020.050 Public Complaints Related to the Delivery of Section Programs

Procedure Number	020.050
Effective Date	September, 1996
Revision Date	July 1, 2015
Subject Matter Expert	Section Chief of Staff
Approval Authority	TB/HIV/STD Section Director
Signed by	Felipe Rocha, M.S.S.W.

1.0 Purpose

The purpose of this policy/procedure is to provide the TB/HIV/STD Section (Section) with a method of resolving client complaints about the delivery of services. It is the policy of the Section to effectively and promptly address all client complaints.

This policy is not intended to address allegations filed against the Section or its Branches regarding staff actions or to be used to request a change or modification of a decision, policy or procedure. This policy should also not be used for purposes of filing a privacy complaint. If a complaint involves a violation of privacy, these complaints will be handled by the agency privacy officer and/or the U.S. Health and Human Services Office of Civil Rights. (See section 5.4 of this Policy for further information.)
 

2.0 Authority

Title II of the Ryan White Care Act Amendments of 2000.
 

3.0 Definitions/Acronyms

Complaint – an allegation of wrongdoing, discrimination or an expression of dissatisfaction with services which may involve an immediate and serious threat to a client, misuse of resources by providers, or denial of services to clients by an entity.

Contractor/Provider – a person, agency or facility approved by DSHS that has entered into a contract with DSHS to deliver state or federal TB, HIV or STD programs to clients.

Immediate and/or serious threat – a situation posing a high possibility for serious injury to a client if the client is not protected from harm or the threat is not removed.

Investigation – the process of gathering information sufficient to allow a decision to be made regarding the validity of the complaint, and/or determining referrals that should be made to ensure the complaint is handled by the appropriate entity.

Services – program activities offered by a provider on behalf of the DSHS TB/HIV/STD Section and its Branches.

TB/HIV/STD Section – a Section in the DSHS Disease Control and Prevention Services Division which includes: the HIV/STD Prevention and Care Branch, the TB/HIV/STD Epidemiology and Surveillance Branch, the TB and Refugee Health Services Branch, and the Pharmacy Branch.
 

4.0 Persons Affected

• All TB/HIV/STD Section employees
• Section Branch Managers
• Section Chief of Staff
• DSHS Contractors
• DSHS Regional staff
   

5.0 Procedures

5.1 Contractor Responsibility

Current contractors and applicants seeking contractual status with DSHS are required to have a procedure in place to resolve civil rights client complaints consistent with federal and state regulations in order to receive DSHS funds.
 

5.2 Processing a Complaint

Any individual wishing to file a complaint can do so in writing, in person, by email, fax or telephone. Complaints should include all details regarding the problem and a desired resolution or outcome. While not required, clients submitting complaints via telephone are encouraged to follow-up in writing in order to minimize the miscommunication of client concerns.

If a complaint is received via email and it contains personal health information, Section staff should follow HIV/STD Section Security Procedure 2016.01, HIV/STD Section Confidential Information Security Procedures. Email, whether encrypted or non-encrypted may not be used to transmit confidential information. Transmitting attachments containing confidential information via email is also prohibited.
 

5.2.1 Complaints Received Through the HIV Care Services Group

Complaints received through the HIV Care Services Group will initially be assessed by the Group’s Manager or the Group’s Team Lead. The assessment will determine whether the complaint can be more quickly and appropriately resolved through the local Administrative Agency (AA) processes or if it should be handled using the Complaint Triage Committee (see Section 5.2.2). If the AA is the more appropriate and timely organization to conduct the investigation, the Group Manager or Team Lead will request that the AA conduct the investigation.

The Group Manager or Team Lead will track the progress of the investigation through the AA’s final findings. If the AA’s final findings are unsatisfactory, the Group Manager or Team Lead will refer the complaint to the Complaint Triage Committee.

Any complaint received by the Group that involves an immediate and/or serious threat shall immediately be referred to the Complaint Triage Committee.

The Group manager or Team Lead will be responsible for collecting appropriate information about these complaints, tracking their successful resolution and keeping all confidential files related to these investigations.
 

5.2.2 Complaint Triage Committee

All complaints are assigned through the Complaint Triage Committee (the Committee) except for HIV Care Services Group complaints specified in Section 5.2.1. The Committee is responsible for:

• Determining if a situation poses an immediate or serious threat;
• Reviewing complaints and determining the issue(s) to be addressed;
• Assigning investigation/resolution responsibility to appropriate DSHS staff, local agency or region;
• Receiving reports on outstanding complaints and monitoring timely resolution; and
• Approving complaint resolutions and authorizing staff to close complaint files.

