CMS SOM App. H, Tag V765

The facility’s internal grievance process

must be implemented so that the patient may file an oral or written grievance with the

facility without reprisal or denial of services. The grievance process must include—

(1) A clearly explained procedure for the submission of grievances.

(2) Timeframes for reviewing the grievance.

(3) A description of how the patient or the patient’s designated representative will be

informed of steps taken to resolve the grievance.

Interpretive Guidance § 494.180(e)(1), (2) and (3)

The facility’s policies and procedures must describe all available grievance procedures to the

patient which must include the ability to file an oral or written grievance with the facility. The

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facility must inform the patient and/or the patient’s designated representative (also called

“designee”) of its internal grievance process. Refer to the requirement at V465 under the

Condition for patients’ rights.

Each facility must implement a process to ensure that there will be no reprisal or denial of

services for any patient who files an internal grievance and the grievance procedure will be

clearly explained to patients. The existence of grievances should not be viewed negatively, as this

would be an indication that patients understand the internal grievance process and believe that

filing a grievance will not result in reprisal or denial of services. Lack of grievances does not

indicate a lack of an internal grievance process.

The facility’s grievance process should ensure those grievances involving situations or practices

that place patients or staff members in immediate danger (e.g. the patient's grievance brings

attention to hazardous environmental conditions) are prioritized as needing immediate attention

and resolved in a timely manner as to avoid any injury or harm to the patients and staff

members..

The facility’s process must include clearly defined timeframes for a grievance to be

acknowledged, investigated, and addressed. Timeframes should be sufficient to conduct an

investigation yet ensure that the grievance is addressed in a timely manner.

The patient/designee should be informed of the status of the investigation periodically, and when

resolution is attained or considered attained by the facility. Each grievance should demonstrate

a completed cycle of reviewing the grievance and reporting back to the patient.