CMS SOM App. L, Tag Q-0225

The ASC must establish a grievance procedure for documenting the existence,

submission, investigation, and disposition of a patient’s written or verbal grievance

to the ASC. The following criteria must be met:

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(4) The grievance process must specify timeframes for review of the grievance and

the provisions of a response.

(5) The ASC, in responding to the grievance, must investigate all grievances made

by a patient, the patient’s representative, or the patient’s surrogate regarding

treatment or care that is (or fails to be) furnished.

(6) The ASC must document how the grievance was addressed, as well as provide

the patient, the patient’s representative, or the patient’s surrogate with written

notice of its decision. The decision must contain the name of an ASC contact

person, the steps taken to investigate the grievance, the result of the grievance

process and the date the grievance process was completed.

Interpretive Guidelines: §§416.50(d)(4), (5), & (6)

What is a Grievance?

A “patient grievance” is a formal or informal written or verbal complaint that is made to

the ASC by a patient or a patient’s representative or surrogate, regarding a patient’s care

(when such complaint is not resolved at the time of the complaint by the staff present),

abuse, neglect, or ASC compliance issues.

• A complaint from someone other than a patient or a patient’s representative or surrogate

is not a grievance.

• A complaint that is presented to the ASC’s staff and resolved at that time is not

considered a grievance; the grievance process requirements do not apply to such

complaints. For example, a complaint that discharge instructions are unclear may be

resolved relatively quickly before the patient is discharged, and would not usually be

considered a “grievance.”

If a patient care complaint cannot be resolved at the time of the complaint by the staff

present, is postponed for later resolution, is referred to other staff for later resolution,

requires an investigation, and/or requires additional actions for resolution, the complaint

is then considered a grievance for purposes of these requirements. Billing issues are not

usually considered grievances for the purposes of this grievance requirement.

Although complaints may be both written and verbal, a written complaint is always

considered a grievance. This includes written complaints from a current patient, a

released/discharged patient, or a patient’s representative or surrogate regarding the

patient care provided, abuse or neglect, or the ASC’s compliance with the CfCs. For the

purposes of this requirement, an email or fax is considered written.

Information obtained from patient satisfaction surveys conducted by the ASC usually is

not considered a grievance. However, if an identified patient writes or attaches a written

complaint on the survey and requests resolution, the complaint must be treated as a

grievance. If an identified patient writes or attaches a complaint to the survey, but does

not request resolution, the ASC should treat this as a grievance if the ASC 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 or surrogate telephones the ASC with a complaint regarding

the patient’s care or with an allegation of abuse or neglect, or a failure of the ASC to

comply with one or more of the CfCs.

Whenever the patient or the patient’s representative or surrogate requests that his or her

complaint be handled as a formal complaint or grievance, or when the patient requests a

response from the ASC, the complaint is considered a grievance and all the grievance

requirements apply.

Grievance Process

The ASC must have an established procedure in place for documenting the existence,

submission, investigation, and disposition of a grievance. As part of its obligation to

notify patients of their rights, the ASC must inform the patient and/or the patient’s

representative or surrogate of the ASC’s grievance process, including how to file a

grievance.

All grievances submitted to any ASC staff member, whether verbally or in writing, must

be reported by the staff to an ASC official who has authority to address grievances. The

ASC’s grievance policies and procedures must identify the person(s) in the ASC who

have the authority to respond to grievances. The ASC is expected to educate staff on

their obligation to report all grievances, including whom they should report the grievance

to.

All grievances must be investigated, but the regulation stresses this in particular for

grievances related to treatment or care that the ASC provided or allegedly failed to

provide. In its investigation the ASC should not only respond to the substance of the

grievance, but should also use the grievance to determine if there are systemic problems

indicated by the grievance that require resolution. An ASC would be well-advised to

integrate its grievance process into its overall quality assessment and performance

improvement program.

The ASC’s grievance process must include a timeframe for the completion of the ASC’s

review of the grievance allegations, as well as for the ASC to provide a response to the

person filing the grievance. The timeframe must be reasonable, i.e., allowing the ASC

sufficient but not excessive time to conduct its review and issue its response. CMS does

not mandate a particular timeframe. The application of the ASC’s timeframe begins with

the date of the receipt of the grievance by the ASC.

The ASC must document for each grievance how it was addressed. The ASC must also

notify the patient or the patient’s representative or surrogate, in writing, of the ASC’s

decision regarding each grievance.

The ASC may use additional methods to resolve a grievance, such as meeting with the

patient’s family. There are no restrictions on the ASC’s use of additional effective

methods to handle a patient’s grievance. However, in all cases, the ASC must provide a

written notice of its decision on each patient’s grievance. The written notice must

include the name of an ASC contact person, the steps the ASC took to investigate the

grievance, the results of the grievance process, and the date the process was completed.

When a patient communicates a grievance to the ASC via email, the ASC may respond to

the patient via email, pursuant to the ASC’s policy. (Some ASC may have policies

prohibiting communication to patients via email.) If the patient requests a response via

email, the ASC may respond via email. If the email response contains the name of an

ASC contact person, the steps taken to investigate the grievance, the results of the

grievance process, and the date the process was completed, the email meets the

requirements for a written response.

In its written response to any grievance, the ASC is not required to include statements

that could be used in a legal action against the ASC, but the ASC should provide

adequate information to address the specific grievance. A form letter with generic

statements about grievance process steps and results is not acceptable.

Survey Procedures: §§416.50(d)(4)(5), & (6):

• Determine whether the ASC has a written policy addressing the grievance process.

Does the process specifically address how grievances are documented, how they are to be

submitted, how they are to be investigated, and how the findings are to be used to dispose

of the grievance? Does the policy comply with the regulatory requirements concerning

reporting of grievances, timeframe, and notice of disposition?

• Ask the ASC how many grievances it received during the past year. Ask how it

documents the existence of grievances. Ask what the disposition was of grievances

processed during that period. Ask to see a sample of grievance files. If this is a

complaint survey concerning a grievance, ask to see grievances submitted at the time of

the grievance that triggered the complaint survey.

• Review a sample of grievance files to determine if grievances are properly documented

and handled in accordance with the ASC’s policy and the regulatory requirements.

• Interview staff to see if staff is aware of the ASC’s grievance policies. Do staff know

the difference between a complaint handled on the spot and a grievance?

• Interview patients and/or representatives or surrogates to determine if they know how to

file a grievance and who to contact if they have a complaint/grievance.

• Interview staff and patients to see how staff and patients are educated regarding to

whom grievances and allegations should be reported.