These regulations govern the administrative process to be used to ensure that the rights of residents residing in the Behavioral Health Administration facilities are protected. Although the residents and the legal assistance providers ultimately shall decide whether to invoke the Resident Grievance System, it is the intent that the Resident Grievance System provide a fair, efficient, and complete mechanism for receiving, investigating, and resolving resident complaints, including rights issues, in a timely manner. In this chapter, the following terms have the meanings indicated. Terms Defined. “Central Review Committee” means the Maryland Department of Health (MDH) staff or their respective designees in the following positions: The Director of the Behavioral Health Administration; The clinical director of the Behavioral Health Administration; and The Director of the Resident Grievance System. “Chief executive officer (CEO)” means the individual appointed by the Director of the Behavioral Health Administration to act on the Director’s behalf in the overall management of a Behavioral Health Administration facility. “Coe consent decree” means the legally binding consent decree in Coe v. Hughes ordered by the United States District Court for Maryland which sets forth the legal rights of Mental Hygiene Administration facility residents with respect to the provision of legal and other related services by the legal assistance provider and the rights advisor. “Department (MDH)” means the Maryland Department of Health. “Director of Resident Grievance System” means the individual designated by the Deputy Secretary of Public Health Services to supervise the rights advisors and to perform the duties required to implement the Resident Grievance System. “Facility” means an inpatient or residential institution that is owned or directly operated by the Behavioral Health Administration. “Grievance” means a written or oral statement, as authorized in Regulation .05B of this chapter, alleging that a: Resident's rights have been unfairly limited or violated or are likely to be violated in the immediate future; Resident has been abused, neglected, or mistreated; or Facility has acted in an illegal or improper manner with respect to a resident or a group of residents. “Grievant” means a resident on whose behalf a grievance is filed, whether initiated by the resident, an employee of a facility, a family member of the resident, or an interested person. “Legal assistance provider (LAP)” means the lawyers and legally trained individuals who work under the lawyers' supervision who are responsible for providing legal services in accordance with the Coe consent decree. “Resident” means an individual who resides in a Behavioral Health Administration inpatient or residential facility or who was released or discharged from the facility within the past 90 days. “Resident Grievance System (RGS)” means the accessible administrative mechanism designed to protect a resident's rights through the investigation, processing, and resolution of grievances and implementation of the resolution. “Residents' rights committee” means a committee composed of at least nine members who are representative of: Facility staff; Residents, former residents, and residents' family members; and Advocacy groups. “Rights advisor” means an individual assigned as a resident advocate to implement the RGS. “Rights issue” means an alleged violation of a resident's rights guaranteed by federal and State constitutions, statutes, regulations, common law, or policies of the Maryland Department of Health and the facility. “Unit director” means an individual who has administrative authority within an organizational component of a facility. “Working day” means every day excluding Saturdays, Sundays, and holidays on which State offices are closed. When invoked, and when the process provides a fair, efficient, and complete remedy for allegations of rights violations, a grievant, when involved, the grievant's LAP, and the facility shall follow the four-stage administrative procedure outlined in this chapter. Through a timely process of systematic and orderly stages as outlined in this chapter, all those involved in the RGS process shall give grievances a fair consideration. To ensure that the rights of residents in the Behavioral Health Administration facilities are fully protected and that allegations of rights violations are investigated and resolved, the Director of the RGS shall provide an accessible internal system. The rights advisor shall investigate grievances: Promptly, impartially, and with the least disruption to the grievant's treatment plan; and Without abridging the right of a grievant to have the grievance process transpire within the required time frames or be completed within 65 working days. Except in accordance with the provisions outlined in Regulations .06—.10 of this chapter, and except to the extent necessary to conduct an investigation, report on the results of the investigation, and resolve the grievance, the individuals involved in the investigation of a grievance shall keep confidential the information gathered or disclosed during the course of the investigation. If a LAP is involved, the rights advisor shall provide to the LAP reports on the status of the grievances processed, the administrative decisions of the RGS at each stage, and the remaining RGS stages scheduled or to be scheduled. The Department may not subject an individual to discipline, harassment, or retribution for filing a grievance, pursuing a remedy for a grievance or, in cases when a grievance is substantiated, obtaining corrective action through the RGS. A resident who has