MONTANA STATE HOSPITAL

POLICY AND PROCEDURE

PATIENT GRIEVANCE PROCEDURE

Effective Date: September 21, 2018 Policy: PR-03

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I. PURPOSE: To establish a process whereby patients or their authorized representatives

may have their grievances and complaints resolved in a prompt, reasonable and
consistent manner. Also, to provide a mechanism by which Montana State Hospital
(MSH) may investigate and rectify patient rights violations as defined in statute MCA §
53-21-142.

II. POLICY: MSH will provide and adhere to a procedure for receiving, responding to, and
resolving grievances/complaints and concerns of patients or their representatives.

A. MSH patients may use the patient grievance procedure as a formal means to voice
possible violations of patient rights.

B. The Patient Grievance Procedure is a means for inquiring into the issue raised by the
patient or patient representatives, looking at the issue from the patient’s perspective
as well as that of staff members, and identifying actions to be taken to resolve and/or
prevent recurrence. The grievance may be filed by:
1. the patient or patient representative;
2. any other person who the patient asks for help in filing a grievance; or
3. any other person who witnesses a potential patient rights violation.

C. No person shall be punished or retaliated against for filing a Grievance or using the
Patient Grievance Procedure.

D. Use of the Patient Grievance Procedure does not limit the right of a patient to seek
remedy for a complaint in the legal system.

E. Patients and patient representatives will be provided with information regarding

patient advocacy organizations that may assist them with Grievances, such as the
Mental Disabilities Board of Visitors and the Mental Health Ombudsman or other
advocacy agencies.

F. Patients have the expressed right to bypass this entire grievance procedure and
contact the Department of Public Health and Human Services Mental Health
Ombudsman; Montana Mental Disabilities Board of Visitors or other advocacy
agencies at any time.
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III. DEFINITIONS:

A. Patient Grievance: is a formal or informal written or verbal complaint that is made to

the hospital by a patient, or the patient’s representative, regarding the patient’s care
(when the complaint is not resolved at the time of the complaint by staff present),
abuse or neglect, issues related to the hospital’s compliance with the CMS Hospital
Conditions of Participation (COPs), or a Medicare beneficiary billing complaint
related to rights and limitations provided by 42 CFR 489.
1. Verbal or Written Patient Complaint:
• Verbal complaint is a complaint that can be resolved at the time of the
complaint by the staff present. A complaint is considered resolved when
the patient is satisfied with the actions taken on his or her behalf.
• Written complaint is always considered a grievance, whether from a
patient or their representative regarding patient care provided, abuse or
neglect, or the hospital’s compliance with COPs.
• A complaint or grievance does not have to be reported on the designated
MSH grievance form to be considered a valid grievance.
2. Post-Discharge Grievances or Complaints:
• Information obtained with patient satisfaction surveys do not usually meet
the definition of a grievance. However, if an identified patient writes or
attaches a written complaint on the survey and requests resolution, then
the complaint meets the definition of a grievance.
• Patient or patient representative may verbally contact the hospital with a
complaint regarding patient care or with an allegation of abuse or neglect,
or failure of the hospital to comply with CMS requirements.

B. Complainant: Patient or patient representative who expresses a grievance or complaint

regarding a potential violation of patient rights.

C. Medical Grievance: A Medical Grievance is a grievance or complaint specific to the

provision or non-provision of medical care or services. An example might be a grievance
concerning medications, the need for a diagnostic procedure, or a request for an opinion
from another medical practitioner.

D. Minor Request: A request made by the patient or patient’ representative that may be
solved relatively quickly, and would not be considered a grievance; therefore, would not
require a written response. Examples include; a change in bedding, housekeeping of a
room, and/or serving a preferred food.

E. Grievance Committee (GC): Multidisciplinary team will be appointed by the Hospital

Administrator. A member of the Board of Visitors may attend and participate.

F. Grievance Committee Chairperson: A person appointed to this position by the

Hospital Administrator or his designee.
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G. Grievance Procedure: The procedure used when the patient’s or patient representative’s
concern or complaint cannot be resolved at the point of contact or service by the staff
present.

H. Review Officer: A person assigned by the GC to review a grievance when a patient or

patient representative appeals the decision of the GC.

I. Point of Service or Contact: The place and time the services are or were to be provided
or where a barrier was encountered, or where a majority of patients will receive services,
including Admitting, Business Office, Recovery Center, Therapeutic Learning Center or
other areas of MSH Campus.

IV. RESPONSIBILITIES:

A. Grievance Committee: Reviews all grievances that are not resolved to the
satisfaction of the patient or patient representative by the Nurse or Program Manager.
The committee will investigate complaints, make decisions, and provide a written
response to grievances. The Committee is responsible for oversight and coordination
of the Patient Grievance Procedure. The Committee is responsible for enforcing the
time frames prescribed in the Patient Grievance Procedure.

B. Grievance Committee Chairperson: Receives and processes all grievances and

complaints on a week day basis. This position is also responsible for scheduling and
chairing the GC and keeping a record of all grievances and complaints.

