Subject: CLIENT-INDIVIDUAL RIGHTS
Reference: WAC 246-341-0600

POLICY: Clinical—Individual rights. (1) Each agency
licensed by the department to provide any behavioral health service must develop a statement of individual participant rights applicable to the service categories the agency is licensed for, to ensure an individual’s rights are protected in compliance with chapters 71.05,71.12, and 71.34 RCW. In addition, the agency must develop a general statement of individual participant rights that incorporates at a minimum the following statements.

“You have the right to:”

(a) Receive services without regard to race, creed, national
origin, religion, gender, sexual orientation, age or disability;

(b) Practice the religion of choice as long as the practice does
not infringe on the rights and treatment of others or the treatment service. Individual participants have the right to refuse participation in any religious practice;

(c) Be reasonably accommodated in case of sensory or physical
disability, limited ability to communicate, limited-English
proficiency, and cultural differences;

(d) Be treated with respect, dignity and privacy, except that
staff may conduct reasonable searches to detect and prevent possession or use of contraband on the premises;

(e) Be free of any sexual harassment;

(f) Be free of exploitation, including physical and financial
exploitation;

(g) Have all clinical and personal information treated in accord
with state and federal confidentiality regulations;

(h) Review your clinical record in the presence of the
administrator or designee and be given an opportunity to request
amendments or corrections;

(i) Receive a copy of agency grievance system procedures
according to WAC 182-538D-0654 through 182-538D-0680 upon request and to file a grievance with the agency, or behavioral health organization (BHO), if applicable, if you believe your rights have been violated; and

(j) Submit a report to the department when you feel the agency
has violated a WAC requirement regulating behavioral health agencies.

(2) Each agency must ensure the applicable individual participant rights described in subsection (1) of this section are:

(a) Provided in writing to each individual on or before
admission;

(b) Available in alternative formats for individuals who are
visually impaired;

(c) Translated to the most commonly used languages in the
agency’s service area;

(d) Posted in public areas; and (e) Available to any participant upon request.

(3) Each agency must ensure all research concerning an individual whose cost of care is publicly funded is done in accordance with chapter 388-04 WAC, protection of human research subjects, and other applicable state and federal rules and laws.

(4) In addition to the requirements in this section, each agency
providing services to Medicaid recipients must ensure an individual seeking or participating in behavioral health treatment services, or the person legally responsible for the individual is informed of their Medicaid rights at time of admission and in a manner that is understandable to the individual or legally responsible person.

(5) The grievance system rules in WAC 182-538D-0654 through 182-538D-0680 apply to an individual who receives behavioral health services funded through a federal Medicaid program or sources other than a federal Medicaid program.

PROCEDURES

As part of the assessment process Sisters In Common, Behavioral Health Services staff will inform clients, including Medicaid clients, and/or legally responsible others of their client rights and, if applicable, their Medicaid rights, in a culturally competent manner and provide clients, with a copy of their rights.

SIC provides client rights in alternative formats. Clients who are visually impaired will have client rights read to them or SIC will provide them with an audio recording of their client rights. In addition, Sisters In Common posts a written client rights statement in our public area and provide copies to clients.

Sisters In Common shall ensure its statement of client rights incorporates the following and is provided to the client in writing upon admission as well as posted in the agency facility:

It is the practice of Sisters In Common (SIC) to comply with all federal and state non-discrimination laws. SIC ensures that all clients are knowledgeable of their rights and that their rights are always protected while receiving services at SIC. This includes making information about client rights available in those languages most commonly used in the populations served by Sisters In Common.

Subject: DBHR COMPLAINT PROCESS FOR CLIENTS
Reference: WAC 246-341-0605, Reference: WAC 246-341-0420

(1) Any person may submit a report to the department of an alleged violation of licensing and certification laws and rules.

(2) Health care professionals credentialed by the department must comply with the mandatory reporting requirements in chapters 18.130 RCW and 246-16 WAC.

