020.050 Public Complaints Related to the Delivery of Section Programs

Procedure Number	020.050
Effective Date	September, 1996
Revision Date	September 16, 2024
Subject Matter Expert	Operations Unit Director
Approval Authority	HIV/STD Section Director
Signed by	D'Andra Luna

1.0 Purpose

To provide the HIV/STD Section (Section) with a method of resolving client complaints about the delivery of services. The Section effectively and promptly addresses all client complaints.

This policy does not address: 

• Allegations filed against the Section or its units regarding staff actions;
• Requests to change or modify a decision, policy, or procedure; or
• Privacy complaints. 

If a complaint involves a violation of privacy, the Section Privacy Coordinator, fields these complaints. The U.S. Health and Human Services Office of Civil Rights. (See section 5.4 of this Policy for further information.)
 

2.0 Authority

Part B of the Ryan White HIV/AIDS Treatment Extension Act of 2009 (Public Law 111-87); 45 Code of Federal Regulations (CFR) Part 80, Nondiscrimination Under Programs Receiving Federal Assistance through the Department of Health and Human Services Effectuation of Title VI of The Civil Rights Act Of 1964; 24 CFR Part 5, General Hud Program Requirements; Waivers.
 

3.0 Definitions and Acronyms

Administrative Agency (AA) – community-based organizations, governmental entities, and other organizations located within Texas and specifically deemed eligible in the state’s request for proposals (RFP) responsible for ensuring a comprehensive continuum of care exists in their funded HIV Administrative Service Area. The AA accomplishes this through the management, distribution, and oversight of federal and state funds, and under contractual agreement with the Texas Department of State Health Services (DSHS). AAs disburse funds from DSHS through a subcontractor system to provide comprehensive services to people living with HIV (PLWH) and those affected within the service planning area. 

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

Immediate or Serious Threat – a situation posing a high possibility for severe injury to a client if the client doesn’t have protection from harm or the threat remains.

Investigation – the process of gathering information sufficient to allow investigating staff to decide the validity of the complaint or determine what referrals to make to ensure the appropriate entity handles the complaint.

Services – program activities a provider offers on behalf of the Section and its units.
 

4.0 Persons Affected

• Section employees
• Section unit directors
• DSHS contractors
• DSHS regional staff
   

5.0 Procedures

5.1 Contractor Responsibility

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

5.2 Processing a Complaint

Complaints should include all details regarding the problem and a desired resolution or outcome.

5.2.1 Filing a Complaint about a Contractor or Provider

Individuals who wish to file a complaint should submit their complaint directly to the contractor or provider following the provider’s or contractor’s complaint procedure. If the contractor or provider is unable to resolve the complaint, individuals may escalate their complaint to their local Administrative Agency (AA).

5.2.2 Filing a Complaint about an AA or Unresolved Complaints with Contractors or Providers

Individuals who wish to file a complaint about an AA, an immediate or serious threat, or an unresolved complainant with a contractor or provider follow the local AA’s complaint procedure.

5.2.3 Filing a Complaint with the Section

Individuals who wish to file a complaint about an AA or an immediate or serious threat complainant can do so by emailing hivstd@dshs.texas.gov or calling 737-255-4300.
 

5.3 Processing a Complaint

If the Section receives a complaint via email and it contains personal health information, Section staff follow Procedure 2016.01, HIV/STD Section Confidential Information Security Procedures.
 
Staff route complaints received by the Section to the appropriate unit in the Section for assignment. The assignee assesses the complaint to determine whether the local Administrative Agency (AA) processes can resolve the complaint quicker and more appropriately. If the AA conducting the investigation is more appropriate and timely, the unit requests that the AA conduct the investigation.

Each Unit establishes its own procedures for addressing, investigating and resolving complaints based on their funding criteria and unit procedures.

Assignees may record the details on the Complaint Intake Form, 020-050A.
 

5.4 Complaints Involving Violations of Privacy or Discrimination

If a complaint involves a violation of privacy, the assignee informs the Section Privacy Coordinator and proceeds as instructed.

If a complaint alleges discrimination, the assignee informs the Health and Human Services Commission (HHSC) Civil Rights Office and proceeds as instructed.
 

5.5 Notify the Appropriate Individuals of the Findings and Resolution

When the assignee has determined the appropriate action and the unit director has approved and documented the resolution in writing, the assignee sends a written notification of findings and recommended action to the appropriate individuals. The assignee signs letters regarding the findings and resolution. Assignees provide copies of documentation to the appropriate regional staff.
 

5.6 Resolution Time Frames

The following resolution time frames should be followed:

Type of Complaint	Recommended Timeframe
Immediate 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 assignee cannot complete the investigation within the appropriate timeframe, the assignee notifies the complainant and unit director in writing.

Regional offices resolve complaints within the same timeframe as those handled by the Section.
 

5.7 Confidentiality and Anonymous Complaints

The Public Information Act (Texas Government code, §552)

may not exempt the identity of the complainant. Section staff should ensure the complainant understands the Section does not voluntarily release names and other identifying information, but if the Office of General Counsel advises release of certain information upon receipt of an Open Records request, law requires the Section to release the information.

Complaints filed by an individual who does not wish to reveal their name or who does not want their name used during an investigation will be fully investigated, based on the information submitted.

To ensure a breach of confidentiality does not occur, staff deidentify transmissions of confidential information via fax, email, or other methods with the client’s name removed. [See HIV/STD Section Procedure 2016.01, HIV/STD Section Confidential Information Security].
 

6.0 Revision History

Date	Action	Section
9/16/2024	Removed references to complaint committee, simplified complaint follow-up process to prioritize lowest organizational level	All
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

 

7.0 Associated Documents

Document
Complaint Intake Form, 020-050A

 

8.0 Associated Policies

Number	Policy
C-052	HHS Consumer Inquiry and Complaint Policy
2016.01	HIV/STD Section Confidential Information Security
2023.002	HIV/STD Section Assignment Process