Stakeholder Problem Subject: Client Rights, PQI Resolution/Complaint Process

COA: CR 3, PQI Applies to: Entire Organization Effective: June 27, 2007 Revision effective: May 1, 2012 Reviewed: April 27, 2012

Purpose:
Catholic Charities core values include respect for all individuals, compassionate service, and excellence and integrity in all practice. The organization values input from its stakeholders, and is committed to providing opportunities for any stakeholder to express his or her concern about agency decisions and or practice. The purpose of this policy is to define the formal mechanism through which clients and other stakeholders can express and resolve grievances.

Policy:
Catholic Charities personnel will provide fair and equitable treatment to all clients and other stakeholders. A formal problem resolution/complaint process available to all clients and other stakeholders will be established and maintained. Clients and other stakeholders will be informed of their rights and responsibilities, including their right to express dissatisfaction with service and/or agency decisions through the formal problem resolution/complaint (grievance) process. Catholic Charities personnel will be attentive and respectful to any complaint registered by a stakeholder and will prohibit affiliated personnel from discouraging, intimidating, or seeking retribution against stakeholders who seek to exercise their rights to file a complaint.

Scope:
This policy and corresponding procedures apply to all stakeholders and to all programs/work groups of Catholic Charities.

Definitions:
Complaint--As defined by the Council on Accreditation, an expression of verbal or written dissatisfaction that can include, but is not limited to, services, manner of treatment, outcomes, or experiences. For employees or volunteers, dissatisfaction can include personnel matters such as supervision, evaluations, promotions or demotions, the work environment, and overall treatment. The term is synonymously used with GRIEVANCE. (http://www.coastandards.org/glossary.php) Conditions for expressing a complaint are defined as dissatisfaction with decisions concerning the stakeholder and/or service provided to the stakeholder. Problem Resolution Liaison--A designated staff member who is a neutral third party representative of Quality Assurance. First level staff personThe individual against whom the complaint is made, if a specific person is named in the complaint. Due to the nature of services provided, this will most often be a person in a non-management position, or a program/work group manager. If a specific person is not named, the complaint should be considered as being made against the most relevant program/work group.

Responder (# Level Responder)A management level (program manager, director, vice president) staff person who is the next level manager in the organizational structure, usually determined based on the program/work group most directly related to the complaint. The organizational position of the responder at each level may vary with each complaint, depending on who is identified as the first level staff person when the complaint is filed. Stakeholder--Anyone who has a vested interest in the organization. This includes: 1. 2. 3. 4. 5. 6. 7. persons and families served; employees, volunteers, and consultants; members of governing and advisory bodies; donors, funders and contractors; governmental and other regulatory bodies; community partners; and community advocates.

Procedures: (Notes: Employees of Catholic Charities will follow the Employee Problem Resolution
and Grievance Process.) 1. At the beginning of service delivery, all stakeholders will be informed in writing of the right to make a complaint, the avenues and process by which to do so, and the way in which the organization will respond. All stakeholders should be informed that they may initiate the process with the designated problem resolution liaison if they are not comfortable addressing the issue with the first level staff person or the corresponding manager. 2. Complaints may be made in person, by telephone or in writing. If possible, initial complaints should be made to the first level staff member involved in the complaint, that persons immediate supervisor, or to the problem resolution liaison. However, if the stakeholder cannot be put in touch with one of those persons immediately, the staff member receiving the initial complaint initiates the problem resolution process. In all cases, the formal problem resolution process begins with the recipient of the complaint completing, at minimum, Section A of Stakeholder Complaint Form 1027-24 (complaint form). a. If the employee receiving the complaint is not the first level staff person, or if the complaint is made against a program/work group, the employee offers to put the stakeholder in contact with the appropriate person (first level person, that persons immediate supervisor, or the problem resolutionliaison). If an appropriate person cannot be reached, the employee offers to initiate the problem resolution process by completing a Stakeholder Complaint Form 102724 on behalf of the stakeholder. The staff member receiving the complaint completes Section A on the Stakeholder Complaint Form 1027-24, advises the complainant of next steps in the process, and offers to provide the stakeholder with a copy of the problem resolution process brochure (Problem Resolution Process for Distribution to Stakeholders Form 1027-55). b. If the staff member receiving the complaint is not the first level staff person providing services or otherwise named in the complaint, the complaint form is forwarded to the designated first level staff person unless the complainant

requests to speak to a supervisor, in which case it is sent to the first level staff persons manager. If the complaint is about a program/work group, with no individual named, the complaint form is sent to the program/work group manager. FIRST LEVEL INTERVENTION The identified first level staff person attempts to resolve the complaint with the stakeholder as quickly as possible following receipt of the complaint (see timeframes outlined later in this document). The staff member will : review the complaint procedures with the stakeholder; clarify any issues for the stakeholder; seek to resolve the problem; and, complete Section B of the stakeholder complaint form. If the issue is resolved, the first level staff person: sends written notice of the problem resolution to the stakeholder; submits the complaint form to his/her next level manager for review and signature; sends the completed form (with next level manager signature) to the Vice President/Director of Quality Assurance to be filed for Performance and Quality Improvement analysis. Copies are placed in the stakeholders file and sent to the PQI Subcommittee designated in the PQI Plan for review. If the issue is not resolved at this level, the staff person: advises the stakeholder that the complaint will be forwarded to the next level manager for review; documents under additional actions to be taken that second level intervention is required; submits the complaint form to his/her next level manager manager for review and signature (Section B), and additional action (Section C). SECOND LEVEL INTERVENTION Once the appropriate next level manager (Second Level Responder) receives the complaint, (s)he: contacts and/or meets with the parties involved; reviews the complaint procedures with the stakeholder; clarifies any issues for the stakeholder; seeks to resolve the problem; and, completes Section C of the complaint form. If the issue is resolved, this manager: sends written notice of the problem resolution to the stakeholder; submits the complaint form to the next level manager for review and signature; sends the completed form (with next level manager signature) to the Vice President/Director of Quality Assurance to be filed for Performance and Quality Improvement analysis. Copies are placed in the stakeholders file and sent to the PQI Subcommittee designated in the PQI Plan for review.

