Complaints, Grievances, and Appeals

PURPOSE

To ensure that individuals are aware of and have access to a variety of ways to submit a complaint or grievance to Dawn Farm, and that appropriate processes are utilized in responding to any complaint, grievance, or appeal.

APPLICATION

All Dawn Farm staff, contractors, students and volunteers.

DEFINITIONS

Appeal: A request for a review of an action or decision made in response to a complaint or grievance.

Complaint: The raising or submission of an issue to Dawn Farm for resolution.

Formal Complaint or Grievance: Complaints or grievances submitted in writing to Dawn Farm.

Grievance: An expression of dissatisfaction to Dawn Farm about any matter related to services received.

Protected Health Information: Medical, behavioral, and mental health information that is individually identifiable and that is transmitted in any form or medium.

POLICY

Dawn Farm recognizes that all individuals have a right to raise or submit complaints or grievances, as well as the right to appeal any actions or decisions arising out of a complaint or grievance. Dawn Farm also recognizes that complaints and grievances are important not only to maintain the integrity of the organization, but also as a way of gaining valuable feedback about areas and ways in which the quality of services provided may be improved. Therefore, Dawn Farm has established complaint and appeal processes that are:

1. Timely
2. Fair to all parties
3. Administratively simple
4. Objective and credible
5. Accessible and understandable to clients, staff, contractors, students, and volunteers
6. Cost and resource efficient
7. Subject to quality review
8. Free from retaliation or reprisal to the complainant.

EXHIBITS

Confidentiality Statement

Complaint Form

Know Your Rights pamphlet

REFERENCES

Recipient Rights

Sanctions for Breaches of Security or Confidentiality

PROCEDURES

1. All Dawn Farm staff, contractors, students, and volunteers shall be apprised of this policy and procedure, and will be responsible for informing individuals of their options for submitting a complaint or grievance that has been raised.
2. Clients, or anyone acting on behalf of a client, will have access to any and all options for making a complaint or grievance at any time. There is no limitation on the timeframe within which a complaint or grievance must be raised. No client will ever be discouraged from using any option available to them. In the below procedures and processes, the term ‘client’ may also be understood to include anyone acting on behalf of a client.
3. Options for complaints and grievances include:
   • Informal complaints or grievances raised in conversation with Dawn Farm staff, contractors, students, or volunteers, and resolved informally.
   • Informal complaints or grievances submitted in writing through expression on satisfaction questionnaires, through the website, or other means of writing without using a formal complaint form, and resolved informally.
   • Formal complaints or grievances, made using the Dawn Farm Complaint Form, and beginning the formal complaint process described below.
   • Recipient Rights complaints, made by speaking with the Dawn Farm Rights Advisor and beginning the Recipient Rights process.
4. Options for appealing the resolution of a complaint or grievance include:
   • Informal complaints or grievances may be appealed through continued conversation with program staff, Program Coordinator, Clinical Director and/or President. Informal complaints and grievances may also be appealed by submitting a formal complaint or utilizing the Recipient Rights Process.
   • Formal complaints or grievances may be appealed by submitting another Complaint Form detailing the aspects of the decision that were not satisfactory and proposing alternate solution(s). Formal complaints and grievances may also be appealed by utilizing the Recipient Rights process.
   • The Recipient Rights process has built in levels of appeal as described in the Know Your Rights section of the Dawn Farm Client Handbook.
5. Dawn Farm will not retaliate against or permit any reprisals against anyone who submits a complaint or grievance, whether formal or informal, nor will Dawn Farm require individuals to waive their right to any option for submitting a complaint or grievance.
6. Complaint Forms for making formal complaints will be available at all times in the common area of each program, and will be sent to former clients upon request. Information will be given to clients orally and in writing at intake concerning the Recipient Rights process, and will be available at any time upon request.
7. The Recipient Rights Adviser will maintain a system for logging all formal complaints received and for the secure storage of all investigative documents and evidence, and any corrective action. All such documentation will be kept for a minimum of seven (7) years from the date of its creation, or the date it was last in effect, whichever is later.
8. Dawn Farm has adopted policies requiring all staff, contractors, students, and volunteers to protect the confidentiality and security of its clients’ protected health information. Specific allowable uses of protected health information have been set forth in a Notice of Privacy Practices which is posted in the common area of every site and provided to clients upon request, or have been authorized by the proper execution of an Authorization for Release of Information. All staff, contractors, students, and volunteers shall be made aware of policies and procedures protecting the confidentiality and integrity of its clients’ protected health information, and asked to sign a Confidentiality Statement.
9. Dawn Farm will designate an individual (Project Manager) to receive complaints concerning Dawn Farm policies and procedures related to protecting the confidentiality and security of protected health information, or its compliance with such policies and procedures, and to investigate using the process detailed below.
10. Complaints about confidentiality or security should be referred to the Project Manager. Complaints or grievances concerned with the violation of client rights should be referred to the Program Rights Advisor, who will initiate the Recipient Rights Process.
11. The Project Manager will be responsible for reporting on formal complaints and grievances, including complaints about confidentiality or security, and the Program Rights Advisor will be responsible for reporting on Recipient Rights complaints. All reporting will be done on a quarterly and annual basis.

