110 Grievance Procedures for Individuals in Non-Medicaid Home and Community Based Services Programs

Georgia State Seal

Georgia Division of Aging Services
Home and Community-Based Services Manual

Chapter:

100

Effective Date:

02/15/2016

Section Title:

Grievance Procedures for Individuals in Non-Medicaid Home and Community Based Services Programs

Reviewed or Updated in:

MT 2015-11

Section Number:

110

Previous Update:

MT 2015-11

110.1 Summary Statement

The Older Americans Act (OAA) requires Area Agencies on Aging (AAA) to provide grievance procedures for older individuals and persons with disabilities who are dissatisfied with or denied services. Further, the OAA requires the State Unit on Aging to issue guidelines to AAAs regarding grievance procedures.

This chapter provides guidance to AAAs in developing and implementing policies and procedures for handling grievances of individuals who are dissatisfied with or denied services. AAAs and providers will ensure that all program participants are informed of their right to file a grievance and of the process to be used at the time of application for services and upon admission to services.

Any written materials provided to applicants/recipients are to be concise, in sufficiently large print (14-point font or larger) for ease in reading, and in language the individuals/recipients use and best understand. Unless specific circumstances suggest otherwise, materials should be written at an 8th grade reading level.

110.2 Scope

Redress of grievances will be available to all applicants for and recipients of services provided through all non-Medicaid fund sources administered by the AAA.

A consumer can file a complaint for any action or inaction that a AAA and the AAA’s contracted service providers may take. The AAA will establish formal written procedures for handling complaints within its network.

However, only adverse actions, defined as the denial, reduction, or termination of services, are subject to appeal. Examples of adverse actions include, but are not limited to:

Denial:

  • A decision that the applicant is not eligible for a program or service

  • A decision not to provide initial or additional services

The Division does not interpret the placement of individuals for service into waiting list status as a denial of service.

Reduction:

  • A decision that results in diminished amount, extent, or number of services, excluding changes in service providers and/or funding streams when the same level of service(s) provided to the consumer is maintained

Termination:

  • A decision that a consumer is no longer eligible for a program

  • A decision following a service suspension brought about by an unsafe situation for agency or direct provider staff that a consumer cannot or will not resolve within a reasonable established time frame

The following actions are not subject to appeal:

  1. An applicant is placed on a waiting list when services cannot be provided due to insufficient funding

  2. A consumer is terminated due to non-payment of cost share, ensuring that Older Americans Act guidelines and MAN 5600 2025 Fee for Service System Overview and 2026 Cost Share are followed.

110.3 Concept of Due Process

Due process entails the implementation of specific procedures designed to safeguard the legal rights of individuals and to assure maximum fairness in decision making. Grievance and complaint policies and procedures will assure older adults, persons with disabilities, and their families that their concerns will be considered in a fair and timely manner, regardless of the ultimate legitimacy of the claim.

110.4 Individuals’ Rights in Filing a Grievance or Complaint

Individuals in non-Medicaid home and community-based services that are funded in part or in whole by OAA and other federal and state funds have the right to file grievances or complaints regarding specific actions or activities affecting their participation in the program or the conduct of the program as it relates to all individuals at a given site or location without fear of reprisal.

The applicant/recipient has the right to be represented by a friend, advocate, or attorney, at his/her own expense.

Prior to a grievance hearing, the individual and his/her chosen representative may request access to information regarding the service case, including individual records, intake and screening forms, eligibility determination forms, or any other documentation that was used to make the decision regarding denial, reduction, suspension, or termination of services.

110.4A Presentation of the Grievance

An authorized representative, including a caregiver, may present a grievance on behalf of an individual. If the individual chooses this option, s/he shall accompany the representative to every meeting at which the complaint is discussed, unless the individual is so functionally impaired that s/he cannot reasonably attend or participate in a meaningful way. If necessary, the meeting will be held in the individual’s home if his/her condition limits mobility outside the home.

110.4B Resolution

Every effort will be made to resolve grievances at the lowest level of authority to avoid the ineffective use of staff time, time, and resources of the individual, and burdensome documentation. Grievances will be directed as appropriate to the situation to the following authorities in the order indicated:

  1. Site Manager or Director or Case Manager

  2. Program Director or Project Director

  3. Agency Director of the subcontract agency

  4. Area Agency on Aging Director

Once a grievance reaches the AAA level, the AAA is encouraged to select one or more impartial reviewers who have not been directly involved in the initial determination of the adverse action to participate in the review of the appeal. The decision of the AAA shall be the final decision.

