Current through Register 1531, September 27, 2024
(1)
Filing a Complaint. Any person may make a complaint to
the Person in Charge regarding an incident or condition involving a client
which he or she believes to be dangerous, illegal, or inhumane.
(a) An employee who is notified or who
becomes aware that a client wants to file a complaint shall provide the client
with a complaint form and offer the client assistance in completing and filing
the complaint, and shall provide such assistance if requested.
(b) An employee who becomes aware of any
condition or incident which he or she has reason to believe is dangerous,
illegal or inhumane shall immediately complete and file a complaint with the
Person in Charge or verbally notify the Person in Charge or designee, who shall
be responsible for filing the complaint.
(c) The Human Rights Officer shall assist
clients, as necessary, or upon request in filing complaints.
(d) The Human Rights Officer shall use best
efforts to refer a client who lacks, or who appears to lack capacity, or upon
request, to an attorney or advocate, if necessary or appropriate, to ensure
that the client's interests are protected.
(e) The Human Rights Committee may file a
complaint on behalf of a client or group of clients and may intervene as a
party to a complaint by submitting a notice of intervention to the Person in
Charge.
(f)
No
Retaliation. There shall be no retaliation against any individual
who files a complaint or otherwise participates in fact finding or
investigation activities in good faith pursuant to
104 CMR 32.00.
(g) Any employee who receives a complaint
shall immediately forward such complaint to the Person in Charge, who, if
necessary, shall document it on a complaint form.
(2)
When a Complaint is
Received.
(a) Upon receipt of a
complaint, the Person in Charge shall determine if the complaint involves one
of the following:
1. medicolegal
death;
2. sexual assault or
abuse;
3. physical assault or abuse
which results in serious physical harm;
4. attempted suicide which results in serious
physical harm;
5. commission of a
felony;
6. serious physical injury
resulting from restraint or seclusion practices; or
7. an incident that the Person in Charge in
his or her discretion believes is sufficiently serious or complicated as to
require investigation by the Office of Investigations or Director of Licensing
even though it does not otherwise involve one of the categories listed in 104
CMR 32.04(2)(a)1. through 6.
(b) If the complaint comes under one of the
categories specified above in 104 CMR 32.04(2)(a) the following actions shall
be taken.
1. The Person in Charge shall
forward the complaint to the following individuals who shall be the Responsible
Person of the complaint:
a. the Area
Director, if the complaint involves a program or community mental health center
operated or contracted for by the Department, an adult inpatient unit
contracted for by the Area, or a Department office within the control of the
Area;
b. the Director of the Office
of Inpatient Management if the complaint involves an DMH operated adult
inpatient facility other than a community mental health center operated or
contracted by the Department;
c.
the Director of Statewide Program Management, if the complaint involves an IRTP
or CIRT or a Department contracted inpatient unit for children or
adolescents;
d. the Senior Manager
of a Department office other than one controlled by an Area; or
e. the applicable Director of Licensing if
the complaint involves a program or facility licensed, but not contracted for,
by the Department.
2.
The Responsible Person shall:
a. immediately
assign a public log number to the complaint;
b. refer it to the Office of Investigations;
and
c. notify the parties and the
appropriate Human Rights Officer that the complaint has been referred to the
Office of Investigations for investigation and resolution in accordance with
104 CMR
32.05.
(c)
Privacy
Complaints.
1. If the complaint
alleges a violation of a client's privacy rights in a Department operated
program or facility, the Responsible Person must notify the Department's
Director of Privacy and Data Access and the complaint shall be resolved in
accordance with the procedures set forth in the Department's Privacy
Handbook.
2. If the complaint
alleges a violation of a client's privacy rights in a Department-contracted for
or licensed program or facility, the complaint shall be resolved in accordance
with the program or facility's privacy complaint resolution
procedures.
(d) If the
complaint does not come under one of the categories specified in 104 CMR
32.04(2)(a) or (c) the Person in Charge shall be the Responsible Person who
shall:
1.
a. in the case of a Department operated
program or facility, enter the complaint into the Department's complaint
recording system;
b. in the case of
a Department contracted for program or adult inpatient facility, provide a copy
of the complaint to the Area Director, or Statewide Director of Program
Management, as applicable, and to the applicable Director of Licensing, if any,
who shall have the complaint entered into the Department's complaint recording
system;
c. in the case of a
Department licensed, but not Department contracted for, program or facility,
such program or facility shall create and maintain an internal log of
complaints and the Responsible Person shall assign an internal log number;
and
2. determine whether
the complaint shall be resolved by administrative resolution or ten-day
fact-finding in accordance with 104 CMR 32.04(3) or (4).
