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 anyone can raise a concern about care given by or on behalf of Sample Agency, LLC (the "Agency"), that each complaint is taken seriously, investigated and answered, and that patients are never penalized for complaining. The 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)).

This policy covers complaints and grievances from patients, representatives, family members, caregivers, facility staff, physicians, other providers and members of the public, whether made in person, by telephone, in writing, by email or anonymously, and whether about care, staff conduct, respect for property, billing, access to services or discrimination. No Pennsylvania rule sets time frames for a hospice to acknowledge or resolve a complaint; the time frames in this policy are the Agency's own.

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

Every person may complain to the Agency without fear. The Agency accepts complaints in any form, records each one on the complaint log, acknowledges it within 5 and resolves it within 30 as its own standards, documents the investigation and resolution, and tells the complainant the outcome. Complaints that allege abuse or another alleged violation are reported and investigated at once under Policies PA-HSP-ANE-01 and PA-HSP-ANE-02. The Agency tells every patient at admission how to complain to the Agency and to the Department of Health, and it never retaliates against anyone for complaining or cooperating with an investigation.

At admission the RN gives Form PA-HSP-CMP-01-A, How to Make a Complaint, and explains it (Policy PA-HSP-PR-01). The form gives: the Agency's complaint officer and how to reach the Agency 24 hours a day on (717) 555-0199; the Department of Health: Pennsylvania Department of Health, Division of Home Health, 2525 N. 7th Street, Harrisburg, PA 17110. Toll-free complaint hotline, 24 hours a day, seven days a week: 1-800-254-5164. Online complaint form: apps.health.pa.gov/dohforms/FacilityComplaint.aspx; the local long-term care ombudsman on (717) 555-0120; protective services: Pennsylvania Statewide Elder Abuse Helpline and Adult Protective Services Hotline, 1-800-490-8505, 24 hours a day, seven days a week, or the local Area Agency on Aging protective services unit. In an emergency call 911.; and, for Medicare patients, the BFCC-QIO number on the election statement. The Department's guidance is that patients usually raise a concern first with staff and the administrator, but a patient may contact the Department at any time and does not have to use the Agency's process first. Complaints about the Agency's advance directive practices may also be filed with the Department (42 CFR §489.102(a)(4)).

Any staff member who receives a complaint does the following.

1. Listen, thank the person, and do not argue or defend. Make sure the patient is safe.
2. If the complaint alleges abuse, neglect, mistreatment, an injury of unknown source or misappropriation of property, report it immediately to the Administrator (42 CFR §418.52(b)(4)(i)) and follow Policy PA-HSP-ANE-01 for reports to protective services and law enforcement. Do not investigate it yourself.
3. If the matter can be fixed safely on the spot (for example, a missed supply), fix it and tell the person.
4. Record the complaint the same day on the complaint intake page of Form PA-HSP-CMP-01-B (or the electronic log): date, who complained, patient, what happened, any action taken, and the staff member's name. Use the person's own words.
5. Pass the record to the complaint officer the same day, or to the on-call RN after hours if the complaint affects care that night.

The complaint officer handles each complaint as follows.

1. Sort the complaint: an alleged violation (go to Policy PA-HSP-ANE-02 and notify the Administrator if not already done); a possible serious event under 28 Pa. Code §51.3(f)-(g) (Section 8); a clinical concern (involve the clinical manager and, where relevant, the medical director); or a service, billing or conduct concern.
2. Acknowledge the complaint to the complainant within 5 (Agency standard), by telephone or in writing, giving the name of the person handling it.
3. Investigate: review the clinical record and visit notes, speak with the staff involved and with the patient (with the patient's consent where someone else complained), and gather any documents. Staff involved in the matter do not investigate it.
4. Decide what happened and what will change. Take corrective action, which may include changing the plan of care, reassigning staff, retraining, discipline or changing a process.
5. Tell the complainant the outcome and what has been done, within 30 (Agency standard), in plain words and in the person's language. If the investigation needs longer, tell the complainant why and when it will be finished. Respect the privacy of patients and staff in what is shared.
6. Record the investigation, the findings, the action taken, the date the complainant was told, and whether the complainant was satisfied, on Form PA-HSP-CMP-01-B.
7. If the complainant is not satisfied, offer review by the Administrator and remind the complainant of the right to contact the Department of Health and the other bodies on Form PA-HSP-CMP-01-A.

The complaint officer and the Administrator check every complaint against the reporting duties below. Reporting is in addition to the Agency's own handling, never instead of it.

The Department of Health may investigate a complaint by an unannounced visit. Staff cooperate fully and tell the Administrator at once. If the Department issues a written notice of violation, the Administrator submits a plan of correction within the time the Department sets and in any case as 35 P.S. §448.814 requires (Policy PA-HSP-GOV-03), and the complaint officer adds the matter to the complaint log.

No patient, family member, staff member or other person is threatened, punished, or given worse care or service because of a complaint or because he or she cooperated with an investigation. A person who makes a report under the Older Adults Protective Services Act or cooperates with the agency, and the victim, "shall be free from any discriminatory, retaliatory or disciplinary action by an employer or by any other person or entity" (35 P.S. §10225.302(c)). Any staff member who retaliates is subject to discipline up to dismissal. A patient is never discharged because he or she complained.

The complaint officer reports the number, type and outcome of complaints, and any trends, to the QAPI program at least each quarter (42 CFR §418.58; Policy PA-HSP-QA-01). The governing body reviews the complaint summary at least once a year.

Accountability under this policy is allocated as follows.

The complaint officer keeps Form PA-HSP-CMP-01-B (or the electronic log) with each complaint's intake, investigation, resolution and the date the complainant was told, for at least six years. A note that a complaint was made and resolved is placed in the clinical record where it concerns the patient's care; investigation notes about staff are kept in the complaint file, not the clinical record. As the Agency's own standard, the Administrator reviews the log each month for timeliness against 5 and 30.

All staff, contractors and volunteers are trained at orientation and yearly on how to receive and record a complaint, which complaints must be reported immediately, and the no-reprisal rule. The complaint officer is also trained in investigation. Training is recorded in the personnel record.

This policy implements the following authorities.

• 42 CFR §418.52(b)(1)(iii)-(iv), right to voice grievances without reprisal
• 42 CFR §418.52(b)(4), alleged violations
• 42 CFR §418.58, quality assessment and performance improvement
• 42 CFR §418.24(b)(7), BFCC-QIO information
• 42 CFR §489.102(a)(4), complaints about advance directive requirements
• Health Care Facilities Act, 35 P.S. §448.814, plans of correction
• 28 Pa. Code §51.3(f)-(g), notification of serious events
• Older Adults Protective Services Act, 35 P.S. §10225.302(c) and §10225.701

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