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HomeMy WebLinkAboutIDD-509 Grievance Procedure - Waiver Funded Individuals Right to Appeal1 FRANKLIN/FULTON COUNTY MENTAL HEALTH/INTELLECTUAL & DEVELOPMENTAL DISABILITIES/EARLY INTERVENTION 425 Franklin Farm Lane Chambersburg, PA 17202 (717) 264-5387 MH/IDD/EI PROCEDURE STATEMENT PROCEDURE SUBJECT: Grievance Procedure – Waiver Funded Individual’s Right to Appeal PROCEDURE NUMBER: IDD-509 Effective Date: July 1, 2008 Date Revised: October 15, 2021 Reference: IDD Bulletin 00-08-05, Due Process and Fair Hearing Procedures for Individuals with Mental Retardation INTRODUCTION: Individuals of the Franklin/Fulton Intellectual & Developmental Disabilities Program of MH/IDD/EI have the right to due process whether those services are provided directly by Franklin/Fulton MH/IDD/EI or funded through the waiver. In order to clarify an individual’s right to due process, this policy and procedure has been developed and is applicable to all individuals who are receiving services funded through the Person Family Directed Supports (P/FDS), Community Living and Consolidated Waivers. This process can run concurrently with the MH/IDD Due Process grievance/appeal process. An individual’s right to fair hearing and appeal will be discussed at least annually during the Individual Support Plan (ISP) annual review meeting and at any time the individual or surrogate requests to change services or add new services. The discussion will be documented on the individual’s ISP and through a service note in Home and Community Services Information System (HCSIS). The Administrative Entity (AE) staff will also inform individuals of their rights to fair hearing/appeals during intake, service delivery preference, level of care determination/re- determination, and anytime there is a denial, reduction, or termination of services. All information relating to such grievance/appeal shall be kept strictly confidential in accordance with all HIPAA regulations. Consent forms must be used for all information shared with any outside person or agency. PROCEDURE: When any of the following actions occur, Franklin/Fulton’s Administrative Entity is required to provide a copy of the Department’s Fair Hearing and Appeal procedures to the individual or the 2 individual’s surrogate and explain the right to a fair hearing. The Supports Coordination Organization may issue rights to fair hearing and appeal only with the concurrence of Franklin/Fulton’s AE around the following circumstances: 1. The individual is determined likely to require an Intermediate Care Facility for the Intellectually Disabled (ICF/ID) or Intermediate Care Facility for Other Related Conditions (ICF/ORC) level of care and is provided information about Waiver-funded services. 2. The individual who is determined likely to meet an ICF/ID or ICF/ORC level of care and is enrolled in Medical Assistance or surrogate is asked to sign the service delivery preference form (DP 457). 3. A decision or an action is taken that affects the individual’s claim for eligibility or receipt of services. This applies to the individual’s annual planning meeting as well as to any meeting or time that services are discussed with the individual or surrogate. 4. A decision or an action is taken to deny the individual a Waiver-funded service or to deny a willing and qualified provider of the individual’s choice. 5. A decision or an action is taken to deny, suspend, reduce, or terminate a Waiver-funded service that is authorized on the individual’s ISP. 6. The individual or surrogate notifies Franklin/Fulton’s AE of the decision to file an appeal, or requests information about the individual’s appeal and fair hearing rights under the Waiver. Franklin/Fulton’s AE may not limit or interfere with the individual’s or surrogate’s freedom to file a request for a hearing. Franklin/Fulton’s AE will help the individual file the appeal if assistance is requested using form DP 458. 7. Franklin/Fulton’s AE will review the appeal internally to assure that the decision in question is in accordance with Department regulations and policies and that Franklin/Fulton’s AE decision was correct. If Franklin/Fulton’s AE determines that the decision was correct, the appeal is forwarded to the Bureau of Hearings and Appeals, the appropriate Office of Developmental Programs (ODP) Regional Office, and the ODP Central Office within three (3) business days from the date the appeal was received and date stamped using the required cover sheet. A cover sheet is also attached to the appeal. If Franklin/Fulton’s AE finds that the decision in question is not in accordance with Department regulations and policies or if new or additional information that alters the decision is included with the appeal, Franklin/Fulton’s AE will forward the appeal to the Bureau of Hearings and Appeals, the appropriate ODP Regional Office, and the ODP Central Office within three (3) business days from the date the appeal was received and date stamped with the required cover sheet. In addition, Franklin/Fulton’s AE will take corrective action to resolve