The Complaint Triage Committee shall consist of the following staff positions:

• HIV/STD Prevention and Care Branch Manager
• TB/HIV/STD Epidemiology and Surveillance Branch Manager
• TB and Refugee Health Services Branch Manager
• The Pharmacy Branch Manager
   

5.2.3 DSHS Staff Procedures

Any regional or Section staff receiving a complaint must record all the details on the Complaint Intake Form, 020-050A. The staff receiving the complaint shall immediately take the complaint to a Triage Committee Member (TCM) who will:

1. Determine whether a complaint involves an immediate and/or serious threat to a client. If the complaint is received by a Regional office, regional staff will make the determination. Investigations of complaints posing an immediate and/or serious threat are given the highest priority and all allegations of abuse, neglect or other immediate health threats require immediate action;
2. Notify other Triage Committee members;
3. Assign the complaint to the appropriate Section/Branch employee or Regional employee;
4. Assign a due date;
5. Take the original intake form to the Section Chief of Staff who will:
   1. Assign a tracking number
   2. Send an acknowledgement letter to the complainant (unless the complaint is received from an anonymous source). The letter acknowledges receipt of the complaint, indicates who to contact if there are any questions regarding the ongoing investigation, includes the complaint tracking number for reference, and an approximate date when a resolution can be expected (if available).
   3. Ensure the assignee has a copy of the complaint and all supporting documentation; and
   4. Place copies of all documents into a pending file for tracking.

NOTE: Regional staff should immediately fax intake forms to a Triage Committee Member, ensuring that any confidential information in the complaint follow the appropriate security procedures below which are from HIV/STD Section Procedure 2016.01. Regional staff should follow-up with a phone call to ensure the complaint is acted upon in a timely manner.

From HIV/STD Section Procedure 2016.01, HIV/STD Section Confidential Information Security Procedures, Section 5.2, Faxing:

1. Confidential information sent using a facsimile must be faxed under a cover sheet. The cover sheet must not contain the words HIV, AIDS, or STD anywhere on it.
2. The information to be faxed must be
   1. de-identified (client's name and all other identifying information removed) OR
   2. the identifying information must be sent in a separate fax transmission only after the sender has confirmed receipt of the first fax with the receiver; OR
   3. All TB/HIV/STD related information has been removed or converted to a code
   4. Anyone sending a fax must confirm that the information faxed was received by the intended recipient
3. Fax machines used to send or receive confidential information must be located in a secure area.
4. Programs are encouraged to use separate fax machines instead of multifunctional machines which include faxing capabilities.

Email, whether encrypted or non-encrypted, may not be used to transmit confidential information. Transmitting attachments containing confidential information via email is also prohibited.
 

5.3 Complaints Involving Violations of Privacy or Discrimination

If a complaint involves a violation of privacy, the assignee must inform the Section Security Officer and proceed as instructed.

If a complaint alleges discrimination, the assignee should inform the Health and Human Services Commission (HHSC) Office of Civil Rights and proceed as instructed (hhs.texas.gov/about-hhs/your-rights/civil-rights-office).
 

5.4 Investigating the Complaint

• Section/Branch or Regional employees investigate all complaints (except for complaints received by the HIV Care Services Group as outlined in Section 5.2.1 of this Procedure).
• If a complaint lacks sufficient information to conduct an investigation, additional information should be requested from the complainant.
• Requests for additional information for complaints deemed to be an immediate and/or serious threat to the client should be requested by telephone or in person.
• A complaint may be closed if the complainant does not respond to this request within ten business days and sufficient information is not available from another source to enable a determination.
• When the complaint involves personnel outside the jurisdiction of the Branches, the assignee may investigate and/or refer the complaint to the appropriate authority.
• Resolution of complaints should be made at the lowest possible organizational level.
• Unless there is a serious and/or immediate threat to the client, complainants who have not pursued local resolution prior to contacting the Section will be referred back to the most appropriate level of the local organization. Investigation of the complaint will be conducted under the local complaint process of the contractor.
• The assignee should investigate as appropriate and/or maintain contact with the Region, the service provider, the HIPAA officer, or other offices/agencies actively involved in investigating and resolving the complaint.
• A complaint remains open until notified by the contractor that the investigation has been completed and an appropriate resolution has been implemented.
   

