Patient Grievances and Complaints

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 families of Sample Agency, LLC (the "Agency") can raise any concern about their care easily and safely, that every concern is taken seriously and answered promptly, and that the Agency learns from complaints.

This policy covers complaints and grievances from patients, families, representatives, facility staff, physicians, community members and staff about any care, treatment or service furnished, or not furnished, by the Agency or by anyone furnishing services on its behalf, in any setting, and about the lack of respect for a patient's property or person.

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

Every patient 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 "To not be subjected to discrimination or reprisal for exercising his or her rights" (42 CFR §418.52(b)(1)(iii)-(iv)). The governing body has established "Policies and procedures to receive and respond to patient grievances regarding medical treatment, quality of care, the lack of respect for person or property, mistreatment, neglect, exploitation, verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by any individual furnishing services on behalf of the hospice care program" (OAC 3701-19-06(C)(1)(b)), with notification procedures, documentation requirements and time frames for response, reporting of verified violations, and timely corrective action. This policy and Policy OH-HSP-ANE-02 are those policies, and the Administrator implements the patient grievance program (OAC 3701-19-06(C)(3)(e)).

• At admission, before care begins, the Agency gives the patient or representative the Notice of Patient Rights and Responsibilities, which explains the right to complain (Policy OH-HSP-PR-01), and Form OH-HSP-CMP-01-A, which explains how to complain to the Agency and to outside agencies.
• Ohio Medicaid patients receive a copy of the Agency's grievance procedures at the time hospice is elected (OAC 5160-56-02(G)(2)(a)).
• The process is explained in the patient's language and in a way the patient understands (Policy OH-HSP-GOV-07).
• Residents of facilities receive the same information; the facility's own complaint process does not replace the Agency's.

A complaint can be made in any way, and no one has to use a form:

• To any staff member or volunteer, who passes it to the complaint officer the same day.
• By telephone to the office at (614) 555-0100 (after hours (614) 555-0199), or to the complaint officer at (614) 555-0111.
• By email to person1@example.com or office@example.com, or by letter to the Agency at 100 Example Street, Suite 100, Columbus, Ohio 43215.
• On Form OH-HSP-CMP-01-A, which staff help complete if asked.
• Anonymously, although the Agency may then be unable to reply.

1. Receive and record: the staff member who receives a complaint listens, writes down what was said, makes sure the patient is safe, and tells the complaint officer the same day. The complaint officer enters it on Form OH-HSP-CMP-01-B.
2. Screen at once: if the complaint alleges mistreatment, neglect, verbal, mental, sexual or physical abuse, an injury of unknown source, misappropriation of patient property or exploitation, the complaint officer tells the Administrator immediately, and Policy OH-HSP-ANE-02 (and, where it applies, Policy OH-HSP-ANE-01 or OH-HSP-ANE-03) is followed at the same time as this policy.
3. Acknowledge: the complaint officer acknowledges the complaint within 5 of receipt, in the complainant's preferred way, and explains what will happen next (Agency standard).
4. Investigate: the complaint officer, or a manager not involved, reviews the record, talks with the complainant, the patient and the staff involved, and finds out what happened.
5. Resolve: the complaint officer gives the complainant a response within 30 of receipt, in writing if the complainant asks or the complaint was in writing, stating what was found, what has been or will be done, and how to take the matter further. If more time is needed, the complaint officer tells the complainant why and when to expect the answer (Agency standard).
6. Act: any corrective action is assigned an owner and a date and checked by the complaint officer.
7. Close: the complaint officer records the outcome and the date on Form OH-HSP-CMP-01-B.

If the complainant is not satisfied, the Administrator reviews the complaint and responds. If still not satisfied, the complainant may ask for review by the governing body, which responds in writing (Agency standard). A complainant may contact the outside agencies in Section 9 at any time, whether or not the Agency's process has ended.

• The Ohio Department of Health investigates complaints about hospices. Contact 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. ODH does not take complaints about incidents more than one year old, and does not handle billing, employment disputes, guardianship, power of attorney, professional practice or complaints against a specific practitioner; it refers those to the appropriate agency.
• For patients in long-term care facilities, and for problems with home care and other support services, contact 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.
• Ohio Medicaid consumers may call the Ohio Department of Medicaid Consumer Hotline at 1-800-324-8680.
• Suspected abuse, neglect or exploitation of an adult aged 60 or older at home: Adult Protective Services, a program of the Ohio Department of Job and Family Services: call 1-855-OHIO-APS (1-855-644-6277) at any time, contact the county Job and Family Services office, or use the Ohio Adult Protective Services Online Referral at https://aps.jfs.ohio.gov/. If someone is in immediate danger, call local law enforcement immediately.
• Discrimination: the U.S. Department of Health and Human Services, Office for Civil Rights (Policy OH-HSP-GOV-07).

No patient, family member, staff member or other person is threatened, punished, discharged, or given less care or attention because of a complaint (42 CFR §418.52(b)(1)(iv)). Any staff member who retaliates is disciplined. Care continues as planned while a complaint is being handled.

If the Agency has 15 or more employees, it has a grievance procedure for complaints of discrimination under Section 1557 of the Affordable Care Act (45 CFR §92.8(c)), handled by the person the governing body names on Form OH-HSP-GOV-01-A as described in Policy OH-HSP-GOV-07. Privacy complaints are passed to the privacy official, Lee Sample, who documents them and their disposition (45 CFR §164.530(d); Policy OH-HSP-PRV-01). Both are also logged on Form OH-HSP-CMP-01-B.

The complaint officer reports the number, types, timeliness and outcomes of complaints, and any patterns, to the QAPI program each quarter and to the governing body (Policy OH-HSP-QA-01). Themes are shared with staff without naming complainants.

Each role named below carries the duties shown.

Form OH-HSP-CMP-01-B (the complaint and grievance log) and each complaint file, with the dates received, acknowledged and resolved, the investigation, the response and corrective action, are kept for at least six years (Agency standard; privacy complaints for six years under 45 CFR §164.530(j)). Complaint files are kept separate from the clinical record; the clinical record notes only what is needed for care. Each quarter the complaint officer checks that every complaint met the acknowledgment and response time frames.

All staff and volunteers learn at orientation and every year how to receive a complaint, the difference between a complaint and an alleged violation that must go to the Administrator immediately, and the no-reprisal rule (Policies OH-HSP-HR-01 and OH-HSP-VOL-01).

This policy implements the following authorities.

• OAC 3701-19-06(C)(1)(b) and (C)(3)(e), grievance policies and program (effective December 29, 2025)
• OAC 3701-19-20(B), nondiscrimination
• OAC 5160-56-02(G)(2)(a), Ohio Medicaid election materials
• 42 CFR §418.52(b), exercise of rights and alleged violations
• 45 CFR §92.8(c), Section 1557 grievance procedure; 45 CFR §164.530(d), privacy complaints
• Ohio Department of Health, Complaints - Healthcare Facilities and Nursing Homes

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.