F-3: Grievance/Complaint System Analyst Notes F-3-a: Operation of When there is a grievance/complaint system: Grievance/Complaint Is the state agency that operates the grievance/complaint system identified? System Yes No Does the state describe the types of complaints that can be addressed, the F-3-b: Operational process and timelines? Yes No Responsibility Is the participant informed that filing a grievance or making a complaint is not a pre-requisite or substitute for a Fair Hearing? Yes No F-3-c: Description of System (Complete only if the has indicated that it has a grievance/complaint system.) Instrument for Reviewing 1915 (c) Waiver Applications Worksheet G: Participant Safeguards G-1: Response to Critical Events or Incidents Analyst Notes Does the state provide for the reporting and investigation of major and serious G-1-a: State Critical Event or Incident incidents (abuse, neglect, and exploitation at a minimum)? Yes No Reporting Requirements G-1-B State Critical Does the state’s description include: Event or Incident Definitions of the types of critical events or incidents that must be reported? Reporting Requirements Yes No Identification of the individuals/entities that must report critical events and incidents? Yes No Timeframes within which critical events or incidents must be reported? Yes No
F-3: Grievance/Complaint System Analyst Notes F-3-a: Operation of Grievance/Complaint System F-3-b: Operational Responsibility F-3-c: Description of System (Complete only if the has indicated that it has a grievance/complaint system.) When there is a grievance/complaint system: Is the state agency that operates the grievance/complaint system identified? Yes No Does the state describe the types of complaints that can be addressed, the process and timelines? Yes No Is the participant informed that filing a grievance or making a complaint is not a pre-requisite or substitute for a Fair Hearing? Yes No Instrument for Reviewing 1915 (c) Waiver Applications Worksheet G: Participant Safeguards G-1: Response to Critical Events or Incidents Analyst Notes G-1-a: State Critical Event or Incident Reporting Requirements Does the state provide for the reporting and investigation of major and serious incidents (abuse, neglect, and exploitation at a minimum)? Yes No G-1-B State Critical Event or Incident Reporting Requirements Does the state’s description include: Definitions of the types of critical events or incidents that must be reported? Yes No Identification of the individuals/entities that must report critical events and incidents? Yes No Timeframes within which critical events or incidents must be reported? Yes No