(e)
Health, Safety or
Welfare. If the Person in Charge or the Responsible Person
concludes at any time during the course of resolution of the complaint that
immediate action is necessary to protect the health, safety, or welfare of a
person, he or she shall take steps to ensure that such action is taken and
shall document the action taken.
(3)
Administrative
Resolution.
(a) If the
Responsible Person has a reasonable basis to believe that a complaint meets one
of the following criteria, the complaint may be resolved administratively in
accordance with 104 CMR 32.04(3):
1. concerns
an allegation of an incident or condition that is not dangerous, illegal or
inhumane within the scope of
104 CMR 32.00;
2. makes allegations that are objectively
impossible;
3. repeats allegations
of fact that have previously been investigated and decided in accordance with
104 CMR 32.00;
4. alleges a violation of regulation, policy
or procedure that does not present a health or safety risk to a client or other
individual and which may be resolved or corrected without need for additional
fact finding;
5. is withdrawn by
the client or complainant, provided the complaint does not concern the health
or safety of a client or other individual; or
6. presents undisputed facts which allow the
Responsible Person to determine that the complaint can best be resolved through
the administrative process.
(b) In resolving a complaint pursuant to 104
CMR 32.04(3), the Responsible Person or designee must meet with the client and
the complainant, if different, unless the client and/or complainant declines to
meet with the Responsible Person or designee, or despite reasonable efforts,
cannot be located.
1. The Responsible Person
shall notify client and the complainant, if different, of the availability of
the Human Rights Officer to attend the meeting at the client's or complainant's
request.
2. Unless the client or
complainant declines to meet or cannot be located, this meeting shall take
place within three business days of the determination that the complaint meets
the criteria of administrative resolution pursuant to 104 CMR
32.04(3)(a).
3. The purpose of this
meeting shall be to:
a. review the specific
allegations in the complaint;
b.
determine whether there are disagreements concerning the facts underlying the
allegations that require further fact-finding; and
c. discuss and, if possible, agree upon
actions, if any, that may be taken by the Responsible Person or designee to
address the concerns raised by the complaint.
(c) If at any time the Responsible Person
determines that the criteria for administrative resolution are not met,
including without limitation, that there is disagreement concerning the facts
underlying the allegations in the complaint that require formal fact-finding in
order to resolve, the Responsible Person shall refer the complaint for
fact-finding or investigation in accordance with 104 CMR 32.04(4) or
34.04(5).
(d) Within five business
days of the filing of the complaint, or two business days of the meeting held
pursuant to 104 CMR 32.04(3)(b), whichever is later, the Responsible Person
shall provide the parties with a written decision that includes a statement of
the applicable criteria for administrative resolution, the grounds upon which
the determination for administrative resolution has been made, the actions, if
any, that will be taken by the Responsible Person, the right to request
reconsideration, and the client's right of appeal in accordance with 104 CMR
32.04(7).
(e) In the case of a
Department contracted for program or adult inpatient facility, a copy of the
written decision shall be provided to the Area Director, or an IRTP or CIRT or
a Department contracted inpatient unit for children or adolescents to the
Director of Statewide Program Management.
(f) If at any time during the course of
ten-day fact finding or investigation pursuant 104 CMR 32.04(4) or (5),
respectively, the Responsible Person determines that the criteria for
administrative resolution are met, the Responsible Person may elect to stop the
fact finding or investigation and proceed under 104 CMR 32.04(3). The
determination shall be in writing and shall include the factual basis for the
election.
(4)
Responsible Person Ten-day Fact-finding.
