Frequently Asked Questions About Making a Complaint

When should I make a complaint?

If you believe you have been treated unfairly by anyone, or if you have not been offered the rights listed above.

Can anyone make a complaint?

Yes. Anyone who has witnessed, or has knowledge of, a violation of a consumer's rights can bring the matter to the agency's attention.

Who can help me make a complaint?

You may ask a family member, friend, advocate, case manager, or anyone else you choose to help you. If you feel you need the assistance of an advocate, there may be a Consumer Advocate or advocacy group at your agency, or you may choose from the list of advocacy groups below.

The Mental Health Association of Southeastern Pennsylvania (MHASP) can help consumers with individual advocacy and provide information about advocacy groups that they can join. Call the Mental Health Association of Southeastern Pennsylvania for information about the nearest advocacy or self-help group, or find out if your agency has its own group by asking for information at the receptionist's desk.

What will happen if I make a complaint?

People will ask you to give details about what happened, when it happened, where it took place, and who was involved. You should not be threatened, punished or forced to leave a program just because you make a complaint. Community mental health programs are not permitted to mistreat consumers or terminate services because someone speaks up about a problem.

What the agency will do about the situation depends on what the problem is, but they are required to let you know promptly what they will do to address the situation and try to prevent it from happening again.

Can I question or appeal a Medicare or Managed Care Plan coverage decision?

You have a right to appeal many decisions about your Medicare coverage services. Your health plan must provide you with written instructions on how to appeal. You may file an appeal if your health plan denies services, or terminates or refuses to pay for services that you believe should be covered.

After you file an appeal, the health plan reviews its decision. Then, if your health plan does not decide in your favor, the appeal automatically goes to an independent review organization with contracts with Medicare. You may be eligible for a fast decision (within 72 hours ) if your health or ability to function could be seriously harmed by waiting the amount of time needed for a standard decision.

If you believe you are being discharged too soon from a hospital, you have a right to immediate review by the Peer Review Organization. In Pennsylvania call, Quality Insights of Pennsylvania 1-800-633-4227. For more information see: www.medicare.gov and search under appeals process.

What if I am being unfairly treated in a Nursing Home or at a Personal Care Home ?

Being aware of your rights in the home is an important step first step in solving problems. These rights should be posted in a visible area within the home. Second, become familiar with the grievance procedure of the home. The law requires that you are entitled to a reasonable response to any complaints. It is helpful in the beginning to start with the nursing home, when at all possible.

Talk to the staff person in charge and attempt to work the problem out with the person involved. If you do not receive an adequate response try talking to his supervisor. Many facilities have resident or family councils. These are groups that meet together to make suggestions and voice concerns about life in the nursing home. If this doesn't resolve the difficulty, or if you feel uncomfortable discussing the matter with staff, you may want to discuss the matter with the ombudsman for the home or a legal service provider. In the Delaware Valley, the local ombudsman groups are:

Philadelphia:
Center for Advocacy for the Rights and Interests of the Elderly (CARIE)
1315 Walnut St. #1000
Philadelphia, PA 19107
Telephone: 215-545-5724

Northwest Philadelphia:
Interfaith Movement (NIM)
6757 Greene St. 3rd Floor
Philadelphia, PA 19119
Telephone: 215-843-0304

Delaware County:
Horizons Unlimited
107 N. Monroe St.
Media, PA 19063
Telephone: 610-566-6248

Montgomery County:
Long Term Care Ombudsman Program
One Montgomery Plaza
Room 406, Swede And Airy Sts.
Norristown, PA 19404
Telephone: 610-278-3601

Bucks County:
Bob Jacobi, Ombudsman Office
30 E. Oakland Avenue
Doylestown, PA 18901
Telephone: 215-348-0510

Chester County:
Donna Eaves, Ombudsman
Chester Department of Aging
601 Westtowne Rd.
Suite 130
West Chester, PA 19380-0990
Telephone: 610-344-6350

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