CMS SOM App. A, Tag A-0119

[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?