Minnesota Administrative Rules

CHAPTER 4680, HEALTH FACILITIES GRIEVANCE MECHANISM

DEPARTMENT OF HEALTH

4680.0100 DEFINITIONS.

Subpart 1.

Scope.

Definitions for parts 4680.0100 to 4680.1300 are as follows in subparts 2 to 6.

Subp. 2.

Grievance mechanism.

"Grievance mechanism" means grievance and/or complaint procedures.

Subp. 3.

Hospital.

"Hospital" means any entity licensed as such pursuant to Minnesota Statutes, sections 144.50 to 144.56.

Subp. 4.

Outpatient surgery center.

"Outpatient surgery center" means a freestanding facility organized for the specific purpose of providing elective outpatient surgery for preexamined prediagnosed low risk patients. Services provided at an outpatient surgery center shall be limited to surgical procedures which utilize local or general anesthesia and which do not require overnight inpatient care. "Outpatient surgery center" does not mean emergency medical services, or physician or dentist offices.

Subp. 5.

Patient.

"Patient" means an individual in or admitted to a hospital or outpatient surgery center for the purpose of prevention of disease, medical diagnosis, or medical treatment. The term "patient" includes inpatient, outpatient, and emergency room patient.

Subp. 6.

Representative.

"Representative" means a person designated by the patient as a responsible party, a parent of a minor, a guardian, or one who is in loco parentis to a patient unable to act for himself or herself.

Statutory Authority:

MS s 144.691

History:

17 SR 1279

Published Electronically:

May 12, 1997

4680.0200 APPLICABILITY.

Parts 4680.0100 to 4680.1300 apply to hospitals and outpatient surgery centers.

Statutory Authority:

MS s 144.691

Published Electronically:

May 12, 1997

4680.0300 MINIMUM STANDARD.

Every hospital and every outpatient surgery center shall establish, operate, and maintain a grievance mechanism designed to process and resolve patient grievances in accordance with parts 4680.0100 to 4680.1300.

Statutory Authority:

MS s 144.691

Published Electronically:

May 12, 1997

PROCEDURAL REQUIREMENTS

4680.0400 DESIGNATED PERSON.

Every hospital and every outpatient surgery center, shall designate an individual, by name or by title, to be accountable for the operation of a grievance mechanism.

Statutory Authority:

MS s 144.691

Published Electronically:

May 12, 1997

4680.0500 COMPLAINTS.

Any patient, or the patient's representative, may initiate any oral or written complaint related to those subjects specified in part 4680.1000.

Such complaints may be made to a person designated by the facility under part 4680.0400, or to any other person authorized to receive complaints by the facility. A person authorized to receive complaints shall be physically within the facility and able to receive complaints during ordinary business hours. Persons authorized to receive complaints, other than a person designated under part 4680.0400 shall, in all complaint cases, report any response or resolution, or refer the complaint, to a person designated under part 4680.0400.

Statutory Authority:

MS s 144.691

History:

17 SR 1279

Published Electronically:

May 12, 1997

4680.0600 TIME FOR RESPONSE.

Response to a complaint, or notice of the resolution of a complaint, shall be provided to the complainant as soon as possible. Such responses, or notices of resolution, shall be in writing, if requested by the complainant.

Statutory Authority:

MS s 144.691

Published Electronically:

May 12, 1997

4680.0700 NOTICE OF TIME LIMIT.

The authorized individual to whom any oral complaint is made shall, upon receipt of the complaint, inform the complainant of the best estimate of when the facility could respond to the complaint.

Statutory Authority:

MS s 144.691

History:

17 SR 1279

Published Electronically:

May 12, 1997

4680.0800 COMPLAINT RECORDS.

The following complaint records shall be maintained by the facility for at least one year:

A.

an annotation of the date, time, and substance of each complaint made by, or in behalf of, any patient;

B.

a reference to any previous complaints made by, or in behalf of, the same patient during the patient's current stay in the facility; and

C.

an annotation of the date, time, and substance of any response to, denial of, or resolution of, the complaint.

The arrangement of such records shall be such that identification of particular patients and complainants is possible.

Statutory Authority:

MS s 144.691

History:

17 SR 1279

Published Electronically:

May 12, 1997

4680.0900 PATIENT NOTICE.

Subpart 1.

Notice of mechanism.

Written notice of the existence and availability of the grievance mechanism shall be posted conspicuously in all facilities, along with the notice required under Minnesota Statutes, section 144.652, and furnished, unless an emergency prevents such furnishing, to the patient or the patient's representative if and when the former is actually admitted to the facility. If an individual patient notice is required to be furnished to the patient or the patient's representative under Minnesota Statutes, section 144.652, written notice under these rules shall be furnished at the same time.

Subp. 2.

Content of the notice.

Such written notice shall include the following:

A.

a statement that complaints or grievances related to rights expressed in the Patients' Bill of Rights (Minnesota Statutes, section 144.651), or to any other rights, may be able to be resolved within the facility;

B.

a statement that the facility maintains a grievance mechanism for this purpose;

C.

a statement specifying an individual or type of individual to whom such complaints or grievances can be directed; and

D.

a statement that any complainant has the right to request and to receive a written response to any complaint.

