{"ref":"NC-HH-CMP-01","title":"Complaints and Grievances","category":"Client rights","own":false,"summary":"Requires the Agency to investigate every complaint made by a patient or family within 72 hours, as G.S. 131E-144.6(b) requires, to document both the complaint and its resolution, to act to prevent further problems and retaliation while it investigates, and to tell every patient in writing how to complain to the Agency and to the Division of Health Service Regulation Complaint Intake Unit.","inShort":["Thank anyone who complains, write down what was said, and tell the complaint officer or on-call nurse the same day. Never argue or discourage a complaint.","The Agency must investigate within 72 hours of the complaint, weekends and holidays included.","If the complaint is about abuse, neglect, theft or an injury no one can explain, also follow the abuse and staff allegation policies at once.","Patients may complain to the State at any time, without asking us first: 1-800-624-3004 (within North Carolina) or 919-855-4500.","Never treat a patient or family worse because they complained."],"primaryCitation":"G.S. 131E-144.6(b)","citations":["G.S. 131E-144.6","G.S. 131E-144.4","G.S. 131E-141","G.S. 131E-144.3","10A NCAC 13J .1007(b)","10A NCAC 13J .1007(c)"],"federalCitations":["42 CFR §484.50(c)(3)","42 CFR §484.50(c)(9)","42 CFR §484.50(c)(11)","42 CFR §484.50(e)","45 CFR §164.530(d)"],"surveyorAsks":["Show me your complaint log. When did you start investigating this complaint, and how was it resolved?","How do patients know they can complain to the state, and what number do you give them?","A daughter complained that the aide was rough with her mother. What did you do?","How do you protect a patient who complains from retaliation?"],"version":"1.0","effectiveDate":"2026-10-01","reviewDate":"2027-10-01","approvedBy":"Pat Sample, Administrator","forms":[{"ref":"NC-HH-CMP-01-A","title":"Where to Direct a Complaint"},{"ref":"NC-HH-CMP-01-B","title":"Complaint Log"}],"sections":[{"heading":"Terms of Reference","body":["This section sets out the standing under which this policy is issued, who owns it, who is bound by it, and how it is kept current. It is not itself a procedure. The obligations begin at Section 1."],"table":{"caption":null,"headers":[["Item"],["Detail"]],"rows":[[["Issued by"],["The governing body of ",{"k":"field","name":"agency.name","text":"Sample Agency, LLC"}]],[["Document owner"],[{"k":"field","name":"people.administrator.name","text":"Pat Sample"},", ",{"k":"field","name":"people.administrator.title","text":"Administrator"}]],[["Authority"],["Adopted under G.S. 131E-144.6(b) (agency investigation of complaints within 72 hours), G.S. 131E-144.3(4) (right to voice grievances), G.S. 131E-144.4(a)(3) and (4) (complaint contact information in the admission packet), G.S. 131E-141 (Division hotline notice), and 10A NCAC 13J .1007(b) and (c). Also under 42 CFR §484.50(c)(3), (c)(9), (c)(11) and (e) (patient rights; investigation of complaints) and 45 CFR §164.530(d) (privacy complaints). The Agency is a home health agency as defined in G.S. 131E-136(4): a licensed home care agency certified to receive Medicare and Medicaid reimbursement, and it meets 42 CFR Part 484. A licensed home care agency that is not Medicare-certified is bound by 10A NCAC 13J but not by 42 CFR Part 484, and follows the federal provisions in this policy as its own standard."]],[["Applies to"],["Every employee and contracted staff member who receives a complaint, the complaint officer, the agency director, and the supervising nurse."]],[["Status"],["Mandatory. Adherence is a condition of employment and of any contract for services. No provision may be waived, shortened, or varied by any employee."]],[["Not covered here"],["Allegations of abuse, neglect or exploitation, which are also reported under Policies NC-HH-SG-01, NC-HH-SG-02 and NC-HH-SG-03. Incident investigation (Policy NC-HH-QA-03). Medicare and Medicaid coverage appeals, which follow the notices in Policy NC-HH-DC-02."]],[["Review"],["Reviewed by the document owner at least every ",{"k":"field","name":"settings.reviewFrequencyMonths","text":"12"}," months, and within 30 days of any amendment to a rule cited at Section 13. The policy and administration review in