VI.
PROCEDURES
Procedure A: Resident Health Care Grievance Process,
General
1. The Grievance Review
Officer designated to review grievances under Policy 29.1, Grievance Process,
General, shall also serve as the Grievance Review Officer for health care
issues. The staff person designated to be acting Grievance Review Officer under
Policy 29.1 shall have that same function under this policy.
2. Prior to using the grievance process, a
request for medical or mental health care must first be made by the resident
using the established facility health care procedures (e.g., by submitting a
sick call slip, submitting a request for mental health services, or presenting
a problem during a chronic care clinic).
3. The facility's Health Services
Administrator (HSA) shall be responsible to attempt, or designate staff to
attempt, informal resolutions with residents for medical and mental health
complaints.
4. During the
orientation process for each resident admitted or transferred to a juvenile
facility, the resident shall be informed that a copy of this grievance policy
and procedures, resident grievance forms, and envelopes are readily available
in each housing unit, the special management unit, the infirmary, and the
library. The health care grievance process and how to obtain assistance with
the process shall also be explained.
5. It is the responsibility of the Juvenile
Program Manager, or designee, of the housing unit assigned to a resident who
needs or requests assistance with the grievance process to provide assistance
in a timely manner, including, but not limited to, as appropriate, a sign
language interpreter, foreign language interpreter, reasonable accommodation
for a resident with a physical or mental disability, assistance to a resident
who is illiterate, and assistance to a resident whose access to paper and/or
writing materials has been restricted for safety or security reasons. A
resident may also be assisted in the grievance process by another staff member
on a voluntary basis or by any other person with whom the resident is permitted
to have contact, provided that in all cases the grievance and grievance appeal
forms are filed by the resident.
6.
A resident of a juvenile facility may file a grievance with the Grievance
Review Officer to request administrative review of any policy, procedure,
practice, action, decision, or event that directly affects the medical or
mental health care received by the resident, that he/she believes is not
responsive to his/her medical or mental health needs, is in violation of
his/her rights or is in violation of Departmental policies and procedures, and
for which he/she believes a Departmental health care employee or contractor is
responsible.
7. The Chief
Administrative Officer, or designee, shall ensure that this grievance policy
and procedures, as well as resident grievance forms (Attachment A) and
envelopes are readily available in each of the facility's housing units, the
special management unit, the infirmary, and the library. A resident may use
only this form to submit a grievance. Any attempt by a resident to submit a
grievance by a letter or in any other way shall not be accepted.
8. A resident shall be allowed to submit a
grievance form or a grievance appeal form in an envelope sealed by the resident
and addressed to the Grievance Review Officer. Any attempt by a resident to
submit a grievance or a grievance appeal to anyone other than the Grievance
Review Officer shall not be accepted. The Chief Administrative Officer, or
designee, shall provide a grievance mailbox or other means for residents to
submit grievance forms and grievance appeal forms to the facility Grievance
Review Officer. A resident who has a grievance about a matter concerning
medical or mental health care that occurred at a Departmental juvenile facility
that he or she was previously housed in shall be allowed to submit a grievance
form or grievance appeal form to that facility's Grievance Review Officer by
mailing it through the U.S. Mail. If the resident wishes to have it treated as
privileged mail, he or she may do so by marking it as such on the outside of
the envelope.
9. A resident housed
at one Departmental juvenile facility who has a grievance about a matter
concerning medical or mental health care that occurred at another Departmental
juvenile facility shall direct the grievance form to the Grievance Review
Officer at the facility where the matter occurred.
10. A resident housed in a jail, in another
jurisdiction's facility, or a Departmental adult facility who has a grievance
about a matter concerning medical or mental health care that occurred while
housed at a Departmental juvenile facility shall request a grievance form from
the Grievance Review Officer at the Departmental juvenile facility where the
resident was previously housed and shall submit the grievance form to that
facility's Grievance Review Officer. A resident housed in a jail, in another
jurisdiction's facility, or a Departmental adult facility who has a grievance
about any other matter shall use that facility's grievance process.
11. If a resident's grievance concerns a
policy, procedure, or practice concerning medical or mental health care, the
grievance form must be filed within fifteen (15) days of when the policy,
procedure, or practice first affected the resident. If the grievance concerns
an action, decision, or event concerning medical or mental health care that is
ongoing, the grievance form must be filed within fifteen (15) days of when the
action or event first occurred or the decision was first made. If the grievance
concerns any other action, decision, or event concerning medical or mental
health care, the grievance form must be filed within fifteen (15) days of when
the action, decision, or event occurred. In any case in which a grievance
implicates more than one of the above, the grievance form must be filed within
the shortest of the above time limits.
