Due Process and Grievance Procedures

* These Due Process and Grievance Procedures also apply to remote training, telesupervision, and remote clinical services.

I.  DUE PROCESS 

This document provides Counseling & Psychological Services (CAPS) Psychology interns and staff with an overview of the identification and management of f interns’ problems and concerns and an explicit discussion of the related due process procedures. The basic meaning of due process is to inform and to provide a framework to respond, act, or dispute. Due process ensures that decisions about interns are not arbitrary or personally based.  It requires that the training program identify specific procedures, which are applied to all intern complaints, concerns, and appeals.

A.  Overview of Due Process Guidelines

1. During the orientation period, interns will receive, in writing, CAPS’ expectations related to professional functioning.  The Training Director will discuss these expectations in both group and individual settings.
2. The procedures for evaluation, including when and how formal evaluations will be conducted will be described.  Formal evaluations will occur at mid-year and end-of-year. Additionally, informal feedback will be given throughout the training year. 
3. The various procedures and actions regarding problem behaviors or interns concerns will be described.
4. CAPS will communicate early and often with the intern and the intern’s Academic Training Director, when needed, if any difficulties are identified that are significantly interfering with performance.
5. The Training Director will institute, when appropriate, a remediation plan for identified inadequacies, including a time frame for expected remediation and consequences of not rectifying the inadequacies.
6. If an intern wants to institute an appeals process, this document describes the steps of how an intern may officially appeal the action (see section G below, Due Process Procedures: Appeals Process).  
7. CAPS Due Process Procedures ensure that interns have sufficient time (as described in this due process document) to respond to any action taken by the program before the action is implemented.
8. When evaluating or making decisions about a intern’s performance, CAPS will use input from licensed staff involved in supervising the intern.
9. The Training Director will document, in writing, and provide to all relevant parties, the actions taken by the program and the rationale for all actions.
10. All interns are expected to abide by the APA Code of Ethics, California laws and regulations as well as University rules and procedures.  Either administrative leave or termination would be invoked in cases of severe violations of the APA Code of Ethics, or when imminent physical or psychological harm to a client, staff member, or other trainee is a major factor, or the intern is unable to complete the training program due to physical, mental, or emotional illness. Interns are required to abide by University rules and procedures as outlined in the University’s Human Resources Policies:  https://myusf.usfca.edu/human-resources/policies-procedures

B.  Due Process Procedures: Identifying Problematic Behavior

Problematic Behavior is defined broadly as an interference in professional functioning, which is      reflected in one or more of the following ways: 

• An inability and/or unwillingness to acquire and integrate professional standards into one's   repertoire of professional behavior; 
• An inability to acquire professional skills in order to reach an acceptable level of competency and/or 
• An inability to manage personal stress, strong emotional reactions, and/or the presence of psychological dysfunction, which interferes with professional functioning.

It is a professional judgment when a intern’s behavior is considered problematic rather than “of concern.”  Interns may exhibit behaviors, attitudes, or characteristics that, while of concern and requiring remediation, are not unexpected or excessive for training professionals.  Problematic behavior is typically identified when one or more of the following characteristics exist:

• The intern does not acknowledge, understand, or address the problem when it is identified;
• The problem is not merely a reflection of a skill deficit that can be rectified by academic or didactic training;
• The quality of services delivered by the intern is significantly negatively affected;
• The problem is not restricted to one area of professional functioning;
• A disproportionate amount of attention by training personnel is required; and/or
• The intern’s behavior does not change as a function of feedback, remediation efforts, and/or time.

C.  Due Process Procedures: Addressing & Managing Problematic Behavior

Minimum level of competency issues: 

Interns are formally evaluated on a Likert scale from one to seven for each element on the CAPS Psychology Intern Evaluation Form.  It is expected that an Intern will receive a rating of 3 (Emerging Competence) on all elements in all Competency areas at mid-year. If an Intern receives a rating of two at mid-year on any element, the primary supervisor provides specialized attention to increase the Intern’s functioning to the expected level of competency which may include remedial work. If an Intern receives a rating of one on any element at mid-year, the Primary Supervisor, in collaboration with the Training Director, develops and institutes a specific remediation plan. At this time, the Training Director will provide the Academic Training Director with the written remediation plan and subsequently will provide follow-up documentation about the intern’s progress in meeting the requirements of the plan. 