the annual evaluation of the Agency’s total operation (10A NCAC 13J .1004(a) to (c)) also covers this policy. Each review is recorded at Section 16 whether or not the text changes."]],[["Amendment"],["Any change requires the approval of the governing body and the issue of a new version number. Superseded versions are retained for six years."]],[["Distribution"],["Master copy held in the policy manual at each licensed premises, where it is available for inspection by the Division of Health Service Regulation (10A NCAC 13J .1001(a)). Staff named in the Applies to row receive it at orientation and when it changes."]],[["Questions"],["Direct to the document owner on ",{"k":"field","name":"agency.phone","text":"(919) 555-0100"}," or ",{"k":"field","name":"agency.email","text":"office@example.com"},"."]]]},"edited":false},{"heading":"1. Purpose","body":["This policy makes sure every patient and family member of ",{"k":"field","name":"agency.name","text":"Sample Agency, LLC"}," can raise a concern easily and without fear, that every complaint is looked into quickly and fairly, and that the Agency uses complaints to improve its care."],"edited":false},{"heading":"2. Scope","body":["This policy covers any expression of dissatisfaction about the Agency’s care, services, staff, billing or treatment of a patient’s property or person, made by a patient, representative, family member or caregiver, orally or in writing, to anyone at the Agency, and complaints from other people such as physicians or neighbors."],"edited":false},{"heading":"3. Definitions","body":["For the purposes of this policy, the following terms have the meanings below. 10A NCAC 13J and the Home Care Clients’ Bill of Rights (G.S. 131E-144.1 to 131E-144.7) say \"client\"; 42 CFR Part 484 says \"patient\". This policy says \"patient\", and the two words mean the same person here."],"table":{"caption":null,"headers":[["Term"],["Meaning"]],"rows":[[["Complaint (grievance)"],["Any expression of dissatisfaction, oral or written, about treatment or care that is (or fails to be) furnished, about lack of respect for property or person, or about any other matter, by or for a patient. The Agency uses the two words to mean the same thing."]],[["Complaint officer"],[{"k":"field","name":"people.complaintOfficer.name","text":"Pat Sample"},", ",{"k":"field","name":"people.complaintOfficer.title","text":"Administrator"},", who receives, logs and oversees the investigation of complaints."]],[["Investigate"],["To gather the facts: contacting the person who complained, the patient and the staff involved, and reviewing the record. Under G.S. 131E-144.6(b) the Agency must investigate within 72 hours. The statute does not say whether the 72 hours is the time to start or to finish, so the Agency completes these fact-finding steps within 72 hours, as the Agency’s own standard; the resolution may follow."]],[["Resolution"],["The outcome of the investigation and the actions taken, communicated to the person who complained."]]]},"edited":false},{"heading":"4. Policy Statement (G.S. 131E-144.6(b); 42 CFR §484.50(e)(1))","body":["\"A home care agency shall investigate, within 72 hours, complaints made to the agency by a home care client or the client's family and must document both the existence of the complaint and the resolution of the complaint.\" (G.S. 131E-144.6(b)). \"An agency shall comply with G.S. 131E-144.6(b).\" (10A NCAC 13J .1007(c)). Each patient has the right \"To voice grievances about care and not be subjected to discrimination or reprisal for doing so.\" (G.S. 131E-144.3(4)).\n\nUnder 42 CFR §484.50(e)(1) the Agency must investigate complaints made by a patient, the patient’s representative, caregivers and family about treatment or care that is (or fails to be) furnished, is furnished inconsistently or is furnished inappropriately, and about mistreatment, neglect, abuse, including injuries of unknown source, or misappropriation of patient property by anyone furnishing services on its behalf; document both the existence of the complaint and its resolution; and \"Take action to prevent further potential violations, including retaliation, while the complaint is being investigated.