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.

Patients and families have the right to voice grievances about their care without fear (19 CSR 30-35.010(1)(F)3.B). Complaints tell the Agency where care or service has fallen short. This policy makes it easy to complain, makes sure every complaint is taken seriously and answered, and makes sure the Agency learns from it.

This policy covers complaints and grievances from patients, families, legal representatives, facility staff, physicians, other providers, staff and members of the public about any care or service furnished, or not furnished, by or on behalf of the Agency, in any setting.

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

Every patient and family has the right to voice grievances regarding treatment or care that is, or fails to be, furnished or regarding lack of respect of property or person by anyone who is furnishing services on behalf of the hospice, and is not subjected to discrimination or reprisal for doing so (19 CSR 30-35.010(1)(F)3.B). Every patient has the right to access the Missouri home health and hospice toll-free hotline and to be informed of its telephone number, the hours of operations, and its purpose for the receipt of complaints and questions regarding hospice services (19 CSR 30-35.010(1)(F)3.J). Any person may complain against a certified hospice to the Department, in writing or verbally, and the Department investigates complaints received (19 CSR 30-35.030(2)(B); RSMo §197.268).

If the Agency is Medicare-certified, the patient also has 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 who is furnishing services on behalf of the hospice, and not to be subjected to discrimination or reprisal for exercising his or her rights (42 CFR §418.52(b)(1)(iii) and (iv)).

• At admission the nurse explains how to complain and gives the patient bill of rights (Form MO-HSP-PR-01-A), which includes the hotline number, hours and purpose, and Form MO-HSP-CMP-01-A, which stays in the home folder.
• The nurse explains that the patient can complain to any staff member, to the complaint officer, to the Administrator, or directly to the Department, and that complaining will not affect care.
• The Department's contact details are: 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. People who are deaf, hard of hearing or speech-disabled can use Relay Missouri 1-800-735-2966 (text) or 1-800-735-2466 (voice).
• Residents of nursing facilities and other long-term care facilities are also told about the Missouri Long-Term Care Ombudsman Program, 912 Wildwood Drive, P.O. Box 570, Jefferson City, MO 65102-0570, 1-800-309-3282, LTCOmbudsman@health.mo.gov.
• Information is given in the patient's language or format, with free interpreters and auxiliary aids when needed (Policy MO-HSP-GOV-07).

Anyone may complain in any way: in person, by telephone, in writing, by email, or through someone else. Any staff member who receives a complaint:

1. Listens, thanks the person, and does not argue, blame others or discourage the complaint.
2. Deals first with any immediate risk to the patient (for example a missing medication or an uncontrolled symptom) by calling the on-call nurse.
3. Writes down what the person said, their name and contact details (if they give them), and what they would like to happen, or helps them complete Form MO-HSP-CMP-01-A.
4. Passes the complaint to the complaint officer the same day (the next business day if received after office hours, unless it is urgent).
5. If the complaint suggests abuse, neglect, exploitation or misappropriation, the staff member also follows Policy MO-HSP-ANE-01 (or MO-HSP-ANE-02 for a child) and tells the Administrator immediately (Policy MO-HSP-QA-02).
6. If the complaint alleges discrimination, it also goes to the Section 1557 Coordinator (Policy MO-HSP-GOV-07). If it is about privacy, it also goes to the privacy official (Lee Sample, Policy MO-HSP-PRV-01).
7. If the person wants to complain to the Department, the staff member gives the hotline number and address and offers help.

Missouri rules do not set time frames for a hospice's own complaint process. The Agency follows the time frames in Table 1, which the governing body has set.

At any stage, and whether or not the Agency's process is finished, the person may complain to the Department through the hotline or in writing. A Medicare beneficiary may also contact Medicare at 1-800-MEDICARE (1-800-633-4227) or the beneficiary and family centered care quality improvement organization named in the Medicare notices the Agency gives.

