CMS SOM App. A, Tag A-0123

§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?