Desert Rose Grievance Policy and Procedure
POLICY:
It is the policy of Desert Rose to ensure that individuals applying for or receiving substance abuse services are guaranteed the protection of fundamental human, civil, constitutional and statutory rights, including those specified in F.S. 397.501(1-10).
Resident Rights
Individuals applying for or receiving substance abuse services are guaranteed the protection of fundamental human, civil, constitutional, and statutory rights, including those specified in subsections 397.501(1)-(10), F.S.
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Provisions. Basic Resident rights will include:
A. Provisions for informing the Resident, family member, or authorized guardian of their rights and responsibilities, assisting in the exercise of those rights, and an accessible grievance system for resolution of conflicts;
B. Provisions assuring that a grievance may be filed for any reason with cause;
C. The prominent posting of notices informing Residents of the grievance system;
D. Access to grievance submission forms;
E. Education of staff in the importance of the grievance system and Resident rights;
F. Specific levels of appeal with corresponding time frames for resolution;
G. Timely receipt of a filed grievance;
H. The logging and tracking of filed grievances until resolved or concluded by actions of the provider’s governing body;
I. Written notification of the decision to the appellant; and
J. Analysis of trends to identify opportunities for improvement.
RESIDENT RIGHTS
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RIGHT TO INDIVIDUAL DIGNITY. –The individual dignity of the Resident must be respected at all times and upon all occasions, including any occasion when the Resident is admitted, retained, or transported. Substance abuse Residents who are not accused of a crime or delinquent act may not be detained or incarcerated in jails, detention centers, or training schools of the state, except for purposes of protective custody in strict accordance with this chapter. A Resident may not be deprived of any constitutional right.
2. RIGHT TO NONDISCRIMINATORY SERVICES.
A. Service providers may not deny a Resident access to substance abuse services solely on the basis of race, gender, ethnicity, age, sexual preference, and human immunodeficiency virus status, prior service departures against medical advice, disability, or number of relapse episodes. Service providers may not deny a Resident who takes medication prescribed by a physician access to substance abuse services solely on that basis. Service providers who receive state funds to provide substance abuse services may not, provided space and sufficient state resources are available, deny a Resident access to services based solely on inability to pay.
B. Each Resident in treatment must be afforded the opportunity to participate in the formulation and periodic review of his or her individualized treatment or service plan to the extent of his or her ability to so participate.
C. It is the policy of the state to use the least restrictive and most appropriate services available, based on the needs and the best interests of the Resident and consistent with optimum care of the Resident.
D. Each Resident must be afforded the opportunity to participate in activities designed to enhance self-image.
3. RIGHT TO QUALITY SERVICES.
A. Each Resident must be delivered services suited to his or her needs, administered skillfully, safely, humanely, with full respect for his or her
dignity and personal integrity, and in accordance with all statutory and regulatory requirements.
B. These services must include the use of methods and techniques to control aggressive Resident behavior that poses an immediate threat to the Resident or to other persons. Such methods and techniques include the use of restraints, the use of seclusion, the use of time-out, and other behavior management techniques. When authorized, these methods and techniques may be applied only by persons who are employed by service providers and trained in the application and use of these methods and techniques. The department must specify by rule the methods that may be used and the techniques that may be applied by service providers to control aggressive Resident behavior and must specify by rule the physical facility requirements for seclusion rooms, including dimensions, safety features, methods of observation, and contents.
4. RIGHT TO COMMUNICATION.
A. Each Resident has the right to communicate freely and privately with other persons within the limitations imposed by service provider policy.
B. Because the delivery of services can only be effective in a substance abuse free environment, close supervision of each Resident’s communications and correspondence is necessary, particularly in the initial stages of treatment, and the service provider must therefore set reasonable rules for telephone, mail, and visitation rights, giving primary consideration to the well-being and safety of Residents, staff, and the community. It is the duty of the service provider to inform the Resident and his or her family if the family is involved at the time of admission about the provider’s rules relating to communications and correspondence.
5. RIGHT TO CARE AND CUSTODY OF PERSONAL EFFECTS OF RESIDENTS.
Each Resident has the right to possess clothing and other personal effects. The service provider may take temporary custody of the Resident’s personal effects only when required for medical or safety reasons, with the reason for taking custody and a list of the personal effects recorded in the Resident’s clinical record.
6. RIGHT TO CONFIDENTIALITY OF RESIDENT RECORDS.
A. The records of service providers which pertain to the identity, diagnosis, and prognosis of and service provision to any individual Resident are confidential in accordance with this chapter and with applicable federal confidentiality regulations and are exempt from the provisions of s.119.07(1) and s. 24(a), Art. I of the State Constitution. Such records may not be disclosed without the written consent of the Resident to whom they pertain except that appropriate disclosure may be made without such consent:
1. To medical personnel in a medical emergency.
2. To service provider personnel if such personnel need to know the information in order to carry out duties relating to the provision of services to a Resident.
