1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 OKLAHOMA STATE DEPARTMENT OF HEALTH ADMINISTRATIVE POLICIES AND PROCEDURES NUMBER: TITLE: RESPONSIBLE SERVICE: 1-30 Office of Accountability Systems Office of Accountability APPROVED: _________________________ Terry Cline, Ph.D. Commissioner _________________________ Martha A. Burger President, Board of Health I. The purpose of this administrative policy and procedure is to provide a framework for the interaction between the Office of Accountability Systems (OAS), employees and the public. This policy and procedure also provides a framework for the review and evaluation of complaints filed with OAS.1 18 19 20 21 22 23 24 25 26 27 28 Purpose II. Statutory Authority The OAS was created pursuant to Title 63 of the Oklahoma Statutes. 2 The director for OAS reports directly to and under the direct supervision of the Board of Health (BOH). The BOH will provide guidance and direct the work of OAS and its director. 29 30 31 The commissioner of health will have administrative oversight of the director of OAS (i.e. provide guidance to general operations of OAS, approve leave and travel requests of OAS Director, etc.). 32 The duties and authorities of the OAS are established as: 33 34 35 36 1. Coordinate audits and investigations and make reports to the Oklahoma State Department of Health (OSDH) and commissioner of health within the OSDH and State health officer relating to the administration of programs and operations of the OSDH3. 1 Public Health Accreditation Board (PHAB) Standards and Measures, Domain 11.1.1A Title 63 O.S. § 1-105f (2006) 3 63 O.S. § 1-105f (A) (1) 2 Page 1 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 2. Except as otherwise prohibited by current law, access all records, reports, audits, reviews, documents, papers, recommendations, or other material which relate to programs and operations with respect to which the director of the OAS has responsibilities4. 3. Request assistance from other state, federal and local government agencies5. 4. Issue administrative subpoenas for the production of all information, documents, reports, answers, records, accounts, papers, and other data and documentary evidence6. 5. Administer to or take from any current or former employee of the OSDH an oath, affirmation, or affidavit7. 6. Receive and investigate complaints or information from an employee of the OSDH, service recipient or member of the public concerning the possible existence of an activity within the OSDH constituting a violation of law, rules or regulations, mismanagement, gross waste of funds, abuse of authority or a substantial and specific danger to the public health and safety8. 7. Cause to be issued on behalf of OAS credentials, including an identification card with the State Seal9. 8. Keep confidential all actions and records relating to OAS complaints10. 9. Keep the State BOH and the commissioner of health fully informed of matters relating to fraud, abuses, deficiencies and other serious problems of which the director is aware relating to the administration of programs and operations within the OSDH. Further, the director shall recommend corrective action concerning such matters and report to the BOH and the commissioner of health on the progress of the corrective matters11. 10. Report expeditiously to the appropriate law enforcement entity whenever the director has reasonable grounds to believe that there has been a felonious violation of state or federal criminal law12. 4 63 O.S. § 1-105f (A) (2) 63 O.S. § 1-105f (A) (3) 6 63 O.S. § 1-105f (A) (4) 7 63 O.S. § 1-105f (A) (5) 8 63 O.S. § 1-105f (A) (6) 9 63 O.S. § 1-105f (A) (7) 10 63 O.S. § 1-105f (A) (8) 11 63 O.S. § 1-105f (B) (1) 12 63 O.S. § 1-105f (B) (3) 5 Page 2 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 The director of OAS may exercise the duties listed in paragraphs (3), (4), (9) and (10), above with the written approval of the president of the BOH and/or the commissioner of health. Identification cards issued by the OSDH meet the requirements of paragraph (7) above. The director of OAS may exercise the duties listed in paragraphs (1), (2), (5), (6), and (8), above, when a complaint is received by OAS directly involving any member of the BOH, the commissioner of health, or a member of senior leadership of the OSDH. In exercising the duties listed in paragraphs (1), (2), (5), (6) and (8), above the director of OAS shall follow the procedures set forth herein. III. Definitions For purposes of administering Title 63 of the Oklahoma Statutes13, these definitions shall apply. Abuse of Authority: To deliberately exceed or make improper use of delegated or inherent authorized powers by government officials for illegitimate and private gain. Mismanagement: This means gross mismanagement. A management action or inaction that