110.4C Additional Redress

This policy does not remove the right of the individual to pursue other avenues of redress, such as filing with the Office of Civil Rights of the U.S. Department of Health and Human Services.

110.4D Time Frames for Filing

Grievances must be filed within thirty calendar (30) days of the action that is the basis of the grievance or upon thirty calendar (30) days of receipt of notification of the action which is the basis of the grievance, whichever is later. A waiver or extension of the time frame to file a grievance may be requested based upon proving good cause, including but not limited to serious illness, hospitalization, or other reasonable extenuating circumstances.

110.5 Forms and Content of Grievances

Individuals may file grievances orally or in writing and must state in sufficient detail the basis for the complaint and the reasons the individual objects to the action or circumstances in question. AAAs and providers shall supply a written outline to prepare for the oral filing to assure the coverage of the following points:

  1. The notice, document, policy, situation, or event that is the reason for the complaint.

  2. Significant dates pertaining to the complaint.

  3. The names of organizations and individuals involved.

  4. Reference to any provision of the Older Americans Act or other laws, regulations, or policies believed to have been violated by site management, subcontract agency, or AAA.

  5. The action or decision desired by the individual to resolve the issue.

110.6 Disposition of Grievances

The following timeline and process will be followed to ensure prompt and thorough resolution of grievances:

  1. The responsible authority will investigate the grievance, make any changes necessary to attempt to resolve the grievance, and notify the individual(s) of the resolution in writing within thirty (30) calendar days of receipt of the written grievance.

  2. If the Manager’s or Service Provider Director’s response is not satisfactory to the individual, the individual may forward the matter for further consideration to the next higher authority as specified in 110.4B Resolution. Such intent must be received by the Manager/Director within ten (10) calendar days of the date of the written response to the grievance.

  3. At each level at which the grievance/complaint is not resolved, the individual must notify the agency representative (orally or in writing) of the desire for a continuing grievance action within ten (10) calendar days of the date of the most recent written response to the grievance action. The agency representative will develop a memorandum detailing the circumstances of the grievance, attach all pertinent documentation regarding the findings and actions taken at the level of authority and forward it to the next level with a request for a meeting of the parties concerned with the issue. Each level of authority must attempt to resolve the grievance and notify the individual within thirty (30) calendar days of the receipt of the individual’s request.

  4. An individual may withdraw a grievance at any time. Failure by an individual to comply with required time frames will be considered withdrawal of a grievance unless compliance with time frames creates a hardship for the individual.

  5. When the grievance is resolved, all parties will provide joint written notification of having reached agreement to each level of authority involved.

110.8 Mitigation of Grievances and Complaints

The AAA will assure that each individual or recipient of services is notified of his/her right to file a grievance/complaint and that reasonable attempts are made to resolve them at the lowest level of authority possible.

The following actions are suggested to mitigate the quantity and/or duration of grievances and complaints:

  1. Ensure that all staff, especially staff having direct contact with a consumer either by telephone or in person, are trained in DAS and agency policies and procedures. Focus should be made on policies related to eligibility, individual prioritization, screening and assessment, and aspects of service delivery.

  2. Ensure that all staff who have responsibility for screening and/or assessing individuals and recipients are thoroughly trained and, when applicable, certified to administer the required assessment instruments.

  3. Ensure that all staff who have direct contact with a consumer, either by telephone or in person, are trained in proper documentation techniques.

  4. Ensure that staff who have responsibility for any part of determining eligibility or appropriateness for services are trained in how to match specific domains of assessments to service needs and goals of consumers.

  5. Ensure that all staff who have direct contact with a consumer either by telephone or in person are trained in customer service, with attention to methods for communicating policy to consumers in a clear, concise, and understandable manner.

  6. Provide a robust quality assurance program to identify areas for improvement and additional training in the topics listed above and other topics identified by the AAA.

110.9 Review of Resolution and Appeal Logs

The AAA will develop a process for internal review of the procedures used in resolving each grievance/complaint to determine whether the local authorities at all levels adhered to the process and correctly followed the prescribed steps. If necessary, the AAA will implement corrective action plans to ensure compliance with grievance policy and protocols.

The AAA will maintain logs of all actions for which appeals or grievances were filed within its network that include, at a minimum:

  1. Date of appeal or grievance

  2. Name of person filing appeal

  3. Summary of findings

  4. Resolution of appeal or grievance

  5. Date of resolution

The Appeal Logs shall be made available upon request to the Division for quality assurance or monitoring purposes.

References

MAN 5300, Chapter 202
MAN 5600, Chapter 2025
MAN 5600, Chapter 2026
MAN 5600, Chapter 3016