3. To the secretary of the department or the secretary’s designee, for purposes of scientific research, in accordance with federal confidentiality regulations, but only upon agreement in writing that the Resident’s name and other identifying information will not be disclosed.
4. In the course of review of records on service provider premises by persons who are performing an audit or evaluation on behalf of any federal, state, or local government agency, or third-party payor providing financial assistance or reimbursement to the service provider; however, reports produced as a result of such audit or evaluation may not disclose Resident names or other identifying information and must be in accord with federal confidentiality regulations.
5. Upon court order based on application showing good cause for disclosure. In determining whether there is good cause for
disclosure, the court shall examine whether the public interest and
the need for disclosure outweigh the potential injury to the Resident,
to the service provider-Resident relationship, and to the service
provider itself.
B. The restrictions on disclosure and use in this section do not apply to communications from provider personnel to law enforcement officers which:
1. Are directly related to a Resident’s commission of a crime on the premises of the provider or against provider personnel or to a threat to commit such a crime; and
2. Are limited to the circumstances of the incident, including the Resident status of the individual committing or threatening to commit the crime, that individual’s name and address, and that individual’s last known whereabouts.
C. The restrictions on disclosure and use in this section do not apply to reporting of incidents of suspected child abuse and neglect to the appropriate state or local authorities as required by law. However, such restrictions continue to apply to the original substance abuse Resident records maintained by the provider, including their disclosure and use for civil or criminal proceedings which may arise out of the report of suspected child abuse and neglect.
D. Any answer to a request for a disclosure of Resident records which is not permissible under this section or under the appropriate federal regulations must be made in a way that will not affirmatively reveal that an identified individual has been or is being diagnosed or treated for substance abuse. The regulations do not restrict a disclosure that an identified individual is not and never has been a Resident.
E . An order of a court of competent jurisdiction authorizing disclosure and use of confidential information is a unique kind of court order. Its only purpose is to authorize a disclosure or use of Resident identifying information which would otherwise be prohibited by this section. Such an order does not compel disclosure. A subpoena or a similar legal mandate must be issued in order to compel disclosure. This mandate may be entered at the same time as, and accompany, an authorizing court order entered under this section.
F. An order authorizing the disclosure of Resident records may be applied for by any person having a legally recognized interest in the disclosure which is sought. The application may be filed separately or as part of a pending civil action in which it appears that the Resident records are needed to provide evidence. An application must use a fictitious name, such as John Doe or Jane Doe, to refer to any Resident and may not contain or otherwise disclose any Resident identifying information unless the Resident is the applicant or has given a written consent to disclosure or the court has ordered the record of the proceeding sealed from public scrutiny.
G. The Resident and the person holding the records from whom disclosure is sought must be given adequate notice in a manner which will not disclose Resident identifying information to other persons, and an opportunity to file a written response to the application, or to appear in person, for the limited purpose of providing evidence on the statutory and regulatory criteria for the issuance of the court order.
H. Any oral argument, review of evidence, or hearing on the application must be held in the judge’s chambers or in some manner which ensures that Resident identifying information is not disclosed to anyone other than a party to the proceeding, the Resident, or the person holding the record, unless the Resident requests an open hearing. The proceeding may include an examination by the judge of the Resident records referred to in the application.
I. A court may authorize the disclosure and use of Resident records for the purpose of conducting a criminal investigation or prosecution of a Resident only if the court finds that all of the following criteria are met:
1. The crime involved is extremely serious, such as one which causes or directly threatens loss of life or serious bodily injury, including but not limited to homicide, sexual assault, sexual battery, kidnapping, armed robbery, assault with a deadly weapon, and child abuse and neglect.
2. There is reasonable likelihood that the records will disclose information of substantial value in the investigation or prosecution.
3. Other ways of obtaining the information are not available or would not be effective.
4. The potential injury to the Resident, to the physician-Resident relationship and to the ability of the program to provide services to other Residents is outweighed by the public interest and the need for the disclosure.
7. RIGHT TO COUNSEL. — Each Resident must be informed that he or she has the right to be represented by counsel in any involuntary proceeding for assessment,
stabilization, or treatment and that he or she, or if the Resident is a minor his or her parent, legal guardian, or legal custodian, may apply immediately to the court to have an attorney appointed if he or she cannot afford one.
8. RIGHT TO HABEAS CORPUS. At any time, and without notice, a Resident involuntarily retained by a provider, or the Resident’s parent, guardian, custodian, or attorney on behalf of the Resident, may petition for a writ of habeas corpus to question the cause and legality of such retention and request that the court issue a writ for the Resident’s release.
9. LIABILITY AND IMMUNITY.
A. Service provider personnel who violate or abuse any right or privilege of a Resident under this chapter are liable for damages as determined by law.
B. All persons acting in good faith, reasonably, and without negligence in connection with the preparation or execution of petitions, applications, certificates, or other documents or the apprehension, detention, discharge, examination, transportation, or treatment of a person under the provisions of this chapter shall be free from all liability, civil or criminal, by reason of such acts.