creates a substantial risk of significant adverse impact on the agency’s ability to accomplish its mission. It is more than de minimis (i.e., minor) wrongdoing or negligence and does not include management decisions that are open to discussion or debate. Gross Waste of Funds: A more than debatable expenditure, and is one that is significantly out of proportion to the benefit reasonably expected to accrue to the government. OSDH Senior Leadership: OSDH senior leadership is defined as the commissioner of health, senior deputy commissioner, a deputy commissioner, the chief operating officer and the director of state and federal policy. IV. Scope of Authority of OAS to Review Complaints Depends on Type of Complaints Received The OAS may receive complaints from an employee or an individual external to the OSDH. OAS will distribute non-OAS issues to the correct department. (see Table 1) A complaint received by OAS may in part fall within the authority of 13 63 O.S. § 1-105f (A) (1) Page 3 117 118 OAS and in part within the authority of another department. OAS may bifurcate a complaint in order to ensure it is managed by the correct department. 119 120 The table below sets out guidelines for the distribution of OAS versus non-OAS complaints or inquiries. 121 Table 1 Department OAS Audit Human Resources and Other Departments 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 Scope of Authority to Review Complaints Matters involving members of the BOH or OSDH senior leadership which may involve violations of law, rule or regulation; gross mismanagement; abuse of authority; or substantial and specific danger to the public health and safety. Issues that fall within the defined scope of the OSDH auditing function; inappropriate use of funds; or, improper internal controls There are broad arrays of issues that are not under the scope of OAS as defined above and require some review or investigation. Depending on the nature of the issue the complaint/inquiry will be managed outside the OAS process. Examples include, but are not limited to, EEOC complaints, hostile work environment, complaints about a manager, complaints about a senior leader that does not fall within the scope of OAS above, a performance management process complaint. Employees are encouraged to submit complaints to the appropriate department. However, when a complaint is submitted to the OAS and is not within the scope of the OAS as defined above the OAS director will review with other members of the Coordinating Complaint Council (CCC) and redirect the complaint as described herein to the appropriate program or department. Complaints not within the scope of authority of the OAS shall be assigned a nonOAS case number as determined by the director of OAS. V. Complaint Process A. OAS Complaint Submission Process A complaint may be initiated by utilizing any one of the following:  Submitting a written letter or completed ODH No. 130 “OAS Complaint Form” to the OAS Page 4 o In-person, at any health department 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 o By mail to 1000 N.E. 10th Street, Room 512, Oklahoma City, OK 73117  By contacting the OAS by e-mail at OAS@health.ok.gov  Calling the OAS hotline at 1-866-271-7211. Upon receipt of a complaint, a written acknowledgment of receipt shall be provided to the complaining party. B. C. Intake Procedure for Complaints  Upon receipt of the complaint, the complaint will be submitted to the director of OAS to determine the nature of the complaint.  Upon determining the nature of the complaint, the director of OAS is required to follow the procedure set forth herein. OAS Complaint Evaluation Procedure Upon completion of the intake procedure for a complaint, the director of OAS shall determine whether the complaint directly falls within the OAS scope of authority as delineated herein and directly involves: 163  A member or members of the BOH, or 164 165 166  A member or members of OSDH Senior Leadership. 167 Table 2 will determine who will initially review the complaint. Table 2 If complaint directly involves: President BOH Governance Team: OAS director, commissioner of health, and chair of the accountability, ethics and audit committee (AEAC) Chair of Accountability, Ethics and OAS director, commissioner of health, and BOH Audit Committee president Other BOH Members OAS director, commissioner of health, BOH president, and chair of the AEAC Page 5 Commissioner of Health OAS director, BOH president, and chair of the AEAC Other Members of Senior Leadership OAS director, commissioner of health, BOH president, and chair of the AEAC Director of OAS commissioner of health, BOH president, and chair of the AEAC 168 169 170 171 172 173  This initial conference with the governance team will review the need for an investigation, if warranted.  