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 it easy for patients of Sample Agency, LLC and the people who care for them to raise a concern, and makes sure every complaint is heard, looked into, answered on time, and used to improve care.

This policy covers how complaints may be made, the written summary of the process, posting the hotline, logging, acknowledgment, investigation, response time frames, written responses, outside agencies, the EPD Waiver and DC Medicaid requirements, protection from reprisal, and review of complaints by the QAPI committee and the governing body.

For the purposes of this policy, the following terms have the meanings below. 22-B DCMR Chapter 39 and 42 CFR Part 484 both say "patient". The District of Columbia Medicaid rules (29 DCMR Chapters 42 and 50) say "beneficiary". In this policy these words mean the same person: someone receiving home care services from the Agency.

The Agency has "policies and procedures for an internal complaint process that shall allow the patient or his or her representative to present a complaint to agency staff, contract personnel, or the home care Director" (22-B DCMR §3913.1). "A complaint may be presented orally or in writing" (§3913.4). A written summary of the process is given to the patient or representative upon acceptance or denial of services (§3913.2(a)). "The telephone number of the Home Health Hotline maintained by the Department of Health shall be posted in the home care agency's operating office in a place where it is visible to all staff and visitors" (§3913.3).

"The home care agency shall respond to the complaint within fourteen (14) calendar days of its receipt, and shall document the response" (§3913.5). "If the patient indicates that he or she is not satisfied with the response, the agency shall respond in writing within thirty (30) calendar days from the date of the agency's initial response. 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 Home Health Hotline maintained by the Department of Health" (§3913.6).

Each patient has the right "To voice a complaint or other feedback in confidence and without fear of reprisal from the agency or any agency personnel, in writing or orally, including an in-person conference if desired, and to receive a timely response to a complaint as provided in these rules" (§3912.2(l)), and the Agency informs all patients of their right to complain to the Department of Health "in confidence and without fear of reprisal from the agency or any agency personnel, in writing or orally, including an inperson conference if desired" (§3912.3). Where the EPD Waiver, DC Medicaid, or Medicare rules set shorter or additional requirements for a patient, the Agency follows the strictest rule that applies.

• At acceptance or denial of services, the patient or representative receives the written summary of the complaint process (the Patient Rights and Responsibilities packet and Form DC-HH-CMP-01-A), in English or Spanish or in another language or format the patient needs (22-B DCMR §3913.2(a); §3912.6; Policy DC-HH-PR-04). The patient is told orally and in writing of the complaint and referral procedures and the DC Health hotline number (§3912.2(c)(5), (c)(7)).
• The DC Health complaint hotline number, (202) 442-4779, is posted in the District operating office where all staff and visitors can see it (§3913.3).
• Patients are told they may complain to the Agency, to DC Health, or both, in confidence, orally or in writing, including an in-person conference if they wish (§3912.2(l); §3912.3), and that the Agency will not retaliate.
• If the Agency is enrolled with DC Medicaid for personal care aide services, the beneficiary’s rights statement covers the right "To voice a complaint or grievance about treatment, care, or lack of respect for personal property by persons providing services without fear of reprisal" and the "Complaint and appeal procedures" (29 DCMR §5014.3(i), (k)(5)), and is given before services begin or at the initial care planning visit (§5014.1).

• Any staff member or contract worker may receive a complaint, by phone, in person, in a patient’s home, by letter, or by email (§3913.1, §3913.4). The patient may also go straight to the complaint officer or the Director.
• The person who receives it listens, does not argue or promise an outcome, writes down what the patient says on Form DC-HH-CMP-01-A (or helps the patient complete it), and passes it to the complaint officer the same day.
• If the complaint suggests a patient is in danger, or alleges abuse, neglect, mistreatment, or theft, tell the supervising nurse or Director at once and follow Policies DC-HH-SG-01 to DC-HH-SG-03 as well as this policy.
• Anonymous complaints are accepted and investigated as far as possible.

The complaint officer enters every complaint in the complaint log on the day it is received, with the date received, who complained, the patient, the nature of the complaint, and the staff involved, and opens Form DC-HH-CMP-01-B. The complaint officer acknowledges each complaint to the complainant within 5 days of receipt as the Agency’s own standard, and sooner when the complaint involves risk to the patient.

• The complaint officer, or a supervisor the complaint officer assigns who is not the subject of the complaint, looks into the facts: talks with the complainant (offering an in-person conference), the staff involved, and witnesses; reviews the clinical record, schedules, EVV data, and billing records as needed.
• Immediate action is taken for anything that affects safety or care, for example changing a caregiver, adding a visit, or correcting a bill.
• If the Agency is Medicare-certified, it investigates complaints about treatment or care that is (or fails to be) furnished, is furnished inconsistently, or is furnished inappropriately, and about mistreatment, neglect, abuse, injuries of unknown source, and misappropriation of patient property; documents both the existence of the complaint and its resolution; and takes action to prevent further potential violations, including retaliation, while the complaint is investigated (42 CFR §484.50(e)(1)). The Agency does this for every patient.

The Agency aims to resolve each complaint within 30 days of receipt as the Agency’s own standard. Whatever that target is, the following rule time frames are never exceeded:

For a patient who is not in the EPD Waiver, the Agency addresses any complaint that poses an immediate risk to the patient within 24 hours or the next business day as the Agency’s own standard.

