POLICY PROCEDURE REGARDING:
CMHS Consumer Complaint and
Grievance Resoluation Procedure
Jo Ruffin, L.C.S.W.
Deputy Director of Health
Date: January 21, 1998
|Manual Number: 3.11-03
Substantive Revision. Replaces Policy 3.11-03 of 12/20/95.
SUGGESTIONS FOR IMPROVEMENT
Consumers suggestions are an important part of providing effective care. Consumers are welcome to submit ideas for improvement to any program service using convenient suggestion boxes available at each site, or by mailing them directly to the Quality Improvement Office located at 1380 Howard Street, 2nd Floor, San Francisco, CA 94103.
It is the practice of CMHS to resolve consumer/parent concerns, issues and complaints on an informal basis as part of the regular delivery of service. Informal complaints are to be handled promptly by the consumer's service provider or by the program director. In the event that a consumer complaint involves a private provider, the complaint will be submitted to the Provider Systems Office. Every effort will be made by providers, and/or the Provider Systems Office to resolve problems or complaints from clients at an informal level as quickly and as simply as possible.
Clients may ask for the assistance of the Consumer Relations Office of CMHS or Patient's Rights Advocacy Services (PRAS) in resolving complaints regarding the provision of mental health services. Other persons may serve a advocates, such as family members or friends, at the request of the consumer. This complaint procedure is to be implemented consistent with the CMHS operating principle of consumer guidance of services. Clients/parents may ask questions, ask for a new therapist or Care Manager, make requests or complain about the services they receive without reprisal.
All providers and the Provider Systems Office will maintain a log of complaints which will be summarized and reported to the respective age-related Quality Improvement Committee (QIC) on a quarterly basis. As part of on-going program monitoring, the Age-Specific Quality Improvement Committees will discuss issues identified as a result of the complaint resolution process on a quarterly basis in order to address any needed system changes.
The grievance procedure provides a formal avenue for the resolution of consumer concerns when the informal process is not sufficient to resolve the problem. A complaint becomes a grievance when it is put in written form and submitted to the Quality Improvement Office at 1380 Howard Street, 2nd floor. The person filing a grievance may obtain assistance from the Office of Consumer Relations, Patient's Rights Advocate Services (PRAS), or any one else at the client's request. While the use of the complaint process to resolve issues promptly and informally is to be encouraged, a grievance may be filed without a complaint and without reprisal at any stage of the process. This is to be made clear to all clients. Grievance forms and self-addressed envelopes shall be available for beneficiaries to pick up at all CMHS sites.
STEPS OF THE GRIEVANCE PROCEDURE
All Grievances will be submitted to the the Quality Improvement Office, 1380 Howard Street, 2nd floor. The Grievance Procedure involves two basic steps:
Step 1: Grievance, reviewed by Quality Improvement and referred to the appropriate CMHS Administrative section for disposition.
Step 2: Final Appeal, reviewed by Quality Improvement and referred to the Director of Mental Health or his/her designee for disposition. The Director may assign an independent third party or parties for review of grievances at his/her discretion.
This grievance procedure is to be implemented consistent with the CMHS operating principle of consumer guided services Clients/parents may ask questions, ask for a new therapist or Care Manager, make requests and complain or grieve about the services they receive without reprisal.
In implementing the grievance procedure, staff are asked to remember that:
- The unique individual merits of each case need to be heard.
- It is possible to deviate from technical adherence to this procedure if warranted to protect the consumer as long as no rights or guarantees are violated and the consumer has given consent.
- A written acknowledgement will be issued by the Quality Improvement Office within 5 working days of receipt of a grievance.
This policy is to be implemented consistent with laws and regulations regarding confidentiality for consumers. (See policy 3.06-1).
ADDITION TO EXISTING RIGHTS
Use of this grievance procedure does not replace any existing avenues of review or redress provided by law. Consumers have full access to the grievance procedure and to all rights guaranteed under the law.
This procedure does not preclude assistance through the Office of Consumer Relations, Patient's Rights Advocacy Services, through parent/student advocates, through legal counsel or normal due process through Special Education and/or the Department of Social Services. In addition to existing rights, parents whose children are in Special Education with mental health services on their Individual Educational Program (IEP) plan have the right to request Due Process through Special Education at any time.
Any grievance relating to involuntary 5150 holds, 5250 holds and conservatorships is handled through the existing legal remedies rather than through this process.
This grievance procedure is not a substitute for the work of Patients' Rights Advocacy Services (PRAS), nor for private legal counsel or other complaint options. Mental health patients are guaranteed certain rights by law, and counties are required to provide advocates to protect patients' rights.