12. The Chief Administrative Officer, or
designee, shall ensure that grievance forms and grievance appeal forms are
collected and date stamped at least once every business day. A grievance form
or grievance appeal form is considered filed on the day it is collected and
date stamped. The Grievance Review Officer shall grant an exception to the time
limit for filing if and only if it the resident makes a clear showing that it
was not possible for the resident to file the form within the fifteen (15) day
period. The fact that a resident was seeking assistance, gathering information,
or conducting research shall not be grounds for an exception to the time limit
for filing a grievance form or grievance appeal form, unless the resident's
Juvenile Program Manager confirms that it was not possible for the resident to
file the form without assistance and that the Juvenile Program Manager, or
designee, was unable to provide the assistance in a timely manner. The fact
that a resident is not housed at a Departmental facility shall not be grounds
for an exception to the time limit for filing a grievance or grievance appeal
form.
13. The resident shall state,
using one grievance form only, as briefly and concisely as possible, the
specific nature of the medical or mental health complaint, including all the
persons and dates involved. The resident shall provide sufficient information
to show when the fifteen (15) day time limit began. The resident shall also
state the specific remedy requested.
14. A resident may not bring up more than one
medical or mental health subject in any one grievance. Except for photocopies
of relevant documents (e.g., health care report, etc.), the resident shall not
submit any attachments with the grievance form.
15. No resident using the grievance process
in good faith shall be subjected to retaliation in the form of an adverse
action or a threat of an adverse action for using the grievance process.
However, a resident may have his/her access to the grievance process suspended
under Procedure G. and/or may be subjected to disciplinary action for abuse of
the grievance process.
16. A
resident shall be entitled to pursue, through the grievance process, any
complaint that the resident has been subjected to retaliation for using the
grievance process in good faith.
17.
A resident may withdraw his/her grievance at any time by written notice to the
Grievance Review Officer.
Procedure B: First Level Review of a Resident
Grievance
1. The Grievance
Review Officer shall first review a grievance form to determine whether the
subject is grievable, whether the grievance form has been filed within the
fifteen (15) day time limit (or an exception should be granted), whether the
complaint is a duplicate of an earlier grievance, or whether there has been an
obvious abuse of the grievance process by the resident.
2. If the Grievance Review Officer determines
the subject is not grievable, the grievance form has been submitted untimely,
the complaint is a duplicate of an earlier grievance, the grievance is
obviously frivolous in nature or there has otherwise been an obvious abuse of
the grievance process by the resident, the Grievance Review Officer shall
dismiss the complaint and return the original grievance form to the resident,
along with a form noting the reason for the dismissal of the complaint
(Attachment B). The Grievance Review Officer shall make a copy of the grievance
form and the form noting the reason for dismissal for the file. No appeal of a
dismissal is allowed.
3. Any attempt
to file a grievance about a decision of the Grievance Review Officer acting as
the Grievance Review Officer shall be treated as not grievable and dismissed.
No appeal of a dismissal is allowed.
4. If the information provided by the
resident on the grievance form is not sufficient for the Grievance Review
Officer to determine whether it was filed within the required fifteen (15) day
time limit, the Grievance Review Officer shall immediately return the original
grievance form to the resident, along with a form noting the reason for the
return of the complaint (Attachment B). The Grievance Review Officer shall make
a copy of the grievance form and the form noting the reason for return for the
file. The resident must resubmit the grievance form with the missing
information within seven (7) days of the date it was returned to the resident,
or within the original fifteen (15) day time limit for filing a grievance,
whichever is later, in order to utilize the grievance process.
5. If a complaint is dismissed, but the
Grievance Review Officer determines that the complaint requires follow up, the
Grievance Review Officer shall forward the complaint to the Chief
Administrative Officer, or designee, for determination, outside the grievance
process, as to any other action required.
6. Unless the complaint is dismissed or
returned for additional information, the Grievance Review Officer shall date
the form with the date the grievance was date stamped, log the receipt of the
grievance, and assign to the grievance a log number. The log number shall
consist of the last two digits of the year, the initials for the facility, and
the order of receipt of the grievance (e.g., the thirteenth grievance received
by the Long Creek Youth Development Center Grievance Review Officer in the year
2011 would be logged as 11-LC-13). That log number shall be used to identify
the grievance throughout the entire grievance process.
Procedure C: Informal Resolution Process
1. Unless the resident is housed in a jail,
another jurisdiction's facility, or a Departmental adult facility, once logged,
the Grievance Review Officer shall immediately send a copy of the grievance and
the Informal Resolution Form (Attachment C) to the facility Health Services
Administrator and shall so advise the resident. The Health Services
Administrator shall meet with the resident to attempt to resolve the grievance
informally, if possible. Any informal resolution requires the agreement of the
Health Services Administrator and resident and must be consistent with
Departmental policies, procedures, and practices.
