{"ref":"TX-HSP-CMP-01","title":"Complaints and Grievances","category":"Patient rights","own":false,"summary":"Explains how patients, families, guardians and health care providers can complain about hospice care without fear of reprisal, how staff take and log every complaint, how the Agency acknowledges, investigates and resolves it within the time frames in this policy and Texas rule, and how patients can go directly to HHSC.","inShort":["Treat every complaint seriously and politely, and never argue or discourage it.","Write down what was said and pass it to the complaint officer, Pat Sample, the same working day.","If the complaint sounds like abuse, neglect or exploitation, follow the abuse reporting policy at once.","Patients can always complain to HHSC at 1-800-458-9858. No one loses care for complaining."],"primaryCitation":"26 TAC §558.250(c)","citations":["26 TAC §558.250(c)-(e)","26 TAC §558.282(a), (d), (f)(8)","26 TAC §558.301(a)(9)(L)","26 TAC §558.287(a)(1)(A)(ii)(V), (iv)","Tex. Hum. Res. Code §102.003(f)"],"federalCitations":["42 CFR §418.52(b)(1)(iii)-(iv)","45 CFR §164.530(d)"],"surveyorAsks":["Show me your complaint log and pick one: when was it received, when did the investigation start, and when did it close?","What written statement about complaints did this patient receive at admission?","How long does the Agency take to review and resolve a complaint?","Ask an aide: a daughter tells you she is unhappy that the nurse came late. What do you do?","How do complaints reach your QAPI Committee?"],"version":"1.0","effectiveDate":"2026-10-01","reviewDate":"2027-10-01","approvedBy":"Pat Sample, Administrator","forms":[{"ref":"TX-HSP-CMP-01-A","title":"How to Make a Complaint"},{"ref":"TX-HSP-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 Hospice, LLC"}]],[["Document owner"],[{"k":"field","name":"people.complaintOfficer.name","text":"Pat Sample"},", ",{"k":"field","name":"people.complaintOfficer.title","text":"Administrator"},", accountable to ",{"k":"field","name":"people.administrator.name","text":"Pat Sample"},", ",{"k":"field","name":"people.administrator.title","text":"Administrator"}]],[["Authority"],["Adopted under 26 TAC §558.250(a), (c)-(e) (complaint investigations), §558.282(a) and (d) (grievance mechanism and complaint statement), and, if the Agency is Medicare-certified, 42 CFR §418.52(b)(1)(iii)-(iv)."]],[["Applies to"],["Every employee, contractor and volunteer, and every complaint about the Agency’s care or services, however it is made."]],[["Status"],["Mandatory. No complaint is too small to record."]],[["Not covered here"],["Allegations of abuse, neglect or exploitation, which are reported at once under Policy TX-HSP-ANE-01 and investigated under Policy TX-HSP-ANE-02. Privacy complaints are investigated here and also assessed under Policy TX-HSP-PRV-03."]],[["Review"],["Reviewed by the document owner at least every ",{"k":"field","name":"settings.reviewFrequencyMonths","text":"12"}," months. Each review is recorded at Section 14."]],[["Amendment"],["Any change requires the approval of the governing body and a new version number. Superseded versions are retained for at least six years."]],[["Distribution"],["Master copy in the policy manual. Patients receive Form TX-HSP-CMP-01-A at admission."]],[["Questions"],["Direct to the complaint officer on ",{"k":"field","name":"people.complaintOfficer.phone","text":"(512) 555-0111"}," or ",{"k":"field","name":"people.complaintOfficer.email","text":"person1@example.com"},"."]]]},"edited":false},{"heading":"1. Purpose","body":["A family caring for a dying person rarely has time or energy to complain, so when they do, it matters. This policy makes sure that ",{"k":"field","name":"agency.name","text":"Sample Hospice, LLC"}," (the \"Agency\") listens, acts quickly, puts things right, and learns, and that patients know they can complain to the Agency or directly to HHSC without any effect on their care."],"edited":false},{"heading":"2. Scope","body":["Complaints made by a patient, the patient’s family or guardian, or the patient’s health care provider (including a nursing facility) about treatment or care the Agency furnished, treatment or care it failed to furnish, or a lack of respect for the patient’s property by anyone furnishing services on the Agency’s behalf (26 TAC §558.250(c)(1)). As the Agency’s own standard, complaints from anyone else, such as a neighbor or referral source, are handled the same way."],"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 hospice services; 26 TAC Chapter 558 says \"client\" and the two mean the same person here."]],[["Complaint or grievance"],["Any expression of dissatisfaction with the Agency’s care, services, staff or conduct, spoken or written, whether or not the word complaint is used. The Agency treats \"complaint\" and \"grievance\" as the same."]],[["Receipt"],["The date any employee, contractor or volunteer first hears of the complaint."]],[["Complaint officer"],[{"k":"field","name":"people.complaintOfficer.name","text":"Pat Sample"},", ",{"k":"field","name":"people.complaintOfficer.title","text":"Administrator"},", who manages complaints for the Agency."]]]