‘accessibility’ and ‘consent.'”
Individual Interview with Alex:
- Maria asks Alex, “Who decided what was in your WRAP?”
- Alex hesitates, “Well, Sarah had some good ideas… I mostly agreed.”
- Maria asks, “Were you aware your crisis plan was not followed during the recent incident?”
- Alex looks down, “Yeah, but I guess they have their own rules. It’s my word against their protocol, right?”
- Auditor’s Note: “Individual feels disempowered and that their plan is secondary to organizational protocol. This is a critical failure in the WRAP model.”
Leadership Interview with David:
- Maria asks David, “What is your policy on storing WRAPs and obtaining consent?”
- David shows her a general confidentiality policy but nothing WRAP-specific. He admits, “We train our crisis team on general de-escalation, but we haven’t drilled down on specific WRAP crisis plan adherence.”
- Auditor’s Note: “Lack of specific policies and targeted training creates systemic risk for rights violations.”

The Outcome: Corrective Actions for Compliance

Maria’s final audit report concludes that Crestwood is “Out of Fidelity” with the WRAP model due to multiple violations of the Required Rights of People. She mandates a corrective action plan.

Corrective Actions Required:

Policy & Procedure Overhaul:
- Create a WRAP-Specific Rights Policy detailing self-direction, voluntary participation, and confidentiality.
- Implement a new Informed Consent Form for WRAP sharing, specifying who can see it and for what purpose.
Staff Training & Culture Shift:
- Mandatory re-training for all staff on the ethics of WRAP, focusing on the facilitator’s role as a supporter, not a director.
- Specialized training for the crisis team on locating, reading, and adhering to the individual’s WRAP crisis plan as the primary response guide.
System Changes:
- Remove all WRAPs from the general EHR and store them in a secure, access-controlled digital folder. Access requires the individual’s consent.
- Establish a clear, simple process for individuals to update their WRAP or revoke consent at any time.
Empowerment & Communication:
- Develop a “WRAP Bill of Rights” handout for every individual starting a plan.
- Create a feedback mechanism for individuals to report if their WRAP rights are not respected.

Conclusion and Lessons Learned

This case study illustrates that compliance is not about having a WRAP program, but about how it is implemented.

The “Rights of People” are practical, not theoretical. They require specific policies, consistent behaviors, and robust systems to protect them.
An audit is a diagnostic tool. It uncovers the gap between an organization’s intentions and its practices.
True compliance creates a culture of empowerment. When Crestwood completes its corrective actions, it won’t just be “passing an audit.” It will be transforming its relationship with the people it serves, placing them truly in the driver’s seat of their own recovery. For Alex, this means his voice will finally be heard and his choices respected.

White paper on WRAP Compliance and Audit

The Wellness Recovery Action Plan (WRAP) is an evidence-based practice that empowers individuals to manage their mental health and well-being. Its efficacy is intrinsically tied to its foundational principle: the absolute primacy of the individual’s autonomy and rights. This white paper argues that true WRAP compliance is not merely the completion of a document, but the demonstrable and systemic upholding of the “Required Rights of People.” We will define these rights, outline a framework for operationalizing them within an organization, and detail how a rigorous, rights-based audit process is essential for ensuring fidelity, improving outcomes, and aligning with modern person-centered care standards.

1. Introduction: The Paradigm Shift of WRAP

Traditional healthcare models often operate on a paternalistic framework, where the provider is the expert and the patient is a passive recipient of care. WRAP, developed by Mary Ellen Copeland and grounded in peer support, represents a radical paradigm shift. It posits that the individual is the expert on their own life and wellness.

This shift necessitates a corresponding shift in organizational ethics and operations. The focus moves from “What did we do for the person?” to “How did we empower the person to direct their own recovery?” This empowerment is codified in a set of non-negotiable rights that must be protected throughout the WRAP process. Compliance, therefore, is the measurable adherence to these rights, and an audit is the objective verification of that adherence.

2. The Required Rights of People: A Detailed Framework

The “Required Rights of People” are the bedrock of the WRAP model. They are not aspirational; they are mandatory for fidelity.

Right	Core Principle	Practical Manifestation
1. Self-Direction & Ownership	The individual is the author and owner of their WRAP.	The plan is written in the first person (“I,” “me,” “my”); the individual controls the content, pace, and process of creation.
2. Voluntary Participation	Engagement must be free from coercion.	WRAP cannot be mandated as a condition for receiving services, housing, or any other benefit.
3. Informed Consent & Confidentiality	The individual controls access to their WRAP.	Explicit, specific, and revocable consent is required for anyone to view or use the WRAP. The document is stored securely, separate from the clinical record unless consented.
4. Definition of Personal Wellness & Crisis	The individual’s lived experience is the definitive authority.	Their identified Wellness Tools, Triggers, Early Warning Signs, and Crisis Plan are respected and followed without judgment or override by staff.
5. Revision and Revocation	The WRAP is a living document.	The individual can easily change their WRAP or revoke consent for its use at any time.

