Current through Register Vol. 49, No. 9, September, 2024
1.
Purpose. This
policy provides the administrative procedure for receiving reports, gathering
information, and resolving concerns regarding any organization or individual
licensed or certified by DDS to provide services to persons with
disabilities.
2.
Scope. DDS will accept reports of concerns from any
person.
3.
Service
Concern. DDS will accept for investigation any concern regarding
services provided by a licensed or certified program to an individual with a
developmental disability.
DDS will not accept concerns related to employee grievances
against their employer or any personnel issues, unless it affects the provision
of services to individuals.
4.
Receipt of
Concerns. Any DDS staff person who receives verbal or written
service concerns will immediately relay the information to the DDS Quality
Assurance Investigation Unit.
5.
Mandated Reporting Responsibility. DDS employees will
fulfill their responsibility as mandated reporters by reporting any covered
incident to Adult Protective Services or the Child Abuse Hotline, as
appropriate.
A. The DDS staff who reports the
incident to the appropriate hotline must inform the DDS Quality Assurance
Assistant Director that they have made the report.
B. The DDS Quality Assurance Assistant
Director will contact the Executive Director of the provider agency and provide
them with the details of the report, excluding the name of the reporter.
6.
Investigation Unit Process. The Investigation Unit
maintains primary responsibility for investigation of service concerns. In
conjunction with the Certification and Licensure Manager, the Investigation
Unit Supervisor may assign investigation responsibility, in whole or part, to
Certification and Licensure staff. The Certification and Licensure
Administrator maintains responsibility for the final determination regarding
the outcome of any investigation. All timeframes mentioned below are subject to
extension, based on the approval of the Certification and Licensure
Administrator.
A. The DDS Investigator will
make initial contact, by telephone or face-to-face, with the individual
expressing the concern within three working days of receipt of the concern. The
Investigator will obtain, as appropriate:
1)
The name and contact information of the person,
2) The name and contact information of the
individual receiving services and who is the subject of the concern,
3) A complete accounting of the concern,
including the names of all persons involved, locations, dates and any other
pertinent information.
B. If the Investigator is unable to make
initial telephone or face-to-face contact within three working days, the
Investigator will send a certified letter to the person expressing the concern
that requests that he make contact with the Investigator within three working
days of his receipt of the letter. If the individual does not contact the
Investigator within the specified period, the Investigator will not pursue the
matter unless it appears that the health and safety of an individual who is
receiving services is jeopardized.
1) If the
Investigator determines that the health and safety of an individual is
jeopardized, he will initiate an investigation by contacting the individual's
i. Waiver Case Management provider,
or
ii. Center-Based service
provider.
C.
The Investigator will begin the fact-finding process within one working day
after completion of the initial interview with the person expressing the
concern in order to determine if there is sufficient evidence to conduct a full
investigation. The fact-finding will include:
1) Telephone or face-to-face interviews with
involved parties, and as necessary,
2) Review of pertinent documents related to
the concern.
D. With the
approval of the Certification and Licensure Administrator, the Investigator
will determine whether to initiate an investigation.
1) If the determination is not to proceed
with a full investigation, the Investigator will:
Complete a written summary of events within ten calendar days
of
i. the decision
ii. Make a referral to another party, such as
the DDS Ombudsman or DMS Program Integrity, if appropriate
2) If the determination is to
proceed with a full investigation, the Investigator will initiate an
investigation based at any or all of the following;
i. The provider center,
ii. The provider owned group home,
iii. The provider owned apartment,
iv. The provider owned home,
v. A provider employee owned home,
vi. The home of the individual who is the
subject of the concern, only if the concern came from the individual or their
guardian, or
vii. The DDS
office.
3) The
Investigator will base the determination as to where to conduct the
investigation on factors such as the severity of the allegation and the number
and severity of related concerns received regarding the provider, the alleged
perpetrator or the individual during the preceding six months.
The decision will be subject to the Certification and Licensure
Administrator's approval.
i. The team
who conducts the investigation at the provider location routinely consists of
no more than two persons. The Certification and Licensure Administrator must
obtain approval from the DDS Director to allow more than two persons to conduct
an on-site investigation.
E. The investigator will complete the
investigation within 30 calendar days of receipt of the concern. The
investigator may conduct any or all of the following activities during
investigation:
1) Telephone or face-to-face
interviews with involved parties
2)
Conduct an unannounced visit to the location as described in D2,i-vii either
during regular working hours, after-hours or on weekends
3) Photograph physical evidence
4) Review of case notes, plans of care, time
sheets, or physical plant inspections
5) Review of documentation of staff
training
6) Review of agency
policies and personnel files
7)
Review of any other pertinent information
F. Upon completion of the investigation, the
investigator will determine if the facts support a finding that the provider
did not adhere to DDS Standards for Center-Based Community Services, DDS
Certification Standards for ACS Waiver Services, or any other applicable
policy, regulation or standard.
1) If the
facts support a finding, within 15 calendar days of the conclusion of the
investigation,"'the investigator will send to the provider a report that
contains at least the following information:
i. A summary of the issue,
ii. When and how the concern was submitted,
iii. A brief summary of the
investigation methods, interviews and facts,
iv. A justification of the determination of
the finding, including a citation of the applicable standard or rule,
A request for a time-bound Assurance of Adherence to the v.
standard or rule vi. A notice that the provider may request a meeting with the
Certification and Licensure Administrator to discuss the findings of the review
and to produce additional evidence if warranted, and vii. A notice that the
decision is subject to appeal under the provisions of DDS Administrative
Appeals Policy 1076.
2) With the approval of the Certification and
Licensure Administrator, the Investigator may request that Certification and
Licensure staff initiate a full licensure or certification review of the
program.
3) If the facts do not
support a finding, the investigator will, within 15 calendar days of the
conclusion of the investigation;
i. Send to
the provider a report which contains the information described in F.1) i-iii.,
or
ii. Produce a brief summary of
events, which describes minimal activities conducted to arrive at the
conclusion
G.
The Investigator will provide the investigative report, either electronically
or by regular mail, with or without findings, to the following:
1) The Executive Director of the program or
individual provider who was the subject of the investigation,
2) The President of the Board of Directors of
the program,
3) The Certification
and Licensure Manager, and
4) The
Certification and Licensure Administrator
H. At the completion of the fact-finding or
the investigation, the Investigator will respond either electronically or by
regular mail, to the individual who expressed the concern. The response will
reveal only if:
1) DDS did or did not conduct
an investigation, and
2) The
investigation resulted in a finding of non-compliance with a DDS Standard.
