Scope of Complaint

5030.1 – Scope of Complaint (Rev. 28, Issued: 10-21-16, Effective: 10-21-16, Implementation: 10-21-16) In obtaining information from the beneficiary about the nature or scope of the complaint, the QIO must focus on the episode of care to which the complaint pertains. The beneficiary is not required to identify all specific aspects of the medical care received during the episode in describing the complaint, nor is the beneficiary required to specifically state that the practitioner and/or provider did not “meet professionally recognized standards of care.” The QIO should not unnecessarily narrow the focus of the scope of a review based on a beneficiary’s statements about why care was problematic because most beneficiaries are not health care practitioners or providers, and thus they do not have sufficient knowledge and/or experience to render such judgments about the care received. In addition, as the expert in conducting Quality of Care Reviews, a QIO should not focus solely on a beneficiary’s assumptions and/or conclusions about the care received. The beneficiary’s assumptions and/or conclusions may be misleading or not relate to the actual problem encountered. For instance, a beneficiary’s statement about a single problematic aspect associated with an episode of care (e.g., the wait time in the emergency room was too long) or why the beneficiary believes the care did not meet professionally recognized standards of care (e.g., the physician should have ordered a specific test based on the beneficiary’s health condition) may not be the reason the beneficiary received poor care or received appropriate care but experienced a negative outcome. The following examples are designed to assist QIOs in taking the appropriate approach during review of a Beneficiary Complaint: • EXAMPLE 1: A beneficiary’s spouse contacts the QIO and complains about the care the beneficiary received while in the hospital. In discussing the concerns, the spouse specifically mentions the length of time the beneficiary waited in the emergency room before the beneficiary was admitted. The spouse also mentions that the beneficiary might have received the incorrect medication during the hospital stay. o In this scenario, the scope of the QIO’s review is not limited to the wait time in the emergency room and the medication provided to the beneficiary. A QIO’s review should include ALL care the hospital provided to the beneficiary, from arrival in the emergency room through the conclusion of the hospital stay. A QIO must convey information about any Quality of Care Concern for which care did not meet professionally recognized standards of care related to the beneficiary’s hospital stay as well as the QIO’s conclusions about the specific concerns the spouse mentioned (emergency room wait and medication error) in the complaint, even if the standard of care was met for these issues. • EXAMPLE 2: A beneficiary contacts the QIO to complain about medication, which was requested but never received, during a 6-hour stay in a hospital. The beneficiary ultimately left the hospital without receiving medication. During the QIO’s review, the QIO confirms the beneficiary’s description but in addition, the QIO determines that the beneficiary was in a lock-down unit of a psychiatric hospital and should not have been allowed to leave. In this scenario, the scope of the QIO’s review is not limited to the failure to receive the medication requested. o The QIO’s review should include ALL care provided to the beneficiary by the psychiatric hospital, including the failure to properly lock down the facility, which resulted in the beneficiary being able to leave. The QIO must convey information about any Quality of Care Concern for which care did not meet professionally recognized standards of care related to the hospital stay (failure to properly lock down the facility) as well as the QIO’s conclusions about the specific items the beneficiary mentioned (failure to receive requested medication and the length of wait time). • EXAMPLE 3: A beneficiary representative called to complain that an elderly beneficiary who was a relative, had told the representative that the wrong antibiotic medication was given during a recent hospitalization for pneumonia. Through chart review, the QIO discovered that the antibiotic medication was correct and administered timely, but the beneficiary had received an overdose of anti-seizure medication during the same episode of care. o The QIO’s review must include a review of ALL care provided to the beneficiary during the episode. The QIO must convey information about any Quality of Care Concern for which care did not meet professionally recognized standards of care (i.e. the overdose of the anti-seizure medication) as well as the QIO’s conclusions about the specific item the beneficiary representative mentioned (wrong antibiotic medication), even where the QIO’s review demonstrates that the standard of care was met for the antibiotic medication.