Approval of the entire BOH is required, if the governance team determines outside resources are necessary to complete a proper investigation. 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199 200  The governance team shall oversee the investigation and shall receive updates regarding the investigation a minimum of once a month from the director of the OAS. 201 202 D. Coordinating Complaint Council (CCC) The OAS director will meet with the CCC for any complaint received by OAS not within the scope of authority listed above. The CCC will consist of  The director of OAS  A member of the personnel advisory committee (PAC)  A member of the office of the general counsel, who is not a member of the PAC The director of OAS shall refer the complaint upon the recommendation of the CCC to the appropriate service or program area, or make a determination that the issues raised in the complaint fall outside the jurisdictional authority of the OSDH. If the CCC determines some of the issues contained in the complaint fall within the scope of authority of the OAS while other issues fall outside the authority of OAS, the director of OAS shall make initial contact as referenced above. E. Referral Memorandum Page 6 203 204 205 206 207 208 209 210 211 212 213 214 Upon completion of the review by the CCC and determining the appropriate course of action the director of OAS will complete a memorandum that properly refers the complaint. If the memorandum refers the complaint for an OAS investigation, the memorandum will identify the issues raised in the complaint to be investigated. F. OAS Investigations The investigator, whether using the resources within the OSDH or outside OSDH, will commence the investigation upon receipt of the referral memorandum and a copy of the OAS complaint. 215 216 217 218 The investigation will only cover the issues stated in the referral memorandum. To reduce unnecessary dupulication of investigations, the investigator may also rely on findings obtained in a prior investigation to arrive at their recommendation. 219 220 221 222 223 224 225 226 227 228 229 230 231 232 233 234 235 236 237 238 239 240 241 242 243 244 245 The investigator will submit interim reports weekly to the director of OAS providing status updates of any investigations. If additional issues arise during the investigation, the investigator will report these issues to the director of OAS. The director, in consultation with the appropriate governance team, will determine whether the additional issues should be investigated. Once a determination is made regarding the investigation of additional issues, the director will prepare a memorandum which includes the date of the determination, who participated in the determination, the issues discussed and the determination made. The memorandum will be placed in the file and sent to the investigator. Upon completion of the investigation, the investigator will write a report and submit the report to the director. G. Submission of Investigation Report to the Director of OAS The director will provide the final report to the appropriate governance team who will review the report and make any recommendations, including corrective action, concerning any further action that should be undertaken. The director will issue a confidential report to the AEAC; the commissioner of health, unless otherwise instructed by the BOH; and to anyone additionally identified by the Chair of the AEAC, the President of the BOH and/or the commissioner of health. H. Malicious or Intentionally False Reports Page 7 246 247 248 249 250 251 252 253 254 255 256 Any employee filing a malicious or intentionally false complaint to the OAS may be subject to corrective discipline. I. Confidentiality The OAS will attempt to keep complainant’s name confidential if requested. However, the OAS cannot guarantee confidentiality can be maintained during the investigative process or if the complaint does not fall under the OAS scope of authority. VI. Scheduled Review 257 258 259 The director of OAS is responsible for the review of this policy and procedures at least every twenty-four months or if there is a change in state law, administrative rule, or other legislation. 260 261 The periodic review and any revisions of this administrative policy and procedure shall be reviewed by the commissioner of health and the BOH. 262 263 Any exceptions to this administrative procedure require prior written approval of the commissioner of health and the president of the BOH. 264 265 266 267 268 VII. 269 VII. 270 271 Associated Forms ODH No. Title ODH No. 130 Complaint Form Policy and Procedure Review History The table below identifies the procedure review history regarding the origination date, review date(s) and revision date(s). Origination Date: Review Date(s): Revision Date(s): August 2005 September 2011 April 2017 273 Page 8