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.

This policy makes sure every patient and family of Sample Agency, LLC knows how to raise a concern with the Agency and with AHCA, that every complaint is taken seriously, looked into, and answered, that no one suffers for complaining, and that the Agency learns from complaints.

Any expression of dissatisfaction about the Agency's care, services, staff, or business, made by a patient, a patient's representative, caregiver, or family member, or anyone acting for the patient, in person, by phone, in writing, by e-mail, or through any staff member, and any complaint AHCA or another body refers to the Agency.

For the purposes of this policy, the following terms have the meanings below. In this policy "the Agency" means Sample Agency, LLC, and the state Agency for Health Care Administration is called "AHCA". Part III of chapter 400, Florida Statutes, chapter 59A-8, Florida Administrative Code, and 42 CFR Part 484 all use the word "patient" for a person who receives home health services (s. 400.462(26), F.S.; Rule 59A-8.002(20), F.A.C.). Chapter 408, Part II, F.S. uses "client" for anyone a licensee serves (s. 408.803(6), F.S.); where a Florida text says "client", it means the same person.

On or before the first day services are provided to a patient, the Agency informs the patient and his or her immediate family or representative, if appropriate, of the right to report complaints, giving the statewide toll-free number in a manner that is clearly legible, with the words the statute requires (s. 408.810(5)(a)1., F.S.): "To report a complaint regarding the services you receive, please call toll-free 1-888-419-3456." The statute also provides: "Each licensee shall establish appropriate policies and procedures for providing such notice to clients." (s. 408.810(5)(b), F.S.); this policy and Policy FL-HH-PR-01 are those procedures. The Agency investigates every complaint, documents both the existence of the complaint and its resolution, and does not retaliate against anyone who complains. Florida law sets no time limit for a home health agency's own complaint process; the Agency acknowledges each complaint within 5 and resolves it within 30, as its own standard. A patient may complain to AHCA at any time, before, during, or after using the Agency's process.

• At admission each patient receives the first-day notice with To report a complaint regarding the services you receive, please call toll-free 1-888-419-3456., To report abuse, neglect, or exploitation, please call toll-free 1-800-962-2873., and To report suspected Medicaid fraud, please call toll-free 1-888-419-3456. (s. 408.810(5)(a), F.S.; Policy FL-HH-PR-01), the Agency's complaint form (Form FL-HH-CMP-01-A), and the name and phone number of the complaint officer.
• If the Agency is Medicare-certified, the written notice of rights includes contact information for the administrator, including the administrator's name, business address, and business phone number, in order to receive complaints (42 CFR §484.50(a)(1)(ii)); patients have the right to make complaints to the Agency regarding treatment or care that is (or fails to be) furnished, and the lack of respect for property and/or person by anyone furnishing services on its behalf (42 CFR §484.50(c)(3)); and patients must be advised of the state toll-free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs (42 CFR §484.50(c)(9)). The Agency gives the AHCA number 1-888-419-3456 and the hours of operation that AHCA currently publishes.
• Information is given in plain language and in the patient's language, with auxiliary aids and services where needed (Policy FL-HH-PR-04).

1. Any staff member who receives a complaint listens, thanks the person, and does not argue or make promises he or she cannot keep.
2. If the complainant wants help to write the complaint, the staff member helps or writes it down in the complainant's words on Form FL-HH-CMP-01-A.
3. The staff member passes the complaint to the complaint officer the same day, as the Agency's own standard, by phone and then in writing.
4. The complaint officer enters it in the complaint log on Form FL-HH-CMP-01-B with the date received, the complainant, the patient, the topic, and the staff involved.
5. Anonymous complaints are logged and investigated as far as the information allows.

Some complaints cannot wait for the normal process. The complaint officer, or any staff member, acts at once as Table 1 shows, and the complaint then continues through Sections 8 and 9.

• The complaint officer acknowledges the complaint to the complainant within 5, by phone or in writing, and records the date.
• The complaint officer, or a person the complaint officer names who is not involved in the matter, investigates: talks with the complainant, the patient, and the staff involved; reviews the clinical record, schedules, EVV data, and other documents; and records the findings on Form FL-HH-CMP-01-B.
• If the Agency is Medicare-certified, it must investigate complaints made by a patient, the patient's representative (if any), and the patient's caregivers and family, including, but not limited to, treatment or care that is (or fails to be) furnished, is furnished inconsistently, or is furnished inappropriately, and mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and/or misappropriation of patient property by anyone furnishing services on its behalf; document both the existence of the complaint and the resolution of the complaint; and take action to prevent further potential violations, including retaliation, while the complaint is being investigated (42 CFR §484.50(e)(1)). The Agency follows these steps for every patient, as the Agency's own standard.
• While a complaint about a staff member is investigated, the Administrator decides whether the staff member should be reassigned away from the patient.
• Complaints about clinical care are reviewed by the director of nursing, Robin Sample, RN.

