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 every complaint about the Agency's care or services is taken seriously, looked into quickly, answered honestly and used to improve care, and that no one is treated worse for complaining.

This policy covers complaints and grievances about any service the Agency gives directly or under arrangement, made by a patient, a family member, a representative, a facility, a physician, a volunteer or anyone else, in person, by telephone, in writing, by email, through a survey comment or online.

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

Every patient has the right "To voice grievances about care and not be subjected to discrimination or reprisal for doing so." and "To receive a reasonable response to his or her requests of the agency." (G.S. 131E-144.3(4), (13), applied by 10A NCAC 13K .0604(a)). "A hospice agency shall initiate an investigation within 72 hours of complaints made by a patient or his or her family. Documentation of both the existence of the complaint and the resolution of the complaint shall be maintained by the agency, for a minimum of one-year, in accordance with hospice agency policy and procedures." (10A NCAC 13K .0604(c)). The Agency applies the same 72-hour start to complaints from anyone (Agency standard). If the Agency is Medicare-certified, every 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 furnishing services on behalf of the hospice, and to not be subjected to discrimination or reprisal for exercising his or her rights (42 CFR §418.52(b)(1)(iii), (iv)).

"A hospice agency shall provide patients with a business hours telephone number for information, questions, or complaints about services provided by the agency. The agency shall also provide the Division of Health Service Regulation's complaints intake telephone numbers: within N.C. (800) 624-3004; outside of N.C. (919) 855-4500." (10A NCAC 13K .0604(b)). At admission, with the written notice of rights (Policy NC-HSP-PR-01), every patient receives Form NC-HSP-CMP-01-A, which gives:

• The Agency's business-hours number, (919) 555-0100 (Monday through Friday, 8:00 a.m. to 5:00 p.m. Eastern), and after-hours number, (919) 555-0199, and the complaint officer's name and contact details.
• The Division of Health Service Regulation complaint intake details: North Carolina Division of Health Service Regulation, Complaint Intake Unit, 2711 Mail Service Center, Raleigh, NC 27699-2711. Complaint Hotline 1-800-624-3004 (within North Carolina) or 919-855-4500, 9:00 a.m. to 12:00 p.m. and 1:00 p.m. to 4:00 p.m. on weekdays, except holidays. Fax 919-715-7724. Email DHSR.ComplaintIntake@dhhs.nc.gov. Complaint forms in English and Spanish: https://info.ncdhhs.gov/dhsr/ciu/filecomplaint.html
• Other places to go: the Medicare Beneficiary and Family Centered Care Quality Improvement Organization (Acentra Health, the Medicare Beneficiary and Family Centered Care Quality Improvement Organization for North Carolina (Region 4): toll free 888-317-0751, TTY 711) for Medicare quality of care concerns; the HHS Office for Civil Rights (U.S. Department of Health and Human Services, Office for Civil Rights, 1-800-368-1019) for privacy or discrimination; the Long-Term Care Ombudsman (Office of the State Long-Term Care Ombudsman, NCDHHS Division of Aging, 2101 Mail Service Center, Raleigh, NC 27699-2101; telephone (919) 855-3400) for residents of nursing facilities and adult care homes; the county department of social services for abuse, neglect or exploitation ((919) 555-0121).
• A statement that complaining will never affect the patient's care.

Any staff member, contractor or volunteer who receives a complaint:

1. Listens, thanks the person, and does not argue or blame anyone.
2. Fixes at once anything that can be fixed safely within his or her role (for example, rescheduling a visit or bringing a missing supply).
3. Writes down the person's name, contact details, relationship to the patient, the date and time received, and what the complaint is about, in the person's own words where possible.
4. Tells the complaint officer the same day, and at once by telephone if the complaint involves possible abuse, neglect, exploitation, misappropriation, an injury, a privacy breach or a risk to a patient (Agency standard).

A complaint that alleges abuse, neglect, exploitation, misappropriation of property, diversion of drugs or an injury of unknown source is reported to the Administrator at once and handled under Policy NC-HSP-ANE-01 and, if staff are involved, Policy NC-HSP-ANE-02, including the 24-hour report to Health Care Personnel Investigations. A complaint about privacy goes also to the Privacy Official (Policy NC-HSP-PRV-01, Section 12). A complaint about a Medicare discharge or end of services follows Policy NC-HSP-DC-01. This policy still applies to the response to the complainant.

The complainant may ask the Administrator to review the decision, and then the governing body. Each review is answered in writing within 14 days (Agency standard). The complainant may contact the Division, the QIO or another agency in Section 5 at any time; the Agency never discourages this.

The Division investigates all allegations of non-compliance with the hospice licensing rules (10A NCAC 13K .0604(b)). The Division states that it investigates complaints about incidents within the past year, that its investigations are unannounced, and that it does not share the complainant's identity with the agency. If a surveyor arrives to investigate a complaint, staff follow Policy NC-HSP-GOV-04. The Agency never tries to find out who complained and never treats a patient or family differently because a complaint may have been made.

No patient, family member, staff member or other person is subjected to discrimination or reprisal for making a complaint, inside the Agency or to any outside agency (G.S. 131E-144.3(4); 42 CFR §418.52(b)(1)(iv)). Care continues as planned while a complaint is open. Any staff member who retaliates is disciplined (Agency standard).

The complaint officer reports complaints, by type and outcome, to the quality committee each quarter and the governing body each year, and complaints are part of the annual evaluation (Policy NC-HSP-QA-01). Patterns lead to performance improvement work (Agency standard).

Each role named below carries the duties shown.

Documentation of both the existence of each complaint and its resolution is kept for a minimum of one year (10A NCAC 13K .0604(c)); the Agency keeps the complaint log and each complaint file for six years (Agency standard). Privacy complaints and their disposition are also kept six years (45 CFR §164.530(d)(2), (j)). Each quarter the quality lead checks a sample of complaints for the 72-hour start, the acknowledgment and the resolution (Agency standard).

All staff and volunteers are trained at orientation and every year on Sections 5, 6 and 9 (Agency standard), as part of patient rights training (10A NCAC 13K .0402(b)(14)). The complaint officer and managers are trained on Sections 7 and 8.

This policy implements the following authorities.

• 10A NCAC 13K .0301(a)(11), handling of complaints about services
• 10A NCAC 13K .0604(a), (b), (c), notice of rights, complaint numbers, investigation within 72 hours, records for at least one year
• G.S. 131E-144.3(4), (13), rights to voice grievances without reprisal and to a reasonable response (applied by 10A NCAC 13K .0604(a))
• 42 CFR §418.52(b)(1)(iii), (iv), grievances and freedom from reprisal (Medicare-certified hospices)
• 45 CFR §164.530(d), privacy 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.