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 the people who care about them can raise concerns with Sample Agency, LLC easily and without fear, that every complaint is taken seriously, investigated and answered, and that the Agency learns from complaints. 42 CFR §484.50(c)(3) gives each patient 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," and §484.50(e)(1) requires the Agency to investigate them. Michigan does not license home health agencies and sets no complaint time frames for them; this policy follows the federal Conditions of Participation that bind the Agency, with time frames the governing body has set.

This policy covers how patients are told about the complaint process, how complaints are received, logged and acknowledged, routing of complaints that need special handling, protection of the patient during the investigation, investigation and resolution, written responses, review by the Administrator and the governing body, outside bodies a patient may contact, non-retaliation, records, and use of complaint data in QAPI.

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

Any person may complain to the Agency at any time, in any way: in person, by phone, in writing, by email, on Form MI-HH-CMP-01-A, or anonymously. Staff help anyone who needs help to make a complaint, including with interpreters and auxiliary aids at no cost (Policy MI-HH-PR-04).

The Agency investigates complaints made by a patient, the patient’s representative (if any), and the patient’s caregivers and family, including complaints about "Treatment or care that is (or fails to be) furnished, is furnished inconsistently, or is furnished inappropriately" and about "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 behalf of the HHA" (42 CFR §484.50(e)(1)(i)). It documents "both the existence of the complaint and the resolution of the complaint," and takes "action to prevent further potential violations, including retaliation, while the complaint is being investigated" (§484.50(e)(1)(ii) and (iii)).

As the governing body’s standard, the Agency acknowledges every complaint within 5 and resolves it, with a written response to the complainant, within 30 of receipt.

Every patient has the right to "Be free from any discrimination or reprisal for exercising his or her rights or for voicing grievances to the HHA or an outside entity" (§484.50(c)(11)). Making a complaint never affects a patient’s care.

• At the initial evaluation visit, before care starts, each patient and legal representative receives the written notice of rights (Policy MI-HH-PR-01), which includes the Administrator’s name, business address and business phone number for complaints (§484.50(a)(1)(ii)), how to use this complaint process, and the state toll-free home health hotline, its contact information, its hours of operation and its purpose of receiving complaints or questions about local home health agencies (§484.50(c)(9)).
• Each patient’s home folder contains Form MI-HH-CMP-01-A (in English and Spanish, and in other languages on request) and the Agency’s phone number (517) 555-0100 and after-hours number (517) 555-0199.
• Staff remind patients at any time that they can raise concerns, and never discourage a complaint.

1. Any staff member who receives a complaint listens, thanks the person, and does not argue or make promises they cannot keep.
2. If the complaint can be put right at once and safely (for example rescheduling a visit time), the staff member does so and still records it.
3. The staff member writes down what the person said, with the date, time and the person’s contact details, and passes it to the complaint officer the same business day. After hours, a complaint about safety or care goes to the on-call nurse at once.
4. The complaint officer enters every complaint in the complaint log (Form MI-HH-CMP-01-B) the day it is received, including complaints resolved at once, anonymous complaints, and concerns raised in satisfaction surveys or calls that identify a problem.

• The complaint officer and the clinical manager decide, on the day the complaint is received, what is needed to prevent further potential violations while it is investigated (§484.50(e)(1)(iii)): for example assigning a different staff member, an RN visit, a supervisory visit, or a call to the patient’s practitioner.
• Any staff member named in a complaint is told not to discuss it with the patient or family and that retaliation is forbidden. For allegations of abuse, neglect or misappropriation, the staff member is removed from patient contact (Policy MI-HH-SG-03).
• The patient is told how to reach the complaint officer directly if anything else happens.