concerns, including grievances, may request resolution from: The treatment team; or If the resident chooses not to involve the treatment team, the RGS. Except as provided in §J of this regulation, a grievant may terminate a grievance through the RGS at any time, either orally or in writing. If the termination is oral, the rights advisor shall document the oral termination of a grievance in the record of the grievance that is maintained by the rights advisor. If a grievant seeks to terminate a grievance that alleges abuse or serious harm or the potential for abuse or serious harm, the rights advisor shall notify the CEO and the Director of the RGS, either of whom may determine whether the investigation may continue. Within the time periods specified in Regulations .06—.09 of this chapter, the rights advisor shall file, investigate, and review a grievance, render a decision, and notify the grievant. In cases in which grievances alleging abuse have been substantiated, the facility shall take corrective action immediately. If time periods for stages lapse and extensions are denied, the rights advisor shall proceed with the next stage of the grievance. Those involved in the RGS process shall ensure that they complete the process within 65 working days. The rights advisor shall: Investigate all complaints in a professionally appropriate manner; Attempt to resolve grievances fairly and thoroughly; Prepare written reports for each grievance investigated; Maintain the RGS reports; Attempt to identify residents who may benefit from services offered by the LAP and: Refer the residents identified to the LAP; and Advise the LAP of the referrals; Investigate abuse allegations, even though the State police and the facility also may be conducting an investigation of the same allegations; Monitor any corrective action used to resolve grievances, and: Notify the CEO if corrective action has not been taken; and If corrective action has not been taken by the CEO within a reasonable period of time, notify the RGS Director; When a rights advisor discusses a grievance with a grievant, inform the grievant that, if the grievant requests, the rights advisor is available to attend and advocate for the grievant before the Behavioral Health Administration committees, boards, and tribunals; Inform the grievant of the right to appeal a decision during any stage of the grievance process, and if a grievant wishes to appeal: Upon request, file an appeal on behalf of the grievant; Advise the grievant that the resident may be represented by a LAP following the completion of stage 2 of the grievance procedure; and With the grievant's consent, attend and advocate in the best possible manner for the grievant on appeal, except in cases when, as a result of the rights advisor's professional judgment, the grievant's case is determined to be frivolous; and In cases when, as a result of the rights advisor's professional judgment, the grievant's case is determined to be frivolous, forward the grievance to the Director of the RGS. The Director of the RGS shall: If the rights advisor for a facility is not available for 2 or more consecutive working days, designate an alternate rights advisor; Arrange for the provision of appropriate training to: The rights advisors; and Facility staff, regarding relevant legal documents, including Department policies and procedures, related to residents' rights; If a rights advisor informs the Director of the RGS that the CEO has not taken corrective action within a reasonable period of time, notify the Director of the Behavioral Health Administration, who shall ensure that grievance resolution, at any level, is implemented promptly; If a rights advisor informs the Director of the RGS that the rights advisor has determined that a grievant's grievance is frivolous, review the determination, and, following that review, if the Director of the RGS: Agrees with the rights advisor and a LAP is involved, forward the grievance to the LAP, who may request continuation of the RGS process; or Does not agree with the rights advisor, notify: The rights advisor to proceed with the grievance; and The LAP of the action taken; and Make appropriate arrangements to ensure that a rights advisor shall: Be independent to discharge responsibilities; As necessary to conduct an investigation, have the access to facility staff, the LAP, and others relevant to the investigation; and Have access to a resident's medical records: Excluding conditions outlined in Regulation .05C(2)(c) of this chapter, subject to the provisions in Health-General Article, §10-701(d), Annotated Code of Maryland, or any other applicable provisions of law; and Immediately, in cases of allegations of abuse or neglect of the resident. A facility shall provide for a direct and effective means of communication between the residents and the rights advisor, including but not limited to communication by telephone and in person. The following may present a grievance to a rights advisor: A resident; An employee of a facility; A resident's family member; A LAP; or An interested person. If the grievance is initiated orally, the rights advisor shall: Assist in completing a grievance form and, if possible, obtain the grievant's signature; and If a grievance is initiated on the resident's behalf: Contact the resident to determine if the resident wants the matter to be investigated; Counsel the resident about the resident's rights regarding the grievance procedure; and If the resident elects to proceed with the grievance, obtain the resident's written consent to investigate or, if the resident does not sign, document the rationale for not obtaining the resident's signature. Pursuant to §E of this regulation, a resident about whom a grievance is initiated may elect not to file a grievance or may withdraw a grievance before disclosure of identity of the resident is made, if the resident notifies the rights advisor of the withdrawal or election not to file. If a resident elects not to file a grievance or if the grievant has requested that a grievance be withdrawn or is unable or unwilling to respond, the rights advisor shall proceed with the investigation if the: Rights advisor believes that the: Situation has resulted or may result in serious harm to the grievant or other residents; Complaint appears to have substantial merit and requires further investigation; Grievance highlights issues which may affect a substantial number of other residents; or Director of the RGS grants approval to proceed. The rights advisor shall keep the identity of the grievant confidential except when: Confidentiality interferes with investigation or resolution of the grievance; or Good cause requires disclosure of the grievant's identity. If the rights advisor determines that disclosure of the identity of the grievant is necessary according to the provisions of §F of this regulation, the rights advisor shall: Inform the grievant of the disclosure; and Assure that disclosure be limited to that which is necessary to investigate, assess, and resolve the grievance. A facility employee shall report immediately to the CEO and the rights advisor all physical or sexual abuse as defined in Health-General Article, §10-705(a), Annotated Code of Maryland. A facility employee shall file a grievance on behalf of a resident when, in that employee's reasonable judgment, there exist instances of rights violations, mental, physical, or sexual abuse, neglect or mistreatment, or instances when the facility has acted in an illegal or improper manner with respect to a resident or a group of residents. If requested by a resident, a facility employee shall: Notify the rights advisor immediately of the request; or If the rights advisor is not immediately available: Leave a written or a tape-recorded message concerning the request; and Contact the Director of the RGS for issues which require an immediate response. Except for good cause, the rights advisor shall process grievances in the order received, if first priority is given to cases alleging: Abuse; Neglect; or Mistreatment. If a grievance alleges abuse: The rights advisor shall investigate; The CEO of the facility shall refer the grievance to the Maryland State Police or the appropriate law enforcement agency for investigation; and For residents up to 18 years old, the CEO shall refer the grievance to the local department of social services. In addition to the requirements outlined in §L of this regulation, the CEO may: Conduct an investigation of the alleged abuse case; and Refer the alleged abuse case to the treatment team. If grievances refer to the same incident: The rights advisor may treat the grievances as one issue; and For cases involving more than one grievant, the rights advisor shall send separate notices and copies of decisions and appeals of decisions to each grievant. If the rights advisor is the subject of the grievance, the rights advisor shall inform the grievant of the name, mailing address, and telephone number of the Director of the RGS who shall: Appoint a substitute rights advisor for the purpose of that grievance; and Notify the CEO of the substitute appointment. The LAP may conduct interviews with residents. When the LAP refers a case that results in a grievance or is asked by the grievant for representation, the LAP: Shall inform the grievant that the LAP may not represent the grievant in the RGS process until stage 2 of the grievance procedure has been completed; May represent a grievant pursuant to the requirements and limitations outlined in this chapter; and Shall receive reports from the rights advisor while the investigation is in progress and at the conclusion of each stage. For a grievance that is initiated after the effective date of this chapter, and upon request by the grievant, the rights advisor shall provide the grievant or, if involved, the LAP, with the documents that may be considered in making a decision on the grievance. Rights Advisor's Investigation and Mediation. The rights advisor shall respond to the grievance by meeting with: The grievant; The individual filing the grievance, if other than the resident; The grievant's LAP, if involved; and If applicable, any witness to the incident. Except for good cause, the rights advisor shall notify the grievant before reviewing the grievant's medical record. The rights advisor shall: Determine an appropriate course of action for processing the grievance, which may include, but is not limited to: Interviews in person or by telephone; Requests for documents and correspondence; Notification to the grievant regarding the facility's clinical review panel option if the grievance relates to a grievant's refusal to take medication prescribed for treatment of a mental disorder; and Classification of alleged rights violations in accordance with guidelines developed by the Director of the RGS; Keep the grievant informed of all steps taken to resolve the grievance; and Render a decision on a grievance within 10 working days of receipt of the grievance. The rights advisor shall make every effort to negotiate, mediate, and resolve the grievance fairly at this stage. If action is taken and the grievant is satisfied, the case is closed. If, as a result of the rights advisor's professional judgment, a grievance is determined to be frivolous, the rights advisor shall inform the grievant of that finding and