CLIENT RIGHTS AND CIVIL RIGHTS GRIEVANCE PROCESS Before

client rights and civil rights grievance process ================================================ before treatment is begun, luthera

CLIENT RIGHTS AND CIVIL RIGHTS GRIEVANCE PROCESS
================================================
Before treatment is begun, Lutheran Social Services (LSS) must inform
you of your rights as a client of LSS and how to use the agency’s
grievance process, as stated below. In addition to the LSS Grievance
Resolution Process, anyone receiving inpatient or community-based
services for mental health, alcohol or other drug abuse, or a
developmental disability has rights under Wisconsin and Michigan state
law. In addition to this document, LSS staff should have given you
written information about these rights. If you require additional
information regarding these rights, please see a staff member of the
facility or program providing your services and it will be provided to
you. Each service provider must post a client rights statement where
anyone can easily see it. You may not be threatened or penalized in
any way for presenting your concerns informally by talking with staff,
or formally by filing a grievance with the Client Rights Specialist.
Please note if you are a client receiving inpatient or community-based
services, alcohol or other drug abuse services, or services for a
developmental disability: You may, instead of filing a grievance with
LSS or at the end of the LSS grievance process, or any time during it,
choose to take the matter to court to sue for damages or other court
relief if you believe your rights have been violated.
LSS GRIEVANCE RESOLUTION PROCESS
1.
If you feel your client rights have been violated while you are
receiving services through LSS, you have the right to initiate the
grievance resolution process within 45 calendar dates from the
date the event occurred unless otherwise specified in this
document. To address a grievance, you should speak to the LSS
staff person(s) who provides your direct care to try to resolve
the issue.
2.
If you feel your concern cannot be resolved with the staff person,
then you should contact the LSS Program Supervisor or the Program
Manager. The Program Supervisor or Manager, or that person’s
designee, shall respond to you within 48 hours after being
notified of your concerns. That person will offer a face-to-face
or phone meeting to resolve the concern.
3.
If you disagree with any resolutions that have been offered by
program staff, you have the right to file a written grievance with
the LSS Client Rights Specialist, who will respond to you within
48 hours of receiving your written grievance. The LSS Client
Rights Specialist will have 30 days to complete a Client Rights
Report with the LSS Client Rights Specialist’s determination of
the grievance.
4.
Both the LSS Program Supervisor or the Program Manager and the
client must agree with the decision. Once the LSS Client Rights
Specialist issues a Client Rights Report with the determination of
the grievance, the client has 14 days to appeal the determination
or from the date of issue.
5.
If the client appeals the LSS Client Rights Specialist’s
determination, the client has a right to file a written grievance
with Performance and Quality Improvement. This individual will
respond to the client within 48 hours of receiving the written
grievance. This individual will then have 10 days to complete a
determination of the grievance and notify the client and the
Client Rights Specialist of the decision.
Contact information for each level of the LSS grievance process is
listed below:
1) Program Supervisor:  
Address/Phone:  
2) Program Manager: Lindsay Fortin
Address/Phone: 57405 Mine Street, Calumet, MI 49913/906-281-2031
3) Client Rights Specialist: Dennis Hanson
Address/Phone: 6737 W. Washington Street, Ste. 2275, West Allis, WI
53214/ 414-246-2711
4) Performance and Quality Improvement Representative: Amanda
Krzykowski
Address: 6737 W. Washington Ave Suite 2275, West Allis WI 53214
Phone: 414-246-2305 Fax: 414-246-2524
If you feel that your grievance was not resolved through the LSS
Grievance Resolution Process, you may have additional grievance rights
as outlined on the following pages.
DISCRIMINATION COMPLAINTS (WISCONSIN & MICHIGAN)
If you believe that you have been discriminated against based on race,
color, religion, national origin, age, sex, disability, you have the
right to complain in writing within 180 days of the alleged
discrimination. You may contact your program staff for pertinent
documents and additional information. A person believing he or she has
a complaint is requested, but not required, to follow the LSS