the issue and notify the appellant and the Supports Coordinator in writing of the action taken to correct the issue under appeal. A copy of the notification will be kept in the individual’s file and the corrective action taken and date of the written notification will be documented in a service note or on the appropriate eligibility screens in HCSIS. If the appellant is satisfied with the corrective action, the individual or surrogate may submit a written request to Franklin/Fulton’s AE to withdraw 3 the appeal. The written request for withdrawal that includes a visible date stamp received notation will be forwarded to the Bureau of Hearings and Appeals for processing. The individual or the individual’s surrogate has the right to request a pre-hearing conference with Franklin/Fulton’s AE. This pre-hearing conference will follow procedure statement MHIDD- 305. The pre-hearing conference is optional for the individual or surrogate. The pre-hearing conference gives both parties the opportunity to discuss and attempt to resolve the matter prior to the hearing. Neither party is required to change its position. The pre-hearing conference will not replace or delay the fair hearing process. The date of the pre-hearing conference and notes of the discussion should be entered in a service note or the appropriate eligibility screen in HCSIS. All fair hearing and appeals information will be tracked in Franklin/Fulton’s AE database for Quality Management. Individuals Grievances/Appeals will be viewed as confidential information. Also, all applicable procedures relating to the management of confidential information will be followed. Those children/adolescents and their families who are involved in the Child and Adolescent Service System Program (CASSP) and want to grieve/appeal an Intellectual & Developmental Disabilities Program’s decision resulting from a CASSP Team meeting, the above procedures will apply. ATTACHMENT: DP 458 Fair Hearing Request Form This form is for waiver funded services. DP 458 10/18 OFFICE OF DEVELOPMENTAL PROGRAMS INTELLECTUAL DISABILITY/AUTISM WAIVERS, TARGETED SUPPORT MANAGEMENT, OR INTERMEDIATE CARE FACILITIES INSTRUCTIONS • FAIR HEARING REQUEST FORM If you are applying for Waiver services or services in an Intermediate Care Facility for persons with an Intellectual Disability (ICF/ID), or if you object to an action taken by the Administrative Entity (AE), County Program, or the Office of Developmental Programs (ODP) that adversely affects your claim or authorization for Waiver services, you have the right to a Fair Hearing before the Department of Human Services, Bureau of Hearings and Appeals (BHA). You may request a Fair Hearing in the following circumstances: • You are determined likely to meet an ICF/ID or ICF/ORC level of care and are enrolled to receive Medical Assistance but are not given the opportunity to express a service delivery preference for either Waiver or ICF/ID services. • You are denied your preference of Waiver, TSM, or ICF/ID services. • Based on a referral from the AE or County Program, a Qualified Developmental Disability Professional (QDDP) determines that you do not require an ICF/ID or ICF/ORC level of care and eligibility for services denied or terminated. • You are denied Waiver service(s) of your choice, including the amount, duration, and scope of service(s). • You are denied the choice of willing and qualified Waiver or TSM provider(s). • A decision or an action is taken to deny, suspend, reduce, or terminate a Waiver service authorized on your Individual Support Plan (ISP). FILING THE FAIR HEARING REQUEST/APPEAL: You have the right to file a Fair Hearing request directly with the agency that made the determination affecting your claim or authorization for Waiver, TSM, or ICF/ID services (the County Program, AE, or ODP). You have a right to appeal any adverse action and to have a hearing if you are dissatisfied with any decision to deny, suspend, reduce, or terminate Waiver services, Form DP 458 (attached) must be used to file your appeal. TO: The AE or County Program that made the determination affecting your claim or authorization for Waiver, TSM, or ICF/ID services should complete the TO section of the DP 458 form and send the form to you with the written notice of determination. If you did not receive a DP 458 form from the AE or County Program or the TO section was not completed, please fill this section in with the name and address of the entity (the AE, County Program, or ODP) that made the determination. Please remember: All Fair Hearing requests/appeals must be sent directly to the agency that made the determination regarding your claim or authorization for Waiver, TSM, or ICF/ID services. FROM: The appellant is the person whom the determination directly impacts. While a surrogate can fill out the DP 458 form on behalf of the appellant, this section should be completed with the appellant’s information. I REQUEST THIS APPEAL BASED ON THE FOLLOWING ACTIONS: Write or type the reason for your appeal. This should be based on the written notice provided by the AE, County Program, or