Consumers who are Medi-Cal beneficiaries, and who receive a Notice of Action indicating their services have been denied, reduced, or terminated may request a State Fair Hearing. If the hearing is requested within 10 days of receipt of notice, under certain circumstances the level of services will be maintained pending the outcome of the hearing. The Office of Consumer Relations, and/or Patient's Rights Advocate Services (PRAS) may assist clients in requesting a State Fair Hearing.
INFORMING CONSUMERS ABOUT THE GRIEVANCE PROCEDURE
- Each CMHS Program is to post the following information regarding the grievance procedure:
The Grievance Procedure Information form (MHS 314, Attachment 1) or the Grievance Procedure Information poster, in appropriate language/s.
This form and poster are available from the Forms Control Manager, CMHS Administration, 1380 Howard St., 5th Floor, 255-3408.
It is available in English, Spanish, Russian, Vietnamese and Chinese (or other "threshhold languages" as defined in regulations) and in large type to accommodate persons with visual problems. Requests for translations in additional languages should be submitted to Consumer Relations, CMHS Administration, 1380 Howard St., San Francisco, CA 94103. These requests will be reviewed by the Committee on Culturally Competent Systems of Care, which will decide the number of different languages in which translations of these forms will be made available in the future.
- Programs serving minors must also post a list of free and low-cost community-based advocacy groups and attorneys who specialize in children's and/or parents' rights.
This list can be obtained from the Children's Services Office, 415/255-3413.
- A copy of this policy is to be available at all direct treatment programs for review by consumers upon request.
CONSUMERS, as used here and in the remainder of the policy, include adults, age 18+; the parents and guardians of children under the age of 18 who receive CMHS services; and youth between the ages of 14 and 18 who receive CMHS services.
- Clinical staff shall inform consumers about the complaint and grievance procedures:
- at the initial face to face evaluation,
- at admission to any new program or private provider,
- at least annually during treatment reauthorization
- when services are reduced, denied or terminated
- Informing consumers means explaining the process to them, in their primary language, and giving them copies of
- The Grievance Procedure Information form: (MHS 314, Attachment 1); and
- The Grievance Form (MHS 316, Attachment 2) and a self-addressed envelope.
- Staff are to document that consumers have been informed about this procedure at initial face to face evaluation and at admission any new program or private provider. (steps a and b above).
Record this in the Progress Notes OR
use the check-off on the Consent for Treatment Form (MRD80).
- Staff are to document that consumers have reviewed the grievance procedure annually. Record this in the Progress Notes.
FILING GRIEVANCES AND APPEALS
- Grievances may be filed by consumer, their family members and support persons. This includes:
- Consumers age 18 or over
- Parents/guardians of children and youth receiving services
- Youth between the ages of 14 and 18 who are receiving services, if their position is different from that of their parent/guardian.
- Family members of consumers ("Family" is defined to include close personal friends and support persons.)
- While CMHS encourages programs to resolve consumer complaints informally whenever possible, invoking this grievance procedure is always at the consumer's discretion.
- Parents, guardians and youth have several grievance procedures they may use in addition the CMHS procedure. To determine the procedure that will be most responsive to their concerns, they should be encouraged to contact:
- For issues regarding children and youth receiving mental health services as part of their Individual Education Program (IEP), Contact AB3632 Unit Case Manager, 415/474-7310.
- For other issues regarding children and youth, contact the Children's Compliance Coordinator, 415/206-7612.
- When grievants have issues regarding the need for accommodations for disabilities, they may contact the Disabilities Coordinator, 415/255-3444.
- For general information about this procedure, grievants may contact the Director for Consumer Relations, 415/255-3422.
- For information and advocacy regarding rights, grievants may contact PatientsŐ Rights Advocacy Services (PRAS) 415/552-8100; or 1-800-729-7727.
- Grievants may use a personal representative of their choice to assist them in this process at any time.
Representatives may include, but are not limited to:
Parents and guardians of minors and children of any age may contact a certified representative from the list posted at the program. For a copy of this list of representatives, contact the Children's Services Office, 415/255-3413.
- If a personal representative is not employed by CMHS or a CMHS contractor, confidentiality must be protected:
- The consumer, including the child, must sign a "Release of Information" form available at all sites, in order to allow CMHS to discuss the issues with the representative present.
- The representative must sign an "Oath of Confidentiality", also available at all sites, to assure that they will discuss the issues only with the consumer and those involved in the consumer's treatment.
- When a program has its own grievance procedure, the consumer must still be informed about the CMHS procedure and given the choice of which procedure to use. An internal grievance procedure must be:
CLIENTS CANNOT BE REQUIRED TO GO THROUGH A PROGRAM'S INTERNAL GRIEVANCE PROCEDURE BEFORE
THEY ARE ALLOWED TO USE THE CMHS PROCEDURE, AND CAN CHOOSE THE CMHS PROCEDURE AT ANY TIME.
