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Patient Care: Advocacy Organizations

State and Private Agencies Investigate Complaints of Poor Treatment
By: CaregiverZone

What if you are not satisfied with the quality of care?

One of the most difficult challenges for caregivers occurs when problems arise with the facility or heath care professionals who are supposed to help the senior. If you are not satisfied with the quality of care, discuss your concerns with the facility's director. You might also want to speak with the senior's physician, facility medical director or other appropriate staff member.

Misunderstandings rather than poor intentions cause many problems, and talking with staff and managers can frequently resolve them. Moreover, federal and state laws require facilities to investigate complaints about treatment. However, if directly approaching those involved does not produce results, you may have to turn to one or more advocacy organizations. These include:

  • Ombudsman programs, which investigate complaints against long-term care facilities

  • Peer review organizations (PROs), which oversee quality of care for Medicare patients

  • State survey agencies, which conduct reviews of nursing homes

  • Professional licensing boards, which can sanction their members

  • Law enforcement agencies, which can investigate criminal activities

Ombudsman programs

If you have a complaint about a nursing home or other facility you cannot resolve with the staff, try the local ombudsman program. Ombudsman programs are independent nonprofit agencies mandated by law to protect the rights of residents in long-term care facilities and investigate complaints. Every state has an ombudsman program; most of the programs maintain local branches in different parts of the state.

State and federal laws require facilities to post contact information for the ombudsman program in their area. Ombudsmen can meet with residents and their caregivers and families to discuss quality of care, financial issues, dietary matters and other areas of concern. Ombudsmen can also mediate disputes between facilities and residents or their representatives.

Ombudsmen have no enforcement authority. However, ombudsmen refer their findings to the state survey agency, which is mandated to regulate nursing homes. Since neither the facility nor the state employs them, their recommendations carry special weight with state survey agencies.

Peer review organizations

If you have a complaint about a doctor, hospital, managed care plan or nursing home that you cannot resolve with that physician or organization, try contacting your state's Peer Review Organization. These organizations - also known as Quality Improvement Organizations - investigate complaints about any care a patient has received under Medicare.

However, like ombudsmen, they have no enforcement authority. If enforcement is necessary, the PRO may refer a complaint to the state survey agency or the relevant licensing board.

State survey agencies

If neither the ombudsmen nor the PRO is able to help you, you can turn to the state survey agency, also sometimes known as a state licensing agency. These agencies enforce federal guidelines regulating nursing homes and have the power to issue sanctions and impose penalties against facilities with substandard practices.

The possible penalties vary widely, from monetary fines to bringing in a temporary management team to even - although this is rare - closing down a facility. These agencies also conduct annual inspections of every Medicare- or Medicaid-certified nursing home.

Professional licensing boards

If your complaint is with a nursing home, the state survey agency has enforcement authority; however, if your complaint is with a physician, nurse or hospital, you can turn to the professional licensing board. The boards oversee standards for medical professionals and facilities and can exercise disciplinary authority if necessary.

For example, physicians are licensed through a state board of medical examiners which can sanction them or revoke their medical licenses; nurses are licensed through a state board of nursing, and most hospitals undergo accreditation through the Joint Commission on the Accreditation of Hospital Organizations. You can find phone numbers in the state government section of your telephone book.

Law enforcement agencies

If you have a complaint about a facility or care provider that is so serious you believe a law has been broken, you should call a law enforcement agency. These agencies have responsibility in cases of criminal misconduct. For example, a licensed medical professional who steals a patient's pain medication could face both malpractice and criminal charges. Licensing boards deal only with the professional licenses, so the state's attorney general or the local police would investigate a possible criminal violation.

In serious or life-threatening situations, such as physical or sexual abuse, any individual can call the local police department, the city attorney's office or the state's attorney general. You can find the numbers in the government section of your telephone book.

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