2. If the grievance is resolved, the Health
Services Administrator shall date and sign the form, note on the form what the
resolution is, including the implementation date, have the resident sign the
form acknowledging the resolution of the grievance, and return the grievance
form and the informal resolution form to the Grievance Review Officer within
seven (7) days of being sent the grievance, with copies to the
resident.
3. If the grievance is not
resolved, the Health Services Administrator shall date and sign the form, list
on the form the actions taken in the attempt to resolve the complaint, have the
resident sign the form acknowledging the lack of resolution of the grievance,
and return the grievance form and the informal resolution form to the Grievance
Review Officer within seven (7) days of being sent the grievance, with copies
to the resident.
4. No Health
Services Administrator may refuse to comply with any requirement of this
procedure, for any reason.
5. If an
informal resolution is reached, the Grievance Review Officer shall document the
resolution in the grievance log and close out the grievance.
6. If the informal resolution is not
implemented by the specified date, the resident may file another grievance
within fifteen (15) days of the date specified in the informal resolution. This
grievance shall be handled through the formal grievance process, with no
further attempt at an informal resolution.
7. If an informal resolution is not reached,
the Grievance Review Officer shall proceed with the formal grievance
process.
8. If the resident is
housed in a jail, another jurisdiction's facility, or a Departmental adult
facility, the Grievance Review Officer shall not initiate the informal
resolution process but immediately proceed with the formal grievance process.
Procedure D: Formal Grievance Process
1. The formal grievance process shall begin
with an investigation by the Grievance Review Officer. This may include, but is
not limited to, conducting interviews with the resident, staff, or others,
requesting copies of documents, requesting oral or written reports from staff,
reviewing policies and procedures, etc. All staff shall cooperate fully with
the requests of the Grievance Review Officer.
2. The Grievance Review Officer shall respond
to the grievance, in writing, no later than thirty (30) days following receipt
of the grievance form from the resident, indicating any action taken to resolve
the resident's grievance or the reasons for the denial of the grievance
(Attachment D). The Grievance Review Officer shall include a grievance appeal
form (Attachment F) with the response.
3. If the only remedy for the grievance
requires action by the Chief Administrative Officer, the Grievance Review
Officer shall forward the grievance, together with any investigative reports
and other documentation, to the Chief Administrative Officer for review and
shall so advise the resident.
4. If
the only remedy for the grievance requires action by the Commissioner (e.g.,
changing a Departmental policy or procedure), the Grievance Review Officer
shall forward the grievance to the Commissioner for review and shall so advise
the resident.
5. If a response
cannot be made within the thirty (30) days, the Grievance Review Officer shall
so advise the resident and shall indicate when the response will be made, which
must not be later than an additional ten (10) days.
Procedure E: Second Level Review of a Resident's
Grievance
1. If, after receipt
of the response from the Grievance Review Officer, the resident wishes to
appeal, the appeal must be filed with the Grievance Review Officer, using the
grievance appeal form, within fifteen (15) days of the date of the response
(the date the Grievance Review Officer signs the response and sends it to the
resident). The resident shall include on the appeal form the log number
assigned to the grievance by the Grievance Review Officer. If the resident does
not appeal within the fifteen (15) day time period, the Grievance Review
Officer shall close the case. A resident may use only this form to submit an
appeal. Any attempt by a resident to submit an appeal via letter or in any
other way shall not be accepted.
2.
The resident shall state, using one grievance appeal form only, the reasons for
the appeal. The resident shall not raise an argument on appeal that was not
raised in the original grievance or the response to the original grievance.
Except for photocopies of relevant documents (e.g., health care report, etc.),
the resident shall not submit any attachments with the grievance
form.
3. The Grievance Review
Officer shall first review a grievance appeal form to determine whether the
grievance appeal form has been filed within the fifteen (15) day time limit (or
an exception should be granted). If the Grievance Review Officer determines the
grievance appeal form has been submitted untimely, the Grievance Review Officer
shall dismiss the appeal and return the grievance appeal form to the resident,
along with a form noting the reason for the dismissal of the appeal (Attachment
B). The Grievance Review Officer shall make a copy of the grievance appeal form
and the form noting the reason for dismissal for the file. No appeal of a
dismissal is allowed.
4. Unless the
appeal is dismissed, the Grievance Review Officer shall log the receipt of the
appeal and forward the grievance appeal form, together with all prior
correspondence and documentation, to the Chief Administrative
Officer.
