The following procedure will be shared with every customer and customer representative at the beginning of services provided by the Company and at the beginning of each plan year.

Introduction

The Company and employees are committed to treating all clients with compassion, care, and dignity and ensuring the provision high quality services. Any complaint or grievance received from a customer about actions by an employee that is contrary to law, rule, or policy will be given the highest priority by the Company. All complaints received from an individual or others acting on their behalf will be reported to the individual’s CDDP. If the customer’s complaint is associated in any way with abuse or a violation of the individual’s rights, the recipient of the complaint will immediately report the issue to the the Company and the CDDP.

An individual may make a complaint at any time. Complaints may include an expression of dissatisfaction with the company’s services or an allegation of circumstances or events that are contrary to law, administrative rules, or that are adverse to the interests of the individual, Other types of complaints will be handled in the same way.

Every customer, or his/her legal representative, will be given both oral and written notification of the Company’s complaint and grievance procedure. The information will be conveyed in a manner that is appropriate for the customer’s needs and abilities. If the customer is a Medicaid client, they will also receive information about their right to have their complaint move directly to a hearing at any time during the complaint and grievance process.

Important Note: This section does not apply to complaints about abuse, which are covered in another section.

Informal Process for Handling Complaints

If a customer is unhappy with any aspect of the services they receive from the Company, the customer or a legal representative is encouraged to discuss the complaint with the employee. If the customer or customer’s representative or legal guardian does not reach a resolution of the complaint they can bring the complaint to the employee’s lead. If the customer or legal representative is not comfortable bringing the complaint to the employee involved they may bring their complaint directly to the Company. If the employee’s lead’s attempts to review and resolve the complaint fail, the customer or representative can bring the complaint to the Company’s directors who will attempt to resolve the complaint within five (5) working days.

Nothing in this section precludes a individual from bypassing the Company’s procedures and making the complaint to the CDDP case manager. In a case where the case manager contacts the employee directly, the employee should refer the case manager to a Company director.

Complaints and Grievances Log

Where “individual” or “customer” is mentioned in this section, it is acknowledged that an individual may request that someone act as the individual’s representative.

All complaints and grievances by customers should be logged in the Company’s billing and progress notes system on the date when the complaint was made. Any follow-ups should be added to the same notes. Complaints kept in the Company’s progress notes that are specifically complaints or grievances against the Company should be marked as such in the progress notes.

The billing program automatically notes the name of the complainant and the person recording the complaint. The complaint must appear in the progress notes on the day it is received.

Complaints or grievances against other entities should also be documented as such in the individuals progress notes, but solely to document how Company employees provided assistance to the individual in the making of the complaint.

Complaints may be oral or written. Employees should make every effort to log the complaint in the customer’s own words. Once a complaint is entered, the employee should contact their lead DSP or company directors and inform them of the new entry. The lead DSP or company directors will return a written acknowledgement to the individual with five business days and add another entry to the progress notes indicating the date the written acknowledgement was sent. As part of the acknowledgement, the company will invite the complainant and/or representative to participate in an informal discussion of events surrounding the complaint to occur within 10 days after the written acknowledgement.

The company will make a good faith effort to reach a resolution with the customer/representative during the informal discussion and fully document the resolution and deliver it in writing to the individual within 10 days. The resolution must contain the following:

• An investigation of the complaints and records above and the rationale for the outcome.
• All documentation and information related to the outcome.
• Informing the individual of the right to view all documentation and information.
• Informing the individual of the right to request a formal review of the outcome.

This part of the process must be completed within 45 days of the complaint. An additional 45 days may be taken with the consent of the individual.

Review of the Outcome

The individual may request a formal review within 30 days of the written outcome. A written acknowledgement will be mailed by the Company within five business days of the request. Along with the acknowledgement, there will be an offer of having an informal discussion, which will include a company director within 10 days of the acknowledgement. If a resolution is reached, a written determination will mailed to the individual within ten business days and be included in the complaint record.

The determination will include the rationale for the determination, documentation, and other related information.

Outcomes

Most outcomes will be in the form of changes to the way services are delivered, whether a change in personnel or other things agreed to by the individual and the company. Some outcomes may result in the denial, reduction, suspension, or termination of services.

In these latter types of outcomes, notification will be provided on state form 0947 and include:

• The date the notification of denial, reduction, suspension, or termination of services.
• The date that service levels will change.
  • For a denial of service, the effective date is the same date the Notification of Planned Action is mailed or hand delivered to the individual and the representative of the individual.
  • For a reduction, suspension, or termination of service, the effective date is:
    • For a Notification of Planned Action mailed or hand delivered on or before the 18th of the month, the end of the calendar month in which the Notification of Planned Action is mailed or hand delivered to the individual and the representative of the individual, if applicable; or
    • For a Notification of Planned Action mailed or hand delivered on or after the 19th of the month, the end of the calendar month following the month in which the Notification of Planned Action is mailed or hand delivered to the individual and the representative of the individual, if applicable; or
    • No fewer than 10 calendar days after the date the Notification of Planned Action is mailed or hand delivered to the individual and the representative of the individual, if applicable.
• The specific service or unit of service to be denied, reduced, suspended, or terminated.
• The rationale for the denial, reduction, suspension, or termination, including a reference to the specific reports, documents, or other information relied on in making the determination. For an action taken based on the result of a completed Oregon Needs Assessment for the determination of meeting ICF/IID Level of Care, the Notification of Planned Action must identify the specific questions, and responses to those questions, related to the areas of major life activity, identified in OAR 411-317-0000 for ICF/IID Level of Care, in which an individual does not demonstrate significant impairment.
• The specific sections of the rules or statutes upon which the determination is based.
• Notification that the documents relied upon may be reviewed by the individual or the representative of the individual.
• Notification that if the individual or the representative of the individual disagrees with the determination to deny, reduce, suspend, or terminate a service, the individual has the right to request a hearing, or the representative of the individual has the right to request a hearing on the behalf of the individual, as provided in ORS chapter 183 and OAR 411-318-0025. The notification of the right to a hearing must include all the following:
  • The timeline for requesting a hearing.
  • How to request a hearing.
  • The right to receive assistance from the local program in completing and submitting a request for hearing.
  • The right of the individual to receive continuing services at the same level until a Final Order has been issued or, at the request of the individual or the representative of the individual, or until the individual has exhausted the appeals processes identified in OAR 411-318-0025.
  • Notification of the time frame within which the individual or the representative of the individual must request continuing services.
  • Notification of how, when, and where the individual or the representative of the individual may request continuing services.
  • Notification that the individual may be required to repay the Department for any continuing services received during the hearing process if the Final Order upholds the determination to reduce, suspend, or terminate the services.
  • The Notification of Planned Action must be made available using language, format, and presentation methods appropriate for effective communication according to the needs and abilities of the individual and the representative of the individual.

The responsibility for holding hearings is not under the purview of the company, but the company will provide information to the individual on how to request a hearing.