(a) Unless a complaint is resolved pursuant
to 104 CMR 32.04(3), is referred to the Office of Investigations pursuant to
104 CMR 32.04(2)(b), or is a Privacy Complaint pursuant to 104 CMR 32.04(2)(c),
the Responsible Person shall undertake or within two days of receipt of the
complaint, assign the matter for fact-finding in accordance with
104 CMR
32.06 which shall be completed within ten
days of assignment. The Responsible Person may authorize an extension of up to
ten days if the complaint is sufficiently complicated or if the parties or
essential witnesses cannot be interviewed within the initial ten day period.
The Responsible Person shall document in the file the reasons for any
extension.
(b) In the case of a
Department contracted for program or adult inpatient facility, a copy of such
documentation shall be provided to the Area Director, or for an IRTP or CIRT or
a Department contracted inpatient unit for children or adolescents to the
Director of Statewide Program Management.
(c) The individual conducting such
fact-finding shall provide a written report of findings of fact and, unless the
Responsible Person conducts the fact finding, recommended conclusions to the
Responsible Person.
(d) In the case
of a Department contracted for program or adult inpatient facility, a copy of
the written report of findings of fact shall be provided to the Area Director,
for an IRTP or CIRT or a Department contracted inpatient unit for children or
adolescents to the Director of Statewide Program Management.
(e) The Responsible Person shall issue a
written decision within five days following completion of the fact
finding.
(f) The written decision
shall contain findings of fact and conclusions, and any actions to be taken.
The decision shall also notify the parties of the right to request
reconsideration and the client's right of appeal in accordance with 104 CMR
32.04(7).
(g) In the case of a
Department contracted for program or facility, a copy of the written decision
shall be provided to the Area Director, or for statewide contracted for
programs, to the responsible Central Office contract manager.
(5)
Complaints
Referred to the Office of Investigations.
(a)
Responsibilities of the
Office of Investigations.
1.
Whenever a complaint is forwarded to the Office of Investigations pursuant to
104 CMR 32.04(2), the Director of Investigations, or designee, shall, within
two days, complete the following:
a. confirm
the complaint has been logged into the Office of Investigations' database and
assigned a public log number, update log as necessary and open a case
file;
b. determine and document
whether or not another entity has jurisdiction to conduct an investigation and
if so, whether that entity is aware of the incident or condition complained of
and is undertaking an investigation;
c. if another entity is undertaking an
investigation, determine in accordance with 104 CMR 32.04(6) whether the
Department shall defer investigating the matter to that entity and document the
determination; and
d. assign an
investigator.
2. If the
Director of Investigations, or designee, does not believe an investigation by
the Office of Investigation is necessary or appropriate, the Director, or
designee, shall consult with the applicable Responsible Person, who shall
determine the appropriate process for resolution of the complaint.
3. The Office of Investigations shall
coordinate investigatory activity with the appropriate Responsible
Person.
(b)
Responsibilities of the Investigator.
1. Within 30 days from the assignment of the
investigation pursuant to 104 CMR 32.04(5)(a), the investigator shall conduct
an investigation and file a report containing written findings of fact and
recommended conclusions with the Responsible Person.
2. The investigator may request in writing an
extension of the time required for filing the report, which may be granted for
good cause by the Director of Investigations, in consultation with the
Responsible Person.
3. If such an
extension is granted, the investigator shall give written notice of the revised
due date to the parties and the Area Director, Director of the Office of
Inpatient Management, Director of Statewide Program Management, Director of
Licensing, or Senior Manager, as applicable. In the case of an investigation
involving a Child, Youth and Family Services program, a copy of such notice
shall also be provided to the Area Director of Child, Youth and Family
Services.
(c)
Responsibilities of the Responsible Person.
1. Within ten days after receipt of the
investigator's report or the report of an investigation by another legally
authorized entity, the Responsible Person shall:
a. issue a decision accepting the findings of
fact and recommended conclusions, identifying corrective actions to be taken,
if any, and designating who is responsible for carrying out such
actions;
b. conduct or refer the
matter for further fact-finding, to be completed within a specified time
period, on matters identified by the Responsible Person; or
c. issue a decision making his or her own
conclusions, including an explanation of the rationale for not accepting the
investigator's recommended conclusions, and identifying corrective actions to
be taken, if any, and designating who is responsible for carrying out such
actions.
2. The decision
shall be provided to the parties with notice of the right to request
reconsideration and the client's right to appeal in accordance with 104 CMR
32.04(7).
(6)
Deferred Investigations.