3. The Compliance Imperative: Embedding Rights into Organizational Culture

Compliance is the active process of embedding these rights into the fabric of an organization. It requires a multi-layered approach:

Policy Layer: Formal, written policies must explicitly protect each right (e.g., a “WRAP Confidentiality and Consent Policy”).
Training Layer: All staff, from facilitators to crisis responders to leadership, must be trained not just on WRAP mechanics, but on the ethics of rights protection. Role-playing and scenario-based training are critical.
Procedural Layer: Simple, clear processes must be established for obtaining consent, storing WRAPs securely, accessing them during a crisis, and facilitating updates.
Cultural Layer: The organization must foster an environment where staff genuinely believe in self-direction and where individuals feel safe to exercise their rights without fear of retribution or loss of services.

Failure Point Example: An organization may have a perfect WRAP template (Policy), but if its facilitators direct individuals to use “clinically-approved” wellness tools (Culture/Training), the right to Self-Direction is violated, and the organization is non-compliant.

4. The Audit Process: Verifying Rights with Rigor

A WRAP fidelity audit is a systematic investigation to verify that the Required Rights of People are being upheld in practice. It moves beyond checklist compliance to assess real-world impact.

The Audit Methodology employs a triangulation of evidence:

Document Review:
- WRAPs: Are they in the first person? Are they personalized?
- Policies: Do they explicitly address WRAP-specific rights?
- Consent Forms: Are they specific, signed, and current?
- Crisis Reports: Do they demonstrate that the individual’s crisis plan was followed?
Structured Interviews:
- With Individuals: “Who decided what went into your plan?” “What happens if you want to change it?” This is the most critical source of truth.
- With Staff: “How do you ensure the person leads the process?” “What is your first step in a crisis?”
- With Leadership: “How do you resource and support this rights-based approach?”
Direct Observation:
- Observing WRAP groups to assess facilitator style (guiding vs. directing).
- Reviewing physical and digital storage systems for security.

The Outcome of an audit is a fidelity report that scores the organization and provides a roadmap for corrective action, ensuring that rights are not just theoretical but operational.

5. The Consequences of Non-Compliance

Failure to uphold these rights has serious consequences:

Ethical Harm: It disempowers individuals, violates trust, and perpetuates paternalistic systems.
Clinical Inefficacy: A WRAP that is not self-directed loses its personal relevance and power, leading to poor engagement and outcomes.
Legal & Reputational Risk: Violating confidentiality or ignoring a crisis plan could lead to grievances, litigation, and damage to an organization’s reputation.
Loss of Certification: Organizations found to be “Out of Fidelity” may lose their certification to provide WRAP.

6. Conclusion and Recommendations

Upholding the Rights of People is the definitive measure of a high-quality, ethical WRAP program. Compliance is a continuous journey, and auditing is an essential tool for accountability and quality improvement.

We recommend that organizations:

Formalize Commitment: Draft and ratify a “WRAP Rights Charter” endorsed by leadership and peer staff.
Invest in Training: Implement ongoing, mandatory ethics and rights-based training for all staff.
Implement Systems: Develop secure, consent-based systems for WRAP storage and sharing.
Embrace Audits: Conduct regular internal audits and engage willingly with external ones, viewing them as opportunities for growth.
Center Lived Experience: Involve individuals with lived experience in the design, implementation, and review of the WRAP program.

By championing the Required Rights of People, organizations do more than pass an audit—they build a culture of respect, empowerment, and genuine recovery.

Industrial Application of WRAP Compliance and Audit

Courtesy: Industrial Audit & Compliance Support Bureau

The principles of the Wellness Recovery Action Plan (WRAP), developed in the mental health sector, offer a powerful, evidence-based framework for proactively managing well-being and performance in high-stakes industrial environments. This white paper explores the industrial application of the “Rights of People” within a WRAP-inspired model. We argue that by granting employees the right to self-direct their well-being plans and subjecting these systems to rigorous compliance audits, industrial organizations can significantly enhance safety, reduce critical errors, improve retention, and build a more resilient workforce. This represents a strategic shift from reactive, company-mandated wellness programs to a personalized, human-centric operational discipline.

1. Introduction: The Industrial Well-being Imperative

Industrial sectors—including manufacturing, energy, logistics, and construction—face unique challenges: high-pressure environments, safety-critical tasks, shift work, and physical demands. Traditional approaches to workforce well-being are often top-down, generic, and focused solely on physical safety. However, human factors—such as stress, fatigue, and mental load—are leading contributors to incidents and errors.

A WRAP-inspired model applies the core philosophy of personal ownership and self-direction to employee well-being, creating a structured yet flexible system where individuals are empowered to manage their own state to perform safely and effectively.

2. Re-framing “Rights of People” for an Industrial Context

In this context, the “Required Rights of People” are translated from clinical rights into operational principles that support both individual well-being and organizational safety.

