PATIENT HANDBOOK

The Steps of the Grievance Process

LEVEL ONE-CLINIC LEVEL – INITIAL GRIEVANCE FILING

1. In the event that the patient cannot resolve the issue informally, they or their representative will file a written grievance with the Grievance Team, chaired by the Executive Director
2. If the grievance involves the Executive Director or there is an allegation of misconduct by an associate, the grievance will go directly to Executive Leadership Team (Level Two ), and be handled in accordance with personnel policies.
3. The Executive Director, or designee, will arrange a meeting with the patient and/or their representative and the Grievance Team within 3 business days of the filing of the grievance, to work toward a resolution with the patient and/or their representative.
4. In the event, the patient and/or their representative does not agree or is unable or unwilling to meet ( face-to-face ) with the Grievance Team within 3 business days, then the Executive Director may extend the prerequisite to forego a face-to-face meeting, and process the patient's written grievance.
5. The Executive Director will issue a written response to the patient within 3 business days of the face-to-face meeting, or three business days of the filing of the grievance if no face-to-face meeting occurs.
6. The patient’s record will reflect documentation of the grievance. the meeting with the patient and the outcome of the meeting.
7. A Copy (pertinent info blacked out) of the resolved Level One grievance will be given to the Patient Advocate for data analysis and quality improvement.
8. Any action taken against the grieving patient will be interrupted until a final determination of the investigation is completed at the corporate level.
9. Exceptions To Part H:
10. The clinic's medical director can make an exception if the medical benefit outweighs the postponement. In these unique situations, a clinical note will indicate the reason for the exception in the patient’s record.
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12. If the Executive Director, Medical Director. and Clinical Supervisor agree that a patient must be immediately discharged with or without detoxification, due to imminent health and safety issues, then action against the patient will not be interrupted until an investigation is completed.
13. If the patient has been placed on a administrative taper from the MD due to violating policy 60019 part one (1), the action against the patient will not be interrupted unless the decision to discharge is reversed by the grievance process.
14. If there are ongoing medical and/ or psychological concerns, the clinic will make every effort to refer or transfer the patient to another program or level of care
15. In the instance of take home revocation- no reinstatement will be made until Final determination of investigation.

2. LEVEL TWO- CORPORATE LEVEL – APPEAL PROCESS

1. If the patient and/or their representative is unsatisfied with the findings at the Clinic level the patient and/or their consented representative may appeal the decision in writing or verbally to the Patient Advocate within 3 days of receiving the decision from the Executive Director or designee.
2. The Patient Advocate will notify the Clinic directors of the Board of Directors (Level Two) grievance.
3. The Patient Advocate and the Program Director or designee, will compile information and present their findings to the Quality Improvement Committee. The information collected will include and not be restricted to:
4. Discussion with the patient and/or their representative
5. Review of the patient’s record
6. Discussion with sector director or any additional associates
7. The Medical Director will review the patient’s medical chart and make recommendations directly to the clinic's medical director.
8. Any action taken against the grieving patient will be interrupted until a final determination of the investigation is completed at the corporate level.
9. Exceptions to part E:
10. The clinic's medical director can make an exception if the medical benefit outweighs the postponement. In these unique situations, a clinical note will indicate the reason for the exception in the patient’s record.
11. If the Executive Director, Medical Director. and Clinical Supervisor agree that a patient must be immediately discharged with or without detoxification, due to imminent health and safety issues, then action against the patient will not be interrupted until an investigation is completed.
12. If the patient has been placed on a administrative discharged and taper from the MD due to violating policy 60019 part one (1), the action against the patient will not be interrupted unless decision to discharge is reversed by the grievance process.
13. If there are ongoing medical and/ or psychological concerns, the clinic will make every effort to refer or transfer the patient to another program or level of care
14. In the instance of take home revocation- no reinstatement will be made until Final determination of investigation.
15. The Quality Improvement Committee will be assembled when there is a Level Two grievance and will make a determination as to whether or not there is a need for an investigation.
16. If there is a need for an investigation, then the Chair of the Grievance Team will forward the grievance, with the Grievance Team's findings to Compliance Officer.
17. The Compliance Committee will conduct its investigation of the grievance and the Compliance Officer will be responsible for providing the patient and/or their representative with any subsequent written formal responses within 15 business days of the Level Two grievance submission.
18. If there is NO need for an investigation by the Compliance Committee, the recommendations of the Quality Improvement Committee will be sent to the Board of Directors for review.
19. If consensus is reached by the Board of Directors and the Quality Improvement Committee, the patient and/or their representative will receive a formal written response from the QI Committee Chair within 15 business days of the Level TWO grievance submission.
20. In the event the Quality Improvement Committee and Board of Directors are unable to reach consensus, then the President of SOAR will be petitioned to review the disputed items and make a final ruling, which will be given to the patient and/or their representative by the QI Committee Chair within 5 business days of the President receiving the grievance.
21. Quality Improvement Committee's findings will be documented. A designated Quality Improvement Committee member will maintain a grievance log, which contains:
22. Date of complaint
23. Nature of complaint

LEVEL THREE - APPEAL OF CORPORATE GRIEVANCE OR COMPLIANCE COMMITTEE - EXTERNAL>

1. If an investigation by the Quality Improvement Committee was not warranted and the patient and/or their representative is not satisfied with the Level Two — Corporate Decision, then the patient and/or their representative will be instructed to contact the Patient Advocate for future assistance.
2. The Patient Advocate will attempt to resolve the patient’s grievance a final time.
3. In the event that the Patient Advocate cannot resolve the matter internally, then they will provide the patient and/or their representative with phone numbers to the appropriate state regulatory agencies.