PROCEDURE:
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Upon admission every Resident will be given a copy and explained Resident Rights. The Resident Rights will be given out in the Resident Handbook and posted in common areas of residences.
2. Basic Resident Rights provisions include the following concerning the grievance procedure:
A. Informing the Resident, family members or authorized guardian of their rights and responsibilities, assisting in the exercise of those rights and an accessible grievance system for the resolution of conflicts.
B. Assuring that the grievance may be filed for any reason with cause.
C. Assuring that the notice informing Residents of the grievance system is posted.
D. Granting access to grievance forms.
E. Educating staff on the importance of grievance procedure and Resident Rights.
F. Specifying level of appeal with corresponding time frames for resolution.
G. Providing for the immediate receipt of a filed grievance.
H. Logging and tracking of filed grievances until resolved or concluded by actions of the governing body.
I. Written notification of the decision to the appellant.
J. Analysis of trends to identify opportunities for improvement.
3. Desert Rose shall post the number of the abuse hotline, the local Florida Advocacy Council, the Florida Association of Recovery Residences and the district Alcohol, Drug Abuse, and Mental Health Program Office in a conspicuous place within each facility and residences and provide a copy to each Resident placed in services.
AGENCY GRIEVANCE PROCEDURE:
1. Any person(s) who believes that their rights have been violated or has a compliant or grievance may file a complaint pursuant to the procedures set forth below, on their behalf, or on the behalf of another person. All persons are encouraged to file a complaint and/or grievance. By filing a complaint, the individual will not subject themselves to any form of adverse action, reprimand, retaliation, or otherwise negative treatment by Desert Rose. Residents shall have immediate access to the grievance form located in their program information packet; a posting of the grievance procedure will be in the first-floor lounge area with the levels of appeals, in the Resident handbook, in each residence and on the agency website.
2. To register a grievance, the following steps will be followed:
A. Residents, family members, and authorized guardians of a Resident’s rights and responsibilities shall be informed of their rights and responsibilities during the orientation, have knowledge of the grievance system, be assured that the can file a grievance at any time, and be knowledgeable of where the notice of grievance is located and where the forms are. Grievance Forms are located in the reception area and in each of the residences. The
Grievance Form will be discussed with the Resident with 24 hours of the Grievance Form being given to the therapist.
B. Residents are encouraged to discuss any problems with their primary therapist. The Resident and therapist will try to find a resolution within 24 hours. The grievance will be tracked and logged until resolved or concluded by actions of the provider’s governing body. Analysis of trends to identify opportunities for improvement will be conducted and submitted to the QA Committee quarterly meeting.
C. If the Resident is not satisfied with the results, the Resident will meet with the Clinical Director within 24 hours of the date of meeting with the therapist. The Clinical Director will meet with the Resident’s primary therapist. The decisions made regarding the grievance are considered final at this point and will be documented and submitted to the Resident in writing. If the Resident is dissatisfied at this point, the Resident has the right to contact the Abuse Registry at 1-800-96-ABUSE.
D. Resident’s grievance and a final internal step in the grievance process and decision is resolved or concluded by action of Desert Rose’ Governing Board.
E. In the event that a Resident does not feel a resolution has been reached they may contact DCF or file a grievance with FARR through their webpage.
3. Any allegations of physical or sexual abuse by a staff member shall be brought to the immediate attention of the Clinical Director. The Resident will be afforded the opportunity to contact the Abuse Hotline, The Department of Children and Families, or the Florida Association of Recovery Residences (FARR). The contact information for the abuse registry, district Human Rights Advocacy Committee, FARR and the SAMH Program Office will be posted in a common area.
4. Notification to all parties of these rights shall include affirmation of an organizational non-relationship policy that protects a party’s right to file a grievance or express their opinion and invokes applicability of state and federal protections.
5. The Clinical Director and the Human Resource Director shall take steps to ensure an appropriate investigation of each complaint to determine its validity. These rules contemplate informal, but thorough, investigations, affording all interested persons and their representatives, if any, an opportunity to submit evidence relevant to the complaint.
6. In the even that a Resident is dissatisfied at any point, the Resident has the right to contact the right to voice complaints, questions or concerns about service, treatment, procedures, rights and policies by calling any one of the following agencies:
A. HRS Abuse Registry Hot Line, 1-800-96ABUSE 1-800-962-2873
B. Florida Association of Recovery Residences (561) 299-0405
C. Department of Children & Family Services (P – 954) 467-4272
D. Disability Rights Florida 1-800-342-0823
E. The HIPAA Privacy Officer/Corporate Compliance Officer: (888) 576-8373
F. The U.S. Department of Health and Human Services at for privacy or breach of confidentiality (HIPAA):
The U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Washington, D.C. 20201
Toll Free: 1-877-696-6775
All Residents will be given a copy of the telephone number to the Abuse Hotline, Florida Association of Recovery Residences, and Department of Children and Families Program Office at the time of admission. All Residents will be afforded the opportunity to contact the any of the above phone numbers without fear of retaliation. The telephone number of the hot line is posted in the common areas of each residence.
