Sec. 10.21.14.05. Procedures for Filing a Grievance

A. 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.

B. The following may present a grievance to a rights advisor:

(1) A resident;

(2) An employee of a facility;

(3) A resident's family member;

(4) A LAP; or

(5) An interested person.

C. If the grievance is initiated orally, the rights advisor shall:

(1) Assist in completing a grievance form and, if possible, obtain the grievant's signature; and

(2) If a grievance is initiated on the resident's behalf:

(a) Contact the resident to determine if the resident wants the matter to be investigated;

(b) Counsel the resident about the resident's rights regarding the grievance procedure; and

(c) 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.

D. 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.

E. If a resident elects not to file a grievance or if the grievant has requested that a grievance be withdrawn or is unable or unwilling to respond, the rights advisor shall proceed with the investigation if the:

(1) Rights advisor believes that the:

(a) Situation has resulted or may result in serious harm to the grievant or other residents;

(b) Complaint appears to have substantial merit and requires further investigation;

(c) Grievance highlights issues which may affect a substantial number of other residents; or

(2) Director of the RGS grants approval to proceed.

F. The rights advisor shall keep the identity of the grievant confidential except when:

(1) Confidentiality interferes with investigation or resolution of the grievance; or

(2) Good cause requires disclosure of the grievant's identity.

G. 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:

(1) Inform the grievant of the disclosure; and

(2) Assure that disclosure be limited to that which is necessary to investigate, assess, and resolve the grievance.

H. 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.

I. 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.

J. If requested by a resident, a facility employee shall:

(1) Notify the rights advisor immediately of the request; or

(2) If the rights advisor is not immediately available:

(a) Leave a written or a tape-recorded message concerning the request; and

(b) Contact the Director of the RGS for issues which require an immediate response.

K. Except for good cause, the rights advisor shall process grievances in the order received, if first priority is given to cases alleging:

(1) Abuse;

(2) Neglect; or

(3) Mistreatment.

L. If a grievance alleges abuse:

(1) The rights advisor shall investigate;

(2) The CEO of the facility shall refer the grievance to the Maryland State Police or the appropriate law enforcement agency for investigation; and

(3) For residents up to 18 years old, the CEO shall refer the grievance to the local department of social services.

M. In addition to the requirements outlined in §L of this regulation, the CEO may:

(1) Conduct an investigation of the alleged abuse case; and

(2) Refer the alleged abuse case to the treatment team.

N. If grievances refer to the same incident:

(1) The rights advisor may treat the grievances as one issue; and

(2) 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.

O. 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:

(1) Appoint a substitute rights advisor for the purpose of that grievance; and

(2) Notify the CEO of the substitute appointment.

P. 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:

(1) 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;

(2) May represent a grievant pursuant to the requirements and limitations outlined in this chapter; and

(3) Shall receive reports from the rights advisor while the investigation is in progress and at the conclusion of each stage.

Q. 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.