Grievance Resolution Process at the beginning of this document and to
contact the appropriate people listed at the beginning of this
document. If the complainant is not satisfied with the response and
continues to believe that an infringement of laws, regulations, or
accreditation standards has occurred, the complainant has the right to
file a complaint with the Office of Civil Rights.
Office of Civil Rights
Address: Office of Civil Rights, U.S. Department of Health and Human
Services, 233 N. Michigan Ave., Suite 240, Chicago, IL 60601
Toll Free: 800-368-1019 or TDD: 800-537-7697.
Fax: 312-886-1807.
Email: [email protected].
Page 2 of 2
Required Section
Formal Review Process for Services Provided in the State of Wisconsin
County Level Review – Part 2 of Level II
Please check box if this applies to the client:
*
If a county agency is paying for your services, there is an extra
step in the grievance process. You may appeal the LSS decision to
the County Agency Director. The County Agency Director must issue
a written decision within 30 days. Either party may appeal to the
state level review within 14 days.
County Agency Director Contact Information
*
Address:  
*
Phone:  
State Level Review – Level III
Please check box if this applies to the client:
Clients Rights Office/State Grievance Examiner
Please note: This applies to clients who are receiving mental health
inpatient or community-based treatment, services for a developmental
disability, and services for alcohol and other drug abuse if a
resolution cannot be reached at an earlier step.
*
The address to appeal is: The Department of Health Services,
Clients Rights Office, PO Box 7851, Madison, WI 53707-7851.
*
Telephone: (608) 266-2717 (Main division line)
*
If the grievance went through the State Level Review and either
party is dissatisfied with the decision, then the dissatisfied
party may appeal it to the Final State Level Review. You have 14
days to appeal.
Final State Level Review – Level IV
-----------------------------------
Please note: Anyone directly affected by the Level III decision may
request a final state review by the Administrator of the Division of
Mental Health and Substance Abuse Services (DMHSAS) or designee. Any
appeal to Level IV must be sent within 14 days.
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Please check box if this applies to the client:
-----------------------------------------------
*
Address: DMHSAS Administrator, PO Box 7851 Madison, WI 53707-7851
*
Telephone: (608) 266-0554
You May Also Communicate Your Concerns Directly To The Following:
Wisconsin Division of Quality Assurance
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PO Box 2969
-----------
Madison, WI 53701-2969
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Telephone: 608-266-8481
-----------------------
Toll free: 1-800-642-6552
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Additional Advocacy and Review Resources for the State of Wisconsin
MetaStar for Medicare Beneficiaries:
*
If Medicare is paying for your services, you may also request
review of your medical treatment by the peer review organization
called MetaStar at the following Address: MetaStar, 2909 Landmark
Place, Madison, WI 53713.
The Board on Aging and Long Term Care Ombudsman Program:
An Ombudsman is an advocate for long term care consumers aged 60 and
over who resides in nursing homes and group homes and participants of
the Family Care and Opportunity Options Program. Each county in the
State of Wisconsin has a Regional Ombudsman. Anyone who has questions
or concerns about the rights of long term consumers or suspects that
someone in a long term care setting is not receiving proper care may
contact the Ombudsman Program.
Address: Board on Aging and Long Term Care, 1402 Pankratz Street,
Suite 111, Madison, WI 53704-4001
Telephone: 1-800-815-0015
Email: [email protected] Fax: (608) 246-7001
Disability Rights of Wisconsin:
Disability Rights Wisconsin is a private non-profit organization
designated by the State as a “protection and advocacy agency” for
people of all ages, including people with developmental disabilities,
people with mental illness, people with physical or sensory
disabilities, and people with traumatic brain injury. Disability
Rights Wisconsin does not provide legal assistance for bankruptcies,
traffic tickets, criminal cases or family law issues like child
custody, child support or divorce. Advocacy services are free.
Contact Information:
Madison
131 W. Wilson St., Suite 700
Madison, WI 53703
608-267-0214
TTY: 888-758-6049
Fax: 608-267-0368
Toll Free: 800-928-8778
Milwaukee
6737 W. Washington St., Suite 3230
Milwaukee, WI 53214
414-773-4646
TTY: 888-758-6049
Fax: 414-773-4647
