{"ref":"PA-HH-CMP-01","title":"Complaints and Grievances","category":"Client rights","own":false,"summary":"Gives every patient the right to complain about care or treatment without discrimination or reprisal, tells patients how to complain to the Agency and to outside bodies including the Department of Health home health complaint line (1-800-254-5164), and sets the Agency’s procedure to acknowledge, investigate, document and resolve each complaint within the Agency’s own time frames. Chapter 601 has no complaint procedure section; the Agency applies 42 CFR §484.50(e) to all patients, which is binding if the Agency is Medicare-certified.","inShort":["Patients may complain at any time, to anyone, and must never be treated worse for it.","Listen, keep the patient safe, and tell the complaint officer, Pat Sample, the same working day.","If the complaint is about abuse, neglect or missing property, also make the abuse report yourself at once.","We acknowledge complaints within 5 and resolve them within 30.","Patients can also call the Department of Health home health complaint line at 1-800-254-5164."],"primaryCitation":"42 CFR §484.50(e)","citations":["28 Pa. Code §51.3(g)(6)","28 Pa. Code §601.22(c)","35 P.S. §10225.302"],"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 for the last year. How long did each complaint take to resolve?","How does a patient know how to complain to you and to the Department of Health?","What did you do about this complaint, and how did you protect the patient from retaliation?","Which complaints did you also report as abuse?"],"version":"1.0","effectiveDate":"2026-10-01","reviewDate":"2027-10-01","approvedBy":"Pat Sample, Administrator","forms":[{"ref":"PA-HH-CMP-01-A","title":"Where to Direct a Complaint"},{"ref":"PA-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.complaintOfficer.name","text":"Pat Sample"},", ",{"k":"field","name":"people.complaintOfficer.title","text":"Administrator"}]],[["Authority"],["Adopted under 42 CFR §484.50(c)(3), (c)(9), (c)(11) and (e), binding if the Agency is Medicare-certified and applied to all patients as the Agency’s own standard; 28 Pa. Code §51.3(g)(6); and §601.22(c) (complaint data used in the annual program evaluation)."]],[["Applies to"],["Every employee and contractor who receives a complaint, the complaint officer, the Administrator, and the governing body."]],[["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"],["Abuse reports to outside authorities, which are Policy PA-HH-SG-01. Staff grievances about employment, which follow the Agency’s personnel policies."]],[["Review"],["Reviewed by the document owner at least every ",{"k":"field","name":"settings.reviewFrequencyMonths","text":"12"}," months, at the annual policy review by the group of professional personnel under 28 Pa. Code §601.22(a) where this policy is within its scope, and within 30 days of any amendment to a rule cited at Section 12. Each review is recorded at Section 15 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 at least seven years."]],[["Distribution"],["Master copy held in the policy manual at the Agency office, together with the current copy of 28 Pa. Code Chapter 601 that §601.3(a) requires. Available to every staff member it applies to through the policy library and covered at orientation."]],[["Questions"],["Direct to the document owner on ",{"k":"field","name":"agency.phone","text":"(717) 555-0100"}," or ",{"k":"field","name":"agency.email","text":"office@example.com"},"."]]]},"edited":false},{"heading":"1. Purpose","body":["This policy makes sure that patients and families of ",{"k":"field","name":"agency.name","text":"Sample Agency, LLC"}," (the \"Agency\") can raise concerns easily and safely, that every complaint is taken seriously and resolved, and that the Agency learns from complaints."],"edited":false},{"heading":"2. Scope","body":["This policy covers any expression of dissatisfaction, oral or written, by a patient, representative, caregiver, family member or other person about the care or treatment the Agency furnishes or fails to furnish, the lack of respect for the patient’s property, the conduct of staff, billing, or any other Agency service."],"edited":false},{"heading":"3. Definitions","body":["The following terms have the meanings given below when used in this policy."],"table":{"caption":null,"headers":[["Term"],["Meaning"]],"rows":[[["Patient"],["A person receiving home health services from the Agency. 