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 gives every client a clear, fair and safe way to complain, makes sure every complaint is answered within the time the rules require and is investigated, and makes sure the Agency learns from complaints. It implements 22-B DCMR §9917.1 to §9917.6, §9917.9 and §9908.2(g).

This policy applies to every complaint about the Agency's services made by a client or client representative, and, as the Agency's own standard, to concerns about services raised by family members, neighbors, other providers or staff on a client's behalf.

For the purposes of this policy:

"Each home support agency shall respond to each complaint received by it within fourteen (14) days of receipt, shall investigate the complaint as soon as reasonably possible, and shall, upon completion of the investigation, provide the complainant with the results of the investigation." (22-B DCMR §9917.5) "If the client indicates that he or she is not satisfied with the response, the home support agency shall respond in writing within thirty (30) days from the client's expression of dissatisfaction. The response shall include the telephone number and address of all District government agencies with which a complaint may be filed and the telephone number of the Complaint Hotline maintained by the Department." (§9917.6) The rule does not say business days, so the Agency counts these days as calendar days.

"A complaint may be presented to the home support agency orally or in writing." (22-B DCMR §9917.2) Each client has the right to voice a complaint or other feedback to DC Health or the Agency "in confidence and without fear of reprisal from the home support agency or any home support agency personnel, in writing or orally, including an in-person conference if desired" (§9916.2(k)). A complaint may therefore be made:

• By phone to the office ((202) 555-0100) or the complaint officer ((202) 555-0111), or after hours to (202) 555-0199.
• In writing, by letter, by email to office@example.com, or on the complaint form (Form DC-HC-CMP-01-A), which the client receives at admission and can ask any staff member for.
• In person, at the operating office at 100 Example Street NW, Suite 100, Washington, DC 20001 or at a conference in the client's home, with the complaint officer or the Director.
• To any employee, including the aide, who passes it to the office the same day.
• Anonymously. An anonymous complaint is logged and investigated as far as possible, and the log says it is anonymous (§9917.9(b)).

A client who needs an interpreter, large print, or help writing a complaint gets that help free of charge (Policy DC-HC-ETH-03). A client may ask a family member, friend or advocate to complain on his or her behalf.

Each client is informed orally and in writing of the complaint process and of the telephone number of the DC Health Complaint Hotline (22-B DCMR §9916.2(c)(4) and (5)), and that complaints and feedback may be made to DC Health or the Agency in confidence, without fear of reprisal, in writing or orally, including an in-person conference (§9916.3). Therefore:

• A written summary of the complaint process is given to the client or client representative upon acceptance or denial of services (§9917.3). On acceptance it is in the admission packet with the statement of client rights (Form DC-HC-CR-01-A) and Form DC-HC-CMP-01-A; on denial it is in the notice of denial (Form DC-HC-ADM-01-B).
• The service agreement states the number for DC Health's Complaint Hotline (§9911.1(f); Form DC-HC-ADM-03-A).
• The telephone number of the DC Health Complaint Hotline, (202) 442-4779, is posted in the operating office in a place where it is visible to all staff and visitors (§9917.4).
• The written rights and responsibilities policy, which includes the complaint process, is made available to the general public (§9916.5), including on the Agency's public website.

As the Agency's own standards:

1. Any employee who receives a complaint, in any form, writes down what was said, the date and time, and the complainant's contact details, and passes it to the complaint officer the same day. An employee never tries to talk a client out of complaining.
2. The complaint officer enters it in the complaint and incident log (Form DC-HC-CMP-01-B) on the day it is received. The date of receipt is the date any employee received it.
3. If the complaint describes possible abuse, neglect, self-neglect or exploitation, it is reported to Adult Protective Services at once (Policy DC-HC-ANE-01) and handled as an incident as well (Policy DC-HC-INC-01). If it describes an immediate risk to the client's safety, the Client Service Coordinator acts the same day.
4. The complaint officer acknowledges the complaint to the complainant within the acknowledgment period the governing body has set (5). The acknowledgment never replaces the response within 14 days.

The Agency responds to each complaint within fourteen (14) days of receipt (22-B DCMR §9917.5). As the Agency's own standard, the response is in writing (or, if the complainant asks for a phone call, given by phone and confirmed in a note in the log), and says: what the Agency understood the complaint to be; anything already done to fix the problem; who is investigating; when the complainant can expect the results; and how to contact DC Health (DC Health, Facility Complaints, 2201 Shannon Place SE, Second Floor, Washington, DC 20020; Intermediate Care Facilities Division Complaint Hotline (202) 442-4779; online complaint form at https://dchealth.dc.gov/page/doh-complaint-incident-report-form). If the complaint has been fully resolved within the 14 days, the response also gives the results of the investigation.

The Agency investigates each complaint "as soon as reasonably possible" and, upon completion of the investigation, gives the complainant the results (22-B DCMR §9917.5). In its response to comments on the final rule, DC Health said the Agency's policies "can explain what its reaction will be to each situation as long as explanations for investigations are reasonable." Table 1 sets out how the Agency investigates each kind of complaint, as its own standard. The investigator is never a person the complaint is about.

If an investigation will take longer than the target, the complaint officer tells the complainant why and when the results will come. The results say what was found, whether the complaint was substantiated, and what the Agency has done or will do. They are given in writing and, where the client prefers, explained in person.

