Complaints and Grievances

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.

A complaint is often the first sign that a patient's care or safety is at risk. This policy makes it easy to complain, makes sure every complaint is taken seriously and answered, and makes sure the Agency learns from it.

This policy covers every complaint or grievance, oral or written, from a patient, representative, family member, caregiver, facility, physician, staff member, volunteer or member of the public, about anything the Agency does or fails to do.

The following terms have the meanings given below when used in this policy.

Every patient has the right "To voice grievances regarding treatment or care that is (or fails to be) furnished and the lack of respect for property by anyone who is furnishing services on behalf of the hospice" and "To not be subjected to discrimination or reprisal for exercising his or her rights" (42 CFR §418.52(b)(1)(iii)-(iv)). California requires the Agency's complaint management policies to cover: the documentation patients or families need to submit a complaint; investigation and review of complaints received; follow-up requirements to resolve a complaint; safety management, such as real or potential threats to the health or safety of personnel or patients; and criminal misconduct, including investigation and reporting of abuse, neglect and exploitation to the appropriate law enforcement agency (22 CCR §74880(d)(4)(C)(i)-(v)). This policy covers each of them.

• At the first visit, before care begins, the admitting nurse explains the right to complain and gives Form CA-HSP-CMP-01-A with the patient rights notice (Policy CA-HSP-PR-01), in the patient's or representative's primary language. Rights must be given verbally and in writing "in a language and manner that the person understands" (Health & Safety Code §1751.100(a)).
• Form CA-HSP-CMP-01-A stays in the home folder and is given to facilities where patients live. It lists the Agency contacts and the outside routes in Section 9.
• Staff remind families during care that they can raise any concern at any time, including about a staff member, and that it will not affect care.

No documentation is required to make a complaint. A complaint may be made in person, by phone (including after hours to (916) 555-0199), by e-mail, by letter, on Form CA-HSP-CMP-01-A, or through any staff member, and may be anonymous. The staff member who receives an oral complaint writes it down on Form CA-HSP-CMP-01-A, reads it back to the complainant, and gives it to the complaint officer the same day. Any document the complainant wants to give (photos, bills, letters) is accepted and attached. Interpreters are provided at no cost.

1. Triage at once (the person who receives it, with the on-call manager after hours): Is anyone in danger? Does it allege abuse, neglect, mistreatment, an injury of unknown source or theft by anyone furnishing services for the Agency? Does it suggest a crime, a privacy breach, or billing fraud? If so, start the right process the same day: Policies CA-HSP-ANE-01 and CA-HSP-ANE-02 (abuse and alleged violations, reported to the Administrator immediately), CA-HSP-PRV-03 (privacy), CA-HSP-ETH-01 (fraud), and Section 8 (safety).
2. Log: the complaint officer enters every complaint on Form CA-HSP-CMP-01-B the day it is received.
3. Acknowledge: the complaint officer contacts the complainant within 5 of receipt (Agency time frame) to confirm receipt, explain the next steps and give a contact name.
4. Investigate (22 CCR §74880(d)(4)(C)(ii)): review the record, talk with the staff involved and the patient and family, visit if needed, and decide what happened. The investigator is not the person complained about.
5. Resolve: decide on actions (for example a change of staff, a care conference, a plan of care change, a billing correction, retraining). Give the complainant the outcome, in writing if they ask or if the complaint was in writing, within 30 of receipt (Agency time frame), sooner if the complaint affects current care. If more time is needed, tell the complainant why and when to expect an answer.
6. Follow up (22 CCR §74880(d)(4)(C)(iii)): within 30 days after the response (Agency standard) the complaint officer checks with the complainant that the problem is fixed and checks that the actions were carried out. If the complainant is not satisfied, the Administrator reviews the complaint, and may refer it to the governing body.
7. Close: record the findings, actions, response date and follow-up on Form CA-HSP-CMP-01-B.

• A complaint that shows a real or potential threat to the health or safety of a patient or staff member (for example an unsafe home, a threat of violence, missed medications, a caregiver unable to cope) is acted on the same day: a visit, a change in the plan of care, extra support, or a safety plan for staff (Policy CA-HSP-SAF-01).
• A complaint that suggests criminal misconduct, including abuse, neglect or exploitation, is reported to the appropriate law enforcement agency as Policies CA-HSP-ANE-01 and CA-HSP-ANE-02 set out. Mandated reporters still make their own reports.

Patients, families and anyone else may complain directly to any of these at any time, with or without first complaining to the Agency.

• CDPH gives the Agency the substance of the complaint no earlier than at the time of the investigation, and does not disclose the names of people in it unless the complainant asks (Health & Safety Code §1752.1(b)). The Agency never tries to find out who complained.
• The Administrator and all management personnel cooperate fully. Failure by hospice management personnel to cooperate with CDPH in an inspection or complaint investigation is a ground for denial, suspension or revocation of the license (Health & Safety Code §1755(a)(8)).
• Any deficiencies are answered with a plan of correction under Policy CA-HSP-GOV-04.

No patient, family member, staff member or other person is treated worse, has care reduced or is discharged because they complained, inside the Agency or to anyone outside it (42 CFR §418.52(b)(1)(iv); 22 CCR §74880(d)(4)(D)(iii)). Any report of retaliation is itself handled as a complaint and, if it involves a patient, as an alleged violation under Policy CA-HSP-ANE-02.

A complaint from a nursing facility, residential care facility or inpatient facility about hospice care, or from a patient or family about a facility, goes to the complaint officer and is handled under this policy. The designated IDT member for that patient works with the facility to resolve it (Policy CA-HSP-FAC-01). A complaint about care given by the facility that suggests abuse or neglect is reported under Policy CA-HSP-ANE-01; other concerns may be raised with the facility administrator, the ombudsman or the facility's licensing agency.

Each role named below carries the duties shown.

The complaint log (Form CA-HSP-CMP-01-B) and complaint files are kept for at least ten years (Agency standard); privacy complaints also for at least six years under 45 CFR §164.530(j). Each quarter the complaint officer reports to the QAPI program the number and types of complaints, the percentage acknowledged and resolved within the Agency time frames, follow-up results, and themes (Policy CA-HSP-QA-01).

All staff and volunteers learn at orientation and annually how to receive a complaint, the triage questions in Section 7, and the outside routes. Hospice management personnel orientation and annual training include complaint management as described in 22 CCR §74880(d)(4)(C) and the patient rights notifications, including a problem or dissatisfaction with patient care (§74880(d)(5)(B)(ii), (e); Policy CA-HSP-HR-01).

This policy implements the following authorities.

• 42 CFR §418.52(b) (patient rights to voice grievances and freedom from reprisal)
• 22 CCR §74880(d)(4)(C), (d)(4)(D)(iii), (d)(5)(B)(ii)
• Health & Safety Code §§1751.100(a), 1752.1, 1755(a)(8)
• 45 CFR §164.530(d), (j) (privacy complaints)

The following documents are read together with this policy.

This policy is adopted by the governing body of 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.

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 the References section is amended, the amendment is recorded in this table and a new version of this policy is issued.