ODP outlining the determination that affected your claim or authorization for Waiver, TSM, or ICF/ID services. If you did not receive a written notice, summarize the determination that was provided to you verbally. I REQUEST THE FOLLOWING REMEDIES TO RESOLVE THIS APPEAL: Write or type the actions that you would like to see happen to resolve the issue that is being appealed. NAME OF INDIVIDUAL’S SURROGATE, SURROGATE’S MAILING ADDRESS, SURROGATE’S DAY TELEPHONE NUMBER, SURROGATE’S RELATIONSHIP TO APPELLANT: If a surrogate is completing this form on behalf of the appellant, this information should be filled in. PLEASE CHECK THE BOX NEXT TO THE TYPE OF HEARING YOU WANT: BHA will conduct a hearing for you over the telephone or face-to-face. Please check the appropriate box to indicate the type of hearing you want to occur. • Telephone hearings: If you do not have a telephone that can be used to conduct this hearing, you may use a telephone at the County MH/ID Program, AE office, ODP office, or the telephone of a friend, relative, or neighbor. Please indicate the telephone number where all parties may be reached to conduct a hearing. • Face-to-face hearings: This type of hearing is held in one of the following locations: Erie, Harrisburg, Philadelphia, Pittsburgh, Plymouth, or Reading. More information on the exact location of the hearing site will be sent to you and the AE, County Program, or ODP if you request a face-to-face hearing. A second option is also available to the appellant for face-to-face hearings in which the appellant and the Administrative Law Judge will be at BHA and the AE, County Program, or ODP will participate via telephone. FOR THE HEARING: If you need accommodations to attend or participate in the hearing, please indicate the specific accommodations required (language interpreter, communication device, etc.) on the DP 458 form when you file your Fair Hearing request/appeal. All requests for assistance in obtaining an accommodation must be made in advance of the hearing. Please contact the County Program, AE, ODP, or BHA to request assistance. You may also supply your own interpreter or bring your own communication device, etc., to the hearing. SIGNATURES: All DP 458 forms must contain the signature of the appellant or his or her surrogate when the appeal is filed. If the signature or mark is missing from the DP 458 form, BHA will contact the appellant or surrogate directly to obtain the required signature or mark. If the appellant does not have a surrogate and is unable to sign the form, the following alternatives are acceptable. • The appellant may make a mark on the signature line. If this method is utilized, two witnesses should also sign the form at that time. • If the appellant is unable to sign or make a mark, then the signature line should state “unable to sign or make a mark” and two witnesses should also sign the form at that time. Once the AE, County Program, or ODP has received the DP 458 form, they will forward it to the appropriate BHA regional office. DP 458 10/18 APPEAL TIME FRAME FOR THE CONTINUATION OF WAIVER SERVICES: If you are appealing a change (that is, reduction, termination, or suspension) in current Waiver services that are authorized in your ISP and you want those Waiver services to continue without change during the appeal process, you must complete the DP 458 form and send it to the agency that made the determination adversely affecting your authorization of claim for services within 10 DAYS of the mailing date of the AE’s or ODP’s written notification of the decision to change your Waiver services. (Please note that ODP’s notification will be sent via PROMISe™ versus a letter sent from the AE.) APPEAL TIME FRAME WHERE THE CONTINUATION OF WAIVER SERVICES IS NOT INVOLVED: Services that are denied without first being authorized in the ISP cannot be provided pending appeal. There may also be instances when you do not desire to have your current level of Waiver services continue until a decision is reached at the fair hearing. In these situations, as well as for actions taken regarding Waiver service delivery preference or TSM eligibility, you are afforded 30 calendar days to appeal the denial, reduction, suspension, or change. Form DP 458 must be completed and submitted to the agency that made the determination adversely affecting your authorization or claim for services within 30 calendar days of the mailing date of the written notification of the decision or action. APPEAL TIMEFRAME WHERE NO WRITTEN NOTICE WAS PROVIDED: The County Program, AE and ODP are required to provide written notice of any determination made by the agency that adversely affects your authorization or claim for services. If an agency initiates an action on Waiver or TSM services or verbally denies a request for new or a change to your current Waiver services without providing written notice, you have 6 calendar months from the effective date of the action or verbal notification to request a fair hearing. When this appeal is filed, any terminated or reduced services will be reinstated retroactively (if possible) to