West Virginia Code of State Rules › Agency 64 - Health › Title 64 - LEGISLATIVE RULE WEST VIRGINIA DEPARTMENT OF HEALTH AND HUMAN RESOURCES › Series 64-59 - Patient Rights At State-Operated Mental Health facilities › Section 64-59-20 - Patient Advocacy and Grievance Procedure

Current through Register Vol. XLI, No. 28, July 12, 2024
20.1. Patient
				Advocacy. There shall be persons designated as patient or resident advocates
				who are independent of the facility management in every mental health
				facility.
20.2. Right to File A
				Grievance. A grievance may be initiated by a patient or patient advocate, a
				member of a patient's family, a facility employee or other individual on behalf
				of any patient of a mental health facility:
Provided,
That the
				patient advocate must comply with
				42 C.F.R. §
										482.13(a)(2) for filing a
				grievance and the prompt resolution of grievances. A grievance may involve any
				aspect of a patient's care, treatment, housing, services, accommodations, etc.
				and is not restricted to alleged violations of a patient's rights or abuse of
				the patient.
20.2.1. Filing of A Grievance. A
				grievance may be registered by a patient or someone on behalf of the patient,
				orally or in writing, to any facility staff member or to the patient
				advocate.
20.2.2. Oral Grievance.
				When a grievance is orally registered by a patient to a staff member or a
				patient advocate, the staff member or the patient advocate shall promptly
				assist the patient in reducing the grievance to writing on the standard
				grievance form.
20.2.3. A supply of
				grievance forms shall always be maintained in the administrative offices and on
				all units or offices of the facility for continuous access by patients. Each
				facility shall make patients aware of their rights and ensure access to this
				grievance procedure.
20.2.4. Filing
				the Grievance. All grievances shall be reduced to writing as specified in
				subdivision 20.2.2 of this rule and promptly delivered by the staff to the
				facility administrator or the administrator's designee and the patient
				advocate.
20.2.5. Response of The
				Administrator. The administrator or his or her designee, after reviewing the
				grievance, shall respond to the complaining party by the next work day
				following receipt of the grievance, unless the grievance involves abuse or
				neglect, in which case the grievance shall be referred to a patient advocate
				for investigation within one hour of receipt by the administrator or his or her
				designee if the advocate was not involved in the preparation of the abuse or
				neglect grievance. In that case, the grievance shall be answered the next work
				day following receipt of the report of the patient advocate.
20.2.6. The response by the administrator or
				his or her designee shall be in writing on the grievance form and a copy of the
				response shall be delivered to the complainant and the patient advocate. The
				patient advocate is responsible for keeping an accurate record of all
				grievances, of actions taken, and their resolution.
20.2.7. The facility shall seek to resolve
				grievances as expeditiously as possible either by providing the relief
				requested or utilizing internal administrative mechanisms, treatment teams,
				etc. Living units operated by the facility shall have mechanisms in place to
				facilitate communication and resolution of problems such as environmental
				problems and interpersonal conflicts experienced by patients.
20.2.8. Action on Grievances. The
				administrator shall immediately initiate appropriate action to correct
				meritorious grievances.
20.2.9.
				Abuse/Neglect Investigation. All grievances of abuse or neglect, or both, shall
				be investigated by the facility patient advocate or an outside advocate as
				appropriate. Upon receipt of an abuse/neglect grievance, the advocate shall
				immediately interview the patient and review the situation. Within the next
				eight regular working hours, the advocate shall make a written report to the
				facility administrator. As part of the investigative process the advocate shall
				have access to all staff members, pertinent records and documents and shall
				interview witnesses and take statements as appropriate. The advocate shall not
				have access to employee personnel records; all investigations shall be based on
				evidence related to the grievance under investigation only.
20.2.10. Reporting Abuse or Neglect, or both.
				W. Va. Code §
										9-6-9,
				the West Virginia Adult Protective Services Act, requires that any and all
				behavioral health professionals shall immediately report all actual or
				suspected cases of abuse or neglect of incapacitated adults to the Department
				of Health and Human Resources local adult protective services office. If the
				report is made by telephone, the adult protective services requires a written
				report from the individual reporting the incident within 48 hours.
20.2.11. When a facility employee or the
				patient advocate becomes aware or is notified of a grievance of abuse or
				neglect, he or she shall immediately notify the advocate, the local adult
				protective services agency directly or by phone, his or her supervisor, and the
				administrator, and document the incident. Initiation of this procedure in noway
				abrogates the duty of the facility to respond to the grievance filed in the
				manner set forth in this rule.
20.2.12. Initiating an Appeal of a Grievance
				Determination. In the event that the complaining party is not satisfied with
				the determination by the administrator, the complaining party may appeal the
				determination by submitting a copy of the original grievance form and
				determination to the Office of the Court Monitor in accordance with an Agreed
				Amended Order entered on October 15, 2012, in the action
E.H., et al.,
				v. Matin, et al..
Civil Action No. 81-MISC-585 (Circuit Court of
				Kanawha County, West Virginia) or subsequent applicable order that may be
				entered by the court in such action.
20.2.13. No Waiver. Nothing in this rule is
				intended to serve as a precondition to or supplant any other remedial
				initiatives that a patient may wish to pursue relative to a claim. Nothing in
				this rule nor any action by the administrator interferes with or supplants a
				state employee's rights pursuant to W. Va. Code §
										6C-2-1
et seq.,
or application of the grievance procedure for state
				employees, nor should it be considered to change or waive the employee
				grievance timelines for filing a grievance.
20.2.14. Confidentiality/Protection.
				Procedures and investigations conducted under this rule shall be conducted with
				due regard for the confidentiality, rights, and dignity of all parties. The
				facility may not discharge or in any manner discriminate against any patient,
				employee, or other party because of involvement in the grievance or appeal
				process.
20.2.15. Responsibilities
				of Parties. The responsibilities of the parties are set forth below:
20.2.15.a. Employees shall be aware of
				patient rights, know the facility's procedures for reporting and filing
				grievances, report infractions of patient rights, assist patients to access the
				facility advocate, to resolve grievances and assist in investigations of
				infractions of patient rights.
20.2.15.b. Patient advocates shall assist
				patients in registering and filing grievances, acknowledge grievances, conduct
				investigations of grievances, notify the administrator of results of grievance
				investigations, assure that abuse/neglect grievances have been reported to
				Adult Protective Services, educate staff regarding patient rights and maintain
				accurate documentation of all grievances and investigations.
20.2.15.c. The administrator and his or her
				designates shall file responses within established time frames, assure patient
				protection by appropriate staff disciplinary actions, to deal promptly and
				effectively with acts of discrimination or reprisal against staff or patients
				regarding patient rights and supporting staff development efforts toward
				educating all staff regarding patient rights.
20.2.15.d. Staff Development Officers shall
				assure that all staff are made aware of patient rights, facility procedures for
				reporting and resolving grievances, grievance procedures, personnel policies
				regarding reporting of violations of patient rights, staff grievance procedures
				and facility policies to protect staff from harassment and retaliation and
				threats for reporting rights violations.