SECTION 401.464. Notification and Appeals Process

(a) The TXMHMR service system is dedicated to providing mental health and mental retardation services/supports which are viewed as satisfactory by persons receiving those services/supports and their legally authorized representatives. Therefore, local authorities and their contractors shall take steps to assure that these persons:

(1) have a method to express their concerns or dissatisfaction;

(2) are assisted to do so in a constructive way; and

(3) have their concerns or dissatisfaction addressed through a review process.

(b) A request to review decisions described in this section may be made by the person requesting or receiving services/supports, the person's legal representative, or any other individual with the person's consent.

(c) At the time of admission into services and on an annual basis thereafter, the local authority and its contractors shall provide to persons who receive services/supports and their legally authorized representatives written notification in a language and/or method understood by the individual of the local authority or its contractor's policy for addressing concerns or dissatisfaction with services/supports. The notification shall explain:

(1) an easily understood process for persons and legally authorized representatives to request a review of their concerns or dissatisfaction by the local authority or its contractor, whichever is appropriate;

(2) how the person may receive assistance in requesting the review;

(3) the timeframes for the review; and

(4) the method by which the person is informed of the outcome of that review.

(d) Local authorities and their contractors shall notify persons and legally authorized representatives in writing in a language and/or method understood by the individual of the following decisions and of the process to appeal by requesting a review of those decisions:

(1) a decision to deny the person services/supports at the conclusion of a local authority's procedure which determines whether the person meets the criteria for the priority population; and

(2) a decision to terminate services/supports and follow-along from the local authority or its contractor, if appropriate.

(e) The written notification referred to in subsection (d) of this section must:

(1) be given or mailed to the person and the legally authorized representative within ten working days of the date the decision was made;

(2) state the reason for the decision;

(3) explain that the person and legally authorized representative may contact either the local authority or its contractor, whichever is appropriate, within 30 days of receipt of notification if dissatisfied with the decision and request that the decision be reviewed in accordance with subsection (g) of this section; and

(4) include name(s), phone number(s) and address(es) of one or more accessible staff to contact during office hours.

(f) If a person or legally authorized representative believes that the local authority or its contractor has made a decision to involuntarily reduce services by changing the amount, duration, or scope of services/supports provided and is dissatisfied with that decision, then the person may request in writing that the decision be reviewed in accordance with subsection (g) of this section.

(g) The review by the local authority or its contractor shall:

(1) begin within ten working days of receipt of the request for a review and be completed within ten working days of the time it begins unless an extension is granted by the CEO of the local authority or its contractor, whichever is appropriate;

(2) begin immediately upon receipt of the request and be completed within five working days if the decision is related to a crisis service;

(3) be conducted by an individual(s) who was not involved in the initial decision;

(4) include a review of the original decision which led to the person's dissatisfaction;

(5) result in a decision to uphold, reverse, or modify the original decision; and

(6) provide the person an opportunity to express his or her concerns in person or by telephone to the individual reviewing the decision. The review shall also allow the person to:

(A) have a representative talk with the reviewer; or

(B) submit his or her concerns in writing, on tape, or in some other fashion.

(h) Following a review, either the local authority or its contractor, whichever is appropriate, shall explain to the person and legally authorized representative in writing and also in person or by telephone, if requested, the action it will take or, if no action will be taken, why it will not change the decision or believes such action would not be in the person's best interest. This is the final step in the review process.

(i) The notification and review process described in this section:

(1) is applicable only to services/supports funded by TXMHMR and provided or contracted for by its local authorities;

(2) does not preclude a person or legally authorized representative's right to reviews, appeals, or other actions that accompany other funds administered through a local authority or its contractors, or to other appeals processes provided for by other state and federal laws, e.g., Texas Health and Safety Code, Title 7, Chapter 593 (Persons with Mental Retardation Act); 42 USC §1396 (Medicaid statute); and Texas Human Resources Code, Chapter 73 (Chapter 621 of this title (relating to Early Childhood Intervention)), Early Childhood Intervention programs as funded by the Texas Interagency Council for Early Childhood Intervention.

Source Note: The provisions of this §401.464 adopted to be effective February 11, 1994, 19 TexReg 591; amended to be effective January 3, 1997, 21 TexReg 12402