• The complaint officer resolves the complaint within 30 of receiving it. If more time is truly needed, the complaint officer tells the complainant why and when to expect an answer, and records it.
• The complainant receives a response, in writing if he or she complained in writing or asks for it, stating what was looked into, what was found, and what the Agency has done or will do. Information about other patients or staff discipline is not disclosed.
• Every response reminds the complainant that he or she may contact AHCA at any time: Agency for Health Care Administration (Complaint Administration Unit), 2727 Mahan Drive, Tallahassee, FL 32308; toll-free 1-888-419-3456 (Florida Relay Service TDD 1-800-955-8771); online: Licensed Health Care Facility Complaint Form at https://apps.ahca.myflorida.com/hcfc/.
• Every response also gives, where they apply: for a Medicaid managed care plan member, the plan's member grievance process; for a resident of an assisted living facility or adult family-care home, Florida Long-Term Care Ombudsman Program (Florida Department of Elder Affairs), toll-free 1-888-831-0404; and, if the Agency is Medicare-certified, the Medicare Quality Improvement Organization for the area, among the entities 42 CFR §484.50(c)(10) requires the Agency to tell patients about.

A complainant who is not satisfied may ask the Administrator, Pat Sample, to review the decision. The Administrator responds within 30 of the request. A complainant still not satisfied may ask that the governing body review it at its next meeting, as the Agency's own standard. These reviews never delay or replace the complainant's right to go to AHCA.

No patient, family member, or staff member may be threatened, punished, or given worse service because of a complaint, whether made to the Agency, AHCA, or anyone else. A complaint is never a reason to discharge a patient. Staff who retaliate are disciplined up to termination (Policy FL-HH-HR-01). The complaint officer checks with the complainant after resolution that care has continued as before, as the Agency's own standard.

• AHCA will conduct investigations of complaints regarding licensure violations as required in s. 408.811, F.S. (Rule 59A-8.003(3), F.A.C.). Inspections are unannounced, except as s. 408.806, F.S., provides (s. 408.811(1)(a), F.S.).
• The Agency provides, or if requested sends, copies of all records required during an inspection or other review at no cost to AHCA, including records requested during an offsite review (s. 408.811(3), F.S.). The survey response steps in Policy FL-HH-GOV-06 apply.
• A deficiency must be corrected within 30 calendar days after the Agency is notified of inspection results unless an alternative time frame is required or approved by AHCA (s. 408.811(4), F.S.). If AHCA requires a plan of correction, it must be filed within 10 calendar days after notification unless an alternative time frame is required (s. 408.811(5), F.S.).
• Staff never ask a patient whether he or she complained to AHCA and never discourage a patient from cooperating with an investigator.

Each quarter the complaint officer reports to the quality assurance committee the number of complaints by topic, the time to acknowledge and resolve, the outcomes, and any pattern by staff member, service, or office (Policy FL-HH-QA-01). The governing body receives the summary at each meeting (Policy FL-HH-GOV-01). Patterns lead to corrective action plans.

Accountability under this policy is allocated as follows.

Forms FL-HH-CMP-01-A and FL-HH-CMP-01-B, investigation notes, and responses are kept in the complaint file, not in the clinical record, for 6 years, as the Agency's own standard. Privacy complaints and their disposition are documented as 45 CFR §164.530(d) and (j) require (Policy FL-HH-PRV-01). Each quarter the Administrator checks the log for complaints not acknowledged within 5 or not resolved within 30 and follows up.

Every employee and contractor is trained at orientation and each year on how to receive a complaint, the same-day referral to the complaint officer, the immediate abuse reporting duty, and the ban on retaliation (Policy FL-HH-HR-02). The complaint officer and the director of nursing are trained on investigation and written responses.

This policy implements the following authorities.

• s. 408.810(5), Florida Statutes, Minimum licensure requirements: notice of the right to report complaints, abuse, and Medicaid fraud
• s. 408.811, Florida Statutes, Right of inspection; copies; inspection reports; plan for correction of deficiencies
• Rule 59A-8.003(3), F.A.C., Licensure Requirements: complaint investigations
• s. 415.1034, Florida Statutes, Mandatory reporting of abuse, neglect, or exploitation of vulnerable adults
• s. 39.201, Florida Statutes, Required reports of child abuse, abandonment, or neglect
• 42 CFR §484.50(a)(1), (c)(3), (c)(9), (c)(10), and (e)(1), Condition of participation: Patient rights, if the Agency is Medicare-certified
• 45 CFR §164.530(d), Administrative requirements: complaints to the covered entity

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 Section 17 is amended, the amendment is recorded in this table and a new version of this policy is issued.