CMS SOM App. L, Tag Q-0226

…. The following criteria must be met:

(1) All alleged violations/grievances relating, but not limited to, mistreatment,

neglect, verbal, mental, sexual, or physical abuse, must be fully documented.

(2) All allegations must be immediately reported to a person in authority in the ASC.

(3) Only substantiated allegations must be reported to the State authority or the local

authority, or both.

Interpretive Guidelines: §§416.50(d)(1), (2), & (3)

Grievances making allegations related to mistreatment; neglect; verbal, mental, sexual or

physical abuse; or other serious allegations of harm must be fully documented. This

means that all pertinent details of the allegation must be recorded and retained in the

ASC’s files. Documentation of the allegation should include, at a minimum, the date and

time of the alleged occurrence, the location, the names of all individuals involved, and a

description of the behavior that is alleged to have occurred within the ASC and to have

constituted mistreatment, neglect or abuse or other serious harm.

The ASC regulation does define the terms “mistreatment,” “neglect,” or “abuse.”

However, the following definitions from long term care regulations may be helpful in

making common sense judgments about whether an allegation fits into one of these

categories:

• Neglect - Failure to provide goods and services necessary to avoid physical harm,

mental anguish, or mental illness (42 CFR 488.301).

• Abuse - The willful infliction of injury, unreasonable confinement, intimidation,

or punishment with resulting physical harm, pain or mental anguish (42 CFR

488.301).

In addition, according to the Merriam Webster dictionary, “mistreatment” means to treat

badly. It is also a synonym for abuse.

Finally, if there is applicable State law defining mistreatment, neglect or abuse in a

healthcare facility, including ASCs, those definitions will apply.

All grievances alleging mistreatment, neglect or abuse that are submitted to any ASC

staff member, whether verbally or in writing, must be reported immediately, i.e., as soon

as possible, and at least on the same day, by the staff member 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 immediately report all grievances

alleging mistreatment, neglect or abuse, including whom they should report the grievance

to.

Grievances alleging mistreatment, neglect, abuse or other behavior that endangers a

patient should be investigated as soon as possible, given the seriousness of the allegations

and the potential for harm to patients. The ASC must conduct a careful investigation,

balancing the need for speedy resolution with the need to ascertain all pertinent facts.

If the ASC confirms that the alleged mistreatment, abuse, neglect or other serious harm

took place, then the ASC is obligated to report the event to the appropriate local or State

authority, or even both. Depending on the specifics of the case and State or local law, the

appropriate authority(ies) might include the local police, a State healthcare professional

licensing board, a State agency that licenses the ASC, a State ombudsman, etc. The ASC

should contact the appropriate authority promptly after it concludes its investigation of

the grievance.

Survey Procedures: §§416.50(d)(1)(2), & (3)

• Do the ASC’s grievance policies and procedures separately address the process

for investigating grievances alleging mistreatment, abuse, neglect or other serious

harm? Do the policies and procedures conform to the regulatory requirement?

• Interview staff to determine how they would handle a grievance alleging

mistreatment, abuse, neglect or other serious harm? Do they know who to report

the grievance to? Do they know that it should be reported immediately?

• Ask the ASC who is the person authorized to handle such grievances. Interview

that person to determine if he/she understands the requirements to fully document

the allegation, conduct a prompt investigation, and to report substantiated

grievances to the proper authority.

• Ask the person authorized to handle such grievances if the ASC has had any

grievances alleging mistreatment, neglect, abuse or other serious harm? If the

answer is yes, ask to review the files for one or more such grievances. If such

grievances were substantiated, verify whether there is documentation that the

findings were reported to the appropriate authority.