WRAP Right	Industrial Translation & Application
Self-Direction & Ownership	The Right to a Personalized Performance & Safety Plan (PPSP). The employee is the expert on their own triggers for stress, fatigue, and distraction, as well as the strategies that help them maintain focus and readiness. Their plan is unique to them.
Voluntary Participation	The Right to Voluntary Engagement. While safety protocols are mandatory, engagement in creating a personalized well-being plan cannot be punitive or forced. It must be presented as a tool for empowerment and mastery.
Informed Consent & Confidentiality	The Right to Data Privacy. The employee’s personal well-being plan is confidential. Supervisors may only access the specific, consented parts relevant to operational safety (e.g., “If I display X behavior, it is a sign of fatigue”). The details remain private.
Definition of Personal Wellness & Crisis	The Right to Define “At-Risk” States and Mitigations. An operator can define their own “early warning signs” of being off their game (e.g., “When I am stressed, I rush my pre-start checks”) and specify proactive mitigations (e.g., “I need a 5-minute mindfulness break”).
Revision and Revocation	The Right to Adapt. The PPSP is a living document. An employee can update it as they learn what works, especially after a near-miss or incident, ensuring continuous improvement of their personal safety strategy.

3. Compliance: Building a System of Empowered Safety

For this model to work, the organization must build a compliant system that actively supports these rights.

Key Components of Industrial WRAP Compliance:

Structured Facilitation, Not Directive Management:
- How: Train managers and safety officers as facilitators to help employees develop their own PPSPs. Their role is to ask questions like, “What conditions help you perform at your best?” not to dictate behaviors.
- Tool: A standardized template for a PPSP that includes sections for:
  - Daily Performance Tools: Personal rituals for optimal focus (e.g., specific pre-shift checklist review, hydration plan).
  - Triggers: Situations that degrade performance (e.g., conflict with a teammate, poor sleep, high-pressure deadlines).
  - Early Warning Signs: Personal signs of increasing risk (e.g., shortness of temper, difficulty concentrating, skipping steps).
  - Proactive Action Plan: What the employee will do when they notice warning signs (e.g., “I will inform my supervisor I need a 10-minute reset,” “I will use a specific breathing technique”).
  - Crisis Plan/Safety Net: Defined protocols for when they feel it is unsafe for them to perform a specific task.
Integration with Safety Management Systems (SMS):
- The principles of the PPSP are integrated into existing safety protocols like Pre-Job Briefings and Incident Investigations. Briefings can include a personal check-in, and investigations can explore whether an individual’s early warning signs were present and how the system did or did not support them.
A Culture of Non-Punitive Self-Reporting:
- The system is void if an employee is punished for invoking their plan. A compliant culture celebrates an employee who says, “I’m not at my best to operate this machinery today,” viewing it as a high-reliability behavior.

4. The Industrial Audit: Measuring Fidelity and Impact

An audit in this context verifies that the system is functioning as intended—empowering individuals to enhance collective safety.

Industrial Audit Framework:

Audit Scope: Does the program uphold the five core industrial rights?
Methodology:
1. Document Review:
  - Are PPSPs personalized and in the employee’s own words?
  - Do policies protect confidentiality and prohibit coercion?
2. Interviews:
  - With Employees: “Do you feel your plan is truly yours?” “Have you ever been afraid to use your plan?” “Can you give an example of when it helped?”
  - With Facilitators/Supervisors: “How do you support an employee who is using their proactive action plan?” “What is your response if an employee says they are not fit for a task?”
3. Data Analysis:
  - Correlate the rollout of the program with leading indicators: near-miss reports, safety stoppages, absenteeism, and employee engagement scores. An effective program should show an increase in proactive safety reports and a decrease in incidents.
4. Observation:
  - Sit in on Pre-Job Briefings to see if personal well-being is discussed. Observe interactions between supervisors and teams for signs of psychological safety.

5. Tangible Business Benefits & ROI

Implementing a rights-based well-being system is not just an ethical imperative; it is an operational one.

Reduced Safety Incidents: Proactive self-management catches human error upstream.
Increased Operational Uptime: Reduced incidents and accidents mean less downtime.
Improved Retention: Empowering employees builds loyalty and reduces turnover in a competitive labor market.
Enhanced Regulatory Standing: Demonstrating a proactive, human-factor-focused safety system can positively influence regulatory audits.
Strengthened Safety Culture: Moves the culture from “compliance with rules” to “collective responsibility and empowerment.”

6. Conclusion

The industrial application of the “Rights of People” through a WRAP-inspired model represents the next frontier in operational excellence and human performance. By auditing for compliance to these rights, organizations can ensure they are not just creating another program, but are building a resilient, adaptive, and safer workplace where every individual is equipped and empowered to be the guardian of their own and their team’s well-being.

Call to Action: Industrial leaders should pilot this approach in a single unit, training facilitators and co-creating Personalized Performance & Safety Plans with a volunteer team. The resulting data on safety, engagement, and operational performance will make the business case for a wider, systemic rollout.