CMS SOM App. A, Tag A-0118

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?