CMS Pub. 100-11, ch. 11, § 10

A grievance is defined as a complaint, either written or oral, expressing

dissatisfaction with the service delivery or the quality of care furnished.

The PACE organization must have a formal written process to evaluate and resolve

grievances, whether medical or non-medical in nature, by PACE participants, their family

members or representatives. All personnel (employees and contractors) who have contact

with participants should be aware of and understand the basic procedures for receiving

and documenting grievances in order to initiate the appropriate process for resolving

participant concerns. All participants must be informed of the grievance process in

writing upon enrollment into the PACE program and at least annually thereafter.

The PACE organization’s grievance process, at a minimum, must include written

procedures for the following:

• How a participant files a grievance;

• Documentation of a participant’s grievance;

• Response to, and resolution of, the grievance in a timely manner;

• Maintenance of the participant’s confidentiality throughout the grievance

process and thereafter.

The PACE organization’s internal procedures should assure that every grievance is

handled in a uniform manner and that there is communication among different

individuals who are responsible for reviewing or resolving grievances. In addition, the

PACE organization must maintain appropriate documentation so the information can be

utilized in the organization’s QAPI program.

The PACE organization must discuss with, and provide to the participant, in writing, the

specific steps, including timeframes for response, that will be taken to resolve the

participant’s grievance. It is expected that each PACE organization have a process

prepared to acknowledge a beneficiary grievance with timeframes and additional

information on the process; for example, a participant grievance form to acknowledge the

grievance and a letter of resolution informing the participant of the grievance outcome.

The PACE organization must continue providing all required care to the enrolled

participant throughout the grievance process. The PACE organization must maintain,

aggregate and analyze the information on the grievance process. This information must

be utilized as part of the organization’s internal QAPI program. Through analyzing the

filed grievances there may be an opportunity for process improvement, which could lead

to improved quality of care for the participants.

[42 CFR § 460.120; 71 FR 71300 (Dec. 8, 2006)]