• The complaint officer speaks with the person who complained to understand the complaint and what they want, unless they do not want to be contacted.
• The complaint officer reviews the clinical record, visit records, telephone logs and any other relevant records, and speaks with the staff, contractors or volunteers involved and their supervisor.
• Clinical complaints (pain control, missed visits, medications, equipment, care by a contracted facility) are reviewed with the registered nurse coordinator and, where needed, the medical director and the patient's IDG. The plan of care is changed if needed.
• If the complaint involves another provider (a nursing facility, inpatient facility, pharmacy or equipment supplier), the complaint officer works with that provider under the Agency's agreement with it, because the Agency keeps professional management responsibility for the care it arranges (Policy MO-HSP-CON-01).
• The complaint officer records the findings, the actions taken and the date of the response on Form MO-HSP-CMP-01-B (Agency standard). Any staff discipline is recorded in the personnel file, not in the complaint response.

The Department investigates complaints it receives (19 CSR 30-35.030(2)(B)). It may make complaint investigations during normal business hours, in addition to its certification surveys, and a survey may include visits to the place of residence of any appropriate patient or family (19 CSR 30-35.030(2)(A) and (C)).

• The Agency allows Department representatives to enter its premises for a complaint investigation (19 CSR 30-35.030(2)(C)), gives them the records and staff they ask for, and tells the Administrator at once.
• The Administrator records the investigation on Form MO-HSP-GOV-04-A and responds to any deficiencies with a plan of correction as Policy MO-HSP-GOV-04 sets out.
• The Agency never asks a patient or family whether they complained to the Department, and never treats anyone differently because they may have.

No patient, family member or other person is subjected to discrimination or reprisal for voicing a grievance (19 CSR 30-35.010(1)(F)3.B). Care, visit frequency and staff attitude stay the same. Staff who are the subject of a complaint do not contact the person about it. Any staff member who retaliates is disciplined. A patient or family who feels they have suffered reprisal may tell the Administrator, the governing body or the Department.

A grievance alleging discrimination on the basis of race, color, national origin, sex, age or disability is handled by the Section 1557 Coordinator under Policy MO-HSP-GOV-07, using the same time frames. A covered entity that employs fifteen or more persons must implement written grievance procedures that provide for the prompt and equitable resolution of such grievances, must keep the complainant's identity confidential except as required by law or to carry out the investigation, and must keep records of each grievance for no less than three calendar years from the date the grievance is resolved (45 CFR §92.8(c)). The Agency follows these rules whatever its size (Agency standard). The person may also complain to the U.S. Department of Health and Human Services, Office for Civil Rights.

The complaint officer reports complaints by type, service, setting, time to acknowledge and resolve, and outcome to each QAPI committee meeting (Policy MO-HSP-QA-01) and to each governing body meeting (Policy MO-HSP-GOV-01). Repeated complaints of the same kind are treated as an identified problem under the QAPI method for resolving problems.

Each role named below carries the duties shown.

The following records are kept and checked:

• Form MO-HSP-CMP-01-B (the complaint log) and the file for each complaint (Form MO-HSP-CMP-01-A if used, notes, the acknowledgment and the written response), kept for at least six years (Agency standard; at least three calendar years after resolution for discrimination grievances, 45 CFR §92.8(c)(2)).
• Each quarter the complaint officer checks the log for complaints acknowledged or answered late and reports the results to the QAPI committee.
• Complaint files are kept separately from clinical records; the clinical record shows only clinical facts and changes to the plan of care.

All staff and volunteers learn at orientation and every year how to receive a complaint, the hotline number and its purpose, the duty to pass complaints on the same day, and the rule against reprisal. The complaint officer is trained in investigating and responding to complaints.

This policy implements the following authorities.

• 19 CSR 30-35.010(1)(F)3.B and J, grievances and the toll-free hotline
• 19 CSR 30-35.030(2)(A)-(C), surveys and complaint investigations
• RSMo §197.268, complaints; RSMo §197.264.1, bill of rights
• 42 CFR §418.52(b)(1)(iii)-(iv), right to voice grievances without reprisal (Medicare-certified hospices)
• 45 CFR §92.8(c), grievance procedures for discrimination complaints

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.