OAR 411-045-0120: Grievance Process

(1) PACE programs must have written policies and procedures for the receipt, disposition and documentation of all grievances from PACE participants and their representatives. The PACE program's written procedures for handling grievances, must, at a minimum: (a) Address how the PACE program will accept, process and respond to all grievances from PACE participants or their representatives, including expedited and additional reviews; and the continuation of care during the appeal process; (b) Address the resolution of all grievances that PACE participants identify as needing resolution and must describe how grievances will be resolved or reviewed should the PACE participant or his or her representative decline to provide a release of information; (c) Address how information concerning an PACE participant's grievance is kept confidential, with the exception that the Department and the local SPD/AAA office have the right to this information without a signed release from the PACE participant; (d) Describe how the PACE program informs PACE participants, both orally and in writing, about the PACE program's grievance procedures. Information provided to the participant must include at least: (A) Written material describing the grievance process; (B) Assurance in all written, oral, and posted material of PACE participant confidentiality in the grievance process; and (C) Information on alternatives to the PACE programs grievance and appeals process, including but not limited to, the Medicare appeals process, and the state's administrative hearing process. (e) Include a requirement for a Department approved grievance and appeals log to be maintained by the PACE program; and (f) Addresses how the PACE program will ensure the availability of a supply of blank complaint forms (OHP 3001) in all PACE sites and in the administrative offices. (2) The PACE program must assure that a participant's or his or her representative's expression of dissatisfaction, or grievance is recognized and resolved by the PACE program's staff as follows: (a) A PACE participant or the PACE participant's representative may relate any incident or concern to a PACE program staff person by indicating or expressing dissatisfaction. Grievances may also be termed concerns, complaints, problems, or issues by the PACE participant or the participant's representative; (b) If the PACE participant or the participant's representative indicates dissatisfaction or concern, the PACE program staff person will advise the PACE participant or his or her representative that he or she may make a grievance using the PACE program's grievance process; (c) Any PACE staff person the participant makes a grievance to must either resolve the grievance and communicate the grievance and its resolution to the PACE program staff person designated for receiving grievances, or direct the PACE participant to that person; (d) If the PACE participant or participant's representative's intent is unclear, the PACE program's designee will determine if the expression of dissatisfaction is a grievance in need of resolution or if the PACE participant or the participant's representative does not wish a resolution and only wishes to register the grievance. If the participant or his or her representative wishes only to register the grievance, the grievance should be logged and reported the same as other grievances; (e) If a PACE participant or the PACE participant's representative wishes the grievance to be resolved, the PACE program will ask the PACE participant or his or her representative to consent verbally to the release of information regarding the grievance to individuals who are directly involved in the grievance or to other individuals as needed to resolve the grievance. Verbal consent must be documented in the grievance file. A PACE participant's or his or her representative's consent to release information related to the grievance does not constitute consent to release medical information. If the participant or the participant's representative does not give consent, he or she should be advised that the grievance may not be resolved to their satisfaction; (f) For situations when the PACE participant's life, health, or ability to regain maximum functioning is at risk, an expedited grievance process may be requested by the PACE participant or his or her representative, or the PACE program staff. In such cases, the investigation will begin within 24 hours and a determination must be provided to the PACE participant or his or her representative within 72 hours unless the PACE participant requests an extension to 14 days or the PACE program finds that the delay is in the best interest of the participant; (g) Complaints concerning denial of service or service coverage will be handled as appeals as described in OAR 411-045-0130; (h). The PACE program must within 5 working days from the date the participant or his or her representative files the grievance either: (A) Make a decision on the grievance and proceed according to subsection (2)(i) of this rule; or (B) Notify the PACE participant or the PACE participant's representative in writing that a delay indecision of up to 30 calendar days is necessary to resolve the grievance. The letter must specify the reasons the additional time is necessary. (i) The PACE program's decision must be communicated to the PACE participant or his or her representative orally or in writing no later than 30 calendar days from the date of receipt. The decision must contain the following: (A) An oral decision