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 every complaint about the Agency’s services is heard, recorded, looked into and answered fairly and promptly, that consumers know they can also go to the Department of Health and other outside bodies, and that the Agency uses complaints to improve.

This policy covers any expression of dissatisfaction with the Agency’s services, staff, scheduling, billing or communication, made by a consumer, representative, family member or anyone else on a consumer’s behalf, by any means.

For the purposes of this policy, the following terms have the meanings below. 28 Pa. Code Chapter 611 calls the person served a "consumer"; 55 Pa. Code Chapter 52 calls a consumer who receives Medical Assistance waiver services a "participant"; the protective services laws call a person who receives care from a facility a "recipient". In this policy these words mean the same person.

Before services begin, the Agency gives each consumer, legal representative or responsible family member the information packet required by 28 Pa. Code §611.57(c), which includes who to contact at the Department of Health about licensure and compliance, and "The Department's complaint Hot Line (1-866-826-3644) and the telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA)." (§611.57(c)(5)). The Department of Health now lists 1-800-254-5164 as its complaint line, so the Agency gives consumers both numbers (Policy PA-HC-CR-02).

Every consumer has the right to complain to the Agency or to any outside body without retaliation. No consumer’s services are reduced, changed or ended, and no one is treated differently, because of a complaint, as the Agency’s own standard; a person who reports suspected abuse is also protected by law (35 P.S. §10225.302(c)). The Agency acknowledges each complaint within 5 and aims to resolve it within 30; these are the Agency’s own time frames, not Department rules.

If the Agency serves participants in an Office of Long-Term Living waiver or the Act 150 program, it implements "a system to record, respond and resolve a participant's complaint" (55 Pa. Code §52.18(a)) that meets Section 8.

• Tell any employee, including the direct care worker, who passes it to the office the same day.
• Call the office at (717) 555-0100 during office hours (Monday through Friday, 8:00 a.m. to 5:00 p.m. Eastern) or the on-call line at (717) 555-0199.
• Write or email the complaint officer, Pat Sample, at 100 Example Street, Suite 100, Harrisburg, Pennsylvania 17101 or person1@example.com, or use Form PA-HC-CPL-01-A.
• Ask someone else, such as a family member, friend, advocate or ombudsman, to complain for you.
• Staff help anyone who needs help to make a complaint, including free interpreters and other formats (Policy PA-HC-ETH-03).

1. The person who receives the complaint writes it down the same day, using the complainant’s own words where possible, and passes it to the complaint officer.
2. If the complaint suggests abuse, neglect or exploitation, the employee makes the reports in Policy PA-HC-ANE-01 at once; the complaint officer tells the Administrator, who sends the Department of Health notice under Policy PA-HC-INC-01 because complaints of abuse are reportable "whether or not confirmed by the facility" (28 Pa. Code §51.3(g)(6)).
3. If the complaint is about an immediate risk to the consumer (for example, a missed visit leaving the consumer without care), the office acts the same day to make the consumer safe.
4. The complaint officer logs the complaint and acknowledges it to the complainant within 5, by phone or in writing, giving the name of the person looking into it.
5. The complaint officer (or a supervisor not involved in the matter) looks into it: talks to the complainant and staff, checks records, schedules and EVV data, and decides what happened.
6. The complaint officer tells the complainant the outcome and any action taken, within 30 where possible, and in writing if the complainant asks or the complaint was made in writing. If more time is needed, the complainant is told why and when to expect an answer.
7. The complaint officer asks whether the complainant is satisfied and records the answer. If not, the complainant may ask the Administrator to review the decision, and is reminded of the outside contacts in Section 7.
8. Any change needed (to staffing, the service plan, training or a procedure) is recorded with a responsible person and date.

Consumers may contact any of the following at any time, before, during or after using the Agency’s process:

For each complaint by or about a participant, the complaint system records (55 Pa. Code §52.18(b)):

• The name of the participant.
• The nature of the complaint.
• The date of the complaint.
• The Agency’s actions to resolve the complaint.
• The participant’s satisfaction with the resolution.

At least quarterly, the complaint officer reviews the complaint system to analyze the number of complaints resolved to the participant’s satisfaction, the number not resolved to the participant’s satisfaction, and the number referred to the Department of Human Services for resolution (§52.18(c)). If the number resolved to the participant’s satisfaction is less than the number not resolved, the Agency develops a quality management plan to address it (§52.18(d); Policy PA-HC-QM-01). The Agency gives the Department of Human Services a copy of its complaint procedures and its quarterly review information on request (§52.18(e)-(f)). As the Agency’s own standard, the same quarterly review covers all consumers, private-pay and waiver.

Accountability under this policy is allocated as follows.

Form PA-HC-CPL-01-A and the complaint log are kept for at least six years, as the Agency’s own standard. The log shows for each complaint the date received, the complainant, the consumer, the nature of the complaint, the dates acknowledged and resolved, the actions taken, whether the complainant was satisfied, and whether it was referred to an outside body. Each quarter the complaint officer reports to the Administrator and the governing body the number and type of complaints, time to acknowledge and resolve against the Agency’s time frames, satisfaction rates and themes (Policy PA-HC-QM-01).

All staff learn at orientation and each year how to receive a complaint and pass it on, and that complaints must never lead to retaliation (Policy PA-HC-TRN-01). For waiver services, annual training includes participant complaint resolution (55 Pa. Code §52.21(d)(3)).

This policy implements the following authorities.

• 28 Pa. Code §611.57(c)(4) and (5), Consumer protections: information packet
• Health Care Facilities Act §806.3(b)(5) (35 P.S. §448.806c(b)(5))
• 28 Pa. Code §51.3(g)(6), Notification
• Older Adults Protective Services Act §302(c) (35 P.S. §10225.302(c)), Retaliatory action
• 55 Pa. Code §52.11(a)(5)(vi); §52.18, Complaint management; §52.21(d)(3), Staff training (waiver providers only)

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