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 is welcomed, taken seriously, investigated and resolved promptly, that the patient is never penalized for complaining, and that the Agency learns from complaints.

This policy covers every complaint or grievance, spoken or written, from a patient, a representative, a caregiver or family member, or anyone acting for the patient, about treatment or care that is (or fails to be) furnished, is furnished inconsistently or inappropriately, about lack of respect for the patient’s property or person, about billing, privacy, scheduling, communication, discrimination, or any other part of the Agency’s service.

For the purposes of this policy, the following terms have the meanings below. Ohio’s home health licensing law (ORC Chapter 3740 and OAC Chapter 3701-60) and 42 CFR Part 484 say "patient"; the Ohio Medicaid rules (OAC Chapters 5160-1, 5160-12 and 5160-32) say "individual". This policy uses "patient" for the same person.

The patient has the right to make complaints to the Agency regarding treatment or care that is (or fails to be) furnished, and the lack of respect for property or person by anyone who is furnishing services on behalf of the Agency (42 CFR §484.50(c)(3)), and to be free from any discrimination or reprisal for exercising their rights or for voicing grievances to the Agency or an outside entity (42 CFR §484.50(c)(11)). The Agency investigates complaints made by a patient, the patient’s representative and the patient’s caregivers and family; documents both the existence of the complaint and its resolution; and takes action to prevent further potential violations, including retaliation, while the complaint is being investigated (42 CFR §484.50(e)(1)). The Agency acknowledges each complaint within 5 and resolves it within 30, as its own standard.

At the start of care, during the initial evaluation visit and before care is furnished, each patient receives the notice of rights with the Administrator’s name, business address and business phone number for complaints (42 CFR §484.50(a)(1)(ii); Policy OH-HH-PR-01) and Form OH-HH-CMP-01-A, which tells them:

• how to complain to the Agency: any staff member, or the complaint officer, Pat Sample, on (614) 555-0111 or person1@example.com; or the Administrator, Pat Sample, at 100 Example Street, Suite 100, Columbus, Ohio 43215, (614) 555-0100;
• how to complain to the Ohio Department of Health at any time, with or without first complaining to the Agency: the Ohio Department of Health, Bureau of Survey and Certification, Complaint Unit: use the online Complaint Form at https://complainttracking.odh.ohio.gov/publiccomplaint/publiccomplaintform or email HCComplaints@odh.ohio.gov; if you cannot use the internet or email, call 1-800-342-0553 or the Home Health Hotline at 1-800-669-3534. You may file a complaint anonymously. This includes the state toll-free home health hotline, 1-800-669-3534, which receives complaints and questions about home health agencies (42 CFR §484.50(c)(9));
• for Ohio Medicaid patients, the Ohio Department of Medicaid Consumer Hotline, 1-800-324-8680, and, for managed care members, their plan’s member services;
• the long-term care ombudsman program, which also helps people receiving home care: the Office of the State Long-Term Care Ombudsman, Ohio Department of Aging: 1-800-282-1206, OhioOmbudsman@age.ohio.gov, www.Ombudsman.Ohio.gov. Regional ombudsmen also help people living in their own homes with problems with home care and other support services. Ombudsman services are free.
• for privacy complaints, the Agency’s Privacy Official, Lee Sample, and the U.S. Department of Health and Human Services, Office for Civil Rights (45 CFR §164.530(d));
• for suspected abuse, neglect or exploitation of an adult, adult protective services: 1-855-OHIO-APS (1-855-644-6277).

The Ohio Department of Health does not publish the hours of its home health hotline on its website. The complaint officer confirms the hours with the Department each year and records them on the notice of rights and Form OH-HH-CMP-01-A, because patients must be told the hotline’s hours of operation (42 CFR §484.50(c)(9)). The Department says it prefers complaints through its online form or by email, and may refer some kinds of complaints, such as billing disputes, to another agency.

