309-118-0020 Grievance Process (1) Informal Complaint: Whenever possible, a patient or patient’s representative should attempt to present and resolve complaints informally with the individual(s) involved in the complaint. (a) An informal complaint may be made verbally or in writing by the patient or patient’s representative, provided that the writing is not on an OSH Grievance Form. (b) No written response is required for an informal complaint. (c) Informal complaints are not subject to review or appeal. (d) If the patient is dissatisfied with the outcome of the informal complaint or the issue qualifies as a grievance, then the treatment staff shall provide the patient or their representative with the OSH Grievance Form and assist the patient or their representative with completing the form if requested. (2) Grievance: A patient or their representative may submit a grievance using the OSH Grievance Form, and may request treatment staff to assist them with completion of the form. The form shall provide notice to the patient or their representative that the grievance may be submitted directly to the state agency that has licensure survey responsibility over OSH, and provide the patient or their representative with the contact information for that agency. (a) A grievance must include a reason for the grievance and a proposed resolution and must be set out in writing on an OSH Grievance Form. (b) The patient or their representative must put the completed OSH Grievance Form into the designated grievance area; (c) Upon receipt of the Grievance form, the Grievance Committee shall: (A) Assign a treatment staff member, who is not the subject of the grievance, to discuss the matter personally, either in person or through simultaneous telephonic or video means, with the patient and, if applicable, their representative, unless the patient or their representative declines to meet with the treatment staff member; (B) Consider information provided by the patient or their representative, the assigned treatment staff member, appropriate subject matter experts, and any other information relevant to the grievance; (C) Prepare a written response to the grievance, which contains: the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion; (D) Provide a copy of the written response to the patient or their representative and to the Ombuds within 7 calendar days. (E) Notwithstanding subsection (2)(c)(D) of this rule, the Grievance Committee may extend the 7 calendar day response timeline for good cause, including but not limited to the need for additional investigation, multiple grievances included in one form, the number of grievances being processed at one time by the Grievance Committee, or delays caused by quarantine or isolation. If the response time is extended, within 7 calendar days of the Grievance Form being received, the Grievance Committee shall notify the patient or their representative in writing that their grievance is being reviewed and provide an estimated length of time before the patient will receive their written response of resolution and the good cause reason for the delay. (F) For purposes of providing a written response or notice of delay under subsections (2)(c)(D) and (E) of this rule, the response or notice will be considered provided on the date that it is personally delivered, mailed by regular mail to the address on record, or by email to the patient or their representative. (3) The Grievance Committee’s written response under subsections (2)(c)(D) and (E) of this rule resolves the grievance for purposes of the grievance process. (4) Nothing in this rule creates a right to a contested hearing under ORS Chapter 183. Statutory/Other Authority: ORS 179.040, 413.042, 179.321 & 179.360 Statutes/Other Implemented: ORS 426.385, 179.321 & 179.360 History: BHS 25-2022, amend filed 12/20/2022, effective 12/20/2022 BHS 10-2022, temporary amend filed 06/28/2022, effective 06/28/2022 through 12/24/2022 BHS 4-2021, amend filed 02/17/2021, effective 02/17/2021 MHD 15-1982, f. 7-9-82, ef. 7-23-82