of the grievant's right to appeal and the appeal procedure. If a grievance with merit is not resolved to the grievant's satisfaction, and the grievant wishes to appeal, the rights advisor shall forward a copy of the grievance, including a description of the issues and recommendations, to the unit director as outlined in Regulation .07 of this chapter. If, in the rights advisor's professional judgment, the nature of the grievance is not frivolous, but the grievance either cannot be substantiated or appears to have no merit, the rights advisor shall: Inform the grievant of the decision and the right to appeal; With the consent of the grievant, assist the grievant in filing an appeal; and Document the findings and forward a copy of the report describing the findings to: The Director of the RGS; The unit director; The grievant; If involved, the grievant's LAP; and The CEO. If a grievance with merit is resolved to the grievant's satisfaction, the rights advisor shall forward a copy of the decision to: The unit director; The grievant; The CEO; and If involved, the grievant's LAP. If the rights advisor's initial investigation concludes there is substantial risk of serious harm, or there is the potential for serious harm to a grievant if the alleged violation is not remedied promptly: The rights advisor shall inform immediately the: Unit director or the unit director's designee; CEO or the CEO's designee; Director of the RGS; and Director of the Behavioral Health Administration or the Behavioral Health Administration Director’s designee; and The unit director, the CEO, or their respective designees shall: Perform an investigation; and If the grievance is substantiated, develop and implement a solution within 24 hours of receiving the rights advisor's report. The unit director shall: Review the rights advisor's report; Discuss the matter with any individual involved; and Within 5 working days of receipt of the report, decide whether to: Accept the rights advisor's report, completely or in part with respect to the facts as found; or Modify or reject the recommendations made by the rights advisor. The unit director shall write and forward a decision to the rights advisor, who shall forward copies to the grievant, the CEO and, if involved, the grievant's LAP. If the unit director concludes that a grievance has been substantiated and requires remedial action, the unit director immediately shall: Notify the CEO and, if indicated, the clinical director; and Provide a remedy, which may include, but is not limited to: Directing a change in practice; or Seeking approval for changes in policy. If the grievant is: Satisfied with the action taken by the unit director, the grievance ends at this stage; or Dissatisfied with the action taken by the unit director and wishes to pursue the grievance, the rights advisor shall: If the grievant requests the review, request a review by the residents' rights committee, notifying the CEO of the request for the review; and Subsequently request a review by the CEO. If the grievant requests a review by the residents' rights committee before the CEO's review, the residents' rights committee shall: Meet within 15 working days of receipt of the grievance; Review the information obtained by the rights advisor; Review information presented by the grievant; Review the decision of the unit director; If involved, review information presented by the LAP; Review all relevant data pertaining to the grievance; and Forward written recommendations to the CEO. A review by the residents' rights committee: May include further investigation into the circumstances of the grievance; May not be limited to consideration of the record of the grievance from prior proceedings; and At the request of the grievant, may be waived. The rights advisor: Shall notify all interested persons, including involved staff, the grievant, and, if involved, the grievant's LAP of the time and location of the residents' rights committee meetings; Shall present information obtained at prior proceedings; Shall inform the grievant and, if involved, the grievant's LAP of all recommendations made by the residents' rights committee; and May not be present during the residents' rights committee deliberations. All interested persons including involved staff, the grievant, and, if involved, the grievant's LAP: Shall be invited to attend the residents' rights committee meeting to present information relating to the grievance; and May not be present during residents' rights committee deliberations. Upon receipt of the residents' rights committee's recommendations, the CEO or the CEO's designee shall: Determine what action, if any, is to be taken; and Notify the residents' rights committee in writing of any action taken. Completion of time periods specified within stage 3 are dependent upon the following: If the LAP is involved, the CEO or the CEO's designee: Shall respond within 15 working days to the residents' rights committee's recommendations; and May request an oral presentation from the LAP, if the LAP submits a written summary of the presentation before the meeting; If the LAP is not involved, the CEO or the CEO's designee shall respond within 5 working days to the residents' rights committee's recommendations. The CEO or the CEO's designee shall write and forward a decision to the rights advisor. The rights advisor shall forward copies of the decision of the CEO or the CEO's designee to: The grievant; If involved, the grievant's LAP; The Director of the RGS; If involved, the residents' rights committee; and The unit director. If the CEO or the CEO's designee substantiates the grievance, the CEO or the CEO's designee shall identify