• Any staff member who receives a complaint listens, thanks the person, and writes down what the person says, when and how they would like to be contacted. Staff never argue, discourage a complaint, or ask the person to keep it quiet.
• If the complaint alleges mistreatment, neglect, abuse, an injury of unknown source or misappropriation of property by anyone furnishing services for the Agency, the staff member follows Policy OH-HH-SG-03 at once, including any immediate outside report under Policies OH-HH-SG-01 and OH-HH-SG-02.
• If the complaint shows that a patient is at risk now (for example a missed insulin visit), the staff member tells the clinical manager or on-call nurse at once so the risk is fixed today.
• The staff member gives the complaint to the complaint officer the same business day. The complaint officer enters it on the complaint log (Form OH-HH-CMP-01-B).
• A complaint may be made anonymously. The Agency investigates it as far as it can.
• Complaints are accepted in any language and format; interpreters and auxiliary aids are provided at no cost (Policy OH-HH-PR-04).

1. Acknowledge the complaint within 5.
2. Investigate: talk with the person who complained, the patient, the staff involved and others with information; review the clinical record, schedule, visit verification and billing records as relevant.
3. While the investigation is open, take action to prevent any further problem, including retaliation: for example change the staff assigned, increase supervision, or correct a schedule (42 CFR §484.50(e)(1)(iii)).
4. Decide what happened and what the Agency will do, including any change in care, staff action, refund or system change.
5. Resolve within 30: tell the person, in writing where they asked for it or the complaint was written, what was found, what the Agency has done, and that they may take the complaint to the Ohio Department of Health or the other bodies in Section 5 if they are not satisfied. If more time is needed, tell the person why and when to expect an answer.
6. Record the investigation, the resolution and the date on Form OH-HH-CMP-01-B (42 CFR §484.50(e)(1)(ii)).

No patient’s services are reduced, delayed, ended or changed, and no one is treated differently, because a complaint was made to the Agency or to any outside body (42 CFR §484.50(c)(11)). A complaint is never a reason for discharge. A staff member who retaliates against a patient, family member or colleague for a complaint is disciplined, up to dismissal. A staff member who makes a report of abuse, neglect or exploitation is protected by ORC 5101.63(E) (Policy OH-HH-SG-01).

• The Department’s complaint unit receives complaints and its surveyors investigate them; investigations are unannounced (Policy OH-HH-QA-03).
• The Agency cooperates fully, produces the records requested, and never asks a patient or staff member who they think complained.
• Any deficiency found is corrected under Policy OH-HH-QA-03.

The complaint officer reviews the log each month for patterns by type, staff member, service, office and payer. Each quarter all complaints, their resolution times against 5 and 30, and any trends go to QAPI (Policy OH-HH-QA-01), and the governing body receives a summary at its next meeting, as the Agency’s own standard.

Accountability under this policy is allocated as follows.

The complaint log (Form OH-HH-CMP-01-B), complaint forms, investigation notes and resolution letters are kept for at least six years after the complaint is resolved, as the Agency’s own standard, and privacy complaints and their disposition for six years from the date of creation or the date last in effect, whichever is later (45 CFR §164.530(j)(2)). Each quarter the complaint officer checks that every complaint on the log was acknowledged and resolved within the Agency’s time frames, and reports exceptions to QAPI.

All staff are trained at orientation and annually, as the Agency’s own standard, on how to receive a complaint, the outside bodies patients may contact, no reprisal, and when a complaint must go to Policy OH-HH-SG-03.

This policy implements the following authorities.

• 42 CFR §484.50(a)(1)(ii), (c)(3), (c)(9), (c)(11) and (e)(1), Patient rights; investigation of complaints
• 45 CFR §164.530(d), Privacy complaints
• ORC 5101.63(E), Protection of reporters
• ORC 3740.03(A)(1)(a), Skilled home health services license: basis

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 14 is amended, the amendment is recorded in this table and a new version of this policy is issued.