28 Pa. Code Chapter 601 and 42 CFR Part 484 both say \"patient\". The Older Adults Protective Services Act, 6 Pa. Code Chapter 15 and the Medical Assistance rules (55 Pa. Code) say \"recipient\". In this policy these words mean the same person."]],[["Medicare-certified"],["Certified by CMS to take part in Medicare under 42 CFR Part 484. Where this policy says a duty applies \"if the Agency is Medicare-certified\", the duty is a federal Condition of Participation. Under 28 Pa. Code §601.2(c) and §601.11(d) a certified agency is deemed to meet Chapter 601 once it meets §601.11(a)-(c), but the Agency follows the Pennsylvania standards in this policy in every case."]],[["Complaint"],["Any expression of dissatisfaction about Agency care, services, staff or billing, whether made orally or in writing, to any staff member. A patient does not have to use the word \"complaint\"."]],[["Complaint officer"],["The person responsible for receiving and resolving complaints: ",{"k":"field","name":"people.complaintOfficer.name","text":"Pat Sample"},", ",{"k":"field","name":"people.complaintOfficer.title","text":"Administrator"},", ",{"k":"field","name":"people.complaintOfficer.phone","text":"(717) 555-0111"},", ",{"k":"field","name":"people.complaintOfficer.email","text":"person1@example.com"},"."]],[["Acknowledgment"],["Telling the person who complained, orally or in writing, that the complaint has been received and what will happen next, within ",{"k":"field","name":"settings.complaintAckDays","text":"5"}," (Agency standard)."]],[["Resolution"],["The written or documented oral response explaining what was found and what the Agency has done, within ",{"k":"field","name":"settings.complaintResolveDays","text":"30"}," (Agency standard)."]]]},"edited":false},{"heading":"4. Policy Statement (42 CFR §484.50(e))","body":["Every patient has the right to make complaints to the Agency regarding treatment or care that is (or fails to be) furnished, and regarding the lack of respect for the patient’s property by anyone furnishing services on behalf of the Agency (42 CFR §484.50(c)(3)), and to be free from any discrimination or reprisal for exercising these rights or for voicing grievances to the Agency or an outside entity (§484.50(c)(11)). Each patient is given the Department of Health home health complaint line, ",{"k":"field","name":"fixed.complaintHotline","text":"1-800-254-5164"},", with its contact information and purpose (§484.50(c)(9)).\n\nThe Agency investigates complaints made by a patient, the representative or caregivers about treatment or care, mistreatment, neglect, verbal, mental, sexual and physical abuse (including injuries of unknown source), and misappropriation of patient property; documents both the existence of the complaint and its resolution; and takes action to prevent further potential violations, including retaliation, while the complaint is being investigated (42 CFR §484.50(e)(1)).\n\nNeither federal nor Pennsylvania rules set a number of days for acknowledging or resolving a complaint. The Agency acknowledges each complaint within ",{"k":"field","name":"settings.complaintAckDays","text":"5"}," and resolves it within ",{"k":"field","name":"settings.complaintResolveDays","text":"30"}," as its own standard, and sooner where the patient’s safety requires. A complaint of patient abuse is reported at once under Policy PA-HH-SG-01 and notified in writing to the Department of Health, \"whether or not confirmed by the facility\" (28 Pa. Code §51.3(g)(6); Policy PA-HH-QA-02)."],"edited":false},{"heading":"5. Telling Patients How to Complain","body":[],"list":[["At the start of care each patient and representative receives Form PA-HH-CMP-01-A, with the notice of rights (Policy PA-HH-PR-01). Receipt is documented in the record."],["The form gives the complaint officer’s name and contact details, the office number ",{"k":"field","name":"agency.phone","text":"(717) 555-0100"}," and after-hours number ",{"k":"field","name":"agency.afterHoursPhone","text":"(717) 