must address each aspect of the participant's grievance and explain the reason for the PACE program's decision. The oral decision must include informing the PACE participant of his or her rights to an administrative hearing; (B) A written decision must be made if the grievance was received in writing (i) The written decision on the grievance must review each element of the PACE participant's grievance and address each of those concerns specifically, including the reasons for the PACE program's decision; (ii) The written decision must have the Notice of Hearing Rights (DMAP 3030). (j) If the PACE participant does not wish to attempt to resolve the grievance through the use of the PACE program's internal grievance procedure, the staff person will notify the PACE participant or his or her representative that he or she has the right to seek resolution through the state's administrative hearing process, or if the participant is a Medicare beneficiary, through the Medicare appeals process. Under no circumstances may the PACE program discourage a PACE participant's use of the administrative hearing process. The PACE program, however, may explain to the PACE participant the potential benefits of using the PACE program's grievance procedure; (k) Hearing requests made without previous use of the PACE program's grievance process will be forwarded to the PACE staff person designated to receive grievances for additional review by the SPD/AAA PACE Liaison Case Manager and reviewed as an extended grievance or as part of a informal meeting requested by the SPD/AAA Case Manager. (3) Extended Review of Grievance: (a) The PACE program may provide for additional review of a participant's grievance, as follows: If the PACE participant or his or her representative indicates dissatisfaction with the decision on the participant's grievance, the PACE program may provide the PACE participant with the opportunity to request another review pursuant to section (3) of this rule, in addition to the notice of hearing rights and hearing request; (b) The additional or extended review may be offered by the PACE program in conjunction with the decision on the initial grievance and will not release the PACE program from the obligations to notify the participant or his or her representative of the participant's right to an administrative hearing and to provide a copy of DHS 443; (c) The request for additional PACE program review of the grievance may be conveyed by the PACE participant, the PACE participant's representative or PACE programs designee, upon the request of the PACE participant; (d) The additional PACE program review of the grievance will be reviewed, investigated, considered or heard by either: (A) The PACE program's medical or program director; who was not involved in the original action; or (B) A person or group, such as the Quality Improvement Committee or board of directors, responsible for internal review with the authority to make a final clinical or administrative decision at the PACE program level. (e) A written decision, including the reasons for the PACE program's decision, will be mailed to the PACE participant or his or her representative no later than 30 calendar days from the date of receipt of the request for additional PACE program review of the grievance, unless: (A) Further time is needed for the receipt of information requested from or submitted by the PACE participant and the new time frame is communicated to the participant in writing; or (B) The PACE participant fails to provide the requested information within 30 calendar days of the request by the PACE program (or another mutually agreed upon time frame) the grievance may be resolved against the PACE participant. (f) The PACE program's decision on the additional review of the PACE participant's grievance must have an additional Notice of Hearing Rights (DMAP 3030) attached. (4) Responsibility for Documentation and Quality Improvement Review of Grievances: (a) The PACE program's documentation must include, at the minimum: (A) The log of all grievances including grievances that the participant chooses either to resolve through another process, or not to have resolved. The log will identify the PACE participant, the date of the grievance, the nature of the grievance, the resolution and the date of resolution or the date of a grievance where no resolution was requested; and (B) A file of grievances and records of their review or investigation and resolution, including all written decisions and copies of correspondence with the PACE participant related to the grievance will be retained for seven years. (b) The PACE programs must have written procedures for the review and analysis of all grievances received by the PACE program and the operation of the entire grievance process. The analysis of grievances will be forwarded to the Quality Improvement Committee as necessary to comply with the Quality Improvement standards; (c) PACE programs will monitor the written log, on a monthly basis, for receipt, disposition and documentation of grievances. (d) Monitoring of grievances will include, at a minimum, a review for completeness, accuracy, timeliness of documentation, and compliance with plan procedures for receipt, disposition, and documentation of grievances. (5) Issues involving abuse or neglect shall be reported be PACE to the local SPD/AAA Protective Services office and shall be investigated according to the setting in which the incident occurred. PACE program staff are to be considered mandatory reporters under ORS 124.060 and 124.050(5).