CALIFORNIA CODE OF REGULATIONS - State of California

Page 509
TITLE 9. DIVISION 1 — DEPARTMENT OF MENTAL HEALTH § 1796
a. The status of the placement option.
b. Date of the contact.
c. Signature of the person making the contact.
NOTE: Authority cited: Section 14680, Welfare and Institutions
Code. Reference: Sections 5777, 5778 and 14684, Welfare and Institutions
Code.
Article 5.
Problem Resolution Processes
§ 1790. Complaint Resolution Process.
“Complaint Resolution Process” means an informal process for the
resolution of beneficiary concerns or complaints regarding
psychiatric inpatient hospital services.
NOTE: Authority cited: Section 14680, Welfare and Institutions
Code. Reference: Sections 5777 and 14684, Welfare and Institutions
Code.
§ 1791. Denial.
“Denial” means that the MHP does not approve a request for MHP
payment authorization of an admission for psychiatric inpatient
hospital services.
NOTE: Authority cited: Section 14680, Welfare and Institutions
Code. Reference: Section 14684, Welfare and Institutions Code.
§ 1792. Fair Hearing.
“Fair Hearing” means a formal hearing, as required by Federal
regulations and State statutes and regulations, which is conducted
when requested by a beneficiary within specified timelines, because
his/her services or extension of services are denied or terminated.
NOTE: Authority cited: Section 14680, Welfare and Institutions
Code. Reference: Sections 5777, 5778 and 14684, Welfare and Institutions
Code.
§ 1793. Grievance Process.
“Grievance Process” means the MHP’s formal process for the
purpose of hearing and attempting to resolve beneficiary concerns or
complaints regarding psychiatric inpatient hospital services.
NOTE: Authority cited: Section 14680, Welfare and Institutions
Code. Reference: Section 14684, Welfare and Institutions Code.
§ 1794. Terminated.
“Terminated” means that the MHP does not approve a request for
continued stay services after an MHP payment authorization for an
admission.
NOTE: Authority cited: Section 14680, Welfare and Institutions
Code. Reference: Section 14684, Welfare and Institutions Code.
§ 1795. Beneficiary Problem Resolution Processes.
(a) An MHP shall develop problem resolution processes that
enable a beneficiary to resolve a complaint or grievance about any
psychiatric inpatient hospital service–related issue.
(b) The MHP’s beneficiary problem resolution processes shall
include both:
(1) A Complaint Resolution Proces; and,
(2) A Grievance Process (Two Levels)
(c) An MHP shall ensure that each beneficiary has adequate
information about and access to the resolution processes in (b).
(d) The Complaint Resolution Process shall, at a minimum:
(1) Focus upon resolution of a beneficiary’s concerns as quickly
and simply as possible.
(2) Emphasize simple, informal and easily understood procedures.
(3) Inform a beneficiary of his or her right to use the Grievance
Process at any time before, during or after the Complaint Resolution
Process has begun.
(4) Identify a procedure by which issues identified as a result of the
Complaint Resolution Process are transmitted to the MHP’s Quality
Improvement Committee, to the MHP’s administration or to another
appropriate body within the MHP to implement needed action.
(5) Identify the roles and responsibilities of the MHP, the provider
and the beneficiary.
(e) The Grievance Process shall, at a minimum:
(1) Be a formal written procedure that provides for two levels of
review within the MHP.
(2) Allow for the resolution of each level of a grievance within
thirty (30) calendar days of receipt of the grievance by that level of the
MHP.
(3) Identify a procedure by which issues identified as a result of the
Grievance Process are transmitted to the MHP’s Quality
Improvement Committee, to the MHP’s administration or to another
appropriate body within the MHP to implement needed action.
(4) Identify the roles and responsibilities of the MHP, the provider
and the beneficiary.
(5) Provide for:
(A) Recording the grievance in a Grievance Log(s) within one (1)
working day of the date of receipt of the grievance.
(B) The Log entry shall include but not be limited to:
1. The name of the beneficiary.
2. The date of receipt of the grievance.
3. The nature of the problem.
4. The time period allowed for resolution.
5. The party responsible for addressing the grievance.
(C) Recording the resolution of a grievance within the required
time period or document the reason(s) the problem has not been
resolved.
(D) Documenting the notification of a beneficiary of the resolution
of the grievance or documenting efforts to notify the beneficiary if he
or she could not be contacted.
(E) If a provider was included in the grievance, notifying any
provider involved with the resolution of the beneficiary grievance.
(F) Notifying the beneficiary of his or her right to appeal the
grievance decision to a second level of review within the MHP.
(f) The MHP shall ensure that for the Complaint Resolution
Process or the Grievance Process:
(1) A beneficiary may authorize another person to act on his or her
behalf.
(2) Specific MHP staff are identified as having responsibility for
assisting a beneficiary with these processes at the beneficiary’s
request.
(3) A beneficiary shall not be subject to discrimination or any other
penalty for filing a complaint or grievance.
(4) Procedures used shall maintain the confidentiality of a
beneficiary.
(g) An MHP’s Grievance Log(s) shall be open to review by the
Department, the Department of Health Services and the Federal
oversight agency.
(h) A provider may have its own complaint resolution and
grievance processes. A beneficiary shall have access to the provider’s
processes as well as those provided by the MHP.
(i) No provision of an MHP Beneficiary Problem Resolution
Process shall be construed to replace or conflict with the duties of
county patients’ rights advocates designated in Welfare and
Institutions Code Section 5500.
(j) Each MHP shall report to the Department by October 1 of each
year, a summary of beneficiary grievances, as well as their status and
resolution.
NOTE: Authority cited: Section 14680, Welfare and Institutions
Code. Reference: Section 14684, Welfare and Institutions Code.
§ 1796. Fair Hearing and Notice of Action.
(a) An MHP shall provide a written Notice of Action to the
beneficiary that informs him or her of the right to a fair hearing when:
(1) An MHP payment authorization for a planned admission is
denied.
(2) An MHP payment authorization for continued stay services is
terminated for a beneficiary by the MHP while the beneficiary
remains in the hospital.
(b) Fair hearing shall be administered by the Department of Health