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Source: CMS Interpretive Guidlines for Hospital Conditions of Participation Update - October 17, 2008

CMS Conditions of Participation - Patient Rights §482.13 - The Grievance Process

Updated October 17, 2008

§482.13 Condition of Participation: Patient's Rights
A hospital must protect and promote each patient’s rights.
Interpretive Guidelines §482.13

These requirements apply to all Medicare or Medicaid participating hospitals including short-term, acute care, surgical, specialty, psychiatric, rehabilitation, long-term, children's and cancer, whether or not they are accredited. This rule does not apply to critical access hospitals. (See Social Security Act (the Act) §1861(e).)

These requirements, as well as the other Conditions of Participation in 42 CFR 482, apply to all parts and locations (outpatient services, provider-based entities, inpatient services) of the Medicare participating hospital.

Survey Procedures §482.13
Survey of the Patients’ Rights Condition of Participation (CoP) should be coordinated by one surveyor. However, each surveyor, as he/she conducts his/her survey assignments, should assess the hospital’s compliance with the Patients’ Rights CoP.
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A-0116
(Rev. 37, Issued: 10-17-08; Effective/Implementation Date: 10-17-08)

§482.13(a) Standard: Notice of Rights
Interpretive Guidelines §482.13(a)
The hospital must ensure the notice of rights requirements are met.
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A-0117
(Rev. 37, Issued: 10-17-08; Effective/Implementation Date: 10-17-08)

§482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible.

Interpretive Guidelines §482.13(a)(1)
The hospital must inform each patient, or when appropriate, the patient’s representative as allowed by law, of the patient’s rights. Whenever possible, this notice must be provided before providing or stopping care. All patients, inpatient or outpatient, must be informed of their rights as hospital patients. The patient’s rights include all of those discussed in this condition, as well as any other rights for which notice is required under State or Federal law or regulations for hospital patients. (See 42 CFR 482.11.) The patient’s rights should be provided and explained in a language or manner that the patient (or the patient’s representative) can understand.

In addition, according to the regulation at 42 CFR 489.27(b), (which cross references the regulation at 42 CFR 405.1205), each Medicare beneficiary who is an inpatient must be provided a standardized notice, “An Important Message from Medicare” (IM), within 2 days of admission. Medicare beneficiaries who have not been admitted (e.g., patients in observation status or receiving other care on an outpatient basis) are not required to receive the IM. The IM is a standardized, OMB-approved form and cannot be altered from its original format. The IM is to be signed and dated by the patient to acknowledge receipt. See Exhibit 16 for a copy of the IM. Furthermore, 42 CFR 405.1205(b)(3) requires that hospitals present a copy of the IM in advance of the patient’s discharge, but not more than two calendar days before the patient’s discharge. In the case of short inpatient stays, however, where initial delivery of the IM is within 2 calendar days of the discharge, the second delivery of the IM is not required.

The hospital must establish and implement policies and procedures that effectively ensure that patients and/or their representatives have the information necessary to exercise their rights.
Survey Procedures §482.13(a)(1)

Determine the hospital’s policy for notifying all patients of their rights, both inpatient and outpatient;

Determine that the information provided to the patients by the hospital complies with Federal and State law;

Review records and interview staff to examine how the hospital communicates information about their rights to diverse patients, including individuals who need assistive devices or translation services. Does the hospital have alternative means, such as written materials, signs, or interpreters (when necessary), to communicate patients’ rights?;

Ask patients to tell you what the hospital has told them about their rights;

Does staff know what steps to take to inform a patient about their patients’ rights, including those patients’ with special communication needs?; and

Review a sample of inpatient medical records for Medicare beneficiaries, to determine whether the records contain a signed and dated IM provided within 2 days of the admission of the patient. For patients whose discharge occurred more than 2 days after the initial IM notice was issued, determine whether the hospital provided another copy of the IM to the patient prior to discharge in a timely manner.
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A-0118
(Rev. 37, Issued: 10-17-08; Effective/Implementation Date: 10-17-08)

§482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance.
Interpretive guidelines §482.13(a)(2)

The patient should have reasonable expectations of care and services and the facility should address those expectations in a timely, reasonable, and consistent manner. Although 482.13(a)(2)(ii) and (iii) address documentation of facility time frames for a response to a grievance, the expectation is that the facility will have a process to comply with a relatively minor request in a more timely manner than a written response. For example, a change in bedding, housekeeping of a room, and serving preferred food and beverage may be made relatively quickly and would not usually be considered a "grievance" and therefore would not require a written response.

