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.

Complaints tell Sample Agency, LLC (the "Agency") where care or service has fallen short. This policy makes sure that anyone can complain easily and without fear, that every complaint is taken seriously, investigated and answered in writing within the Agency's time frames, that patients know they can also go to the state, and that patterns are used to improve care.

This policy covers complaints and grievances, oral or written, from patients, representatives, family members, caregivers, authorized healthcare providers, Agency staff and the public, about any service the Agency provides directly or under contract, any staff member, billing, scheduling, privacy or the Agency's treatment of a person or property. It covers receiving, logging, acknowledging, investigating, resolving and responding to complaints, outside complaint routes, protection from reprisal, and review by the governing body and the QAPI program.

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

Every patient has the right to "make complaints to the HHA regarding treatment or care that is (or fails to be) furnished, and the lack of respect for property and/or person by anyone who is furnishing services on behalf of the HHA" (LAC 48:I §9125.A.3), and to be free from any discrimination or reprisal for exercising his or her rights or for voicing grievances to the Agency or an outside entity (§9125.A.11). The Agency has written policies on problem and complaint resolution (§9115.B.1.h). The Administrator ensures that complaints reported by patients, families, caregivers, authorized healthcare providers, Agency staff or the public are investigated and addressed in a timely manner (§9103.A.2.i), and the clinical manager performs complaint investigations (§9103.B.2.f). The governing body reviews complaint resolutions in its annual documented review (§9102.B.1).

Louisiana does not set a time limit for an agency to answer a complaint. The Agency's own time frames are: acknowledgment within 5 of receipt, and a written response with the outcome within 30 of receipt. Every patient is told about 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 (§9125.A.9).

If the Agency is Medicare-certified, it investigates complaints made by a patient, the patient's representative, caregivers and family, including complaints about treatment or care that is (or fails to be) furnished, is furnished inconsistently or inappropriately, and about mistreatment, neglect, abuse (including injuries of unknown source) or misappropriation of patient property by anyone furnishing services on its behalf; documents both the existence of each complaint and its resolution; and takes action to prevent further potential violations, including retaliation, while the complaint is investigated (42 CFR §484.50(e)(1)). As the Agency's own standard, these duties apply to all patients.

• Anyone may complain in any way: in person or by telephone to any staff member, by calling the office at (225) 555-0100 or the after-hours line at (225) 555-0199, by email to office@example.com, by letter, or on the Complaint Form (Form LA-HH-CMP-01-A). Complaints may be made anonymously.
• Complaints may be made directly to the complaint officer, Pat Sample, at (225) 555-0111, or to the Administrator, Pat Sample, at (225) 555-0111.
• At admission every patient receives the notice of rights (Form LA-HH-PR-01-A) and the Complaint Form, which explain how to complain to the Agency and to the state (Policy LA-HH-PR-01). The information is given in a language and manner the patient understands, with interpreters and auxiliary aids at no cost (Policy LA-HH-PR-04).
• A patient or family member may ask any staff member to help write a complaint. Staff help without trying to discourage or change the complaint.

1. Any staff member who receives a complaint thanks the person, listens, writes down what the person says (who, what, when, where), and tells the person what will happen next. Staff do not argue, explain away or promise an outcome.
2. If the complaint involves possible abuse, neglect, exploitation, misappropriation or an injury of unknown source, the staff member first follows Policy LA-HH-SG-01 (or LA-HH-SG-02 for a child): the patient's safety and the outside report within 24 hours come first. If the Agency is Medicare-certified, such matters are reported immediately to the Agency and to the appropriate authorities (42 CFR §484.50(e)(2)).
3. The staff member passes every complaint, however small, to the complaint officer and the Administrator the same day, and to the registered nurse on call if it concerns care that may need attention before the next business day.
4. The complaint officer enters the complaint in the Complaint Log and Investigation Record (Form LA-HH-CMP-01-B) on the day it is received, with the date, the complainant, the patient, the category and the due dates for acknowledgment and resolution.
5. The complaint officer acknowledges the complaint within 5, by telephone or in writing, unless the complainant is anonymous.
6. Complaints about privacy are also sent to the privacy official, Lee Sample, who documents them as 45 CFR §164.530(d) requires (Policy LA-HH-PRV-01).

• The clinical manager, Robin Sample, RN, performs the investigation of complaints about care, clinical staff or contract clinical services (LAC 48:I §9103.B.2.f). The Administrator investigates complaints about billing, scheduling, office staff, the clinical manager or the Agency's management. A person named in a complaint never investigates it.
• The investigator talks with the complainant (and the patient, if different) to understand the concern and what outcome the person wants; interviews staff and witnesses; reviews the clinical record, visit schedule, EVV records and other documents; and, where useful, makes a supervisory home visit.
• While the complaint is investigated, the Agency takes action to protect the patient and to prevent further potential violations, including retaliation (42 CFR §484.50(e)(1)(iii); Agency standard for all patients). This may mean assigning a different staff member to the patient.
• If the investigation finds a care problem, the clinical manager makes sure the patient's authorized healthcare provider is told where the problem affects the plan of care, and corrects the care at once.
• The investigator records the steps taken, findings and actions on Form LA-HH-CMP-01-B.