If the issue is not resolved at this level, this manager: advises the stakeholder that the complaint will be forwarded to the next level manager for review; documents under additional actions to be taken that third level intervention is required; submits the complaint form to the next level manager for review and signature (Section C), and additional action (Section D); THIRD LEVEL INTERVENTION Once the appropriate next level manager (Third Level Responder) receives the complaint, (s)he: contacts and/or meets with the parties involved; reviews the complaint procedures with the stakeholder; clarifies any issues for the stakeholder; seeks to resolve the problem; and, completes Section D of the complaint form.

If the issue is resolved, this manager: sends written notice of the problem resolution to the stakeholder; submits the complaint form to the next level manager for review and signature; sends the completed form (with next level manager signature) to the Vice President/Director of Quality Assurance to be filed for Performance and Quality Improvement analysis. Copies are placed in the stakeholders file and sent to the PQI Subcommittee designated in the PQI Plan for review. If the issue is not resolved at this level, the manager: advises the stakeholder that the complaint will be forwarded to the next level manager for review; documents under additional actions to be taken that fourth level intervention* is required; submits the complaint form to the next level manager for review and signature (Section D), and additional action if necessary (Section E).
*NOTE: Under current organizational structure, if the first level staff person was a program/work group manager, the third level intervention staff person would be a Vice President. In this situation, if the issue is not resolved with the VP, and the stakeholder chooses to appeal, the VP will need to complete the Fourth Level intervention section as well as the Third Level intervention section. (This principle applies at any level in which the responder is a VP.)

FOURTH LEVEL INTERVENTION (Reminder: Under current organizational structure, if the first level staff person was a program/work group manager, the fourth level intervention would be the President/CEO. In this case, the VP who completed the third level intervention would complete the fourth level intervention information at the same time, and follow the instructions outlined in the Final Appeal section below.)

Once the appropriate next level manager (Fourth Level Responder) receives the complaint, (s)he: contacts and/or meets with the parties involved; reviews the complaint procedures with the stakeholder; clarifies any issues for the stakeholder; seeks to resolve the problem; and, completes Section E of the complaint form. If the issue is resolved, this manager: sends written notice of the problem resolution to the stakeholder; submits the complaint form to the next level manager for review and signature; sends the completed form (with next level manager signature) to the Vice President/Director of Quality Assurance to be filed for Performance and Quality Improvement analysis. Copies are placed in the stakeholders file and sent to the PQI Subcommittee designated in the PQI Plan for review. If the issue is not resolved at this level, the manager: advises the stakeholder of the final appeal process and asks the stakeholder if (s)he wishes to file an appeal to the President/CEO (see Final Appeal procedures below); completes Section E of the complaint form; forwards the complaint form to the President/CEO for review and signature and initiation of the appeal process.

FINAL APPEAL

If the client states (s)he wishes to appeal the decision by the Vice President, the Vice President: Prepares a Notice of Request for Final Appeal (Form 1011-89); Sends a copy of the Notice of Request for Final Appeal to the President/CEO along with a copy of the complaint form; Sends a copy of the Notice of Request for Final Appeal to the stakeholder. The President/CEO will contact and/or meet with the appropriate parties involved and will attempt to resolve the issue. The President/CEO will make a determination within 10 days of receipt of the request for final appeal. In cases that proceed to the President/CEO, the decision of the President/CEO is final.

The President/CEO then completes Section F Final Appeal. A copy of the complaint form is sent to the Vice President/Director of Quality Assurance to be filed for Performance and Quality Improvement analysis. Copies are placed in the stakeholders file and sent to the PQI Subcommittee designated in the PQI Plan for review.

TIME FRAMES Catholic Charities will acknowledge and document all complaints within 1 business day following receipt. During the complaint process, each intervening progressive level shall address their portion of the resolution process within two business days, resolving or

escalating the complaint within that time until the complaint is referred for final appeal. Except in cases that are referred for final appeal, the stakeholder will be informed in writing of the findings and recommendations within 10 (ten) business days. Determinations on complaints referred to the President/CEO for final appeal will be made within 10 business days of the date the President/CEO receives the complaint. Written notification of the final decision will be mailed to the client within two business days following the date the President/CEOs decision is made. THIRD PARTY REVIEW OF COMPLAINTS

The Vice President/Director of Quality Assurance will submit client complaints to the Chair of the Client Services Committee for aggregated review. All other Stakeholder complaints will be forwarded to the Chair of the Administration Committee for aggregated review. Once resolved, the stakeholder complaints are reviewed quarterly by the PQI Committee, with an aggregated report to the Board of Directors at least annually. As required, legal counsel will be sought to intervene in situations that are not successfully resolved through the complaint process. Catholic Charities will not in any way restrict, discourage, or interfere with stakeholder communication with an attorney, Human Resources, or with the commission for the purpose of filing a complaint. Those departments operating under contracts that include their own problem resolution/complaint processes must notify clients or other stakeholders of those options and provide them with current contact information. This includes programs/work groups employing licensed professionals. These organizations include, but are not limited to:

Texas Health and Human Services Commission Texas Department of Family Protection Services (TDFPS) Texas Department of State Health Services

Related Forms: Notice of Request for Final Appeal Problem Resolution Process for Distribution to Stakeholders Stakeholder Complaint Form Form 1011-89 Form 1027-55 Form 1027-24