The hospital must inform the patient and/or the patient's representative of the internal grievance process, including whom to contact to file a grievance (complaint). As part of its notification of patient rights, the hospital must provide the patient or the patient's representative a phone number and address for lodging a grievance with the State agency. The hospital must inform the patient that he/she may lodge a grievance with the State agency (the State agency that has licensure survey responsibility for the hospital) directly, regardless of whether he/she has first used the hospital's grievance process.

A “patient grievance” is a formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient’s representative, regarding the patient's care (when the complaint is not resolved at the time of the complaint by staff present), abuse or neglect, issues related to the hospital's compliance with the CMS Hospital Conditions of Participation (CoPs), or a Medicare beneficiary billing complaint related to rights and limitations provided by 42 CFR 489.

"Staff present" includes any hospital staff present at the time of the complaint or who can quickly be at the patient's location (i.e., nursing, administration, nursing supervisors, patient advocates, etc.) to resolve the patient's complaint.

If a patient care complaint cannot be resolved at the time of the complaint by staff present, is postponed for later resolution, is referred to other staff for later resolution, requires investigation, and/or requires further actions for resolution, then the complaint is a grievance for the purposes of these requirements. A complaint is considered resolved when the patient is satisfied with the actions taken on their behalf.

Billing issues are not usually considered grievances for the purposes of these requirements. However, a Medicare beneficiary billing complaint related to rights and limitations provided by 42 CFR 489 is considered a grievance.

A written complaint is always considered a grievance. This includes written complaints from an inpatient, an outpatient, a released/discharged patient, or a patient’s representative regarding the patient care provided, abuse or neglect, or the hospital's compliance with CoPs. For the purposes of this requirement, an email or fax is considered "written."

Information obtained from patient satisfaction surveys usually does not meet the definition of a grievance. If an identified patient writes or attaches a written complaint on the survey and requests resolution, then the complaint meets the definition of a grievance. If an identified patient writes or attaches a complaint to the survey but has not requested resolution, the hospital must treat this as a grievance if the hospital would usually treat such a complaint as a grievance.

Patient complaints that are considered grievances also include situations where a patient or a patient's representative telephones the hospital with a complaint regarding the patient’s care or with an allegation of abuse or neglect, or failure of the hospital to comply with one or more CoPs, or other CMS requirements. Those post-hospital verbal communications regarding patient care that would routinely have been handled by staff present if the communication had occurred during the stay/visit are not required to be defined as a grievance.

All verbal or written complaints regarding abuse, neglect, patient harm, or hospital compliance with CMS requirements are considered grievances for the purposes of these requirements.

Whenever the patient or the patient's representative requests that his or her complaint be handled as a formal complaint or grievance or when the patient requests a response from the hospital, the complaint is considered a grievance and all the requirements apply.

Data collected regarding patient grievances, as well as other complaints that are not defined as grievances (as determined by the hospital), must be incorporated in the hospital's Quality Assessment and Performance Improvement (QAPI) Program.
Survey Procedures §482.13(a)(2)

Review the hospital’s policies and procedures to assure that its grievance process encourages all personnel to alert appropriate staff concerning any patient grievance. Does the hospital adhere to its policy/procedure established for grievances?

Interview patients or the patient’s legal representative to determine if they know how to file a complaint (grievance) and who to contact if they have a complaint (grievance).

Is the hospital following its grievance policies and procedures?

Does the hospital’s process assure that grievances involving situations or practices that place the patient in immediate danger are resolved in a timely manner?

Does the patient or the patient’s representative know that he/she has the right to file a complaint with the State agency as well as or instead of utilizing the hospital’s grievance process?

Has the hospital provided the telephone number for the State agency to all patients/patient representatives?

Are beneficiaries aware of their right to seek review by the QIO for quality of care issues, coverage decisions, and to appeal a premature discharge?
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A-0119
(Rev. 37, Issued: 10-17-08; Effective/Implementation Date: 10-17-08)
§482.13(a)(2) (Continued)

[The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance.] The hospital’s governing body must approve and be responsible for the effective operation of the grievance process, and must review and resolve grievances, unless it delegates the responsibility in writing to a grievance committee.