• The complaint officer sends the complainant a written response within 30 of receipt. The response describes, in plain language and in the complainant's language, what the Agency looked into, what it found, what it did or will do, and how to take the matter further, including to the state (Section 9). It does not disclose another person's health information or personnel matters.
• If the investigation needs more time, the complaint officer tells the complainant before the due date why, and the new date.
• The Health Standards Section asks people who have already complained to an agency to allow the agency about 30 days to investigate and send a written response before they file a complaint with the state (HSS complaint form). The Agency's own time frame is set so that the written response is sent within that period.
• If the complainant is not satisfied, the complainant may ask the Administrator to review the outcome. The Administrator reviews it and answers in writing within 10 business days, as the Agency's own standard. The complainant may also go to any outside agency at any time; using the Agency's process first is never required.
• The complaint is closed in the log only when the written response has been sent and every action is complete.

Patients and others may complain to the state or other agencies at any time, before, during or after using the Agency's process. Patients are told about these routes at admission (§9125.A.9 and A.10; Form LA-HH-PR-01-A).

Louisiana law lets the LDH office that investigates complaints decline to investigate an outdated report, defined as a report about an incident that occurred 120 or more days before it was reported to the office (R.S. 40:2009.14(A)(1) and (A)(3)(c)). Staff therefore encourage anyone who wants to complain to the state to do so promptly. LDH may investigate a complaint during an unannounced on-site visit, by administrative review or by telephone (LAC 48:I §9105.E.4). The Agency cooperates fully with any LDH investigation (Policy LA-HH-GOV-03).

• No patient, family member, caregiver or staff member is discriminated against or subjected to reprisal for making a complaint to the Agency or to an outside entity (LAC 48:I §9125.A.11). Services are never reduced, delayed or ended because of a complaint.
• Staff who are named in a complaint do not discuss it with the patient or family except as the investigator directs.
• Any suspected reprisal is itself a complaint, investigated by the Administrator, and is grounds for disciplinary action.

• Each month the complaint officer reviews open complaints with the Administrator and checks that each was acknowledged and resolved within the Agency's time frames.
• Each quarter the complaint officer reports to the QAPI committee the number of complaints by category and service, time to acknowledgment and resolution, outcomes, repeat issues and any LDH complaint investigations (Policy LA-HH-QA-01).
• Once a year the governing body reviews complaint resolutions as part of its documented annual review (LAC 48:I §9102.B.1; Form LA-HH-GOV-01-A).
• The Administrator tracks the number of complaints LDH has found valid in the past 12 months, because more than three valid complaints in a one-year period is a ground for a provisional license (§9105.B.2.b), and reports the count to the governing body each quarter.

Accountability under this policy is allocated as follows.

The complaint officer keeps each Form LA-HH-CMP-01-A, the Complaint Log and Investigation Record (Form LA-HH-CMP-01-B) with investigation notes, the written responses and any review by the Administrator, for at least six years as the Agency's own standard. Complaint files are kept separate from the clinical record; facts relevant to the patient's care are documented in the record. Each quarter the Administrator checks that the share of complaints acknowledged and resolved within the Agency's time frames is reported to QAPI, and that any LDH complaint investigation and its outcome are in the log.

All staff are trained at orientation and every year, as the Agency's own standard, on accepting complaints, the same-day hand-off, the link to abuse reporting, the patient's right to complain to the state, and the ban on reprisal (Policy LA-HH-HR-01). The complaint officer, the clinical manager and the alternate are trained in complaint investigation and in writing clear responses.

This policy implements the following authorities.

• LAC 48:I §9102.B.1, Governing body annual review including complaint resolutions
• LAC 48:I §9103.A.2.i, Administrator ensures complaints are investigated and addressed in a timely manner
• LAC 48:I §9103.B.2.f, Clinical manager performs complaint investigations
• LAC 48:I §9105.B.2.b, Provisional license after more than three valid complaints in a one-year period
• LAC 48:I §9105.E.4, Complaint investigation by LDH
• LAC 48:I §9115.B.1.h, Policies on problem and complaint resolution
• LAC 48:I §9125.A.3, A.9, A.10 and A.11, Patient rights
• R.S. 40:2009.14, Procedure for investigation by the office (outdated reports)
• 42 CFR §484.50(e), Investigation of complaints (if Medicare-certified)
• 45 CFR §164.530(d), Complaints about privacy

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