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 that patients and families can raise any concern about their care easily and safely, that the Agency investigates and answers every complaint fairly and promptly, that people know they can also go to the Louisiana Department of Health and other outside bodies, and that complaints are used to improve care.

This policy covers complaints and grievances, spoken or written, from patients, families, representatives, facility staff, practitioners, volunteers or anyone else, about the Agency’s care, treatment, staff, respect for person, property or privacy, billing, or any service furnished on the Agency’s behalf, in any setting.

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

Each patient has the right to “voice grievances concerning patient care, treatment, and/or respect for person or privacy without being subject to discrimination or reprisal, and have any such complaints investigated by the hospice” (LAC 48:I §8231.A.9). The Agency’s policies address problem and complaint resolution (§8235.C.2), and the director of nurses performs complaint investigations (§8217.E.2.e.ii). Anyone may also report to the Department (R.S. 40:2009.13(B)), which investigates complaints against hospices unannounced (LAC 48:I §8205.E), and no health care provider may take discriminatory or retaliatory action against any person by whom or for whom a good faith communication was made to the Department (R.S. 40:2009.17). If the Agency is Medicare-certified, patients also have 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 furnishing services on behalf of the hospice, and not to be subjected to discrimination or reprisal for exercising their rights (42 CFR §418.52(b)(1)(iii)-(iv)).

• At admission the admitting clinician gives the patient or representative Form LA-HSP-CMP-01-A, “How to Make a Complaint”, explains it in a language and manner the person understands, and records this on the rights acknowledgment (Form LA-HSP-PR-01-B).
• The form gives the complaint officer’s name and number, the Agency’s 24-hour number ((225) 555-0199), and the Department’s complaint contacts: Louisiana Department of Health, Health Standards Section, P.O. Box 3767, Baton Rouge, Louisiana 70821. Home health and hospice complaint line 1-800-327-3419; Health Standards Section main line (225) 342-0138; fax (225) 342-5073; email HSSComplaints@la.gov. Complaint form: https://ldh.la.gov/assets/Medicaid/hss/docs/ALL_Prgms/HSS_Complaint_Form_04_22_2025.pdf.
• It also names other places people may go for help: Adult Protective Services and Elderly Protective Services for abuse (1-800-898-4910 (Adult Protective Services, adults 18 to 59 and emancipated minors); 1-833-577-6532 (Elderly Protective Services, adults 60 and older)); the Long-Term Care Ombudsman for residents of nursing facilities, assisted living and personal care homes (Louisiana Long-Term Care Ombudsman Program, Governor's Office of Elderly Affairs: (866) 632-0922); the Medicare quality improvement organization for Medicare patients (Acentra Health (Medicare Beneficiary and Family Centered Care Quality Improvement Organization for Louisiana): 1-888-315-0636; TTY 711); and Disability Rights Louisiana (Disability Rights Louisiana (formerly the Advocacy Center of Louisiana), 8325 Oak Street, New Orleans, LA 70118; 1-800-960-7705).
• Staff remind patients and families of the process whenever a concern comes up, and the form is in the home folder (Agency standard).

• Any staff member may receive a complaint. He or she listens, thanks the person, takes immediate steps to make the patient safe or comfortable if needed, and does not argue, blame others or promise an outcome.
• The staff member writes down what was said and reports it to the complaint officer the same day, or to the on-call nurse after hours, who passes it on the next business day (Agency standard).
• If the complaint involves possible abuse, neglect, exploitation or misappropriation of property, the staff member reports it immediately to the Administrator and makes his or her own report to the outside authorities within the time Policy LA-HSP-ANE-01 requires. The complaint is then investigated under Policy LA-HSP-ANE-02.
• If the complaint describes a possible crime, the Administrator tells local law enforcement. If it involves a privacy concern, the Privacy Official is told the same day.
• Complaints may be made anonymously. A complainant may ask that his or her name not be shared with the staff involved, and the Agency honors that as far as the investigation allows (Agency standard).

No Louisiana hospice rule sets a number of days for a hospice to answer a complaint; the time frames above are the Agency’s own. The Department’s complaint form asks people who have already complained to a provider to allow the provider approximately 30 days to investigate and respond with its findings before filing with the Department. The Agency’s time frames are set so that its written response reaches the complainant well within that period.

