Wash. Admin. Code § 388-877-0660

Current through Register Vol. 24-24, December 15, 2024

Section 388-877-0660 - Filing a grievance

(1) An individual or individual's representative may file a grievance to express dissatisfaction in person, orally, or in writing about any matter other than an adverse benefit determination, as defined in WAC 388-877-0655, to:

(a) The behavioral health agency providing the behavioral health services; or

(b) The behavioral health organization (BHO), if the agency is contracted with the BHO.

(2) If an individual receives behavioral health services through a behavioral health agency that is not contracted with a BHO, the agency, through its internal process, is responsible to handle the individual's grievances.

(3) There is no time limit to file a grievance.

(4) The ombuds may assist the individual in resolving the grievance at the lowest possible level.

(5)Filing a grievance with a behavioral health agency. If an individual first files a grievance with the behavioral health agency and the individual is not satisfied with the agency's written decision on the grievance, or if the individual does not receive a copy of that decision from the agency within the time required under subsection (7) of this section, the individual may then choose to file the grievance with the BHO. The BHO's written decision on the grievance is the final decision. The grievance does not progress to an administrative hearing except under circumstances described in subsection (9) of this section.

(6)Filing a grievance with a BHO. If the individual first files a grievance with the BHO and not the agency, and the individual is not satisfied with the BHO's written decision on the grievance, the individual cannot file the same grievance with the behavioral health agency, even if that agency or its staff member(s) is the subject of the grievance. The BHO's written decision on the grievance is the final decision. The grievance does not progress to an administrative hearing except under circumstances described in subsection (9) of this section.

(7) When an individual files a grievance, the behavioral health agency or BHO that receives the grievance must:

(a) Acknowledge the receipt of the grievance in writing within five business days;

(b) Investigate the grievance;

(c) At the individual's request, give the individual reasonable assistance in taking any procedural steps;

(d) Inform the individual about ombuds services and how to access these services;

(e) Apply the rules in subsection (8) of this section; and

(f) Send the individual who filed the grievance a written notice describing the decision as expeditiously as the individual's health condition requires, and no longer than ninety calendar days from the date the behavioral health agency or BHO receives the grievance.

(8) The behavioral health agency or BHO that receives the grievance must ensure all of the following:

(a) Other people are allowed to participate in the grievance process, if the individual chooses.

(b) That a grievance is resolved even if the individual is no longer receiving behavioral health services.

(c) That the persons who make decisions on a grievance:

(i) Neither were involved in any previous level of review or decision making nor are subordinates of any person who reviewed or decided on a previous level of the grievance;

(ii) Are mental health or chemical dependency professionals who have appropriate clinical expertise in the type of behavioral health service if deciding a grievance concerning denial of an expedited resolution of an appeal or a grievance that involves any clinical issues; and

(iii) Consider all comments, documents, records, and other information submitted by the individual or the individual's representative.

(d) That the individual and, if applicable, the individual's representative, receives a written notice containing the decision no later than ninety calendar days from the date the agency or BHO receives a grievance. This time frame may be extended up to an additional fourteen calendar days if requested by the individual or the individual's representative or by the agency or BHO when additional information is needed and the agency or BHO is able to demonstrate to the department upon the department's request that it needs additional information and the added time is in the individual's interest. The BHO must:

(i) Make reasonable efforts to give the individual prompt oral notice of the delay; and

(ii) Within two calendar days, give the individual written notice of the reason for the decision to extend the time frame and inform the individual of the right to file a grievance if the individual disagrees with that decision.

(e) That the written notice includes the resolution of the grievance, the reason for the decision, and the date the decision was made and is in an easily understood format following 42 C.F.R. Sec. 438.10 (2017), which includes requirements that each notice:

(i) Be written in the individual's non-English language, if applicable;

(ii) Contains the BHO's toll-free and TTY/TDY telephone number; and

(iii) Explains the availability of free written translation, oral interpretation to include any non-English language, auxiliary aids such as American sign language and TTY/TDY telephone services, and alternative formats to include large print and Braille.

(f) That full records of all grievances and materials received or compiled in the course of processing and attempting to resolve the grievance are :

(i) Kept for a period of no less than ten years after the completion of the grievance process;

(ii) Made available to the department upon request as part of the state quality strategy and made available upon request to the centers for medicare and medicaid services (CMS);

(iii) Kept in confidential files separate from the individual's clinical record;

(iv) Not disclosed without the individual's written permission, except to the department or as necessary to resolve the grievance.

(g) Are accurately maintained and contain, at a minimum, all of the following information:

(i) A general description of the reason for the grievance;

(ii) The date received;

(iii) The date of each review or, if applicable, review meeting;

(iv) Resolution at each level of the grievance, if applicable;

(v) Date of resolution at each level, if applicable; and

(vi) Name of the covered person for whom the grievance was filed.

(9) When the BHO does not act within the grievance process time frames described in this section, the individual is considered to have exhausted the appeal process and has a right to request an administrative hearing.

Wash. Admin. Code § 388-877-0660

Adopted by WSR 16-13-087, Filed 6/15/2016, effective 7/16/2016

Amended by WSR 17-20-006, Filed 9/21/2017, effective 10/22/2017