the date of discontinuance and to the level provided on the date of the action. These services will continue until an adverse decision is rendered after the fair hearing. PRE-HEARING CONFERENCES: In addition to filing a Fair Hearing request/appeal, you may choose to have a pre-hearing conference with the agency that made the determination adversely affecting your authorization or claim for Waiver, TSM, or ICF/ID services (the County Program, AE, or ODP) without forfeiting your appeal rights. If you wish to have a pre-hearing conference, please contact the agency that made the determination immediately upon receipt of your written notice of the adverse decision or action. A pre-hearing conference is optimal for you and must occur before the scheduled Fair Hearing. CONTACT INFORMATION: If you want a pre-hearing conference to discuss your concerns, or if you need assistance to file a Fair Hearing request/appeal, please contact the AE, County Program, or ODP designee listed below (when the form is completed by the entity listed): NAME:ADDRESS: TELEPHONE NUMBER: ( ) The designee will then photocopy the completed DP 458 form and send a copy to you and the appropriate ODP regional office and central office. ODP regional and central office addresses and contact information can be accessed at: http://www.dhs.pa.gov/learnaboutdhs/helpfultelephonenumbers/regionaldevelopmentalprogramfieldoffices/index.htm The Department of Human Services, BHA contact information can be accessed at: http://www.dpw.state.pa.us/findfacilsandlocs/bureauofhearingsandappealsregionaloffices/index.htm REPRESENTATION AT THE HEARING: You have the right to represent yourself at the hearing. You may present the reasons why you disagree with the action or decision to the BHA Administrative Law Judge presiding over the hearing. You may also present evidence and witnesses to support your case. You also have the right to have someone else represent you. If you need legal counsel, a list of legal aid offices is attached. If you request additional help, the designee will refer you to advocacy organizations in your community. QUESTIONS: If you have any questions regarding the completion of the DP 458 form or the information contained in these instructions, please contact your AE, County Program, or Supports Coordinator. You may also contact the ODP Customer Service line at 1-888-565-9435. Toll-free TTY number (telephone for hearing impaired only): 1-866-388-1114. Local telephone: 717-265-7427. A customer service member will answer calls during normal business hours, which are 8:30 a.m. to 4:00 p.m. EST, Monday through Friday. OFFICE OF DEVELOPMENTAL PROGRAMS INTELLECTUAL DISABILITY/AUTISM WAIVERS, TARGETED SUPPORT MANAGEMENT, OR INTERMEDIATE CARE FACILITIES DP 458 10/18 TO:COMPLETED BY ENTITY THAT MADE DECISION IMPACTING SERVICES/ELIGIBILITY OR APPELLANT IF NOT COMPLETED BY ENTITY AE/COUNTY/ODP: STREET ADDRESS: CITY/STATE/ZIP: DATE APPEAL RECEIVED: FROM:COMPLETED BY APPELLANT/SURROGATE NAME OF APPELLANT: STREET ADDRESS: CITY/STATE/ZIP: DAY TELEPHONE NUMBER: MEDICAID RECIPIENT NUMBER: I hereby request a Fair Hearing before the Department of Human Services, Bureau of Hearings and Appeals. I am requesting this appeal on behalf of myself or the appellant listed above who is applying for or receiving services through the Consolidated, Person/Family Directed Support or Community Living Waiver. Please check the box next to the type of hearing you want: I want a telephone hearing. I and my witnesses and anyone helping me will be at this phone number: I want a telephone hearing. I and my witnesses and anyone helping me will be at the following (check one): Administrative Entity (AE) County program ODP I want a face-to-face hearing. I and my witnesses and anyone helping me will be in the hearing room with the judge and AE/county program/ODP staff. I want a face-to-face hearing. I and my witnesses and anyone helping me will be in the hearing room with the judge. The AE/county program/ODP staff will be on the phone. For the hearing: Please check if you need special help because of a hearing impairment or disability. Describe: Please check if you need an interpreter. There will be no cost to you. What language? Signatures: APPELLANT (REQUIRED):DATE: WITNESS (IF APPELLANT MAKES A MARK):WITNESS IF APPELLANT MAKES A MARK): SURROGATE (IF APPLICABLE):DATE: ONCE THE AE/COUNTY PROGRAM/ODP HAS RECEIVED THIS APPEAL, THEY WILL FORWARD IT TO THE APPROPRIATE REGIONAL OFFICE OF THE BUREAU OF HEARINGS AND APPEALS AS LISTED AT: www.dhs.pa.gov/learnaboutdhs/dhsorganization/officeofadministration/bureauofhearingsandappeals/index.htm I REQUEST THIS APPEAL BASED ON THE FOLLOWING ACTIONS (YOU MAY ATTACH MORE PAGES IF NEEDED): I REQUEST THE FOLLOWING REMEDIES TO RESOLVE THIS APPEAL (EXPLAIN): NAME OF APPELLANT’S SURROGATE (IF APPLICABLE): SURROGATE’S MAILING ADDRESS (IF APPLICABLE): SURROGATE’S DAY TELEPHONE NUMBER:SURROGATE’S RELATIONSHIP TO APPELLANT: OFFICE OF DEVELOPMENTAL PROGRAMS INTELLECTUAL DISABILITY/AUTISM WAIVERS, TARGETED SUPPORT MANAGEMENT, OR INTERMEDIATE CARE FACILITIES FAIR HEARING REQUEST FORM