CMS SOM App. L, Tag Q-0228

person.

[(1) The patient has the right to the following:]

(ii) Voice grievances regarding treatment or care that is (or fails to be) provided.

Interpretive Guidelines: §416.50(e) (1)(ii)

This requirement complements the requirement for the ASC to have a grievance system.

Patients have the right to express a grievance regarding the treatment or care they receive

in the ASC.

The patient, or the patient’s representative or surrogate, as appropriate, may file a

grievance, verbally or in writing, before the date of the scheduled procedure, on the date

of the procedure, or after the date of the procedure. The regulation does not prescribe any

limitation as to when a patient may submit a grievance. However, it is understood that, if

a substantial amount of time has passed since the care episode addressed in the grievance,

e.g., several years, that it may, depending on the nature of the grievance, be harder for the

ASC to investigate the grievance and ascertain the pertinent facts.

Survey Procedures: §416.50(e) (1)(ii)

• Interview ASC staff to determine if they are aware of the patient’s right to file a

grievance.

• If the survey is related to a complaint alleging that an ASC ignored a patient’s

grievance, include that medical record in the sample and review it to determine if

there is any evidence of a grievance as well as of action to respond to the

grievance.