Interpretive guidelines §482.13(a)(2)
The hospital's grievance process must be approved by the governing body. The hospital's governing body is responsible for the effective operation of the grievance process. This includes the hospital's compliance with all of the CMS grievance process requirements. The hospital's governing body must review and resolve grievances, unless it delegates this responsibility in writing to a grievance committee. A committee is more than one person. The committee membership should have adequate numbers of qualified members to review and resolve the grievances the hospital receives (this includes providing written responses) in a manner that complies with the CMS grievance process requirements.
Survey Procedures §482.13(a)(2)

Determine if the hospital’s governing body approved the grievance process.

Is the governing body responsible for the operation of the grievance process, or has the governing body delegated the responsibility in writing to a grievance committee?

Determine how effectively the grievance process works. Are patient's or the patient representative’s concerns addressed in a timely manner? Are patients informed of any resolution to their grievances? Does the hospital apply what it learns from the grievance as part of its continuous quality improvement activities?

Is the grievance process reviewed and analyzed through the hospital’s QAPI process or some other mechanisms that provides oversight of the grievance process?
______________________________________________________________________
A-0120
(Rev. 37, Issued: 10-17-08; Effective/Implementation Date: 10-17-08)
§482.13(a)(2) (Continued)

[The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. The hospital’s governing body must approve and be responsible for the effective operation of the grievance process, and must review and resolve grievances, unless it delegates the responsibility in writing to a grievance committee.] The grievance process must include a mechanism for timely referral of patient concerns regarding quality of care or premature discharge to the appropriate Utilization and Quality Control Quality Improvement Organization. At a minimum:

Interpretive Guidelines §482.13(a)(2)
Quality Improvement Organizations (QIOs) are CMS contractors charged with reviewing the appropriateness and quality of care rendered to Medicare beneficiaries in the hospital setting. The QIOs are also tasked with reviewing utilization decisions. Part of this duty includes reviewing discontinuation of stay determinations based upon a beneficiary’s request. The regulations state the functions of the QIOs in order to make Medicare beneficiaries aware of the fact that if they have a complaint regarding quality of care, disagree with a coverage decision, or they wish to appeal a premature discharge, they may contact the QIO to lodge a complaint. The hospital is required to have procedures for referring Medicare beneficiary concerns to the QIOs; additionally, CMS expects coordination between the grievance process and existing grievance referral procedures so that beneficiary complaints are handled timely and referred to the QIO at the beneficiary’s request.

This regulation requires coordination between the hospital’s existing mechanisms for utilization review notice and referral to QIOs for Medicare beneficiary concerns (See 42 CFR Part 489.27). This requirement does not mandate that the hospital automatically refer each Medicare beneficiary’s grievance to the QIO; however, the hospital must inform all beneficiaries of this right, and comply with his or her request if the beneficiary asks for QIO review.

Medicare patients have the right to appeal a premature discharge (see Interpretive Guidelines for 42 CFR 482.13(a)). Pursuant to 42 CFR 412.42(c)(3), a hospital must provide a hospital-issued notice of non-coverage (HINN) to any fee-for-service beneficiary that expresses dissatisfaction with an impending hospital discharge. Medicare Advantage (MA) organizations are required to provide enrollees with a notice of non-coverage, known as the Notice of Discharge and Medicare Appeal Rights (NODMAR), only when a beneficiary disagrees with the discharge decision or when the MA organization (or hospital, if the MA organization has delegated to it the authority to make the discharge decision) is not discharging the enrollee, but no longer intends to cover the inpatient stay.
Survey Procedures §482.13(a)(2)

Review patient discharge materials. Is the hospital in compliance with 42 CFR §489.27?

Does the hospital grievance process include a mechanism for timely referral of Medicare patient concerns to the QIO? What time frames are established?

Interview Medicare patients. Are they aware of their right to appeal premature discharge?
______________________________________________________________________
A-0121
(Rev. 37, Issued: 10-17-08; Effective/Implementation Date: 10-17-08)
[At a minimum:]
§482.13(a)(2)(i) The hospital must establish a clearly explained procedure for the submission of a patient’s written or verbal grievance to the hospital.

Interpretive Guidelines §482.13(a)(2)(i)
The hospital’s procedure for a patient or the patient’s representative to submit written or verbal grievances must be clearly explained. The patient or patient’s representative should be able to clearly understand the procedure.

Survey Procedures §482.13(a)(2)(i)

Review the information provided to patients that explains the hospital’s grievance procedures. Does it clearly explain how the patient is to submit either a verbal or written grievance?

