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 everyone receiving care from Sample Agency, LLC (the "Agency") knows how to complain, that every complaint is taken seriously and answered, that no one suffers for complaining, and that the Agency learns from what it hears.

This policy covers complaints and grievances, spoken or written, from patients, representatives, family members, facility staff, physicians, staff and the public, about any service the Agency furnishes or fails to furnish, the conduct of anyone furnishing services on its behalf, or billing.

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

Each 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)). The Agency acknowledges each complaint within 5 and resolves it within 30 (Agency standards), and keeps a record of every complaint and its outcome.

At the admission visit, with the notice of rights (Policy DC-HSP-PR-01), the admitting nurse gives the patient and representative "How to Make a Complaint" (Form DC-HSP-CMP-01-A) in their language, explains it, and records that it was given. The form is also in the home folder and posted at the office. It lists the Agency’s complaint officer and the outside agencies in Section 9.

1. Any staff member who receives a complaint listens, thanks the person, and, if they can, fixes simple problems at once (for example, arranging a missed delivery).
2. An immediate concern is passed to the clinical manager or on-call nurse at once, by telephone, and acted on the same day.
3. Any complaint that includes an allegation of abuse, neglect, mistreatment, injury of unknown source or misappropriation of property is reported immediately to the Administrator and handled under Policies DC-HSP-ANE-01 and DC-HSP-ANE-02.
4. Every complaint, even one fixed at once, is passed to the complaint officer the same day and entered on the complaint log (Form DC-HSP-CMP-01-B).
5. Complaints may be made anonymously. Staff never discourage a complaint or ask a patient to withdraw one.

1. The complaint officer acknowledges the complaint to the complainant within 5 (Agency standard), by telephone or in writing, and gives a contact name and number.
2. The complaint officer, or a manager the complaint officer assigns who is not the subject of the complaint, looks into the facts: speaks with the complainant, the patient, the staff involved and others; reviews the clinical record, visit records and any other evidence.
3. Where care needs to change, the IDG meets and updates the plan of care.
4. The complaint officer resolves the complaint within 30 (Agency standard) and tells the complainant, in writing if they wish, what was found and what the Agency has done or will do. If more time is needed, the complainant is told why and when to expect an answer.
5. If the complainant is not satisfied, the complaint goes to the Administrator, who reviews it and gives a final Agency response. The complainant is reminded of the outside agencies in Section 9.
6. The outcome, the date of each step and any corrective action are recorded on Form DC-HSP-CMP-01-B.

No patient, family member, staff member or other person may be threatened, punished, have care reduced or changed, or be treated differently because they complained, inside or outside the Agency (42 CFR §418.52(b)(1)(iv)). A complaint does not affect the patient’s care. Any staff member who retaliates is subject to discipline. Privacy complaints are also protected from intimidation and retaliation (45 CFR §164.530(g)).

A patient or anyone else may complain to any of the bodies in Table 1 at any time, without first using the Agency’s process.

If DC Health, CMS, an accrediting organization or another agency tells the Agency of a complaint or arrives to investigate one, the Administrator cooperates fully, gives access to records and staff (Policy DC-HSP-REC-01), enters the complaint on the log, and responds to any statement of deficiencies with a plan of correction (Policy DC-HSP-GOV-03).

Complaints of discrimination on the basis of race, color, national origin (including language access), sex, age or disability are also handled under the Section 1557 grievance procedure in Policy DC-HSP-GOV-07, which a covered entity that employs fifteen or more persons must have. Records of those grievances are kept for no less than three calendar years from the date the grievance is resolved (45 CFR §92.8(c)(2)).

Each quarter the complaint officer reports to the Quality Management Committee the number and type of complaints, the time taken to acknowledge and resolve them, outcomes and trends. Complaints and on-call logs are part of the systematic reviews in the quality management program (Policy DC-HSP-QA-01). The Administrator reports complaints and grievances to the governing body at each meeting.

Each role named below carries the duties shown.

The complaint log (Form DC-HSP-CMP-01-B), investigation notes and responses are kept for at least six years (Agency standard), and Section 1557 grievance records for no less than three calendar years from resolution (45 CFR §92.8(c)(2)). Each quarter the complaint officer checks that every complaint was acknowledged within 5 and resolved within 30, or that the reason for any delay was recorded.

At orientation and each year all staff learn how to receive a complaint, what an immediate concern is, how to pass complaints on, the outside agencies, and the rule against reprisal (Policy DC-HSP-HR-01).

This policy implements the following authorities.

• 42 CFR §418.52(a), Notice of rights and responsibilities
• 42 CFR §418.52(b)(1)(iii)-(iv), Right to voice grievances without discrimination or reprisal
• 42 CFR §488.1110(b), Complaints and State hotline
• 42 CFR §418.24(c)(8)(ii), Right to immediate advocacy through the BFCC-QIO
• 45 CFR §92.8(c), Section 1557 grievance procedures
• 45 CFR §164.530(d), (g), Privacy complaints and non-retaliation

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