C. Admission Clerk: Discusses patient rights and the grievance procedure at the time
of admission with the patient or patient representative.

D. Social Work Staff: Meets with the patient within 3 working days after admission to
revisit the patient rights and grievance procedure with the patient or patient
representative. This may need to be repeated if the patient does not clearly understand
the information when it is first presented. See MSH policy PR-04, Patient Rights and
Grievance Procedure Information.

E. Program or Nurse Manger: Meets with the patient or patient representative to

discuss the grievance and attempt to find resolution to the grievance.

F. All MSH Staff: Maintain the integrity of the grievance process and helping to resolve
patient complaints and disputes. This may include ancillary staff and other managers.

G. Director of Quality Improvement: Oversees the grievance/complaint process and

procedure, and its compliance with applicable state and federal laws and regulations.

H. Review Officer: Meets with the patient or patient representative to discuss the
grievance; investigate the grievance; report back to the Committee with their findings
and recommendations; and participate in the appeal process.
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I. Hospital Administrator: Assigns members to the Committee; ensuring the

grievance procedure is followed; being involved with the appeal process by
facilitating a hearing and will provide a written report regarding his or her findings to
the patient or patient representative within 15 working days.

V. PROCEDURE:

A. At the time of admission, the admission clerk will review patient rights and the
grievance procedure with the patient or the patient representative. The social worker
will revisit the patient rights and the grievance process with the patient within 3
working days of admission and periodically thereafter. The admission clerk and the
social worker will review the MSH Patient Rights with the patient by:
1. explaining the Patient Rights to the patients;
2. asking the patient to sign the Patient Rights form;
3. providing the patient a copy of the signed form; and
4. placing a copy of the patient right form in the patient’s medical record.

B. In conjunction with the Patient Rights the social worker will explain the Patient
Grievance Procedure including the Grievance Appeal Process.

C. The Director of Quality Improvement, in collaboration with the Nurse and Program
Managers will ensure that MSH Patient Rights and the Patient Grievance Procedure
are posted on each MSH unit; and grievance forms are available on all units and
available upon request from all MSH staff. Locked boxes will be available on each
treatment unit for patients to deposit grievance forms.

D. Patients, families or patient representatives may contact any employee to file a

grievance.

E. A representative of the Mental Disabilities Board of Visitors or other advocacy

organization may participate in GC meetings, and will review the grievance and offer
resolution.

F. The Grievance Committee Chairperson is responsible for receipt of grievances on

each weekday and taking primary action by:
1. date stamping receipt of the grievance and initiating the grievance timeline
and process;
2. ensuring a copy of the grievance is sent to the Montana Mental Disabilities
Board of Visitors; and
3. assigning the grievance to a Nurse or Program Manager for initial hearing
and attempted resolution. The GC will meet regularly to make
recommendations for appropriate grievance resolution.

G. The Committee will operate on a consensus basis, working to find a resolution and
response to patient grievances that is acceptable with all members of the committee.
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If the committee is unable to reach consensus, the Chairperson or their designee will
determine the appropriate response with input from all members of the committee.

H. The grievance process may be terminated at any time if:

1. resolution is reached when indicated by the patient and documented by a
patient’s signature on the grievance form;
2. a patient objects to continuing with a grievance filed on their behalf by a
third party; or
3. the grievance has been transferred to another authority.

I. Grievance process:
Step 1 – Review and Response;
Staff will provide grievance forms to patients whenever requested. Staff should
inquire at this time whether there is anything they can do to assist the patient or
resolve the matter.

All grievances received by staff members will immediately be forwarded to the

Grievance Committee Chairperson for tracking, distribution and assignment.

The Program Manager or Nurse Manager assigned to address and attempt to

resolve the grievance will be allowed up to 7 working days to help resolve the
grievance with the client. The 7 working days begin on the date the grievance is
received and stamped by the Chairperson.

If a resolution is reached, both the Program or Nurse Manager and the

complainant will sign and date the grievance form as satisfied. The Program or
Nurse Manager will forward the grievance form to the Chairperson for tracking
and reporting purposes.

If a resolution cannot be reached, the Program or Nurse Manager will forward the
Patient Grievance Form, the Patient Grievance Action Form, and relevant
documentation as necessary, to the GC. The Committee will meet to discuss the
grievance within 7 working days. The complainant and the Program or Nurse
Manager will be notified in writing of the Committee’s decision. The committee
Chairperson will maintain records of the Committee’s findings and actions.

The GC will send written responses to all whose grievance are considered by the
Committee. The response letter will include:
1. the decision;
2. the name of the hospital contact person;
3. the steps taken on behalf of the patient to investigate the grievance;
4. the results of the grievance process; and
5. the date of completion.
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Step 2 – Appeal Process (Internal);

If the complainant is not satisfied with the Step 1 response of the GC, an appeal
may be submitted to the Committee within 10 working days of receiving the
written decision.