(a) Notwithstanding any other provision of
104 CMR 32.00 to the
contrary, the investigation of the complaint may be deferred if another legally
authorized entity is conducting an investigation of the allegations set forth
in the complaint.
1. If an investigation is
deferred upon the request of law enforcement or the DPPC, the Office of
Investigations shall notify the Responsible Person of any such
deferral.
2. The Director of
Licensing or Director of Statewide Program Management may defer an
investigation to the Department of Children and Families, in which case he or
she shall notify the Office of Investigations.
(b) Any investigation deferred for more than
60 days shall be reviewed by the Office of Investigations in consultation with
the Responsible Person to determine whether some fact finding and corrective
action should be pursued notwithstanding deferral; provided however, that the
case shall remain active pending completion of the investigation.
(c) Nothing in 104 CMR 32.04(6) shall
preclude the Responsible Person from taking or ordering any corrective action
deemed necessary during the pendency of the deferral.
(7)
Request for Reconsideration;
Appeal.
(a)
Request
for Reconsideration.
1.
General Provisions. Any party to the complaint has the
right to request reconsideration of a decision issued pursuant to 104 CMR
32.04(3), (4) or (5). Reconsideration is not a prerequisite to a client's
filing of an appeal.
a. A request for
reconsideration must be submitted in writing to the Responsible Person within
ten days of receipt of the decision, which time period may be waived by the
Responsible Person, upon request and for good cause shown. The Responsible
Person shall forward notice of the request for reconsideration to all other
parties.
b. A request for
reconsideration must be based on one or more of the following factors, which
shall be set forth with specificity in the request:
i. The fact-finder failed to interview an
essential witness or to consider an important fact or factor.
ii. The decision is not reasonably supported
by the facts.
iii. The decision is
based on an erroneous interpretation of applicable law or policy.
2.
Response
to Request for Reconsideration:
a. Unless the Responsible Person determines
that additional fact-finding is required, he or she shall within ten days from
receipt of the request for reconsideration issue a final decision affirming,
modifying or reversing the initial decision. The final decision shall be in
writing and shall inform the client of the right to appeal pursuant to 104 CMR
32.04(7)(b).
b. If the Responsible
Person determines additional fact-finding is required, he or she shall conduct
or refer the matter for such fact-finding, which shall be completed within ten
days of receipt of the request for additional fact-finding, but which time
period may be extended for good cause.
c. Within ten days of receipt of the results
of any additional fact-finding, the Responsible Person shall issue a final
decision affirming, modifying or reversing the initial decision. The final
decision shall be in writing, distributed to all parties, and shall also notify
the client of the right to appeal pursuant to 104 CMR 32.04(7)(b). d. A party
adversely affected by a reconsideration decision that substantially alters the
initial decision may request further reconsideration pursuant to 104 CMR
32.04(7)(a).
(b)
Appeal Process.
1.
General
Provisions.
a. A client, a
client's legally authorized representative, or an Authorized Individual may
appeal decisions issued pursuant to 104 CMR 32.04(3) through (5) or (7)(a). In
the case of a client's death, an appeal may be pursued or authorized by the
duly appointed personal representative of the decedent's estate or other
individual with legal authority to act on behalf of the decedent.
b. All appeals must be in writing and filed
within ten days of receipt of the applicable decision, which time period may be
waived by the person responsible for deciding an appeal, upon request and for
good cause shown. The person responsible for deciding an appeal shall forward
notice of the appeal to all other parties.
c.
Subject Matter of
Appeal. Appeals shall be based on one or more of the following
factors, which shall be set forth with specificity in the appeal:
i. The fact-finder failed to interview an
essential witness or to consider an important fact or factor.
ii. The decision is not reasonably supported
by the facts.
iii. The decision is
based on an erroneous interpretation of applicable law or policy.
d.
Additional
Fact-finding. The person responsible for deciding an appeal
pursuant to 104 CMR 32.04(7)(b)(2) or (3) may, within ten days of receipt of
the appeal, direct that additional fact-finding be undertaken. Such
fact-finding shall be undertaken by the Responsible Person, Office of
Investigations or other individual designated by the person responsible for
deciding the appeal within a time-frame as directed by such person, not to
exceed 20 days, which time period may be extended for good cause.
e. Decisions on appeal shall be issued within
30 days of receipt of the appeal, unless further fact-finding is required, in
which case the decision shall be issued within ten days of the report of the
additional fact-finding, which time period may be extended for good
cause.
f. Decisions on appeal shall
also provide notice of applicable rights of further appeal.
