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 patients of Sample Home Health Agency, LLC (the "Agency") and the people who care for them can raise a concern easily, are listened to, get an answer on time, and are never penalized for speaking up. It implements the patient’s right to voice grievances about treatment or care that is, or fails to be, furnished, or about lack of respect for property, without discrimination or reprisal (26 TAC §558.282(f)(8)), and, if the Agency is Medicare-certified, the patient’s right to make complaints to the Agency and to be free from discrimination or reprisal for voicing grievances to the Agency or an outside entity (42 CFR §484.50(c)(3), (11)).

This policy covers every complaint, spoken or written, made by a patient, the patient’s representative, caregivers, family, guardian, or health care provider, about care furnished or not furnished, furnished inconsistently or inappropriately, the conduct of anyone furnishing services for the Agency, respect for the patient’s person or property, billing, scheduling, or privacy (26 TAC §558.250(c)(1); 42 CFR §484.50(e)(1)(i)).

For the purposes of this policy, the following terms have the meanings below. 26 TAC Chapter 558 says "client" and 42 CFR Part 484 says "patient"; in this policy the two words mean the same person.

Every complaint is welcome, recorded, investigated, and answered. The Agency investigates complaints, documents both the existence of each complaint and its resolution, and takes action to prevent further potential violations, including retaliation, while a complaint is investigated (42 CFR §484.50(e)(1)).

No patient is discriminated against or subjected to reprisal for complaining to the Agency or to anyone outside it (26 TAC §558.282(f)(8); 42 CFR §484.50(c)(11)), and the Agency does not retaliate against anyone for filing a complaint, presenting a grievance, or providing information in good faith (26 TAC §558.250(e); Tex. Health & Safety Code §142.0093). Services are never reduced, rescheduled, or ended because someone complained.

The Agency’s acknowledgment and resolution time frames are set no longer than the limits in 26 TAC §558.250: an investigation is always started within 10 days and completed within 30 days of receipt unless a documented reasonable cause justifies a delay. A complaint that alleges abuse, neglect, or exploitation is reported to HHSC or DFPS immediately under Policy TX-HH-SG-01 before anything else is done.

• At the start of care, the admitting clinician gives the patient Form TX-HH-CMP-01-A, Where to Direct a Complaint, and explains it. The form is the written statement required by 26 TAC §558.282(d) and Tex. Health & Safety Code §142.009(b): it tells the patient that a complaint against the Agency may be directed to HHSC Complaint and Incident Intake, P.O. Box 149030, Austin, Texas 78714-9030, toll free 1-800-458-9858; that a complaint may also be directed to the Agency’s administrator or complaint officer; and the time frame in which the Agency reviews and resolves a complaint.
• If the Agency is Medicare-certified, the notice also gives the name, business address, and business phone number of the Administrator to receive complaints (42 CFR §484.50(a)(1)(ii)), and advises the patient of the state toll-free home health hotline, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local home health agencies (§484.50(c)(9)).
• The clinician documents in the clinical record that the patient was informed of how to register a complaint (26 TAC §558.301(a)(9)(L)).
• The form is provided in the patient’s language and in accessible formats, and interpreters are used, at no cost to the patient, under Policy TX-HH-PR-04.

1. Receive (any staff member). Listen, thank the person, and do not argue or promise an outcome. If the complaint alleges abuse, neglect, exploitation, or an injury of unknown source, follow Policy TX-HH-SG-01 at once. Write down who complained, the date, the patient, and what was said, and pass it to the complaint officer the same working day.
2. Log (complaint officer, same working day). Enter the complaint on the Complaint Log, Form TX-HH-CMP-01-B, with the date of receipt. This documents receipt (26 TAC §558.250(c)(2)(A)).
3. Acknowledge (complaint officer, within 5 days). Contact the complainant by phone or in writing to confirm the complaint, explain the next steps, and give the expected resolution date.
4. Protect (complaint officer and supervising nurse, at once). Take any step needed to protect the patient and prevent further potential violations, including retaliation, during the investigation: for example, reassigning a staff member, adding a supervisory visit, or contacting the physician (42 CFR §484.50(e)(1)(iii)).
5. Investigate (complaint officer, started no later than 10 days after receipt). Review the clinical record, schedule, visit verification and billing data; interview the patient, complainant, staff, and witnesses; and document every step (26 TAC §558.250(c)(2)(B)). Use Policy TX-HH-QA-02 for complaints that involve an incident.
6. Resolve (complaint officer, within 30 days and never more than 30 days after receipt unless a reasonable cause for delay is documented). Decide what happened and what will change, and tell the complainant the outcome orally and in writing, including how to contact HHSC if they are not satisfied.
7. Close (complaint officer). Record the resolution and date on the log (42 CFR §484.50(e)(1)(ii)). If the resolution is delayed, record the reasonable cause and the new date before the 30th day and tell the complainant.
8. Learn (QAPI). Report complaints, themes, time frames met, and actions to the QAPI Committee under Policy TX-HH-QA-01, which reviews complaint data as 26 TAC §558.287(a)(1)(A) requires.

A complaint about the Administrator or the complaint officer is handled by Jo Sample, Alternate Administrator, or by a person the governing body names, and reported to the governing body. The complainant may always go directly to HHSC.

A patient may complain to HHSC Complaint and Incident Intake at any time, before, during, or after using the Agency’s process (HHSC Complaint and Incident Intake, P.O. Box 149030, Austin, Texas 78714-9030, toll free 1-800-458-9858). Privacy complaints may also go to the U.S. Department of Health and Human Services, Office for Civil Rights (45 CFR §164.530(d)). If the Agency is Medicare-certified, a Medicare patient may also contact the Quality Improvement Organization serving Texas, whose contact details are on the patient rights notice under Policy TX-HH-PR-01. The Agency cooperates with any outside investigation.

Accountability under this policy is allocated as follows.

The Complaint Log (Form TX-HH-CMP-01-B) and a file for each complaint (intake notes, acknowledgment, investigation notes, resolution letter, and any documented reason for delay) are kept for at least five years after resolution (Agency standard), apart from the clinical record. The patient’s acknowledgment of Form TX-HH-CMP-01-A is kept in the clinical record. Each quarter the QAPI Committee reviews the number and type of complaints, the percentage acknowledged within 5 days, investigated within 10 days, and resolved within 30 days, and any repeat themes.

All staff are trained at orientation on how to receive a complaint, how to recognize when a complaint is really an abuse, neglect, or exploitation report, and the rule against retaliation; training is repeated annually as the Agency’s own standard. The complaint officer is trained on investigation and documentation under Policy TX-HH-QA-02.

This policy implements the following authorities.

• 42 CFR §484.50(a)(1)(ii), (c)(3), (c)(9), (c)(11), and (e), Patient rights
• 42 CFR §484.65, Quality assessment and performance improvement
• 26 Texas Administrative Code §558.282, Client Conduct and Responsibility and Client Rights
• 26 Texas Administrative Code §558.250, Agency Investigations
• 26 Texas Administrative Code §558.301(a)(9)(L), Client Records; §558.287, Quality Assessment and Performance Improvement
• Texas Health and Safety Code §142.009(b), Surveys; Consumer Complaints; §142.0093, Retaliation Prohibited
• 45 CFR §164.530(d), Complaints to the covered entity

The following documents are read together with this policy.

This policy is adopted by the governing body of Sample Home Health 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.