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Reporting Safety or Quality of Care Concerns Policy

1. Purpose

The purpose of this policy is to establish a clear, accessible, and non‑retaliatory process for reporting safety concerns, quality‑of‑care issues, ethical concerns, or compliance risks. This policy supports our organization’s commitment to providing safe, effective, person‑centered, and compliant services in alignment with Joint Commission standards and applicable federal and state regulations.

 

2. Scope

This policy applies to all employees, contractors, volunteers, interns, leadership, and affiliated providers of STAMA Health. It also applies to clients, families, guardians, and other stakeholders who may wish to raise concerns related to safety or quality of care.

 

3. Policy Statement

STAMA Health encourages the timely reporting of any concern related to:

  • Client safety or well‑being

  • Quality, appropriateness, or continuity of care

  • Abuse, neglect, exploitation, or rights violations

  • Ethical or professional conduct

  • Regulatory, legal, or accreditation compliance

Reports may be made without fear of retaliation. The organization strictly prohibits retaliation against any individual who reports a concern in good faith, participates in an investigation, or raises questions regarding safety or quality of care.

 

4. Definitions

Safety Concern: Any condition, practice, or event that could cause or has caused harm to a client, staff member, or visitor.

Quality of Care Concern: Any issue related to the effectiveness, timeliness, appropriateness, or person‑centered nature of services provided.

Reporter: Any individual who raises a concern under this policy.

Retaliation: Any adverse action taken against an individual for reporting a concern in good faith, including but not limited to termination, demotion, harassment, or reduction in hours.

 

5. Reporting Options

Concerns may be reported through one or more of the following channels:

 

5.1 Internal Reporting

  • Immediate Supervisor or Service Manager

  • Compliance Officer or Executive Leadership

  • Human Resources Department

  • Incident Reporting System or Incident Report Form

Reports may be made verbally or in writing. Anonymous reporting is permitted where feasible.

 

5.2 External Reporting

Individuals may also report concerns directly to external agencies without first reporting internally, including but not limited to:

  • The Joint Commission

  • North Carolina Department of Health and Human Services (NCDHHS)

  • Local law enforcement (in cases of imminent danger or criminal activity)

  • Other applicable oversight or licensing bodies

The organization will not interfere with or discourage external reporting.

 

6. Non‑Retaliation Assurance

The organization maintains a zero‑tolerance policy for retaliation. Any act of retaliation will result in disciplinary action, up to and including termination of employment or contract. Individuals who believe they have experienced retaliation should report it immediately using the same reporting channels outlined in this policy.

 

7. Investigation and Response Procedures

  1. All reported concerns will be acknowledged promptly.

  2. The organization will conduct a fair, timely, and confidential review or investigation, as appropriate.

  3. Findings and corrective actions will be documented.

  4. When possible and appropriate, feedback will be provided to the reporter.

  5. Immediate corrective action will be taken if a serious or imminent risk is identified.

 

8. Confidentiality

Reports and investigations will be handled with discretion. Information will be shared only with individuals who have a legitimate need to know in order to address the concern, comply with legal obligations, or ensure safety.

 

9. Documentation and Recordkeeping

All reports, investigation notes, findings, and corrective actions will be documented and maintained in accordance with organizational policy and applicable retention requirements.

 

10. Education and Training

All workforce members will receive training on this policy upon hire and periodically thereafter. Training will emphasize:

  • How to recognize safety and quality concerns

  • How and where to report concerns

  • Protection from retaliation

 

11. Compliance and Enforcement

Failure to comply with this policy may result in disciplinary action. Leadership is responsible for fostering a culture of safety, transparency, and continuous quality improvement.

 

12. Policy Review and Revision

This policy will be reviewed at least annually and updated as needed to reflect changes in regulations, accreditation standards, or organizational operations.

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13.Internal Reporting Contact 

Compliance Manager

Phone: 202-813-2355

Email: Info@stamahealth.com

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14.External Reporting Contacts

The Joint Commission
Office of Quality Monitoring
Phone: 1-800-994-6610
Email: complaint@jointcommission.org
Website: https://www.jointcommission.org/report_a_complaint.aspx

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North Carolina Department of Health and Human Services (NCDHHS)
Division of Health Service Regulation (DHSR) – Complaint Intake
Phone: 1-800-624-3004 (NC only) or 919-855-4500
Website: https://info.ncdhhs.gov/dhsr/ciu/filecomplaint.html

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Local Law Enforcement (Imminent Danger or Criminal Activity)
Emergency: 911


Non-Emergency: Contact the local police or sheriff’s department for the county in which services are provided.

Other Oversight or Licensing Bodies


Depending on the service line or funding source, concerns may also be reported to:

  • Local Managed Care Organizations (LME/MCOs) such as Alliance Health or Trillium Health Resources

  • Medicaid Program Integrity Units

  • Professional Licensing Boards (e.g., NC Board of Nursing, NC Board of Social Work)

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STAMA Health  will not restrict or retaliate against any individual for contacting external oversight agencies.

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