For successful completion of the internship, it is expected that the Intern will receive a rating of 4 (Competence Level) at end of year on all elements in all Profession Wide and Program Specific Competency areas. If a rating of 1-“Remedial”, 2-“Significant Growth Area”, or 3-“Emerging Competence” is given on any element of a Competency area on the final evaluation, the intern does not successfully complete their internship.  

Behavioral issues: If a staff member or trainee has significant concerns about an intern’s behavior (e.g., ethical or legal violations, professional incompetence) the following procedures will be initiated:

1. In some cases, it may be appropriate to speak directly to the intern about these concerns emphasizing the need to discontinue the inappropriate behavior; in other cases, a consultation with the Training Director will be warranted.  This decision is made at the discretion of the staff (or other trainee) who has concerns about the intern.  
2. Once the Training Director has been informed of the specific concerns, they will determine if and how to proceed.
3. If the staff member who brings the concern to the Training Director is not the intern’s supervisor, the Training Director will discuss the concern with the Supervisor(s).
4. If the Training Director and Supervisor(s) determine that the alleged behavior in the complaint, if substantiated, would constitute a serious violation, the Training Director will inform the staff member who initially brought the complaint.

D.  Notification 

It is important to have meaningful ways to address problematic behavior once identified.  In implementing remediation or sanctions, the training staff must be mindful and balance the needs of the intern, the clients involved, members of the intern’s training group, the training staff, other agency personnel, and the campus community.  All evaluative documentation will be maintained in the intern’s file.  At the discretion of the Training Director—in consultation with the Training Committee, Supervisor(s) and/or Senior Director– the intern and intern’s Academic Training Director will be informed through Written Notice that formally acknowledges: 

i.   the Training Director is aware of and concerned with the behavior,

ii.  the concern has been brought to the attention of the intern and the intern will have an opportunity to present information regarding the concern,

iii. the Training Director will work with the intern to rectify the problem or skill deficits.

*If at any time an intern disagrees with the aforementioned notices, the intern can appeal (see Section G below, Due Process Procedures:  Appeals Process).

E. Hearing

A Training Committee (comprised of the Training Director and two CAPS licensed supervisors) and Senior Director of CAPS meet to discuss the concerns and possible courses of action to be taken to address the issues. The Training Committee and Senior Director will then meet with the Supervisor(s), to discuss possible courses of action.

The Supervisor will hold a Hearing with the Training Director (TD) and intern within 10 working days of issuing a Notice of Formal Review to discuss the problem and determine what action needs to be taken to address the issue. If the TD is the supervisor who is raising the issue, an additional supervisor who works directly with the intern will be included at the Hearing. The intern will have the opportunity to present their perspective at the Hearing and/or to provide a written statement related to their response to the problem. Written notification will also be provided if the behavior(s) of concern are not significant enough to warrant more serious action.  

F.  Outcomes

The implementation of sanctions should occur only after careful deliberation and thoughtful consideration by members of a Training Committee. Remediation and sanctions listed below may not necessarily occur in this order. The severity of the problematic behavior plays a role in the level of remediation or sanction. The intern will also be notified if the behavior(s) of concern are not significant enough to warrant further action.  

1. Remediation plan

The Training Director will communicate early and often with the intern and apprise the intern and intern’s Academic Training Director of the implementation of a remediation plan. The academic training director is contacted when the plan is developed to answer any questions they may have as well as to gather any information that may be relevant. The training director provides the intern and academic training director with the written remediation plan at the time that it is developed as well as follow-up documentation about how the intern is progressing in meeting the requirements of the plan. 