• The person who investigates is not the person the complaint is about. If the complaint is about the director of nurses, the Administrator investigates; if it is about the Administrator, a governing body member designated by the governing body does (Agency standard).
• No patient, family member, representative or staff member is discriminated against, threatened, or treated worse because a complaint was made, inside the Agency or to the Department or any other body (LAC 48:I §8231.A.9; R.S. 40:2009.17). Care is never reduced or ended because of a complaint.
• A staff member who retaliates is disciplined. Knowingly or willfully retaliating against a person for a good faith communication to the Department is a misdemeanor punishable by a fine of not less than $100 nor more than $500 (R.S. 40:2009.17).

• Anyone who has knowledge that a state law, minimum standard, rule, regulation, plan of correction or federal certification rule has been violated, or that a consumer has not been receiving the care and treatment to which he is entitled, may submit a report to the Department in writing, by telephone, or by personal visit (R.S. 40:2009.13(B)). The Agency tells patients they may do so at any time, before, during or after using the Agency’s own process.
• The Department reviews each report to decide whether there are reasonable grounds for an investigation. It does not investigate a report it judges not made in good faith, outdated, or trivial; an “outdated report” is one about an incident that occurred 120 or more days before it was reported (R.S. 40:2009.14(A)(1), (3)(c)). The Agency therefore tells patients and families to report to the Department promptly if they wish to.
• Complaint investigations are unannounced (LAC 48:I §8205.E.2). Surveyors are given access to all areas and relevant files and may interview any staff member or patient (§8205.E.6). The Department does not identify the complainant or the consumer to the provider without that person’s consent (R.S. 40:2009.14(B)(2)), and staff never try to find out who complained.
• Where deficiencies are cited, the Agency submits an acceptable plan of correction within the time the Department sets (LAC 48:I §8205.E.3) and tracks it under Policies LA-HSP-GOV-04 and LA-HSP-QA-01.

• The QAPI lead reviews the complaint log every month and reports the number, type, time to resolution and trends to the QAPI committee every quarter (Policy LA-HSP-QA-01).
• Where a complaint shows a problem in care or a process, a corrective action plan is written and its effect is measured (LAC 48:I §8239.H-I).
• Complaints about a contracted provider are shared with the contractor and reviewed at the annual contract review (LAC 48:I §8237.E; Policy LA-HSP-CON-01).

Each role named below carries the duties shown.

The complaint officer keeps the following for at least six years (Agency standard):

• The complaint and grievance log (Form LA-HSP-CMP-01-B), with each complaint’s date, complainant, subject, investigator, findings, actions, date of response and date closed.
• Investigation notes, statements and copies of letters to complainants, kept in a complaint file, not in the clinical record (Agency standard). A note that a concern was raised and addressed may be made in the clinical record when it affects the plan of care.
• Correspondence with the Department about complaint investigations and plans of correction.
• Each quarter the complaint officer checks the log against the time frames in Table 1 and reports misses to the QAPI committee.

At orientation and every year, every staff member and volunteer learns how to receive a complaint, the same-day reporting rule, the difference between a complaint and a report of abuse or neglect, the no-retaliation rule, and the outside contacts in Table 2 (Agency standard).

This policy implements the following authorities.

• LAC 48:I §8205.E, complaint investigations by the Department
• LAC 48:I §8217.E.2.e.ii, director of nurses performs complaint investigations
• LAC 48:I §8231.A.9, right to voice grievances
• LAC 48:I §8235.C.2, policies on problem and complaint resolution
• LAC 48:I §8237.E, annual review of contracts
• LAC 48:I §8239.H-I, corrective action and evaluation
• R.S. 40:2009.13, health care provider complaints; procedure; immunity
• R.S. 40:2009.14, procedure for investigation; confidentiality of reports
• R.S. 40:2009.17, retaliation by health care provider
• 42 CFR §418.52(b)(1)(iii)-(iv), right to voice grievances; no discrimination or reprisal (Medicare-certified hospices)

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.