1. The complaint officer acknowledges the complaint to the complainant within 5, by phone or in writing, saying who will look into it and when to expect an answer. Anonymous complaints are investigated without acknowledgment.
2. The complaint officer, or the person the complaint officer assigns (usually the clinical manager for clinical matters), investigates: speaks with the complainant and the patient, reviews the clinical record, schedules and EVV data, speaks with the staff involved, and gathers any other facts needed.
3. The investigator records the facts found, whether the complaint is substantiated, the cause, and the actions taken or planned on Form MI-HH-CMP-01-B.
4. The complaint officer gives the complainant a written response within 30 of receipt: what was looked at, what was found, what the Agency has done or will do, and how to take the matter further (Sections 10 and 11). Information about staff discipline is not shared, but the complainant is told that appropriate action was taken.
5. If the investigation needs more time, the complaint officer tells the complainant before the time frame ends, gives the reason and a new date, and records it.
6. The complaint is closed in the log only when the response has been sent and the actions have been completed or scheduled.

• A complainant who is not satisfied with the response may ask the Administrator to review it. The Administrator reviews the file, may speak with the complainant, and responds in writing within 30 of the request (Agency standard).
• A complainant who is still not satisfied may ask that the governing body review the complaint. The governing body considers it at its next meeting, or sooner if the complaint concerns patient safety, and the chair responds in writing.
• Asking for a review never prevents the complainant from contacting an outside body at any time.

Patients and families do not have to complain to the Agency first. The written response, Form MI-HH-CMP-01-A and the notice of rights list these bodies:

LARA’s Bureau of Survey and Certification describes its role this way: it accepts complaints against home health agencies, investigates federal allegations, and triages them by federal priority, so that an onsite investigation may begin "as soon as three business days or deferred to the next onsite survey"; it says incidents more than twelve months old usually cannot be investigated under federal authority. These describe LARA’s process, not the Agency’s. The Agency cooperates fully with any complaint investigation.

• No patient, representative, family member or caregiver is threatened, treated differently, discharged or denied services for making a complaint to the Agency or to any outside body (§484.50(c)(11)).
• No staff member is disciplined or treated unfairly for helping a patient complain, for making a complaint, or for taking part in an investigation.
• Any report of retaliation is investigated by the Administrator as a new complaint and, if substantiated, leads to discipline up to termination.

Each quarter the complaint officer reports to the QAPI committee the number and types of complaints, the share acknowledged and resolved within the Agency’s time frames, substantiated complaints, trends by service, staff or location, and the actions taken (Policy MI-HH-QA-01). The committee decides whether any trend needs a performance improvement project. The governing body receives the quarterly summary and reviews every complaint referred to it.

Accountability under this policy is allocated as follows.

The complaint officer keeps the complaint log and, for each complaint, Form MI-HH-CMP-01-B with the investigation notes, the acknowledgment, the written response and any review, for at least seven years from the date the complaint is closed as the Agency’s own standard, so that the Agency can show surveyors both the existence and the resolution of every complaint (42 CFR §484.50(e)(1)(ii)). Complaints are kept separate from the clinical record; the record holds only clinical facts and any change in care. Privacy complaints are also kept for six years as 45 CFR §164.530(j) requires.

All staff are trained at orientation (Policy MI-HH-HR-01) and each year on how to receive a complaint, the routing in Table 1, the same-business-day rule, immediate abuse reporting, and the ban on retaliation. The complaint officer and clinical manager are trained in investigating and responding to complaints.

This policy implements the following authorities.

• 42 CFR §484.50(a)(1)(ii), (c)(3), (c)(9), (c)(11) and (e), Patient rights: notice, right to complain, state hotline, freedom from reprisal, investigation of complaints
• 42 CFR §484.65, Quality assessment and performance improvement
• 45 CFR §164.530(d), Complaints to the covered entity (privacy)
• 45 CFR §92.8, Policies and procedures, including grievance procedures (Section 1557)
• Michigan Medicaid Provider Manual, General Information for Providers chapter, Section 15 (version October 1, 2026)
• LARA Bureau of Survey and Certification, "File a Complaint with BSC" (michigan.gov/lara)

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.