555-0199"},", and the outside bodies in Section 8."],["Staff remind patients that they may complain at any time, to anyone, without affecting their care."]],"ordered":false,"edited":false},{"heading":"6. Procedure","body":[],"list":[["Receive. Any staff member who receives a complaint listens, thanks the person, takes immediate steps to keep the patient safe, and reports it to the complaint officer the same working day. Staff do not argue, promise outcomes, or ask the person to put it in writing."],["Screen for abuse. If the complaint involves possible abuse, neglect, exploitation, injuries of unknown source or misappropriation of property, the staff member also makes the immediate report under Policy PA-HH-SG-01, and the Administrator acts under Policies PA-HH-SG-03 and PA-HH-QA-02."],["Log. The complaint officer enters the complaint on Form PA-HH-CMP-01-B with the date received, the person, the subject and the staff involved."],["Acknowledge within ",{"k":"field","name":"settings.complaintAckDays","text":"5"},"."],["Investigate. The complaint officer, with the supervising nurse for clinical matters, reviews the record, interviews the patient and staff, and documents the facts. While the complaint is open, the Agency takes action to prevent further potential violations, including retaliation (42 CFR §484.50(e)(1)(iii)), for example by changing the staff assigned."],["Resolve within ",{"k":"field","name":"settings.complaintResolveDays","text":"30"},". The complaint officer tells the person what was found and what the Agency has done, in writing if the complaint was written or the person asks, and reminds them of the outside bodies they may contact if not satisfied."],["Escalate. If the person is not satisfied, the Administrator reviews the complaint, and then the governing body if asked."],["Close and learn. The resolution is recorded on the log. Complaints are reviewed quarterly by the QAPI Committee (Policy PA-HH-QA-01), and complaint data feeds the annual program evaluation (28 Pa. Code §601.22(c); Policy PA-HH-GOV-04)."]],"ordered":true,"edited":false},{"heading":"7. Complaints About the Administrator or Complaint Officer","body":["A complaint about the complaint officer goes to the Administrator. A complaint about the Administrator goes to the alternate administrator, ",{"k":"field","name":"people.alternate.name","text":"Jo Sample"},", ",{"k":"field","name":"people.alternate.title","text":"Alternate Administrator"},", who investigates and reports directly to the governing body."],"edited":false},{"heading":"8. Outside Bodies","body":["Patients may contact any of these at any time, whether or not they have complained to the Agency first."],"table":{"caption":["Table 1.  Where patients may also take a concern"],"headers":[["Body"],["For"],["Contact"]],"rows":[[["Pennsylvania Department of Health, Division of Home Health"],["Any complaint about a home health agency"],[{"k":"field","name":"fixed.complaintBlock","text":"the Pennsylvania Department of Health, Division of Home Health, 2525 N. 7th Street, Harrisburg, PA 17110, home health complaint line 1-800-254-5164 (toll free)"}]],[["Local Area Agency on Aging protective services"],["Abuse, neglect, exploitation or abandonment"],[{"k":"field","name":"agency.localProtectiveServicesPhone","text":"(717) 555-0121"}]],[["Statewide Elder Abuse Helpline (24 hours)"],["Abuse of older adults, and of adults 18 to 59 with a disability"],[{"k":"field","name":"fixed.abuseHotline","text":"1-800-490-8505"}]],[["ChildLine (24 hours)"],["Abuse of a child"],[{"k":"field","name":"fixed.childAbuseHotline","text":"1-800-932-0313"}," (TDD ",{"k":"field","name":"fixed.childAbuseTdd","text":"1-866-872-1677"},")"]],[["Long-term care ombudsman"],["Help resolving a concern about long-term care services"],[{"k":"field","name":"agency.localOmbudsmanPhone","text":"(717) 555-0120"}]],[["U.S. Department of Health and Human Services, Office for Civil Rights"],["Privacy and discrimination complaints"],["As shown on the Notice of Privacy Practices and the Notice of Nondiscrimination (45 CFR §164.530(d); Policy PA-HH-GOV-07)"]],[["Medicare Beneficiary and Family Centered Care Quality Improvement Organization (Medicare patients)"],["Quality of care complaints and appeals of service termination"],["As shown on the Medicare notices the patient receives (Policy PA-HH-PR-03)"]]]},"edited":false},{"heading":"9. 