A remediation plan will contain:

i.   a description of the intern 's unsatisfactory performance; 

ii.  actions needed by the intern to correct the unsatisfactory behavior; 

iii. the timeline for correcting the problem; 

iv. type of sanction(s) that may be implemented if the problem is not corrected; and 

v.  notification that the intern has the right to request an appeal of this action* 

2. Schedule Modification is a closely supervised period of remedial training that is designed to be time-limited and return the intern to an appropriate level of functioning.   It is utilized to provide the intern with additional time to respond to personal reactions to environmental stress. Schedule modification is conducted by the primary supervisor in consultation with the Training Committee, with the full expectation that the intern will complete the internship.  Courses of action may include reducing the intern’s workload, increasing the amount or modifying the focus of supervision, and/or recommending personal therapy or other forms of intervention.

3. Probation is also a time-limited, remediation-oriented, and more closely supervised training period for the intern. Its purpose is to return the intern to a fully functioning state. This period will include more closely scrutinized supervision conducted by the primary supervisor in consultation with the Training Committee. The intern, supervisor, and Training Committee will determine the termination of probation.

4. Temporary Withdrawal of Case Privileges means that it has been determined that the welfare of the intern and/or the client has been jeopardized. Therefore, case privileges will be suspended for a specified period of time (i.e., no direct service functions) as determined by the Training Committee. At the end of this period, the supervisor will evaluate the intern, in consultation with the Training Committee, to assess whether the intern has the capacity for effective functioning and case privileges can be reinstated. If the suspension interferes with the successful completion of the training hours needed for completion of the internship, this will be noted for the record. 

5. Suspension involves the withdrawal of all privileges related to CAPS and the University of San Francisco. This would be invoked by the Training Committee in cases where the welfare of the intern's client(s) or the campus community has been compromised. If suspension is recommended, this recommendation will be documented in writing and given to the CAPS Senior Director. A final decision for suspension rests with the Senior Director, in consultation with the Training Committee. If the Senior Director decides to suspend the intern, written notification will be delivered within 24 hours, and the Training Director will notify the intern’s Academic Training Director.

6. Dismissal from the training program involves the permanent withdrawal of all agency responsibilities and privileges.  When specific remediation does not, after a reasonable time period, rectify the problem behavior or concerns and the intern seems unable or unwilling to alter their behavior, the Training Committee will discuss the possibility of termination from the training program or dismissal from the agency with the Senior Director.  Either administrative leave or dismissal would be invoked in cases of severe violations of the APA Code of Ethics, or when imminent physical or psychological harm to a client, staff member, or other trainee is a major factor, or the intern is unable to complete the training program due to physical, mental, or emotional illness. The Senior Director will make the final decision about dismissal or administrative leave in accordance with University policy.

If at any time an intern disagrees with the aforementioned sanctions, the intern can implement Appeal Procedures (see Due Process Procedures: Appeals Process, Section G)

G. Due Process Procedures:  Appeals Process

In the event that an intern does not agree with any of the aforementioned notifications, remediation, or sanctions, the following appeal procedures should be followed:

1.  The intern may file a formal appeal in writing with all supporting documents, with the Senior Director. The intern must submit this appeal within five (5) business days from their notification of any of the above (notification, remediation, or sanctions).

2.   Within three (3) business days of receipt of a formal written appeal from an intern, the Senior    Director will consult with the Training Committee and decide whether to implement a Review Panel or respond directly to the appeal.

3.   If a Review Panel is convened, it will consist of the Training Director and two licensed supervisors. The Senior Director will designate a Chair of the Review Panel. All material relevant to the appeal will be submitted to the Chair of the Panel and the Panel will arrive at a consensus based on the information provided. If the appeal involves the Senior Director, the responsibility to appoint a Review Panel will be delegated to the Training Director.

4.  In the event an intern files a formal written appeal to disagree with a decision that has already been made by the Review Panel and supported by the Senior Director, then that appeal is reviewed by the Senior Director in consultation with all CAPS licensed staff.  The Senior Director will determine if a new Review Panel should be formed to re-examine the case, or if the decision of the original Review Panel will be upheld.  

II.   GRIEVANCE PROCEDURES  

Grievance procedures have been developed in the event a intern encounters difficulties or problems that are not evaluation related (e.g. poor supervision, unavailability of supervisor(s), workload issues, personality clashes, other staff conflicts) during the training program.  During the orientation period, interns will receive, in writing, CAPS’ guidelines related to grievance procedures.  The Training Director will discuss these guidelines in both group and individual settings.

