A-0041
§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
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, when a patient issue cannot be resolved promptly
by staff present. If a complaint cannot be resolved promptly by
staff present or is referred to a complaint coordinator, patient
advocate, or hospital management, it is to be considered a grievance.
A patient issue is not a grievance if the patient issue can be
resolved promptly, on the spot by staff present.
A patient issue could be a grievance if the patient (currently
in the hospital) calls the Patient Representative first and has
not tried to resolve the issue with the involved unit/department.
If the Patient Representative can immediately call the patient’s
unit and if the patient care staff present are able to resolve the
issue at that moment, then it is not a grievance. Issues that are
not resolved on the spot by staff present are grievances.
If other staff must be called in (e.g., the Patient Representative)
to resolve an issue that patient care staff cannot (or do not) resolve
immediately, then it would be considered a grievance in most cases.
Billing issues are not considered grievances unless the complaint
also contains elements addressing patient service or care issues.
Patient grievances would also include situations where patients
or the patient’s representative call or write to the hospital about
concerns related to care or services, who were not able to resolve
their concern during their stay or who did not wish to address their
issue during their stay.
Additionally, whenever the patient or the patient’s representative
requests their complaint be handled as a formal complaint or grievance
or when the patient requests a response from the hospital, then
the complaint is a grievance and all the requirements apply.
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 beverages 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
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. The hospital must
provide the patient or the patient’s representative a phone
number and address for lodging a grievance with the State agency.
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 referrals?
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-0042
§482.13(a)(2) continued
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.
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
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-0043
§482.13(a)(2) continued
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 (QIO) 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 mention 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.
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-0044
§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 explaining 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-0045
§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.
Most complaints are not complicated and should not require extensive
investigation. Occasionally a complaint is complicated and may require
an extensive investigation. A timeframe of 7 days for the provision
of the response would be considered appropriate. We do not require
that the grievance be resolved during the hospital’s specified timeframe
for the response, although most should be resolved. The Code of
Federal Regulations at 42 CFR §482.13(a)(2)(iii) specifies information
the hospital must include in their response. In most cases, the
hospital includes the resolution of the grievance in their response.
If the grievance is not resolved, if the investigation is not complete,
or if the corrective action is still being evaluated, the hospital’s
response should address that the hospital is still working to resolve
the complaint and states that the hospital will follow-up with another
written response within so many days (depending on what actions
the hospital may have to take). The hospital should 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?
______________________________________________________________________
A-0046
§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,
when necessary, understands.
The hospital may use additional tools to resolve a grievance,
such as meeting with the patient and his family, or other methods
it finds effective. 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.
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?
http://cms.hhs.gov/manuals/Downloads/som107ap_a_hospitals.pdf