(3) If the department determines a report should be investigated, the report becomes a complaint. If the department conducts a complaint investigation, agency representatives must cooperate to allow department representatives to:

(a) Examine any part of the facility at reasonable times and as needed;
(b) Review and evaluate agency records including, but not limited to:
(i) An individual’s clinical record and personnel file; and
(ii) The agency’s policies, procedures, fiscal records, and any other documents required by the department to determine compliance and to resolve the complaint; and
(c) Conduct individual interviews with staff members and individuals receiving services.

(4) An agency or agency provider must not retaliate against any:

(a) Individual or individual’s representative for making a report with the department or being interviewed by the department about a complaint;
(b) A witness involved in the complaint issue; or
(c) An employee of the agency.

(5) The department may assess a fee under RCW 43.70.250, or deny, suspend, or modify a license or certification under RCW 43.70.115, if:

(a) Any allegation within the complaint is substantiated; or
(b) The department’s finding that the individual or individual’s representative, a witness, or employee of the agency experienced an act of retaliation by the agency as described in subsection (4) of this section during or after a complaint investigation.

Subject: GRIEVANCE PROCESS AND PROCEDURES FOR CLIENTS
Reference: WAC 246-341-0605, Reference: WAC 246-341-0420

COMPLIANT PROCESS
It is the practice of Sisters In Common to provide a formal grievance process and comply with the DBHR complaint process for all clients in accordance with applicable state law. It is the client’s right to file a grievance, or DBHR complaint, and freedom from retaliation is guaranteed.

SIC Grievance Process and Procedure
The client has the right to designate or appoint a representative. This can be a family member, friend or advocate. Filing of a grievance shall be held confidential and will not be reflected in the client’s record in accordance with applicable regulations.

If a client’s benefit expires during the grievance process and the client meets the criteria for continuance, a new benefit will be authorized until the grievance procedure is complete. Services will be continued during the grievance process in accordance with best practices.

In the event that the existing clinical/client relationship cannot be maintained or by client request, an alternative service provider will be assigned to provide services pending resolution of the grievance.

SIC will work to resolve problems at the lowest possible administrative level.

A staff person who is the object of a grievance shall not participate in the grievance process.

The client is also advised that s/he can request a face to face mediation meeting to resolve the grievance.

SIC BHS staff are available to assist in completing in completing the grievance process if so, requested by the department.

If the client decides to file a grievance:

• Client obtains a Client Grievance Form from the SIC office

• If the client requires help in completing the form, he/she may ask any staff member (not involved in the grievance) to help complete the form.

• After completion of the form, the receptionist signs the form prior to copying. This will document the receipt of the grievance.

• A copy is made of the completed grievance form.

• The original is placed in an envelope and routed to the Administrator or to the Clinical Supervisor, if the Administrator is involved in the grievance.

• The copy is retained by the client.

• The entire investigation of the grievance or complaint shall be documented.

• A written report of the investigation and disposition of the grievance or complaint shall be given to the client within 30 days of its completion.

• The client signs off on the disposition, if an agreement was reached.

• The resolved grievance paperwork is filed in the Grievance or Complaint File maintained in the SIC Administrator’s offices.
• No mention of any part of the grievance or complaint procedure shall be indicated in the
Client’s chart.

Grievance or Complaint Appeals:

The client can appeal the grievance or complaint decision within ten working days. If the client appeals the grievance decision:

• The entire documentation of the grievance or complaint is routed to the Clinical Director.

• The Clinical Director shall provide the client with a written report of the decision/disposition to the client within 30 days of filing the appeal.

• The client signs off on the disposition, if an agreement was reached.

• The client can appeal this decision as well within ten working days. If the client appeals the Clinical Director decision, the grievance or complaint paperwork is routed to the Executive Committee of the SIC Board or their designee.

• The Executive Committee of the SIC Board or their designee shall provide the client with a written report of the decision/disposition to the client within 30 days.

• The client signs off on the disposition, if an agreement was reached.