Toll Free: 800-708-3034
Rice Lake
217 W. Knapp St.
Rice Lake, WI 54868
715-736-1232
TTY: 888-758-6049
Fax: 715-736-1252
Toll Free: 877-338-3724
Formal Review Process for Services Provided in the State of Michigan
Office of Recipient Rights
Please check box if this applies to the client:
General Complaints:
*
You or someone on your behalf has the right to make general
complaints to the Office of Recipient Rights about matters other
than discrimination or hearing issues, including if you feel your
rights have been violated during treatment.
*
Written complaints can be sent to:
Michigan Department of Community Health
Office of Recipient Rights
Lewis Cass Building
320 S. Walnut, Garden Level
Lansing, MI 48913
Telephone: 800-854-9090
Fax: 517-335-0135
For hearing impaired individuals, please use the following number:
Michigan Relay Center:
800-649-3777 or 711
Appeals
*
After you receive the summary report from the general complaint,
you have the right to file an appeal. An appeal must be written
and sent within 45 days.
*
After the appeal was reviewed by the local appeals committee or
the Rights Office, you have 45 more days to make an appeal to the
Michigan Department of Community Health if you believe that the
investigative findings were not consistent with the facts or
relevant laws, rules, policies, or guidelines.
*
If you are not satisfied with the decision from the Michigan
Department of Community Health, you have 21 days to appeal to the
Circuit Court in the county where you reside.
*
At any time during the Appeal process, you have the right to
request a mediation of your dispute. If the mediation process is
not successful, than you have the right to pursue appeals.
HAGUE REGULATIONS
Please check box if this applies to the client:
Please note: This applies to clients receiving services through the
InterCountry Adoption program.
Lutheran Social Services of Wisconsin and Upper Michigan recognizes
the right of any birth parent, prospective adoptive parent, or adoptee
to lodge a complaint about any of the services or activities of the
agency or person that he or she believes raise an issue of compliance
with the Hague Convention on InterCountry Adoption, the InterCountry
Adoption Act (IAA), or the regulations implementing the IAA. Such
individuals shall be advised of the additional procedures available to
them if they are dissatisfied from the agency’s or person’s response
to their complaint.
Lutheran Social Services of Wisconsin and Upper Michigan does not take
any action to discourage a client or perspective client for: making a
complaint; expressing a grievance; providing information in writing or
interviews to an accrediting entity on the agency’s or person’s
performance; or questioning the conduct of or expressing an opinion
about the performance of an agency or person.
A person believing he or she has a complaint is requested, but not
required, to follow the LSS Grievance Resolution Process at the
beginning of this document and to contact the appropriate people
listed at the beginning of this document. If the complainant is not
satisfied with the response and continues to believe that an
infringement of laws, regulations, or accreditation standards has
occurred, the complaint has the right to file a complaint with the
Hague Complaint Registry.
Hague Complaint Registry Contact Information:
Web Address:
http://adoption.state.gov/hague_convention/agency_accreditation/complaints.php
ACKNOWLEDGEMENT OF RECEIPT OF GRIEVANCE PROCEDURES
I have received a copy of the Client Rights and Civil Rights Grievance
Process. This information has been explained to me.
*(Required) CLIENT RIGHTS AND CIVIL RIGHTS GRIEVANCE PROCESS (2 pages)
I have received the Wisconsin state brochure for my rights if the
services I am receiving meet any of the
following:
Wisconsin Community-Based/Outpatient Mental Health, Alcohol or Other
Drug Abuse, or Development Disability Services
Inpatient and Residential Services for Clients Receiving Services in
Wisconsin for Mental Illness, Alcohol and other Drug Abuse, or
Developmental Disabilities
Wisconsin Conditional Release
Children and Adolescents in Outpatient Mental Health Treatment in the
State of Wisconsin
Information on the Formal Review Process for Services Provided in the
State of Wisconsin and Additional Advocacy and Review Resources for
the State of Wisconsin
Information on the Formal Review Process for Services Provided in the
State of Michigan
Hague Regulations

Signature of Client Date
_________________________________________________________________________________________
Signature of Client Date

Legal Guardian’s Signature Date

Lutheran Social Services Representative Date
6/2015