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Client Grievance and Appeals Policy

UCS CLIENT  GRIEVANCE AND APPEALS

PURPOSE:  To establish a formal mechanism for soliciting and responding to complaints, grievances and/or appeals on the part of clients or other interested parties, to utilize such information in the quality improvement efforts of the organization and to ensure compliance with the Vermont Agency of Human Services (AHS) Grievance and Appeals process.

POLICY:  It is the policy of United Community Services (UCO) that any grievance or appeal regarding services and/or support raised by a client, parent, family member, guardian, or a person acting on behalf of the client, who does so with his/her express permission, will be given due consideration.

DEFINITIONS:

An Action means an occurrence of one or more of the following by United Counseling Service for which an internal appeal may be requested.

An appeal is a request for an internal review of an action by United Counseling Service (UCS).

A Fair Hearing means an external appeal that is filed with the Human Services Board, and whose procedures are specified in rules separate from the UCS process.

A grievance is an expression of dissatisfaction about any matter that is not an action.  Possible subjects for grievance include, but are not limited to, the quality of care or services provided, aspects of interpersonal relationships such as rudeness of a provider or employee, or failure to respect the beneficiary’s rights.

AHS Departments:  Department of Mental Health (DMH); Department of Disabilities, Aging and Independent Living (DAIL); Division of Disability and Aging Services (DDAS); Department of Health, Division of Alcohol and Substance Abuse (ADAP); Department of Health, Vision of Children with Special Needs (CSHN), Department of Vermont Health Access (OVHA).

Notices of full state procedures can be found in the Grievance and Appeal Manuals published by:  DMH for mental health programs; DAIL for developmental services and ADAP for substance abuse programs.  The Grievance and Appeals Coordinator will provide copies upon request.

PROCEDURE:  A person receiving or participating in services and/or programs will be oriented to, and receive a copy of, the Agency’s Grievance & Appeal policy and procedure upon enrollment in a program.

A person receiving services, their family member, or other person acting on their behalf, having a grievance or appeal shall complete a Grievance and Appeal Form and/or explain the grievance or appeal to the person’s primary UCS therapist, case manager or service provider who will assist with completion of the Grievance and Appeal Form.  UCS staff shall arrange for reasonable accommodations for language or other needs the beneficiary may have in order to understand and participate in the process.  The primary therapist/case manager/service provider shall report the grievance or appeal to the Division Director using a copy of the Grievance and Appeal Form.  The original form will be forwarded to the Grievance and Appeal Coordinator.  The Division Director will work with the Grievance and Appeal Coordinator to review/investigate all grievances and appeals from the initial filing through resolution.

Grievances must be filed within 60 days of the pertinent issue.  Appeals must be filed within 90 days of the date of the MCE notice of action.

Alleged Harm:  If a grievance concerns a clear report of alleged physical harm or potential harm, UCS will immediately investigate or refer to the appropriate investigatory body.

Letter of Acknowledgment:  All grievances and appeals require a letter of acknowledgment be sent to the client and/or the person filing the grievance or appeal within five (5) calendar days of receipt of the grievance or appeal.  If the issue is resolved within five days, the resolution or outcome notice will be sufficient and no acknowledgment letter will be required. All UCS grievances and appeals will be logged into the Department of Vermont Health Access’s (DVHA) Grievance and Appeal database.  UCS Complaints will be logged into an in-house database.

Disposition:  All grievances shall be addressed within 90 days of receipt.  The decision-maker must provide the beneficiary with written notice of the disposition.  The written notice shall include a brief summary of the grievance, information considered in making the decision, and the disposition.  If the response is adverse to the beneficiary, the notice must also inform the beneficiary of his or her right to initiate a grievance review with DMH as well as information on how to initiate such review.

Appeals: An appeal is a request for an internal review of an action by UCS.  While the details of that review vary dependent on whether the appeal involves a determination of eligibility or level of service, it involves a meeting to which the individual/representative is invited to present information.  The internal review shall be completed within 45 days of a request. The individual/representative may request an extension of up to 14 days.  UCS may request an extension of up to 14 days if that extra time is in the best interests of the individual.  Beneficiaries or their representatives may withdraw appeals orally or in writing at any time.  If an appeal is withdrawn orally, the withdrawal will be acknowledged by the MCE in writing within 5 days.

Fair Hearing: This is a process whereby the individual/representative making an appeal and UCS, working with DMH and the DMH Legal Unit, each presents their side of the situation to the Human Services Board.  A request for fair hearing by the Human Services Board (HSB) must be filed no later than 30 days after receipt of the adverse appeal decision or within 90 days of the original action.

Expedited Appeals Request:  Expedited appeals may be requested in emergent situations in which the beneficiary or the treating provider (in making the request on the beneficiary’s behalf or supporting the beneficiary’s request) indicates that taking the time for a standard resolution could seriously jeopardize the beneficiary’s life or health or ability to attain, maintain, or regain maximum function.  Requests for expedited appeals may be made orally or in writing with the MCE for any MCE actions subject to appeal.

If the request for an expedited appeal is denied because it does not meet the criteria, the MCE will inform the beneficiary that the request does not meet the criteria for expedited resolution and that the appeal will be processed within the standard 45-day time frame. An oral notice of the denial of the request for an expedited appeal must be promptly communicated (within 2 days) to the beneficiary and followed up within 2 days of the oral notification with a written notice.

If the expedited appeal request meets the criteria for such appeals, it must be resolved within 3 working days.  If an expedited appeal cannot be resolved within 3 working days, the time frame may be extended up to an additional 14 days by request of the beneficiary, or by the MCE if the extension is in the best interest of the beneficiary.  If the extension is at the request of the MCE, it must give the beneficiary written notice of the reason for the delay.  An oral notice of the expedited appeal decision must be promptly communicated (within 2 days) to the beneficiary and followed up within 2 days of the oral notification with a written notice.  The written notice for any expedited appeal determination shall include a brief summary of the appeal, the resolution, the basis for the resolution, and the beneficiary’s right to request a fair hearing if not already requested.

Finally, clients shall be advised of their right to representation or the assistance of an advocate at any stage of the grievance and appeal procedure.  They will also be assured of the confidentiality of the proceedings and that no retribution of any kind will result from filing a grievance or an appeal.

Download UCS Grievance and Appeals Policy

Download UCS Grievance and Appeal Form