016.05.13 Ark. Code R. 001

Current through Register Vol. 49, No. 10, October, 2024

Rule 016.05.13-001 - Policy 1010 - Service Concern Resolution

1.Purpose. This policy provides the administrative procedure for receiving reports, gathering information, and resolving concerns regarding any organization or individual licensed or certified by DDS to provide services to persons with disabilities.

2.Scope. DDS will accept reports of concerns from any person.

3.Service Concern. DDS will accept for investigation any concern regarding services provided by a licensed or certified program to an individual with a developmental disability.

DDS will not accept concerns related to employee grievances against their employer or any personnel issues, unless it affects the provision of services to individuals.

4.Receipt of Concerns. Any DDS staff person who receives verbal or written service concerns will immediately relay the information to the DDS Quality Assurance Investigation Unit.

5.Mandated Reporting Responsibility. DDS employees will fulfill their responsibility as mandated reporters by reporting any covered incident to Adult Protective Services or the Child Abuse Hotline, as appropriate.

A. The DDS staff who reports the incident to the appropriate hotline must inform the DDS Quality Assurance Assistant Director that they have made the report.

B. The DDS Quality Assurance Assistant Director will contact the Executive Director of the provider agency and provide them with the details of the report, excluding the name of the reporter.

6.Investigation Unit Process. The Investigation Unit maintains primary responsibility for investigation of service concerns. In conjunction with the Certification and Licensure Manager, the Investigation Unit Supervisor may assign investigation responsibility, in whole or part, to Certification and Licensure staff. The Certification and Licensure Administrator maintains responsibility for the final determination regarding the outcome of any investigation. All timeframes mentioned below are subject to extension, based on the approval of the Certification and Licensure Administrator.

A. The DDS Investigator will make initial contact, by telephone or face-to-face, with the individual expressing the concern within three working days of receipt of the concern. The Investigator will obtain, as appropriate:

1) The name and contact information of the person,

2) The name and contact information of the individual receiving services and who is the subject of the concern,

3) A complete accounting of the concern, including the names of all persons involved, locations, dates and any other pertinent information.

B. If the Investigator is unable to make initial telephone or face-to-face contact within three working days, the Investigator will send a certified letter to the person expressing the concern that requests that he make contact with the Investigator within three working days of his receipt of the letter. If the individual does not contact the Investigator within the specified period, the Investigator will not pursue the matter unless it appears that the health and safety of an individual who is receiving services is jeopardized.

1) If the Investigator determines that the health and safety of an individual is jeopardized, he will initiate an investigation by contacting the individual's

i. Waiver Case Management provider, or

ii. Center-Based service provider.

C. The Investigator will begin the fact-finding process within one working day after completion of the initial interview with the person expressing the concern in order to determine if there is sufficient evidence to conduct a full investigation. The fact-finding will include:

1) Telephone or face-to-face interviews with involved parties, and as necessary,

2) Review of pertinent documents related to the concern.

D. With the approval of the Certification and Licensure Administrator, the Investigator will determine whether to initiate an investigation.

1) If the determination is not to proceed with a full investigation, the Investigator will:

Complete a written summary of events within ten calendar days of

i. the decision

ii. Make a referral to another party, such as the DDS Ombudsman or DMS Program Integrity, if appropriate

2) If the determination is to proceed with a full investigation, the Investigator will initiate an investigation based at any or all of the following;

i. The provider center,

ii. The provider owned group home,

iii. The provider owned apartment,

iv. The provider owned home,

v. A provider employee owned home,

vi. The home of the individual who is the subject of the concern, only if the concern came from the individual or their guardian, or

vii. The DDS office.

3) The Investigator will base the determination as to where to conduct the investigation on factors such as the severity of the allegation and the number and severity of related concerns received regarding the provider, the alleged perpetrator or the individual during the preceding six months.

The decision will be subject to the Certification and Licensure Administrator's approval.

i. The team who conducts the investigation at the provider location routinely consists of no more than two persons. The Certification and Licensure Administrator must obtain approval from the DDS Director to allow more than two persons to conduct an on-site investigation.

E. The investigator will complete the investigation within 30 calendar days of receipt of the concern. The investigator may conduct any or all of the following activities during investigation:

1) Telephone or face-to-face interviews with involved parties

2) Conduct an unannounced visit to the location as described in D2,i-vii either during regular working hours, after-hours or on weekends

3) Photograph physical evidence

4) Review of case notes, plans of care, time sheets, or physical plant inspections

5) Review of documentation of staff training

6) Review of agency policies and personnel files

7) Review of any other pertinent information

F. Upon completion of the investigation, the investigator will determine if the facts support a finding that the provider did not adhere to DDS Standards for Center-Based Community Services, DDS Certification Standards for ACS Waiver Services, or any other applicable policy, regulation or standard.

1) If the facts support a finding, within 15 calendar days of the conclusion of the investigation,"'the investigator will send to the provider a report that contains at least the following information:

i. A summary of the issue,

ii. When and how the concern was submitted,

iii. A brief summary of the investigation methods, interviews and facts,

iv. A justification of the determination of the finding, including a citation of the applicable standard or rule,

A request for a time-bound Assurance of Adherence to the v. standard or rule vi. A notice that the provider may request a meeting with the Certification and Licensure Administrator to discuss the findings of the review and to produce additional evidence if warranted, and vii. A notice that the decision is subject to appeal under the provisions of DDS Administrative Appeals Policy 1076.

2) With the approval of the Certification and Licensure Administrator, the Investigator may request that Certification and Licensure staff initiate a full licensure or certification review of the program.

3) If the facts do not support a finding, the investigator will, within 15 calendar days of the conclusion of the investigation;

i. Send to the provider a report which contains the information described in F.1) i-iii., or

ii. Produce a brief summary of events, which describes minimal activities conducted to arrive at the conclusion

G. The Investigator will provide the investigative report, either electronically or by regular mail, with or without findings, to the following:

1) The Executive Director of the program or individual provider who was the subject of the investigation,

2) The President of the Board of Directors of the program,

3) The Certification and Licensure Manager, and

4) The Certification and Licensure Administrator

H. At the completion of the fact-finding or the investigation, the Investigator will respond either electronically or by regular mail, to the individual who expressed the concern. The response will reveal only if:

1) DDS did or did not conduct an investigation, and

2) The investigation resulted in a finding of non-compliance with a DDS Standard.

016.05.13 Ark. Code R. 001

7/26/2013