A Review Officer will be appointed by the Committee to investigate the

grievance. The selection of the Review Officer will be based on expertise
relevant to the grievance and the ability to objectively investigate the issue. The
Review Officer will submit a written report to the Committee within 10 working
days of the assignment. This report will include documentation of the
investigative activities and a recommendation for resolution.

The Committee will make a decision based on the investigation findings. The
complainant, Program or Nurse Manager, and Patient Advocate (if indicated), will
be notified in writing of the decision within 30 working days of receipt of the
appeal.

Step 3 – Appeal Process (MSH Administration);

If the complainant is not satisfied with the Step 2 response of the GC, an appeal
may be submitted to the Committee within 10 working days of receiving the
written decision.

The Committee will notify the Hospital Administrator of the complainant’s desire
to appeal the decision of the Committee. A hearing will be scheduled and
conducted by the Hospital Administrator, unless waived by the complainant,
within 15 working days of receipt of appeal. The complainant, Patient Advocate
(if involved), Program or Nurse Manager and others involved with the issue will
be notified at least 5 working days in advance of the date, time and location of the
hearing.

Every reasonable effort will be made to ensure full investigation of the issue in a
fair and equitable manner. The patient, patient’s representative, or Patient
Advocate may call witnesses for testimony at the hearing. However, the Hospital
Administrator may limit repetitive or irrelevant testimony and/or the number of
witnesses. If necessary, separate arrangements will be made to hear testimony
from parties unable to attend the hearing.

The Hospital Administrator will prepare a written decision within 15 working

days of the receipt of the Step 3 appeal. The complainant, Patient Advocate (if
involved) and Program or Nurse Manager will be notified in writing of the
decision.

In the event the hearing is waived by the complainant, the Hospital Administrator
will review applicable statements, relevant documentation, and render a written
decision within 15 working days of receipt of the Step 3 appeal.
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Step 4 – Appeal Process (DPHHS);

If the complainant is not satisfied with the Step 3 response of the Hospital
Administrator, an appeal may be submitted to the GC within 10 working days of
receiving the Hospital Administrator’s written decision.

The Administrator of the Addictive and Mental Disorder Division of the

Department of Public Health and Human Services will be notified within 3
working days of receipt of the Step 4 appeal. The appeal and relevant information
will be directed to the Division Administrator.

The Division Administrator will render a written decision within 15 working days
of his/her receipt of the grievance unless he/she requests additional investigation
into the issue. If additional investigation is conducted, the decision will be
rendered within 40 working days of completion of additional investigation.

The complainant, Patient Advocate (if indicated), and GC will be notified in

writing of the decision.

Patients or patient’s representatives may seek the assistance of advocacy groups at

any time during the grievance process.

J. The GC maintains files of all grievances and corresponding documentation,

statements and decisions.

A database of aggregate grievance information (number of grievances filed, types of

complaints, resolutions reached, etc.) is also maintained. This information is reported
quarterly to the Quality Improvement Committee.

K. Medical Grievances – When a grievance is filed that is specific to medical care or

treatment, the Grievance Committee Chairman will review the complaint with the
Medical Director who will appoint staff members with expertise in the area of
concern to review and investigate the complaint and advise the committee on a course
of action.

L. Patients should be encouraged, but are not required, to attempt to appropriately voice
complaints and resolve disputes through routine and informal interactions with staff.

M. When necessary, the Patient Grievance Committee will take additional steps on
behalf of the patients to obtain information to help resolve a grievance.

VI. REFERENCES: Title 53, Chapter 21, section 142(14) Montana Codes Annotated, CMS
Interpretive Guidelines §482.13.

VII. COLLABORATED WITH: Montana Mental Disabilities Board of Visitors, Grievance

Committee Chair, Clinical Services Director, and the Hospital Administrator.
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VIII. RESCISSIONS: PR-03, Patient Grievance Procedure dated June 1, 2018; PR-03.
Patient Grievance Procedure dated February 12, 2016; PR-03. Patient Grievance
Procedure dated May 18, 2012; PR-03, Patient Grievance Procedure dated November
30, 2009; PR-03, Patient Grievance Procedure dated January 14, 2008; PR-03, Patient
Grievance Procedure dated April 10, 2006; PR-03, Patient Grievance Procedure dated
March 31, 2003; PR-03, Patient Grievance Procedure dated February 14, 2000; MSH
13-03G.081390, Patient Grievance Procedure dated September 30, 1996.

IX. DISTRIBUTION: All hospital policy manuals.

X. ANNUAL REVIEW AND AUTHORIZATION: This policy is subject to annual

review and authorization for use by either the Administrator or the Medical Director with
written documentation of the review per ARM § 37-106-330.

XI. FOLLOW-UP RESPONSIBILITY: Grievance Committee Chairperson.

XII. ATTACHMENTS: For internal use only.

Signatures:

Kyle Fouts Connie Worl

Interim Hospital Administrator Director of Quality Improvement