},"edited":false},{"heading":"4. Policy Statement (26 TAC §558.250(c); §558.282)","body":["The Agency has a grievance mechanism under which a patient can participate without fear of reprisal (26 TAC §558.282(a)). Every patient has the right to voice grievances regarding treatment or care that is, or fails to be, furnished, or regarding the lack of respect for property by anyone furnishing services on behalf of the Agency, and must not be subjected to discrimination or reprisal for doing so (26 TAC §558.282(f)(8); 42 CFR §418.52(b)(1)(iii)-(iv)). A patient 60 or older may complain about care or treatment, anonymously or through a person the patient designates, and the Agency must promptly respond to resolve the complaint and may not discriminate or take punitive action against the patient (Tex. Hum. Res. Code §102.003(f)).\n\nThe Agency documents receipt of each complaint and initiates an investigation within 10 days after receipt; documents all components of the investigation (26 TAC §558.250(c)(2)); and completes the investigation and documentation within 30 days after receipt, unless it has and documents reasonable cause for a delay (26 TAC §558.250(d)). Within those limits the Agency acknowledges each complaint within ",{"k":"field","name":"settings.complaintAckDays","text":"5"}," and aims to resolve it within ",{"k":"field","name":"settings.complaintResolveDays","text":"30"},". The Agency does not retaliate against any person for filing a complaint, presenting a grievance, or providing information in good faith (26 TAC §558.250(e))."],"edited":false},{"heading":"5. Telling Patients How to Complain","body":["At admission, the Agency gives each patient a written statement that a complaint against the Agency may be directed to HHSC Complaint and Incident Intake, P.O. Box 149030, Austin, Texas 78714-9030, toll free 1-800-458-9858 (26 TAC §558.282(d)). The statement also tells the patient that a complaint may be directed to the Agency’s administrator and, because it does, it states the time frame in which the Agency reviews and resolves a complaint (26 TAC §558.282(d)). This is Form TX-HSP-CMP-01-A. The clinical record documents that the patient was informed (26 TAC §558.301(a)(9)(L)). HHSC can also be contacted at ",{"k":"field","name":"fixed.hhscComplaintBlock","text":"HHSC Complaint and Incident Intake, P.O. Box 149030, Austin, Texas 78714-9030, toll free 1-800-458-9858"},"."],"edited":false},{"heading":"6. Procedure","body":[],"list":[["Listen and record (any staff member, same day). Thank the person, listen without arguing, and fix anything you safely can at once (for example, call for a missed supply delivery). Record what was said, by whom, the date and time, and give it to the complaint officer the same working day. Never discourage a complaint or suggest it may affect care."],["Check for abuse, neglect or exploitation. If the complaint suggests abuse, neglect, exploitation or an injury of unknown source, follow Policy TX-HSP-ANE-01 at once; the 24-hour outer limit runs from the moment the Agency has cause to believe."],["Log and acknowledge (complaint officer). Enter the complaint on Form TX-HSP-CMP-01-B with the date of receipt, and acknowledge it to the complainant within ",{"k":"field","name":"settings.complaintAckDays","text":"5"},", by telephone or in writing, giving the name of the person handling it."],["Initiate the investigation (complaint officer, no later than 10 days after receipt). Record the date the investigation began (26 TAC §558.250(c)(2)(A)). For a complaint about a current patient’s care, the supervising nurse reviews the care within one working day (the Agency’s own standard)."],["Investigate. Talk to the complainant, the patient where able, and staff involved; review the record, schedules and visit data; and document every step (26 TAC §558.250(c)(2)(B)). If the complaint is about the complaint officer or the Administrator, the governing body assigns someone else."],["Resolve and respond. Decide what happened and what will change. Tell the complainant the outcome, in writing if they wish, and that they may also contact HHSC. Aim to resolve within ",{"k":"field","name":"settings.complaintResolveDays","text":"30"},"."],["Close (no later than 30 days after receipt). Complete the investigation and documentation within 30 days, or document the reasonable cause for delay and the expected date before day 30 (26 TAC §558.250(d))."],["Learn. Report every complaint and its outcome to the QAPI Committee (26 TAC §558.287(a)(1)(A)(ii)(V), (iv); Policy TX-HSP-QA-01)."]],"ordered":true,"edited":false},{"heading":"7. Complaints From or About Facilities","body":["Where a patient lives in a