\"\n\nThe Agency acknowledges each complaint within ",{"k":"field","name":"settings.complaintAckDays","text":"5"},", and in every case investigates it within 72 hours of the complaint being made to anyone at the Agency, completing the fact-finding steps in Section 7 within that time, as the Agency’s own standard. The Agency aims to resolve each complaint within ",{"k":"field","name":"settings.complaintResolveDays","text":"30"},", as the Agency’s own standard."],"edited":false},{"heading":"5. Telling Patients How to Complain","body":[],"list":[["During the initial evaluation visit or before services start, each patient receives \"The address and telephone number for information, questions, or complaints about services provided by the agency\" and \"The address and telephone number of the section of the Department of Health and Human Services responsible for the enforcement of the provisions of this Part.\" (G.S. 131E-144.4(a)(3), (4)). The receipt is signed by the patient and kept (G.S. 131E-144.4(b); Policy NC-HH-PR-03)."],["Each patient is also told in writing of the Division’s complaint hotline, as G.S. 131E-141 requires, and, under 42 CFR §484.50(c)(9), of the state toll-free home health hotline, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local home health agencies."],["Form NC-HH-CMP-01-A, in English and Spanish, gives this information: the Agency’s complaint officer, ",{"k":"field","name":"agency.phone","text":"(919) 555-0100"},", ",{"k":"field","name":"agency.afterHoursPhone","text":"(919) 555-0199"}," and ",{"k":"field","name":"agency.address","text":"100 Example Street, Suite 100, Raleigh, North Carolina 27601"},"; and ",{"k":"field","name":"fixed.complaintBlock","text":"North Carolina Division of Health Service Regulation, Complaint Intake Unit, 2711 Mail Service Center, Raleigh, NC 27699-2711. Complaint Hotline 1-800-624-3004 (within North Carolina) or 919-855-4500, 9:00 a.m. to 12:00 p.m. and 1:00 p.m. to 4:00 p.m. on weekdays, except holidays. Fax 919-715-7724. Email DHSR.ComplaintIntake@dhhs.nc.gov. Complaint forms in English and Spanish: https://info.ncdhhs.gov/dhsr/ciu/filecomplaint.html"}],["Staff explain the form at admission and whenever a patient seems unhappy, and in the patient’s language (Policy NC-HH-PR-04)."]],"ordered":false,"edited":false},{"heading":"6. Receiving and Logging a Complaint","body":[],"list":[["Any staff member who receives a complaint thanks the person, writes down what was said, and tells the complaint officer or the on-call nurse the same day. Staff never discourage a complaint or argue with the person."],["If the complaint alleges abuse, neglect, exploitation, misappropriation of property or an injury of unknown source, staff also follow Policies NC-HH-SG-01, NC-HH-SG-02 and NC-HH-SG-03 at once; the 24-hour Health Care Personnel Registry report may be due before the complaint investigation ends."],["The complaint officer logs the complaint on Form NC-HH-CMP-01-B with the date and time anyone at the Agency first received it; the 72-hour clock runs from that time, including on weekends and holidays."],["The complaint officer acknowledges the complaint to the person who made it within ",{"k":"field","name":"settings.complaintAckDays","text":"5"},", by telephone or in writing, and gives the name of the person investigating."]],"ordered":false,"edited":false},{"heading":"7. Investigation and Resolution","body":[],"list":[["The complaint officer, or a supervisor who is not the subject of the complaint, starts the investigation promptly and, within 72 hours, contacts the person who complained and the patient, interviews the staff involved, and reviews the clinical record, schedules and EVV data (G.S. 131E-144.6(b)). If a step cannot be completed within 72 hours (for example, a staff member cannot be reached), the reason and the date it will be completed are recorded on Form NC-HH-CMP-01-B."],["While the complaint is investigated, the Agency acts to protect the patient and prevent further problems and retaliation, for example by changing the staff assignment (42 CFR §484.50(e)(1)(iii))."],["The investigator records the facts found, the conclusion and the actions taken on Form NC-HH-CMP-01-B."],["The complaint officer tells the person who complained the outcome, in writing if the person asks or if the complaint was made in writing, as the Agency’s