Statutory Authority:

MS s 144.691

History:

17 SR 1279

Published Electronically:

May 12, 1997

4680.1000 PATIENT COMPLAINTS.

Complaints relating to at least the following shall be subject to being processed through a grievance mechanism:

A.

lack of considerate or respectful care;

B.

failure to provide complete, current, and understandable information concerning diagnosis, treatment, or prognosis;

C.

failure to provide the name and specialty, if any, of the physician responsible for coordination of care;

D.

failure to afford consideration of privacy;

E.

failure to afford consideration of individual social, religious, and psychological well-being;

F.

failure to preserve the confidentiality of the medical care program;

G.

failure to provide, upon request, information bearing on the individual case with respect to any relationship of the facility to other health services facilities, medical groups, or other similar entities;

H.

failure to afford continuity of care;

I.

failure to provide requested information, prior to or at the time of admission and during the period spent in the facility, relating to charges for care;

J.

failure to afford the opportunity to participate in the planning of medical treatment;

K.

failure to inform of, or to offer an opportunity to refuse to participate in, experimental research;

L.

retaliatory, arbitrary, or otherwise medically unjustifiable discharge;

M.

interference with or retaliation for the free exercise of any legally prescribed rights;

N.

mental and/or physical abuse;

O.

medically unjustifiable physical and/or chemical restraints;

P.

failure to comply with lawful requests to release or to withhold medical records;

Q.

requiring the performance of services not included for therapeutic purposes in the plan of care;

R.

restriction of the right to associate and communicate privately with others;

S.

interference with the sending and receipt of personal mail;

T.

restriction of the rights to meet with representatives and to participate in commercial, religious, and community activities;

U.

restriction of the right to retain and use personal clothing and possessions, to the extent that space permits; and

V.

failure to respond to questions concerning billing practices, the amount of a specific bill, and the like.

Statutory Authority:

MS s 144.691

Published Electronically:

May 12, 1997

4680.1100 REPORTS.

Every hospital and every outpatient surgery center shall, on or before each February 1, submit to the commissioner of health a report on the experience of their respective grievance mechanisms during the immediately preceding calendar year. Such reports shall include at least the following information:

A.

the name and location of the reporting institution;

B.

the reporting period in question;

C.

the name of the individual(s) responsible for the operation of the grievance mechanism;

D.

the total number of complaints filed with the facility pursuant to part 4680.0500;

E.

the total number of complaints, according to classification under part 4680.1000;

F.

the total number of any other complaints;

G.

the number of patients by whom or for whom more than one complaint was made and the total number of such complaints; and

H.

the total number of complaints resolved to the patient's apparent satisfaction.

Statutory Authority:

MS s 144.691

Published Electronically:

May 12, 1997

SCHEDULE OF FINES

4680.1200 PATIENT NOTIFICATION AND COMPLAINT MISHANDLING.

The following violations of these rules shall constitute grounds for the automatic assessment of a per violation $50 fine:

A.

failure to give individual patient notice, as required under part 4680.0900; and

B.

failure to respond to a patient complaint as soon as possible, as required under part 4680.0600.

Multiple violations with respect to the current stay of a particular patient shall result in fines which in no case exceed $200. Such fines are payable within 30 days of the automatic assessment, unless there is a facility request for a hearing. Such a request shall stay the collection of the assessed fines, pending the outcome of the hearing.

Statutory Authority:

MS s 144.691

Published Electronically:

May 12, 1997

4680.1300 INADEQUATE OR IMPROPERLY FUNCTIONING MECHANISM.

Subpart 1.

Grounds.

The following violations of these rules shall constitute grounds for the issuance of a correction order:

A.

failure to have a grievance mechanism, as required under part 4680.0300;

B.

failure to designate an individual, by name or title, to be responsible for the operation of a grievance mechanism, as required under part 4680.0400;

C.

failure to have an individual within the facility and able to receive complaints during ordinary business hours, as required under part 4680.0500;

D.

failure to maintain complaint records, as required by part 4680.0800;

E.

failure to post notice, as required by part 4680.0900;

F.

failure to submit an annual report, as required by part 4680.1100; and

G.

failure to fulfill the criteria for content of the annual report, as required by part 4680.1100.

Subp. 2.

Time periods for correction.

In no case may the allowable period for correction of any of the violations in subpart 1 exceed 60 days. In no case may the allowable period for correction of violations in subpart 1, items D, F, or G be less than 20 days.

Subp. 3.

Fine amounts.

The amounts which shall be assessed in the event that the facility does not comply with correction orders within the allocated period of time are as follows:

A.

violations as described in subpart 1, item A up to $200 per violation;

B.

violations as described in subpart 1, item B to $100 per violation;

C.

violations as described in subpart 1, item C up to $150 per violation;

D.

violations as described in subpart 1, item D up to $50 per violation;

E.

violations as described in subpart 1, item E up to $100 per violation;

F.

violations as described in subpart 1, item F up to $200 per violation; and

G.

violations as described in subpart 1, item G up to $100 per violation.

Such fines are payable within 30 days of the assessment, unless there is a facility request for a hearing within that period. Such a request shall stay the collection of the assessed fines, pending the outcome of the hearing.

Statutory Authority:

MS s 144.691

Published Electronically:

May 12, 1997