5. The Chief Administrative
Officer, or designee, shall review all prior correspondence and documentation
and may require additional investigation before making a written response to
the resident.
6. The Chief
Administrative Officer, or designee, shall respond to the grievance, in
writing, within twenty-five (25) days of filing of the appeal, indicating any
action taken to resolve the resident's grievance or the reasons for the denial
of the appeal (Attachment E). The Chief Administrative Officer, or designee,
shall include a grievance appeal form with the response.
7. If the only remedy for the grievance
requires action by the Commissioner (e.g., changing a Departmental policy or
procedure), the Chief Administrative Officer, or designee, shall require the
Grievance Review Officer to forward the appeal, together with all prior
correspondence and documentation, to the Commissioner for review and shall so
advise the resident.
Procedure F: Third Level Review of a Resident's
Grievance
1. If, after receipt
of the response from the Chief Administrative Officer, the resident wishes to
appeal, the appeal must be filed with the Grievance Review Officer, using the
grievance appeal form, within fifteen (15) days of the date of the response
(the date the Chief Administrative Officer signs the response and sends it to
the resident). The resident shall include on the appeal form the log number
assigned by the Grievance Review Officer to the grievance. If the resident does
not appeal within the fifteen (15) day time period, the Grievance Review
Officer shall close the case. A resident may use only this form to submit an
appeal. Any attempt by a resident to submit an appeal via letter or in any
other way shall not be accepted.
2.
The resident shall state, using one grievance appeal form only, the reasons for
the appeal. The resident shall not raise an argument that was not raised in the
original grievance, the response to the original grievance, or the response to
the appeal to the Chief Administrative Officer. Except for photocopies of
relevant documents (e.g., health care report, etc.), the resident shall not
submit any attachments with the grievance form.
3. The Grievance Review Officer shall first
review a grievance appeal form to determine whether the grievance appeal form
has been filed within the fifteen (15) day time limit (or an exception should
be granted). If the Grievance Review Officer determines the grievance appeal
form has been submitted untimely, the Grievance Review Officer shall dismiss
the appeal and return the grievance appeal form to the resident, along with a
form noting the reason for the dismissal of the appeal (Attachment B). The
Grievance Review Officer shall make a copy of the grievance appeal form and the
form noting the reason for dismissal for the file. No appeal of a dismissal is
allowed.
4. Unless the appeal is
dismissed, the Grievance Review Officer shall log the receipt of the appeal and
forward the grievance appeal form, together with all prior correspondence and
documentation, to the Commissioner.
5. The Commissioner, or designee, shall
review all prior correspondence and documentation and may require additional
investigation before making a written response to the resident, which must be
done within twenty (20) days of filing the appeal. A copy of the response shall
be forwarded to the Grievance Review Officer and the Chief Administrative
Officer.
6. This level is the final
administrative level of appeal.
Procedure G: Abuse of the Grievance
Process
1. If the Commissioner,
or designee, or the Chief Administrative Officer determines that a resident has
abused the grievance process by filing a frivolous grievance (a grievance is
not frivolous if it is a complaint about a violation of law, a violation of
policy or procedures, a risk to health or safety, or an ongoing or frequent
deviation from a normal practice or condition of confinement), by filing
multiple grievances on the same subject, or by otherwise creating an
administrative burden, or by knowingly making a false statement in a grievance,
the Commissioner, or designee, or the Chief Administrative Officer, may suspend
the resident's access to the grievance process for up to a ninety (90) day
period. If the Commissioner, or designee, or the Chief Administrative Officer
suspends a resident's access to the grievance process, the Commissioner, or
designee, or the Chief Administrative Officer shall notify the resident in
writing (Attachment G). If the Chief Administrative Officer suspends a
resident's access to the grievance process, the Chief Administrative Officer
shall ensure that the Commissioner, or designee, is notified of this decision
at least one (1) week prior to notifying the resident. If the Commissioner, or
designee, does not agree with the Chief Administrative Officer's decision, he
or she shall notify the Chief Administrative Officer prior to the expiration of
the one (1) week time period.
2. A
resident who has been suspended from access to the grievance process may not
file a grievance during the period of suspension unless it concerns a violation
of a constitutional right.
Procedure H: Grievance Records
1. Records regarding the filing and
disposition of individual grievances shall be collected and maintained
systematically within each juvenile facility and shall be handled in the same
manner as other resident records.
2.
Each juvenile facility shall send quarterly reports to the Commissioner
concerning the operation of the grievance process. These reports shall include
the numbers and types of grievances logged, the numbers of grievance appeals
logged, the response times to each, and the highest level response and the
nature of the resolution in each case.