Grievances
Authority
Federal law (Section 1881(c)(2) (D) of the Social Security Act, amended by OBRA 1989) permits investigation of grievances and decision-making about quality of care given to consumers. (A grievance is the report of a condition, circumstance or event that may have ill effects on consumers or the delivery of care.)
Quality Insights Renal Network 3 (QIRN3) Action
QIRN3's action will depend on the situation. QIRN3 will try to resolve grievances by acting as investigator, facilitator, referral source or coordinator between the consumer and the facility.
QIRN3 will try to resolve grievances using one of these roles and
- Assist in solving the grievance by acting in the chosen capacity between the consumer and the facility;
- Interview consumers, providers, and facility staff as needed to understand the grievance.
QIRN3 will become involved in investigating and resolving grievances when the grievance affects Medicare-eligible consumers and/or the services provided by a Medicare-certified facility.
Grievance Process
QIRN3's responsibility is to review the issues raised by the grievance and decide the action required (i.e., investigation and/or referral).
QIRN3 receives, in writing or by telephone, a grievance about dialysis or transplant facilities. The grievance may come from a consumer, from a consumer relative or an interested party.
When QIRN3 receives a grievance, a letter will be sent to the consumer within 15 days. QIRN3 will look at the history of the situation, including attempts to solve the problem.
If QIRN3 decides that a consumer's grievance is better handled by another agency, the consumer will be told this in writing. The letter will have the reason as well as the name, address, and telephone number of the new contact person.
Consumers should use the facility's grievance process before sending a grievance to QIRN3 but this is not a requirement.
Improvement Plans
A grievance may be solved by agreeing with the facility on an improvement plan (IP) and watching the progress the facility makes.
QIRN3 will ask for this when it is decided that a single problem or pattern of care problem is present. The facility develops the plan for change, but, if requested, QIRN3 could help with the plan.
QIRN3 will either accept or reject the plan in 15 calendar days. The plan must be complete and started within 30 days of being told that a problem has been found. This time period lets the facility have 15 days to write the plan, send it to QIRN3, and agree on an acceptable plan.
Referral of Grievances to Others
QIRN3 will look at the concern(s) in a grievance and decide what action is needed. If QIRN3 or federal staff decide that a grievance should be looked at by another agency the consumer will be told and the grievance sent to:
- Carriers and Federal Intermediaries - If the grievance is about payment, QIRN3 will refer the consumer to the paying agency or the regional office.
- State Agencies - If the grievance is a survey issue, QIRN3 will refer it to the state andfederal officials
PRO - QIRN3 will send grievances about all hospital inpatient care to the professional review organization (PRO) where the hospital is found. - State Attorney General’s Office QIRN3 will send complaints that are potential or an alleged fraud or abuse case to the state attorney general's office.
- State Licensing Boards - QIRN3 will send any consumer grievances about services in non-ESRD-related places to the appropriate accreditation, licensing, or certification agency or PRO for resolution.
Conclusion of Investigation
QIRN3 will end the investigation in 90 days of receiving the grievance.
In cases where more than 90 days are needed, all persons will be told by QIRN3, in writing, of the reason for the delay and the new end date.
Life-Threatening Grievances
If the grievance appears to be an immediate and serious threat to consumer safety, the grievance will be sent in 24 hours to state and federal officials.
Consumer confidentiality will be maintained. If federal officials ask QIRN3's assistance, QIRN3 will make its services available and/or will begin the investigation immediately.
QIRN3 will give a response about the quality of care in 60 days of receiving the grievance. The consumer will be told that in addition to QIRN3's involvement, his/her grievance was sent to federal officials.
Grievance Reports and Possible Results
QIRN3 will send a report to the consumer. The report will tell the consumer that if (s)he is not satisfied with the investigation the consumer may send the grievance to state or federal officials.
QIRN3 will send a copy of the report to all of the involved parties. Confidentiality of the consumer will be observed unless the consumer agreed to release his/her name.
If disclosure of information about the results of the investigation might be harmful to the consumer, the results will be given to the consumer's representative.
There are several possible outcomes to use of the grievance procedure.
- Consumer Is Satisfied - The consumer is satisfied when:
- Agreement between the facility and consumer results in a satisfactory outcome for the consumer without the need to decide fault;
- Investigation decides that it is appropriate for the facility to change its behavior and an acceptable improvement plan is completed; or
- Investigation decides that the consumer’s grievance was not found, and explanation/education resolves the consumer’s concern.
- Consumer Is Not Satisfied - The consumer is not satisfied with the results of the investigation because QIRN3 is:
- Not able to confirm the problem; or
- Not able to change facility activity to the extent the consumer wants. QIRN3 will tell the consumer of his/her rights to continue the grievance with federal and/or state officials.
- Grievance Activity Suspended - Grievance activities may be stopped when the concern has been referred, investigated, and acted on by another agency or when no further action can be taken by QIRN3.
Confidentiality and Release of Information
Consumer identity is confidential and will not be released unless the consumer agrees. QIRN3 will apply disclosure requirements in all cases.
If QIRN3 is not able to resolve the grievance without using the consumer's name, the consumer will be told. The consumer may reconsider and agree to the use of his/her name.
If the consumer still does not wish QIRN3 to use his/her name, the consumer will be told that QIRN3 is not able to continue, and QIRN3 will suggest other agencies, such as referral to state or federal officials.
Consumer Representative
A consumer may use whomever he or she chooses as a representative. The consumer representative may act for the consumer in any way that the consumer agrees.
Conflict of Interest
QIRN3 will make sure that a conflict of interest or possible conflict of interest does not exist among members of its committee or a review group handling grievances. Any person who has direct connection to the consumer or the facility will be excluded from the investigation and resolution of the grievance.
The consumer should not find in facility staff a change in attitude or behavior due to filing a grievance. If any reprisal is suffered, QIRN3 should be told immediately.
Problems and Complaints
QIRN3 can be called with problems or complaints that are not serious enough to be a grievance.
Problems and complaints are usually about such things as conflict with a staff person, changing from one facility or shift to another or the television that does not work.
ASSOCIATE REGIONAL ADMINISTRATOR REGION II
Associate Regional Administrator
Division of Medicaid and State Operations
Health Care Financing Administration
26 Federal Plaza, Room 38-130
New York, New York 10278-0063
Telephone: (212) 264-2504
FAX: (212) 264-2790STATES IN REGION II
New Jersey
New York Puerto Rico
Virgin Islands