If the client indicates, at any point and in any way, that he or she is not satisfied with the response, the complaint officer records the date of that expression of dissatisfaction in the log, and the Director responds in writing within thirty (30) days from that date (22-B DCMR §9917.6), using Form DC-HC-CMP-01-C. In its response to comments on the final rule, DC Health said that "it is our position to protect clients as much as possible." The written response includes:

• The Director's review of the complaint and of the earlier response, and anything the Agency will now do differently.
• An offer of an in-person conference with the Director (§9916.2(k)).
• The telephone number of the Complaint Hotline maintained by DC Health: (202) 442-4779.
• The telephone number and address of all District government agencies with which a complaint may be filed (§9917.6). The Agency lists at least: DC Health (DC Health, Facility Complaints, 2201 Shannon Place SE, Second Floor, Washington, DC 20020; Intermediate Care Facilities Division Complaint Hotline (202) 442-4779; online complaint form at https://dchealth.dc.gov/page/doh-complaint-incident-report-form); the DC Office of Human Rights for discrimination (DC Office of Human Rights, 441 4th Street NW, Suite 570 North, Washington, DC 20001; (202) 727-4559); the Office of the Attorney General for the District of Columbia, Office of Consumer Protection, for billing and business practices (Office of the Attorney General for the District of Columbia, Office of Consumer Protection, 400 6th Street NW, Washington, DC 20001; Consumer and Tenant Response team 202-442-9828; consumer.protection@dc.gov); and Adult Protective Services for abuse, neglect, self-neglect and exploitation (Department of Aging and Community Living, 500 K Street NE, Washington, DC 20002; (202) 724-5626; APS Hotline (202) 541-3950). If the complaint concerns a matter handled by another District agency, that agency is added.

No employee may threaten, punish, reduce or end services to, or treat differently a client, client representative or anyone else because a complaint was made to the Agency or to DC Health (22-B DCMR §9916.2(k); §9916.3). Retaliation is serious misconduct under Policy DC-HC-HR-07. A complainant's identity is shared only with those who need it to investigate. Services continue as agreed while a complaint is open. A complaint is never by itself a reason for discharge (Policy DC-HC-DC-01).

DC Health "may receive and investigate a complaint alleging violation of any provision of this chapter and may investigate any incident" (22-B DCMR §9917.11). Under 22-B DCMR §3105, DC Health investigates allegations of life-threatening conditions within 24 hours of receipt and others within 30 days, sends a written report to the Agency within 10 days after the investigation, and may require a plan of correction within 10 days. The Director cooperates fully, produces records at once, and handles any findings under Policy DC-HC-GOV-05. A client's complaint to DC Health is never held against the client.

The Agency keeps one system for documenting complaints and incidents, which reflects all complaint, incident and investigative activity for each year (22-B DCMR §9917.9). The log is Form DC-HC-CMP-01-B. For each complaint it records:

As the Agency's own standard, the log also records the date of the acknowledgment, the date of the response (and whether it was within 14 days), the date the results were given, any expression of dissatisfaction and the date of the written response under §9917.6. Complaint reports and investigations are stored at the operating office or are immediately available electronically there (22-B DCMR §9901.4(e)), and are kept for a minimum of five (5) years (§9915.5).

As the Agency's own standard, the complaint officer and the Director review the log each quarter for patterns and record the actions they decide on. The governing body reviews all complaints each year, including the nature of each complaint, the Agency's response and the resolution, as part of the annual evaluation (22-B DCMR §9906.2(c)(2); Policy DC-HC-QA-01).

Accountability under this policy is allocated as follows.

Each complaint file (the complaint as received, the acknowledgment, the response, investigation notes, the results, any written response under 22-B DCMR §9917.6 and Form DC-HC-CMP-01-B) is kept for a minimum of five (5) years (22-B DCMR §9915.5) and is available to DC Health at all times (§9915.7).

As the Agency's own standard, the Director checks each quarter that every complaint received a response within 14 days, that results were given, and that every expression of dissatisfaction received a written response within 30 days with the agency list and Hotline number. The Director also checks that the Hotline number is still posted. Findings are reported in the annual evaluation (Policy DC-HC-QA-01).

Every employee is trained at orientation and at each annual in-service on: how a client can complain, how to receive a complaint and pass it on the same day, where the Hotline number is posted, and the rule against reprisal (Policy DC-HC-HR-06). The complaint officer, the Director and the Client Service Coordinator are also trained on the 14-day and 30-day time frames, investigation, and the log.

This policy implements the following authorities.

• 22-B DCMR §9917.1 to §9917.6, §9917.9 and §9917.11, Management of Complaints and Incidents
• 22-B DCMR §9916.2(c)(4), (c)(5) and (k), §9916.3 and §9916.5, Client Rights and Responsibilities
• 22-B DCMR §9911.1(f), Client Service Agreement (Complaint Hotline number)
• 22-B DCMR §9908.2(g), Policies and Procedures (complaint process)
• 22-B DCMR §9901.4(e), §9915.5 and §9915.7 (complaint records)
• 22-B DCMR §9906.2(c)(2), Governing Body (annual review of all complaints)
• 22-B DCMR §3105, Complaint Investigations by DC Health
• 22-B DCMR §9999.1, Definitions ("Complaint")
• DC Health's response to comments on the final rule, 67 DCR 9476 (August 7, 2020), comments 20 and 28

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