Complaints and Grievances, and the State Home Health Hotline

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 complaint is welcomed, taken seriously, investigated and resolved, and that no one suffers for complaining. Each 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" (42 CFR §484.50(c)(3)), and to "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" (§484.50(c)(9)).

This policy covers complaints and grievances, spoken or written, from patients, representatives, caregivers, family members and others, about any part of the Agency's services or staff, including contracted services. It covers how patients are told about their rights to complain, the Agency's own procedure, outside complaint routes, and records.

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

The Agency investigates complaints made by a patient, the 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, or misappropriation of patient property by anyone furnishing services on the Agency's behalf (42 CFR §484.50(e)(1)(i)). It documents both the existence of each complaint and its resolution (§484.50(e)(1)(ii)), and takes action to prevent further potential violations, including retaliation, while the complaint is being investigated (§484.50(e)(1)(iii)). No Missouri rule sets a time frame for a home health agency's own complaint handling; the Agency acknowledges each complaint within 5 and resolves it within 30. Any complaint that alleges abuse, neglect, exploitation or misappropriation is reported to the Department immediately under Policy MO-HH-SG-01, before the Agency investigates. No patient is subjected to discrimination or reprisal for voicing a grievance to the Agency or an outside entity (§484.50(c)(11)).

• At the initial evaluation visit, each patient and representative receives the written notice of rights (Policy MO-HH-PR-01), which includes the right to complain, the Administrator's name, business address and business phone number to receive complaints (42 CFR §484.50(a)(1)(ii)), and the state hotline information below.
• State hotline: the Missouri Department of Health and Senior Services, Bureau of Home Care and Rehabilitative Standards, 920 Wildwood Drive, P.O. Box 570, Jefferson City, MO 65102-0570; home health and hospice complaint hotline 1-800-392-0210 (seven days a week, 7:00 a.m. to 8:00 p.m.); complaints may also be made in writing to the address above. The written notice says plainly that the hotline receives complaints or questions about home health agencies, and that the same number is the Department's Adult Abuse and Neglect Hotline.
• Patients are also given the names, addresses and phone numbers of the Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center and Quality Improvement Organization that serve their area (42 CFR §484.50(c)(10)), on Form MO-HH-PR-01-A.
• Form MO-HH-CMP-01-A is left in the admission packet so the patient can write a complaint at any time. Interpreters, large print and relay services (Relay Missouri 1-800-735-2966 (text) or 1-800-735-2466 (voice)) are available at no cost (Policy MO-HH-PR-04).
• Staff remind patients that complaining will never affect their care.

1. Any staff member may receive a complaint, in person, by phone, in writing or electronically. Listen, thank the person, write down the details in the person's words, and do not argue or promise an outcome.
2. If the complaint alleges abuse, neglect, exploitation, mistreatment, misappropriation or an injury of unknown source, make sure the patient is safe and report immediately to the Department under Policy MO-HH-SG-01, then tell the complaint officer.
3. If there is an immediate risk to the patient's health or safety, tell the clinical manager at once so care can be corrected the same day.
4. Pass every complaint to the complaint officer the same business day, or by the next morning if received after hours (Agency standard).

1. The complaint officer enters the complaint in the complaint log (Form MO-HH-CMP-01-B) and sends the person an acknowledgment within 5, saying who is handling it and when to expect an answer.
2. While the investigation is under way, the complaint officer and the clinical manager take action to prevent further potential violations, including retaliation (42 CFR §484.50(e)(1)(iii)): for example, assigning a different staff member to the patient, adding a supervisory visit, or removing a staff member from patient contact.
3. The complaint officer, with the clinical manager for clinical matters, investigates: talks with the patient and the person who complained, the staff involved and any witnesses; reviews the clinical record, visit and EVV data, and orders; and reviews any contracted provider's records.
4. The complaint officer decides the outcome, the actions needed (for example retraining, a change in the plan of care, discipline, a billing correction, or a change in a policy), and who will take each action by when.
5. The person who complained is told the outcome and the actions taken, in writing or by phone followed by a letter, within 30 of receiving the complaint. If more time is genuinely needed, the person is told why and when to expect the answer.
6. The person is also told that if they are not satisfied, they may contact the Administrator, the governing body, or the Department through the state hotline.
7. The resolution is documented on Form MO-HH-CMP-01-B (42 CFR §484.50(e)(1)(ii)). Clinical facts and any change in care are documented in the clinical record; the complaint file itself is kept separately.