in the decision: The corrective action to provide a complete remedy to the grievant for the violation; and Time frames, consistent with this chapter, for implementing the corrective action. If the grievant is: Satisfied with the action taken by the CEO or the CEO's designee, the grievance ends at this stage; or Dissatisfied with the decision of the CEO or the CEO's designee, the rights advisor shall inform the grievant of the appeal process to the Central Review Committee. If requested by the grievant, the rights advisor shall file an appeal to the Central Review Committee within 5 working days after receipt of the decision by the CEO or the CEO's designee. The Central Review Committee: Shall meet within 10 working days of receipt of an appeal; Shall review all prior information concerning the grievance; May perform an investigation of the grievance which shall be accomplished within 10 additional working days; and At the request of the grievant, may sequester those who are presenting information to the Committee. For a grievance that is initiated after the effective date of this chapter, if a LAP is representing a grievant, the Central Review Committee, at the request of the grievant, shall: Allow the LAP to be present for argument or while evidence is presented by any other person; and Hear a presentation from the LAP before making a decision, if the LAP submits a written summary of the presentation before the meeting. The Central Review Committee shall write and forward a decision to: The CEO of the facility; The grievant; If involved, the grievant's LAP; The rights advisor; and If involved, the residents' rights committee. If the grievant is: Satisfied with the decision of the Central Review Committee, the case is closed; or Dissatisfied with the decision of the Central Review Committee, the rights advisor shall promptly inform the grievant of additional relevant legal services which the grievant may contact. Notification of Status. Within 20 working days, the Central Review Committee, through the Director of the RGS, shall request from the facility CEO a written report of the status of the implementation of the recommendations made during the grievance process. Until the decision is fully implemented, the CEO shall make periodic reports to the Central Review Committee through the RGS Director every 30 days. The Director of the RGS shall ensure that RGS reports: May not be released to other persons except as provided within this chapter; and Identify the alleged violations, the decision, and the remedy. With the identity of those involved in the grievance deleted, the Director of the RGS shall ensure that the decisions on all 4th-stage grievances be: Included in the annual report of the RGS Director; Made available for public review at the Department's Resident Grievance System Office; Sent to other rights advisors; Sent to the Deputy Secretary for Public Health Services, the LAP, and members of the Coe Board of Review; and Sent to the Behavioral Health Administration facility CEOs. With the identity of those involved in the grievance deleted, all decisions with Statewide impact, as determined by the Director of the RGS, shall be: Circulated to those enumerated in §B of this regulation; and Sent to all Behavioral Health Administration personnel involved in or affected by the decision. RGS reports and other documents concerning a grievance may not be placed in the resident's medical record unless otherwise required by law. A facility may not place the reports of the RGS in an employee's personnel file. The rights advisor may not be a witness in an agency proceeding against an employee, unless the rights advisor is a first-hand witness to events being reviewed. If allegations are made against an employee: The rights advisor shall immediately give the employee and the employee's Department head a copy of the information relevant to the allegation; and Within 5 working days of receipt of the information, the employee shall respond, in writing, to the rights advisor assigned to that facility. Notice of Grievance Decision. The rights advisor shall give written notice of a grievance decision involving an employee to the director of the division of personnel and the employee's Department head at the facility. The personnel director shall forward a copy of the notice in §D(1) of this regulation to the employee, the employee's supervisor, and the employee's Department head. Nothing shall prevent a facility from taking appropriate action against an employee for events which come to the attention of the facility through the RGS. The RGS may not affect employee rights as mandated by State Personnel and Pensions Article, Annotated Code of Maryland. This chapter does not modify the resident's: Legal rights; Access to seek private legal counsel from attorneys not receiving funding for legal assistance from the Maryland Department of Health; or Access to a court. The Resident Grievance System is not governed by the contested case provisions of the Administrative Procedure Act, State Government Article, Title 10, Annotated Code of Maryland. Health-General Article, §7.5-201, 7.5-205(D), 10-701, Annotated Code of Maryland Effective date: March 28, 1994 (21:6 Md. R. 467) Regulation .01 amended effective October 23, 2017 (44:21 Md. R. 983) Regulation .02B amended effective January 26, 1998 (25:2 Md. R. 76); October 23, 2017 (44:21 Md. R. 983) Regulation .03C amended effective October 23, 2017 (44:21 Md. R. 983) Regulation .04 amended effective October 23, 2017 (44:21 Md. R. 983) Regulation .06H amended effective October 23, 2017 (44:21 Md. R. 983) Regulation .10B, C amended effective October 23, 2017 (44:21 Md. R. 983)