The Complaint and Grievance Process
Policy
The Renal Network is contracted by the Centers for Medicare & Medicaid Services (CMS) as an End-Stage Renal Disease (ESRD) Network and authorized under the Social Security Act to receive, investigate, and when possible resolve complaints and grievances made by or on behalf of ESRD Medicare beneficiaries receiving dialysis or transplant services in Medicare certified facilities in the states of Delaware, Illinois, Indiana, Kentucky, Ohio and Pennsylvania.
In the Conditions for Coverage, published in the Federal Register on April 15, 2008, it states in Section 494.70, that patients are to be informed of external grievance mechanisms and processes, including how to contact the ESRD Network and the State Survey Agency. It also states that patients be informed of the right to file an internal or external grievance without the fear of reprisal or denial of services and that the grievance can be filed personally, anonymously or through a representative of the patient's choice.
Process
When The Renal Network receives a complaint either verbally, electronically, by fax, or by letter:
- It must first determine if the problem can be handled informally through consultation, mediation or education. The Network can (with the complainant's permission) communicate with the facility or practitioner to help the involved parties resolve the problem and arrive at a workable solution. (Informal Complaint)
- If the problem cannot be resolved informally or if the complaint is more serious in nature then a formal grievance can be initiated to examine the issue. The formal grievance process is a longer process and includes: a) A formal investigation and review by the Network Medical Review Board, b) A grievance determination that either substantiates or does not substantiate the grievance, c) Due process for the involved parties, and d) A final report to the grievant. (Formal Grievance)
- If a problem is under the jurisdiction of another regulatory agency, such as, the State Survey Agency or the Quality Improvement Organization (QIO), the Network will refer you to the most appropriate agency for review of their concern. State agency contact information is provided in a table at the bottom of this page. (Referral)
Facility Grievance
All ESRD patients should have information about their facility complaint/grievance process. The Network encourages patients to talk to their facility staff about complaints and to use the facility grievance process as the first step so that the problem can be addressed quickly and resolved, hopefully, to the patient's satisfaction and understanding.
However, complaints/grievances do not have to be filed first with the facility or if the outcome of the grievance with the facility is not satisfactory to the complainant, a complaint or a grievance can be filed with the Network, which investigates every complaint/grievance received.
Network Grievance
The Renal Network's role in resolving complaints, grievances, or inquiries varies, depending upon the situation. The Network's roles include: a) Investigator, b) Facilitator, c) Advocate, d) Educator, e) Coordinator, and f) Referral Agent.
The Network has the authority to act on all complaints/grievances regarding a Medicare certified facility or made by a Medicare beneficiary alleging a facility's failure to provide care and services to which beneficiaries are entitled. To help the Network investigate patient grievances, a Grievance Form has been developed to identify the problem clearly and to help the Network understand what has been done so far to resolve it. Please use the Grievance Form to describe your grievance. (format: PDF, size: 289 kb)
In filing a grievance, a grievant may remain anonymous to the facility. The Network will not release a patent's name to the facility without the patient's permission. However, anonymous grievances allow the Network to do only a general investigation. In addition, a third party may act as the representative for the grievant.
Timeline
The formal grievance process at the Network involves a number of steps. The grievant is sent an acknowledgment of the grievance letter within 5 business days of the Network receiving it. The Network then has up to fifty (50) calendar days for intake, investigation/review and resolution of the grievance. Once the grievance review is completed the Network is required to advise the provider/involved practitioner of the determination and offer him/her an opportunity to comment prior to the release of the final response to the grievant (30 days). If a physician consents to have his/her name released in the grievance letter, that information is confidential and may not be re-released without the physician's consent. All steps of the grievance process will be completed within ninety (90) days plus any follow-up as needed. The Network's Medical Review Board (MRB), which is an interdisciplinary group that includes patient members, reviews all grievances. When their investigation is completed, the grievant receives a written report.
Trends
The Network keeps statistics on the number and kind of complaints/grievances it receives as well as facility trends on the number of complaints/grievances of each Network facility.
Questions
The Renal Network Patient Services Department handles complaints and/or grievances.
Call: 412.325.2250 or 1-800-548-9205
Write: ESRD Network 4, 40 24th Street, Suite 410, Pittsburgh, PA 15222
Email: info@nw4.esrd.net
Both Network 4 and the State Survey Agencies receive and investigate complaints as one of their many services. If you wish to contact your State Survey Agency, the addresses and phone numbers appear below.
| DELAWARE | PENNSYLVANIA |
|---|---|
| Office of Health Facilities Licensing and Certification 258 Chapman Road Chopin Building, Suite 101 Newark, DE 19702 |
Pennsylvania Department of Health Division of Home Health 132 Kline Plaza, Suite A Harrisburg, PA 17104 |
| Toll Free in Delaware only: 1-800-942-7373 Main Number: 1-302-283-7220 |
Toll Free: 1-800-222-0989 Main Number: 1-717-783-1379 |