5.5 Determine findings/resolution

After the investigation is complete, the assignee takes the results of their investigation to the Complaint Triage Committee for review and approval of final disposition. One or more of the following actions should be recommended and documented on the Complaint Intake Form:

1. The assignee determines the allegation was non-verifiable or invalid and dismisses the complaint.
2. The assignee determines the allegation was substantiated and corrective action is warranted. Corrective action may take one or more of the following forms:
   1. A written warning issued to the facility or individual(s) involved.
   2. A written plan of corrective action to be submitted to the Section by the facility or individual(s) involved. The corrective action plan will indicate a time frame in which the corrective actions will be completed.
   3. Any of the sanctions described in HIV/STD Section Policy 540.001, "Sanctions Imposed Upon a Contractor for Non-Compliance with Contracts Involving State/Federal Funds."
3. The investigation of allegations related to licensed social services or health care professionals may result in the referral of the information to the appropriate licensing and/or regulatory authority for further action.
4. The assignee in consultation with the Complaint Triage Committee determines if the complaint should be addressed by a DSHS contractor, subcontractor or other entity. The Committee will make appropriate referrals and, when necessary, monitor the results of the referral.
5. Complaints that potentially involve unlawful activity must be reported to the Texas Health and Human Services Commission Office of the Inspector General.
6. The final report of an investigation involving discrimination will be sent to the HHSC Office of Civil Rights for review prior to release of the report.
    

5.6 Notify Appropriate Individual(s) of Findings/Resolution

When appropriate action has been determined, the resolution is approved by the Committee and documented in writing. Written notification of findings and recommended action are sent to appropriate individuals as determined by the Committee. Any letters regarding the findings and resolution may be signed by the assignee. Copies of documentation are provided to appropriate Regional staff.
 

5.7 Closing the Complaint

The assignee writes a summary to document complex and/or detailed investigation information and signs the intake form to indicate the complaint has been closed. All supporting documents are filed with the complaint and are forwarded to the Committee. The Committee signs and forwards to the Section Chief of Staff for closing of complaint and filing. The Chief of Staff will also be responsible for preparing appropriate record retention schedules and disposition of complaint files once the required retention period is reached.
 

5.8 Resolution Time Frames

The following resolution time frames should be followed:

Type of Complaint	Recommended time frame
Immediate and/or serious threat to a client	Initial investigation within 24 hours; resolution as soon as possible.
Other complaints	Initial investigation within ten days; resolution within 60 days.
Incomplete information resulting in requests for additional, verifiable information	Complainant must comply within 10 days; resolution within 30 days after receipt of additional information or as soon as possible if the complaint poses immediate or serious threat to a client.

If the investigation cannot be completed within the appropriate time frame, the assignee should notify the complainant in writing. A copy should be sent to the Section Chief of Staff.

Complaints handled by Regional offices must be resolved within the same time period as those handled by the Section.
 

5.9 Confidentiality and Anonymous Complaints

The identity of the complainant may not be considered exempt from the Public Information Act (Texas Government code, §552). Section staff should ensure the complainant understands names and other identifying information will not be voluntarily released, but if the Office of General Counsel advises release of certain information upon receipt of an Open Records request, the Unit will be required by law to release the information.

Complaints filed by an individual who does not wish to reveal his/her name or who does not want his/her name used during an investigation will be investigated to the fullest extent possible, based on the information submitted.

To ensure a breach of confidentiality does not occur, transmission of confidential information via fax, email or other methods should be de-identified with the client’s name removed. [See HIV/STD Section Procedure 2016.01, HIV/STD Section Confidential Information Security Procedures] Email, whether encrypted or non-encrypted may not be used to transmit confidential information. Transmitting attachments containing confidential information via email is also prohibited.
 

5.10 Multiple Complaints from Same Person

Multiple complaints received from the same individual about the same organization or situations are tracked using the same number for each incident. Each incident should be addressed in an appropriate manner and the action taken should be documented and routed through the Section Chief of Staff to ensure the completeness of records.
 

6.0 Revision History

Date	Action	Section
9/1/2017	Changed "TB/HIV/STD Unit" to "TB/HIV/STD Section" to reflect new program designation	-
7/1/2015	Revisions made to update Unit and Branch names and new procedures for processing complaints.	All
10/7/2014	Converted format (Word to HTML)	-
7/17/2006	Substantial revisions, considered a new policy. Combines previous policy 020.050 and procedure BUR-BCO-211.001.	All