nursing facility or ICF/IID, a complaint by facility staff about hospice care, or by the hospice about facility care, is handled through the coordination arrangements in Policy TX-HSP-FAC-01. A complaint by the family about facility care is passed, with consent, to the facility and the family is told how to contact HHSC. Any concern of abuse, neglect or exploitation follows Policy TX-HSP-ANE-01."],"edited":false},{"heading":"8. Responsibilities","body":["Accountability under this policy is allocated as follows."],"table":{"caption":null,"headers":[["Role"],["Responsibility under this policy"]],"rows":[[["Governing body"],["Adopts this policy, sets the acknowledgment and resolution time frames within the rule limits, reviews complaint trends, and assigns an investigator for complaints about the Administrator or complaint officer."]],[[{"k":"field","name":"people.complaintOfficer.name","text":"Pat Sample"},", ",{"k":"field","name":"people.complaintOfficer.title","text":"Administrator"}],["Keeps the log, acknowledges, initiates within 10 days, investigates or assigns, responds, closes within 30 days, and reports to the QAPI Committee."]],[[{"k":"field","name":"people.administrator.name","text":"Pat Sample"},", ",{"k":"field","name":"people.administrator.title","text":"Administrator"}],["Ensures the process works, decides corrective action, and handles complaints that also involve abuse, neglect or exploitation under Policies TX-HSP-ANE-01 and TX-HSP-ANE-02."]],[[{"k":"field","name":"people.supervisingNurse.name","text":"Robin Sample, RN"},", ",{"k":"field","name":"people.supervisingNurse.title","text":"Supervising Nurse"}],["Reviews care for complaints about current patients and leads clinical corrective action."]],[["All staff and volunteers"],["Receive complaints courteously, record them and pass them on the same working day."]]]},"edited":false},{"heading":"9. Records and Compliance Monitoring","body":["The complaint log (Form TX-HSP-CMP-01-B) and a file for each complaint, containing the record of receipt, acknowledgment, investigation steps, findings, response and corrective action, are kept for at least six years (the Agency’s own standard), confidential and available to HHSC on request. The complaint officer checks the log weekly for complaints approaching day 10 or day 30. The QAPI Committee reviews the number, type, timeliness and outcome of complaints and the appropriateness of the Agency’s responses at each meeting (26 TAC §558.287(a)(1)(A)(ii)(V))."],"edited":false},{"heading":"10. Staff Training","body":["Every employee, contractor and volunteer is trained at orientation and annually (the Agency’s own standard) on receiving complaints, recording them, recognizing when a complaint is really an abuse, neglect or exploitation report, and the no-retaliation rule."],"edited":false},{"heading":"11. References","body":["This policy implements the following authorities."],"list":[["26 Texas Administrative Code §558.250(c)-(e), Agency Investigations"],["26 Texas Administrative Code §558.282(a), (d) and (f)(8), Client Conduct and Responsibility and Client Rights"],["26 Texas Administrative Code §558.301(a)(9)(L); §558.287(a)(1)(A)"],["Texas Human Resources Code §102.003(f), complaints by elderly individuals"],["42 CFR §418.52(b)(1)(iii)-(iv), right to voice grievances without discrimination or reprisal"],["45 CFR §164.530(d), privacy complaints"]],"ordered":false,"edited":false},{"heading":"12. Related Policies and Forms","body":["The following documents are read together with this policy."],"table":{"caption":null,"headers":[["Reference"],["Title"]],"rows":[[["Form TX-HSP-CMP-01-A"],["How to Make a Complaint"]],[["Form TX-HSP-CMP-01-B"],["Complaint Log"]],[["Policy TX-HSP-PR-01"],["Patient Rights and Responsibilities"]],[["Policy TX-HSP-ANE-01"],["Recognizing and Reporting Abuse, Neglect and Exploitation"]],[["Policy TX-HSP-ANE-02"],["Agency Investigations and Provider Investigation Reports"]],[["Policy TX-HSP-QA-01"],["Quality Assessment and Performance Improvement"]],[["Policy TX-HSP-FAC-01"],["Hospice Care for Residents of a Nursing Facility or ICF/IID"]]]},"edited":false},{"heading":"13. Approval","body":["This policy is adopted by the governing body of ",{"k":"field","name":"agency.name","text":"Sample Hospice, 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":"14. 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 11 is amended, the amendment is recorded in this table and a new version of this policy is issued."],"edited":false}],"missing":[],"editedCount":0,"pack":"tx-hospice","state":"Texas","service":"Hospice","guides":[{"path":"/guides/hospice-policies/","h1":"What policies are required for hospice?"},{"path":"/guides/hospice-conditions-of-participation/","h1":"Hospice Conditions of Participation: which policies each one needs"}],"sample":true,"agency":{"name":"Sample Hospice","legalName":"Sample Hospice, LLC","logo":null}}