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"}],["Owns this policy; logs, acknowledges, investigates and resolves complaints on time; reports to the QAPI Committee."]],[[{"k":"field","name":"people.administrator.name","text":"Pat Sample"},", ",{"k":"field","name":"people.administrator.title","text":"Administrator"}],["Reviews escalated complaints; makes abuse-related notices; ensures no retaliation."]],[[{"k":"field","name":"people.alternate.name","text":"Jo Sample"},", ",{"k":"field","name":"people.alternate.title","text":"Alternate Administrator"}],["Handles complaints about the Administrator."]],[[{"k":"field","name":"people.supervisingNurse.name","text":"Robin Sample, RN"},", ",{"k":"field","name":"people.supervisingNurse.title","text":"Supervising Nurse"}],["Investigates clinical complaints with the complaint officer; reassigns staff where needed."]],[["All staff"],["Receive complaints politely, keep the patient safe, report abuse at once, and report every complaint to the complaint officer the same working day."]],[["Governing body"],["Reviews complaint trends quarterly and hears appeals."]]]},"edited":false},{"heading":"10. Records and Compliance Monitoring","body":["The complaint officer keeps Form PA-HH-CMP-01-B and each complaint file (acknowledgment, investigation, resolution and any appeal) for at least seven years (Agency standard). If the Agency is Medicare-certified, the log documents both the existence of each complaint and its resolution (42 CFR §484.50(e)(1)(ii)). Each quarter the complaint officer reports to the QAPI Committee the number and type of complaints and the percentage acknowledged and resolved within the Agency’s time frames."],"edited":false},{"heading":"11. Staff Training","body":["All staff learn at orientation and yearly how to receive a complaint, how to recognize when it is also an abuse report, and that patients must never suffer reprisal for complaining (Agency standard). The complaint officer reviews this policy and 42 CFR §484.50 at appointment."],"edited":false},{"heading":"12. References","body":["This policy implements the following authorities."],"list":[["42 CFR §484.50(c)(3), (c)(9), (c)(11) and (e), Patient rights: complaints (if Medicare-certified; Agency standard for all patients)"],["28 Pa. Code §51.3(g)(6), Notification of complaints of patient abuse"],["28 Pa. Code §601.22(c), Annual program evaluation"],["35 P.S. §10225.302(c), Protection from retaliation for reporters"],["45 CFR §164.530(d), Privacy complaints"]],"ordered":false,"edited":false},{"heading":"13. Related Policies and Forms","body":["The following documents are read together with this policy."],"table":{"caption":null,"headers":[["Reference"],["Title"]],"rows":[[["Policy PA-HH-PR-01"],["Patient Rights and Responsibilities"]],[["Policy PA-HH-SG-01"],["Abuse, Neglect, and Exploitation of Adults: Mandatory Reporting"]],[["Policy PA-HH-SG-03"],["Employee Alleged to Have Committed Abuse: Plan of Supervision and Suspension"]],[["Policy PA-HH-QA-01"],["Quality Assessment and Performance Improvement and Quarterly Clinical Record Review"]],[["Policy PA-HH-QA-02"],["Incident Reporting, Serious Event Notices to the Department, and Investigations"]],[["Policy PA-HH-GOV-04"],["Group of Professional Personnel, Annual Policy Review, and Annual Program Evaluation"]],[["Policy PA-HH-GOV-07"],["Nondiscrimination and Civil Rights Compliance"]],[["Policy PA-HH-PR-03"],["Patient Agreement, Consent, and Disclosure of Charges"]],[["Policy PA-HH-PRV-01"],["HIPAA Privacy and Pennsylvania Confidentiality Laws"]],[["Form PA-HH-CMP-01-A"],["Where to Direct a Complaint"]],[["Form PA-HH-CMP-01-B"],["Complaint Log"]]]},"edited":false},{"heading":"14. 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":"15. 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 12 is amended, the amendment is recorded in this table and a new version of this policy is issued."],"edited":false}],"missing":[],"editedCount":0,"pack":"pa-hha","state":"Pennsylvania","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}}