A complaint about the Administrator is sent to the chair of the governing body, who appoints a person who is not involved to investigate and reports the outcome to the full governing body. A complaint about the complaint officer is handled by the Administrator.

• Patients and anyone else may complain directly to the Department at any time, with or without using the Agency's procedure. "The department may accept complaints by phone or in writing" (19 CSR 30-26.010(2)(H)). Any person may file a written complaint with the Department setting forth the details and facts supporting the complaint (RSMo §197.435; 19 CSR 30-26.010(2)(H)1).
• The Department decides whether an investigation or referral to another agency is appropriate, and a Department representative may make an on-site visit and write deficiencies (19 CSR 30-26.010(2)(H)3, 4). The Agency cooperates fully and responds to any deficiencies written as a result of a complaint investigation with a plan of correction under Policy MO-HH-GOV-05.
• If the Agency is Medicare-certified, Medicare beneficiaries may also contact Livanta LLC, BFCC-QIO Program (Medicare beneficiary helpline for Missouri: 1-888-755-5580) about the quality of their care or to appeal a discharge or end of services (Policy MO-HH-DC-02).
• Privacy complaints may also be made to the Agency's privacy official and to the Secretary of HHS (45 CFR §164.530(d); §160.306; Policy MO-HH-PRV-01). Discrimination complaints may also be made to the HHS Office for Civil Rights or the Missouri Commission on Human Rights (Policy MO-HH-GOV-08).
• Concerns about MO HealthNet billing or fraud may be reported to Missouri Department of Social Services, Missouri Medicaid Audit and Compliance Unit (MMAC) at 573-751-3399 or toll free 833-818-1183 (Policy MO-HH-ETH-01).

No patient, family member or staff member is threatened, punished, discharged, denied services or treated worse for making a complaint or helping with an investigation (42 CFR §484.50(c)(11)). No person who directs or exercises authority in the Agency may harass, dismiss or retaliate against a patient or employee because he or she, or a family member, made a report of any violation or suspected violation of laws, standards or regulations applying to the Agency (RSMo §192.2475.9). Any staff member who retaliates is disciplined under Policy MO-HH-HR-01.

The complaint officer reports the number and types of complaints, time to acknowledge and resolve, outcomes and trends to the QAPI committee each quarter (Policy MO-HH-QA-01), and the Administrator includes a summary in the quarterly report to the governing body. Complaints that show a pattern lead to a performance improvement action or project.

Accountability under this policy is allocated as follows.

The complaint log and investigation record (Form MO-HH-CMP-01-B), written complaints (Form MO-HH-CMP-01-A or letters), acknowledgments, outcome letters, and any Department correspondence are kept in the complaint file for at least six years (Agency standard). Privacy complaints are also logged as 45 CFR §164.530(d)(2) requires. Compliance is monitored each quarter by checking that every logged complaint was acknowledged within 5 and resolved within 30, and that every abuse-related complaint has a matching report under Policy MO-HH-SG-01.

All staff learn at orientation and each year how to receive a complaint, the same-day handover to the complaint officer, which complaints must be reported to the Department immediately, the state hotline number and hours, and the ban on retaliation. The complaint officer and clinical manager receive training in investigation and written responses.

This policy implements the following authorities.

• 42 CFR §484.50(a)(1)(ii), Administrator contact information for complaints
• 42 CFR §484.50(c)(3), Right to make complaints
• 42 CFR §484.50(c)(9), State home health hotline
• 42 CFR §484.50(c)(10), Contact information for advocacy and assistance entities
• 42 CFR §484.50(c)(11), Freedom from discrimination or reprisal
• 42 CFR §484.50(e), Investigation of complaints
• 19 CSR 30-26.010(1)(A), Incorporation of 42 CFR Part 484
• 19 CSR 30-26.010(2)(H), Department complaint procedure
• RSMo §197.435, Complaint procedure
• RSMo §192.2475.9, Retaliation prohibited
• 45 CFR §164.530(d), Complaints to the covered entity
• 45 CFR §160.306, Complaints to the Secretary

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.