ACHC Requirements for Informing Patients of the Grievance Process

PUBLISHED: Oct 17, 2016

ACHC, the national accreditation organization that has CMS deeming authority for Home Health, Hospice and DMEPOS, requires the Home Health Agency (HHA) to inform the patient, at the initiation of services, of the process for reporting grievances and/or complaints.

ACHC standard HH2-4A requires the HHA have written policies and procedures that address the grievance process. Specifically, written policies and procedures should include:

  • The fact that patients have a right to express grievances and/or complaints regarding their treatment and/or property
  • The person to whom grievances/complaints should be reported
  • Time frames for investigating complaints
  • How information should be reported
  • How information will be reviewed and evaluated
  • Communication with patient/family
  • Documentation (which should include all activities involved in investigation the grievance/complaint, investigation, analysis and resolution)

Additionally, the HHA must:

  • Investigate all grievances/complaints made by patients and patient families
  • Document the existence of the complaint and the resolution
  • Maintain records of all grievances/complaints and the outcome
  • Write a summary report about grievances/complaints that is provided to the HHA owner/governing body

Included with today’s notice are example policies and procedures related to the ACHC HH2-4 required elements for addressing patient grievance/complaints.

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