The complaint officer tells the complainant, in a way the complainant understands, what was found, what the Agency has done or will do, and how to take the complaint further if not satisfied. The response, its date, and how it was given are recorded on Form DC-HH-CMP-01-B (§3913.5). A written response is sent whenever the complainant asks for one as the Agency’s own standard.

The Director reviews the complaint and sends a written response within 30 calendar days of the first response (§3913.6). The written response lists the telephone number and address of every District government agency with which a complaint may be filed, and the DC Health hotline number, at least:

• DC Health (licensing and complaints): 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 Health complaint hotline for home care agencies (named the Home Health Hotline in 22-B DCMR Chapter 39) is (202) 442-4779.
• Department of Health Care Finance (DC Medicaid): District of Columbia Department of Health Care Finance (DHCF), 441 4th Street NW, Suite 900S, Washington, DC 20001; (202) 442-5988; DC Medicaid fraud hotline 1-877-632-2873.
• Adult Protective Services, Department of Aging and Community Living: Department of Aging and Community Living, 500 K Street NE, Washington, DC 20002; (202) 724-5626; APS hotline (202) 541-3950.
• DC Office of Human Rights (discrimination): DC Office of Human Rights, 441 4th Street NW, Suite 570 North, Washington, DC 20001; (202) 727-4559.
• State Health Planning and Development Agency (uncompensated care under a Certificate of Need): State Health Planning and Development Agency (SHPDA), DC Health, 2201 Shannon Place SE, 6th Floor, Washington, DC 20020; (202) 442-5865; https://dcshpda.com.
• For EPD Waiver beneficiaries, the Office of the D.C. Long-Term Care Ombudsman: Office of the D.C. Long-Term Care Ombudsman, Legal Counsel for the Elderly, 601 E Street NW, Washington, DC 20049; (202) 434-2190; DCOmbuds@aarp.org.

A patient may complain to DC Health at any time, before, during, or after using the Agency’s process. DC Health may investigate without notice and must be allowed entry (22-B DCMR §3105.1, §3105.2). DC Health’s rules call for complaints of a life-threatening nature or that represent immediate danger to be investigated within 24 hours of receipt and others within 30 days of receipt or as deemed appropriate (§3105.6). The Agency cooperates fully, and responds to any written report of findings with a plan of correction within 10 days of receiving it if DC Health requires one (§3105.4; Policy DC-HH-GOV-03).

If the Agency is enrolled with DC Medicaid as an EPD Waiver provider, this policy is its complaint documentation and review process (29 DCMR §4254.10). Under §4254.9, a complaint is "an expression of dissatisfaction or a formal charge of wrong-doing brought against an EPD Waiver Provider or individual providing services", and includes denials or reductions of service; delays in the process resulting in a denial of eligibility; provider tardiness or poor quality of care; restriction of individual rights; lack of choice of service provider; obstructing the beneficiary’s choice of preferred provider when available; and violations of the Agency’s privacy plan (Policy DC-HH-PRV-01). The Agency:

• Names the designated complaint officer (see Definitions) (§4254.10(b)).
• Meets the time frames in Section 9 (§4254.10(c)-(d)).
• Keeps "an internal process for tracking and trending information related to the occurrence of complaints and the outcome of investigations" (§4254.11), through the QAPI program (Policy DC-HH-QA-01).
• Keeps a copy of all complaints "on file for a minimum period of ten (10) years" (§4254.12).
• Logs complaints into the EPD Waiver Complaint Database when DHCF issues a transmittal telling providers to do so (§4254.13).

No patient, representative, family member, or staff member may be threatened, punished, or treated differently for making a complaint to the Agency or to any outside agency (§3912.2(l); §3912.3; 42 CFR §484.50(e)(1)(iii)). Services are not reduced, delayed, or ended because someone complained. Any reprisal is serious misconduct under Policy DC-HH-HR-01. Privacy complaints are also handled under 45 CFR §164.530(d) (Policy DC-HH-PRV-01).

• The QAPI committee reviews the complaint log each quarter for trends by type, staff member, and service, and for timeliness (Policy DC-HH-QA-01).
• The governing body’s annual evaluation includes "a review of all complaints made or referred to the agency, including the nature of each complaint and the agency's response thereto" (22-B DCMR §3903.2(c)(2); Policy DC-HH-GOV-04).

Accountability under this policy is allocated as follows.

Forms DC-HH-CMP-01-A and DC-HH-CMP-01-B, the complaint log, written responses, and evidence of each response are kept for at least ten years from the date of the complaint as the Agency’s own standard (the EPD Waiver rule requires ten years for EPD complaints, 29 DCMR §4254.12). Each month the complaint officer checks the log for complaints approaching the 14-day and 30-day limits and reports any late response to the Director.

All staff are trained at orientation and every year on how to receive a complaint, the patient’s right to complain without reprisal, the DC Health hotline, and the time frames in this policy. The complaint officer and supervisors are trained on investigation, written responses, and the EPD Waiver rules.

This policy implements the following authorities.

• 22-B DCMR §3913.1 to §3913.6 (complaint process); §3912.2(c)(5), (c)(7), (l), §3912.3, §3912.6 (rights); §3905.2(f); §3903.2(c)(2) (annual review of complaints); §3105 (DC Health complaint investigations).
• 29 DCMR §5014.1 and §5014.3(i), (k)(5) (personal care aide services) and §4254.9 to §4254.13 (EPD Waiver), if the Agency is enrolled.
• 42 CFR §484.50(e)(1), if the Agency is Medicare-certified; 45 CFR §164.530(d) (privacy complaints).

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