Interview patients or patient representatives. Does the patient, or (if he/she is incapacitated) his/her representative, know about the grievance process and how to submit a grievance?
______________________________________________________________________
A-0122
(Rev. 37, Issued: 10-17-08; Effective/Implementation Date: 10-17-08)
[At a minimum:]

§482.13(a)(2)(ii) The grievance process must specify time frames for review of the grievance and the provision of a response.

Interpretive Guidelines §482.13(a)(2)(ii)
The hospital must review, investigate, and resolve each patient’s grievance within a reasonable time frame. For example, grievances about situations that endanger the patient, such as neglect or abuse, should be reviewed immediately, given the seriousness of the allegations and the potential for harm to the patient(s). However, regardless of the nature of the grievance, the hospital should make sure that it is responding to the substance of each grievance while identifying, investigating, and resolving any deeper, systemic problems indicated by the grievance.

Document when a grievance is so complicated that it may require an extensive investigation. We recognize that staff scheduling as well as fluctuations in the numbers and complexity of grievances can affect the timeframes for the resolution of a grievance and the provision of a written response. On average, a time frame of 7 days for the provision of the response would be considered appropriate. We do not require that every grievance be resolved during the specified timeframe although most should be resolved. 42 CFR 482.13(a)(2)(iii) specifies information the hospital must include in their response.

If the grievance will not be resolved, or if the investigation is not or will not be completed within 7 days, the hospital should inform the patient or the patient's representative that the hospital is still working to resolve the grievance and that the hospital will follow-up with a written response within a stated number of days in accordance with the hospital's grievance policy. The hospital must attempt to resolve all grievances as soon as possible.

Survey Procedures §482.13(a)(2)(ii)
What time frames are established to review and respond to patient grievances? Are these time frames clearly explained in the information provided to the patient that explains the hospital’s grievance process? On average, does the hospital provide a written response to most of its grievances within the timeframe specified in its policy?
______________________________________________________________________
A-0123
(Rev. 37, Issued: 10-17-08; Effective/Implementation Date: 10-17-08)
[At a minimum:]

§482.13(a)(2)(iii) In its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.
Interpretive Guidelines §482.13(a)(2)(iii)

The written notice of the hospital’s determination regarding the grievance must be communicated to the patient or the patient’s representative in a language and manner the patient or the patient’s legal representative understands.

The hospital may use additional tools to resolve a grievance, such as meeting with the patient and his family. The regulatory requirements for the grievance process are minimum standards, and do not inhibit the use of additional effective approaches in handling patient grievances. However, in all cases the hospital must provide a written notice (response) to each patient’s grievance(s). The written response must contain the elements listed in this requirement.

When a patient communicates a grievance to the hospital via email the hospital may provide its response via email pursuant to hospital policy. (Some hospitals have policies against communicating to patients over email.) If the patient requests a response via email, the hospital may respond via email. When the email response contains the information stated in this requirement, the email meets the requirement for a written response. The hospital must maintain evidence of its compliance with these requirements.

A grievance is considered resolved when the patient is satisfied with the actions taken on their behalf.
There may be situations where the hospital has taken appropriate and reasonable actions on the patient's behalf in order to resolve the patient's grievance and the patient or the patient's representative remains unsatisfied with the hospital's actions. In these situations, the hospital may consider the grievance closed for the purposes of these requirements. The hospital must maintain documentation of its efforts and demonstrate compliance with CMS requirements.

In its written response, the hospital is not required to include statements that could be used in a legal action against the hospital, but the hospital must provide adequate information to address each item stated in this requirement. The hospital is not required to provide an exhaustive explanation of every action the hospital has taken to investigate the grievance, resolve the grievance, or other actions taken by the hospital.

Survey Procedures §482.13(a)(2)(iii)
Review the hospital’s copies of written notices (responses) to patients. Are all patients provided a written notice? Do the notices comply with the requirements?
______________________________________________________________________
A-0129
(Rev. 37, Issued: 10-17-08; Effective/Implementation Date: 10-17-08)
§482.13(b) Standard: Exercise of Rights

Interpretive Guidelines §482.13(b)
The hospital must ensure that the exercise of patients’ rights requirements are met.
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December 8, 2006 - Federal Register CMS CoP Final Rule on Patient's Rights - Page 71426

 

 

 

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