own standard, and how to take the matter further if he or she is not satisfied."],["A complainant who is not satisfied may ask the agency director to review the outcome. The agency director’s decision is given in writing."],["Complaints about privacy go to the Privacy Official (45 CFR §164.530(d); Policy NC-HH-PRV-01). Complaints about discrimination or language access also follow Policy NC-HH-PR-04."]],"ordered":false,"edited":false},{"heading":"8. Complaints Outside the Agency","body":["Patients may complain to any of these at any time, with or without first complaining to the Agency, and the Agency will not retaliate (42 CFR §484.50(c)(11)):"],"table":{"caption":["Table 1.  Outside complaint routes"],"headers":[["Concern"],["Where to go"]],"rows":[[["Care or services of a licensed home care agency, Medicare or Medicaid home health agency"],[{"k":"field","name":"fixed.complaintBlock","text":"North Carolina Division of Health Service Regulation, Complaint Intake Unit, 2711 Mail Service Center, Raleigh, NC 27699-2711. Complaint Hotline 1-800-624-3004 (within North Carolina) or 919-855-4500, 9:00 a.m. to 12:00 p.m. and 1:00 p.m. to 4:00 p.m. on weekdays, except holidays. Fax 919-715-7724. Email DHSR.ComplaintIntake@dhhs.nc.gov. Complaint forms in English and Spanish: https://info.ncdhhs.gov/dhsr/ciu/filecomplaint.html"}]],[["Medicare quality of care, or a disagreement with a Medicare discharge"],[{"k":"field","name":"fixed.bfccQio","text":"Acentra Health, the Medicare Beneficiary and Family Centered Care Quality Improvement Organization for North Carolina (Region 4): toll free 888-317-0751, TTY 711"}]],[["Privacy (HIPAA) or discrimination"],[{"k":"field","name":"fixed.ocrHotline","text":"U.S. Department of Health and Human Services, Office for Civil Rights, 1-800-368-1019"}]],[["Medicaid fraud, waste or abuse"],["NC Medicaid Fraud, Waste and Program Abuse Tip Line, ",{"k":"field","name":"fixed.medicaidFraudTipLine","text":"1-877-362-8471"}]],[["Medicare fraud"],[{"k":"field","name":"fixed.oigHotline","text":"U.S. Department of Health and Human Services, Office of Inspector General (Medicare fraud), 1-800-447-8477"}]],[["Abuse, neglect or exploitation of a disabled adult"],[{"k":"field","name":"fixed.abuseReportRoute","text":"the director of the department of social services in the county where the adult lives or is present (G.S. 108A-101(c), 108A-102), orally (by telephone or in person) or in writing; county department of social services contacts are listed at https://www.ncdhhs.gov/divisions/social-services/local-dss-directory, and the NCDHHS Customer Service Center (1-800-662-7030) can help find the right county office. If anyone is in immediate danger, call 911 first."}]]]},"note":["For information: when the Division receives a complaint, North Carolina law sets time frames for its own response and investigation (G.S. 131E-144.6(a), (a1)). The Division investigates incidents that occurred within the past year, its investigations are unannounced, and it does not share the complainant’s identity with the agency. The Agency cooperates fully with any Division investigation."],"edited":false},{"heading":"9. Learning from Complaints","body":["The complaint officer reports complaints by type, service and outcome to the QAPI committee at each meeting (Policy NC-HH-QA-02). Complaints are part of the annual evaluation (Policy NC-HH-QA-01). Repeated complaints about a staff member are addressed through supervision and the performance evaluation."],"edited":false},{"heading":"10. Responsibilities","body":["Accountability under this policy is allocated as follows."],"table":{"caption":["Who is accountable for what"],"headers":[["Role"],["Responsibility under this policy"]],"rows":[[[{"k":"field","name":"people.complaintOfficer.name","text":"Pat Sample"},", ",{"k":"field","name":"people.complaintOfficer.title","text":"Administrator"}],["Complaint officer. Logs and acknowledges complaints; makes sure every complaint is investigated within 72 hours; communicates outcomes; reports to the QAPI committee."]],[[{"k":"field","name":"people.administrator.name","text":"Pat Sample"},", ",{"k":"field","name":"people.administrator.title","text":"Administrator"}],["Owns this policy; reviews outcomes on request; makes sure no one is retaliated against; leads investigations of complaints about supervisors."]],[[{"k":"field","name":"people.supervisingNurse.name","text":"Robin Sample, RN"},", ",{"k":"field","name":"people.supervisingNurse.title","text":"Supervising Nurse"}],["Investigates clinical complaints; changes staff assignments to protect patients; acts on findings."]],[["All staff"],["Accept complaints courteously; pass them on the same day; follow the safeguarding policies when a complaint alleges abuse or neglect."]]]