- consistent with the CMHS procedure; and
- be offered as an option to the CMHS procedure.
- Grievants are to be required to submit their grievance or appeal in writing, preferably using the Grievance Form (MHS 316, Attachment 2). Assistance may be obtained from the Office of Consumer Relations (CMHS), Patient's Rights Advocate Services (PRAS), or any one else at the client's request. Grievants are to be given a copy of their written grievance/appeal upon request.
- Grievances and Appeals are filed with:
Quality Improvement Office
1380 Howard Street, 2nd Floor
San Francisco, CA 94103
DENIAL OR DISCONTINUING SERVICES DURING GRIEVANCE PROCEDURE
- When a a consumer is denied services because of medical necessity criteria, they have right to a face-to-face assessment if they disagree with the denial. A face-to-face assessment must be done before a final appeal is filed.
- When a consumer files a grievance because they are being terminated from a program or because their level of frequency of service is being reduced, services are to continue until the grievance is resolved or a response to the initial appeal is given to the consumer.
- An expedited review of grievances shall occur when the consumer is grieving a decision by a provider or the Mental Health Plan (MHP) to discontinue adult residential or crisis residential services. When the written grievance is received by the MHP prior to the consumer's terminated from the services, the consumer shall continue to receive the adult residential or crisis stabilization services, and the MHP shall continue payment for the services until the MHP responds to the grievance at the first level of review. Services shall not continue if the provider or the MHP determines that ongoing placement of the consumer in that facility poses a danger to the beneficiery or others.
- Consumers who are Medi-Cal beneficiaries, and who receive a Notice of Action indicating their services have been denied, reduced, or terminated may request a State Fair Hearing. If the hearing is requested within 10 days of receipt of notice, under certain circumstances the level of services will be maintained pending the outcome of the hearing. The Office of Consumer Relations, and/or Patient's Rights Advocate Services (PRAS) may assist clients in requesting a State Fair Hearing.
RESPONDING TO GRIEVANCES AND APPEALS
- When a CMHS grievance or appeal is filed, staff are to respond promptly. A written acknowledgement will be issued by the Quality Improvement Office within 5 working days of receipt of a grievance. Step 1 of the Grievance requires personal contact with the grievant whenever possible. While Step 2 may be conducted through a paper review, personal contact is always preferable.
- A written decision to the grievance or appeal is to be made within 30 calendar days from the date it is received by the Quality Improvement Office. An expedited review of grievances shall occur when the consumer is grieving a decision by a provider or the Mental Health Plan (MHP) to discontinue adult residential or crisis residential services. When the written grievance is received by the MHP prior to the consumer's termination from the services, the consumer shall continue to receive the adult residential or crisis stabilization services, and the MHP shall continue payment for the services until the MHP responds to the grievance at the first level of review. Services shall not continue if the provider or the MHP determines that ongoing placement of the consumer in that facility poses a danger to the beneficiary or others.
Responses should be made in a letter stating the grievance decision. (see sample letter attached)
- One copy is to be given or mailed to the consumer.
- One copy, with all supporting documents, is to be sent to the Quality Improvement Office, CMHS Administration, 1380 Howard Street,
2nd Floor, SF, 94103.
- The Quality Improvement Office is responsible for distributing copies of all grievances and appeals it receives:
- To the program against which they were filed
- To the Age Specific Director or his/her designee
RETENTION OF RECORDS
- A copy of all grievances and appeals is to be retained in locked administrative files at the program and in the Quality Management Section for 3 years.
- As required by the State Department of Mental Health, the Quality Management Section maintains a log of all grievances. This log contains at least the following information on each grievance and appeal:
- date filed
- grievant name
- program name
- staff name if grievance is filed against a particular staff person
- type of problem
- date of response
- type of response
- All providers will submit their logs of complaints to the Quality Management Section on a quarterly basis.
The Quality Management Section will track the timeliness of responses to consumer grievances and appeals.
Quality Management staff will make regular reports on complaints and grievances to the Quality Policy Committee (Chaired by the Associate Director for Quality Management and consisting of CMHS administrators, Quality Management staff, contract program administrators, consumers and family members.). The Quality Policy Committee (QPC) is charged with making policy recommendations to assure that CMHS consumers are receiving high quality services.
|Contact Person: ||Jim Gilday,
Quality Management Section|
1380 Howard St., 5th Floor
San Francisco, CA 94103
CMHS policies and procedures are distributed by the Quality Management Section, Susan
Sturtevant, Dir., Health Information Management unit, 255-3484.
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