A. Overview of Grievance Guidelines 

1. When an intern has a grievance, they may choose to first discuss the issue informally with the staff member(s) involved.
2. If the issue cannot be resolved informally or the intern does not wish to proceed with an informal resolution, the intern should discuss the concern with their primary supervisor, who may then consult with the Training Director, a Training Committee, or Senior Director if needed (if the concerns involve the primary supervisor or the Training Director, the intern can consult directly with the Senior Director).
3. If the primary supervisor, Training Director and/or Senior Director cannot resolve the issue of    concern to the intern, the intern can file a formal written grievance, complete with supporting documentation, with the Senior Director.  (If the grievance involves the Senior Director, the intern can file the report with the Training Director.)
4. Once the Senior Director or Training Director has received a formal grievance, they will    implement Review Procedures as described below and inform the intern of any action taken within three (3) business days.
5. CAPS will communicate early and often with the intern regarding a grievance that has been brought to CAPS’ attention.

B. Grievance Procedures:  Initial Review

1. When needed, the Senior Director will convene a Review Panel to examine a grievance filed by an intern.  

a. The Panel will consist of the Training Director and two licensed staff members, selected by the Senior Director with recommendations from the Training Director and the intern who filed the appeal or grievance.  The Senior Director will appoint a Chair of the Review Panel. If the grievance is related to the Senior Director, the responsibility to appoint a Review Panel will be delegated to the Training Director.

b. In response to a grievance, the intern has a right to express concerns about the training program or CAPS staff members and the CAPS program or staff has the right and responsibility to respond. 

2. Within five (5) business days, the Review Panel will meet to review the grievance and to examine the relevant material presented. 

3. Within three (3) business days after the completion of the review, the Review Panel will submit a written report to the Senior Director, including any recommendations for further action.  Recommendations made by the Review Panel will be made by majority vote if a consensus cannot be reached.  

4. Within three (3) business days of receipt of the recommendation, the Senior Director will either accept or reject the Review Panel's recommendations.  If the Senior Director rejects the recommendation, the Senior Director may refer the matter back to the Review Panel for further deliberation and revised recommendations or may make a final decision.  

5. If referred back to the Review Panel, a report will be presented to the Senior Director within five (5) business days of the receipt of the Senior Director's request of further deliberation.  The Senior Director then makes a final decision regarding what action is to be taken and informs the Training Director.

6. The Training Director informs the intern, involved staff members, necessary members of the training staff of the decision, and the interns’ Academic Training Director and any action taken or to be taken.

7. If the intern disputes the Senior Director's final decision, the intern has the right to request a second review following the steps outlined below in Section C (Grievance Procedures: Second Review).

C.  Grievance Procedures: Second Review

In the event that an intern does not agree with the handling of a grievance, the following Procedures should be followed:

1. The intern files a formal statement in writing with all supporting documents, with the Senior Director. The intern must submit this within five (5) business days from their notification of the outcome of the grievance. 
2. Within three (3) business days of receipt of a formal written statement from an intern, the Senior Director will consult with a Training Committee and decide whether to implement a Review Panel or respond directly.
3. If a Review Panel is convened, it will consist of the Training Director and two licensed supervisors. The Senior Director will designate a Chair of the Review Panel. All material relevant to the appeal will be submitted to the Chair of the Panel and the Panel will arrive at a consensus based on the information provided. If the grievance involves the Senior Director, the responsibility to appoint a Review Panel will be delegated to the Training Director.
4. In the event that an intern files a formal written statement disagreeing with a decision that has already been made by the Review Panel and supported by the Senior Director, the statement is reviewed by the Senior Director in consultation with CAPS Licensed Staff.  The Senior Director will determine if a new Review Panel should be formed to re-examine the case, or if the decision of the original Review Panel will be upheld.
5. If the Review Panel cannot resolve the issue or if it is deemed inappropriate for the panel to handle, the matter will be referred to Human Resources.
6. The intern and intern’s Academic Training Director will be notified of the outcome of the process within three (3) business days of the final decision.