Formal Complaint Process

1. Staff provides Dawn Farm Complaint Form upon request.
2. Individual with complaint submits completed Complaint Form to staff, with option of submitting in a sealed envelope.
3. Staff ensures completed form is given to Program Coordinator. In the event the complaint concerns the Program Coordinator, the completed form will be submitted to the Clinical Director.
4. Program Coordinator reviews complaint, performs an investigation as necessary, makes a recommendation, completes the top portion of the Dawn Farm Complaint Investigation form, and submits both the Complaint Form and the Complaint Investigation form to Clinical Director within one week of receiving the Complaint Form. In the event the complaint concerns the Clinical Director, the form will be submitted to the President.
5. Clinical Director reviews complaint, client and Program Coordinator recommendations, performs an investigation as necessary, and makes a decision about Dawn Farm’s response to the complaint. Completes the bottom half of the Dawn Farm Complaint Investigation form. Is responsible for making sure that the client is contacted in writing with the results of the complaint investigation, using the Dawn Farm Response to Complaint form. Returns copies of all forms, with decisions, to Program Coordinator. Assigns any actions resulting from decision. Gives completed forms to Recipient Rights Adviser.
6. Program Coordinator (if complaintant is a client) reviews decision with client, and ensures that the complainant understands that he/she also has the option of making another formal complaint or utilizing the State Recipient Rights procedure to file a complaint against Dawn Farm. Within 14 days of receipt of the complaint, provides client with the written Dawn Farm Response to Complaint. Gives a copy of the Response to Complaint form to Recipient Rights Adviser.
7. Recipient Rights Adviser logs complaint forms and decisions, keeps complaint form, and any documents associated with complaint form, for no less than seven years from the date of the decision.
8. The Project Manager reports quarterly and annually on formal complaints.

Process for Complaints about Confidentiality or Security

1. Client raises a complaint in any manner about confidentiality or security of protected health information.
2. Staff refers client to Privacy Officer
3. Privacy Officer (Project Manager) conducts a thorough and confidential investigation of the allegation in a timely manner, and recommends corrective action to the President and Clinical Director. Investigations will be conducted in a way that does not violate employee rights. In the event that the complaint includes or involved the Privacy Officer, the President may designate appropriate staff to conduct the investigation.
4. Clinical Director/President reviews investigation, decides on and enforces any corrective action. In the event that the complaint involves the Clinical Director, this action will be taken by the President alone. In the event that the complaint involves the President, this action will be taken by the Board of Trustees.
5. Privacy Officer (Project Manager) informs complainant in writing of the results of the investigation and any corrective action taken, and ensures that the complainant understands that he/she also has the option of utilizing the State Recipient Rights procedure to file a complaint against Dawn Farm.
6. Privacy Officer (Project Manager) logs complaint and decision, and reports quarterly and annually on formal complaints. Keeps complaint logs, and any documents associated with complaints, for no less than seven years from the date of the decision.

ENFORCEMENT

All supervisors are directly responsible for enforcing this policy.