2.
Appeal from a
Decision Issued Pursuant to 104 CMR 32.04(3) or (4).
a. A decision concerning a complaint issued
pursuant to 104 CMR 32.04(3) or (4) may be appealed as follows:
i. A decision involving an adult Department
operated or contracted for community mental health center, or program, a
Department contracted adult inpatient unit, or a Department office within the
control of an Area may be appealed to the applicable Area Director;
ii. A decision involving an adult Department
operated or contracted for inpatient facility may be appealed to the Director
of the Office of Inpatient Management; iii. A decision involving an IRTP, CIRT,
or Department contracted child or adolescent inpatient unit, may be appealed to
the Director of Statewide Program Management;
iv. A decision involving a Child, Youth and
Family Services program operated or contracted for by the Department may be
appealed to the applicable Area Director who shall decide the appeal in
consultation with the Area Director of Child, Youth and Family Services;
or
v. A decision involving a
Department office other than one controlled by an Area may be appealed to the
applicable Senior Manager; or
vi. A
decision involving a licensed program or facility may be appealed to the
applicable Director of Licensing.
b. The appeal decision shall:
i. Affirm, modify or reverse the
decision.
ii. Be in writing and
sent to the parties. The decision shall include corrective actions, if any, to
be carried out by the Person in Charge; and
iii. Notify the client of his or her right to
further appeal the decision within ten days to:
(i) the Deputy Commissioner for Mental Health
Services in the case of a decision by an Area Director or Director of the
Office of Inpatient Management;
(ii) the Deputy Commissioner for Child, Youth
and Family Services in the case of a decision by the Director of Statewide
Program Management;
(iii) the Chief
of Staff of the Department, or designee, in the case of a decision by a Senior
Manager;
(iv) the Deputy
Commissioner for Mental Health Services in the case of a decision by the
Director of Community Licensing; or
(vi) the Deputy Commissioner for Clinical
Professional Services in the case of a decision by the Director of Inpatient
Licensing.
c.
The decision of the Deputy Commissioner or Chief of Staff shall be
final.
3.
Appeal from Decision after Investigation by the Office of
Investigations.
a. After an
investigation by the Office of Investigations pursuant to 104 CMR 32.04(5);
i. A decision made by an Area Director or the
Director of the Office of Inpatient Management may be appealed to the Deputy
Commissioner for Mental Health Services, who, in the case of a decision
involving a Department operated or contracted for Child, Youth and Family
program, shall decide the appeal in consultation with the Deputy Commissioner
for Child, Youth and Family Services.
ii. A decision made by the Director of
Statewide Program Management Services may be appealed to the Deputy
Commissioner for Child, Youth and Family Services.
iii. A decision made by a Senior Manager of a
Department office other than one controlled by an Area may be appealed to the
Chief of Staff of the Department, or designee.
iv. A decision made by the Director of
Community Licensing may be appealed to the Deputy Commissioner for Mental
Health Services.
v. A decision made
by the Director of Inpatient Licensing may be appealed to the Deputy
Commissioner for Clinical Professional Services.
b. The appeal decision shall:
i. Affirm, modify or reverse the
decision.
ii. Be in writing and
sent to the parties. The decision shall include corrective actions, if any, to
be carried out; and
iii. Notify the
client of his or her right to further appeal the decision within ten days to
the Commissioner, whose decision shall be final.
(8)
Release of Decision Letters and Written Notice. Any
decision or written notice issued pursuant to
104 CMR 32.00 that is to be
released to a party or any other individual shall be subject to redaction of
Protected Health Information (PHI) or any other information that the recipient
is not legally authorized to receive consistent with the requirements of
federal and state privacy laws including, but not limited to, the provisions of
the federal Health Information Portability and Accountability Act (HIPAA), Fair
Information Practices Act (FIPA), M.G.L. c. 66A, M.G.L. c. 123, § 36, and
applicable exemptions under M.G.L. c. 4, § 7(26).