},"edited":false},{"heading":"11. Records and Compliance Monitoring","body":["Form NC-HH-CMP-01-B and investigation records are kept for six years, as the Agency’s own standard. North Carolina’s home care rules set no retention period for complaint records. Each month the complaint officer checks the log for any complaint that was not investigated within 72 hours and reports it to the agency director."],"edited":false},{"heading":"12. Staff Training","body":["Every staff member learns at orientation and annually, as the Agency’s own standard, how to receive a complaint, the 72-hour investigation rule, the outside complaint routes, and the ban on retaliation. Supervisors are trained in investigating and resolving complaints."],"edited":false},{"heading":"13. References","body":["This policy implements the following authorities."],"list":[["G.S. 131E-141, Inspections"],["G.S. 131E-144.3(4), Home Care Clients’ Bill of Rights"],["G.S. 131E-144.4, Notice to clients"],["G.S. 131E-144.6, Enforcement and investigation"],["10A NCAC 13J .1007(b) and (c), Client Rights and Responsibilities"],["42 CFR §484.50(c)(3), (c)(9), (c)(11) and (e), Patient rights; Investigation of complaints"],["45 CFR §164.530(d), Complaints to the covered entity"]],"ordered":false,"edited":false},{"heading":"14. Related Policies and Forms","body":["The following documents are read together with this policy."],"table":{"caption":null,"headers":[["Reference"],["Title"]],"rows":[[["Policy NC-HH-PR-01"],["Patient Rights and Responsibilities (Home Care Clients’ Bill of Rights)"]],[["Policy NC-HH-PR-03"],["Service Agreement, Consent, Statement of Services and Charges, and Notice About Record Review"]],[["Policy NC-HH-PR-04"],["Language Access, Accessibility, and Nondiscrimination"]],[["Policy NC-HH-SG-01"],["Abuse, Neglect, and Exploitation of Disabled Adults: Recognition and Reporting to the County Department of Social Services"]],[["Policy NC-HH-SG-02"],["Allegations Against Staff: Health Care Personnel Registry Reports and Agency Investigations"]],[["Policy NC-HH-SG-03"],["Child Abuse, Neglect, and Dependency Reporting"]],[["Policy NC-HH-QA-01"],["Annual Program Evaluation and 90-Day Client Record Review"]],[["Policy NC-HH-QA-02"],["Quality Assessment and Performance Improvement (QAPI)"]],[["Policy NC-HH-QA-03"],["Incident Reporting, Investigation, and Adverse Events"]],[["Policy NC-HH-PRV-01"],["HIPAA Privacy and Patient and Employee Confidentiality"]],[["Policy NC-HH-DC-02"],["Reduction, Termination, Transfer, and Discharge Notice, Including Discharge for Cause"]],[["Form NC-HH-CMP-01-A"],["Where to Direct a Complaint"]],[["Form NC-HH-CMP-01-B"],["Complaint Log"]]]},"edited":false},{"heading":"15. Approval","body":["This policy is adopted by the governing body of ",{"k":"field","name":"agency.name","text":"Sample Agency, LLC"},". The effective date, the person who approved it, and the date of approval are shown in the header block and recorded in the signature lines below."],"edited":false},{"heading":"16. Revision History","body":["Every version of this policy, the date it took effect, a summary of what changed, and who approved it is recorded below. Where a rule cited in Section 13 is amended, the amendment is recorded in this table and a new version of this policy is issued."],"edited":false}],"missing":[],"editedCount":0,"pack":"nc-hha","state":"North Carolina","service":"Home health","guides":[{"path":"/guides/home-health-agency-policies/","h1":"What policies and procedures are required for home health agencies?"},{"path":"/guides/home-health-conditions-of-participation/","h1":"Home health Conditions of Participation: which policies each one needs"}],"sample":true,"agency":{"name":"Sample Agency","legalName":"Sample Agency, LLC","logo":null}}