Grievance process is clarified as CoPs revised

Changes already in effect

The Centers for Medicare & Medicaid Services (CMS) has issued revisions to its interpretive guidelines for the hospital conditions of participation (CoP) in Medicare, including clarifications on how patient grievances should be handled and when a billing complaint is considered a grievance. The revisions to the grievance guidelines, which became effective Sept. 19, 2005, are found in Section 482.13, where the conditions specify: “The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance.”

Among other issues, the section addresses who can handle patient complaints and when complaints should be categorized as grievances; the requirements for responding to patient grievances; and when a grievance is considered resolved. Changes to the grievance definition and process were suggested earlier in the year by the Society for Healthcare Consumer Advocacy, an American Hospital Association (AHA) personal membership group for health care consumer advocate professionals.

The revised guidelines define a patient grievance as “a written or verbal complaint [when the verbal complaint about patient care is not resolved at the time of the complaint by staff present] by a patient, or the patient’s representative, regarding the patient’s care, abuse or neglect, issues related to the hospital’s compliance with the CMS Hospital CoP, or a Medicare beneficiary billing complaint related to rights and limitations provided by Title 42 of the Code of Federal Regulations, Part 489.”

Clarifications

Some of the clarifications are as follows:

  • “Staff present” includes any hospital staff present at the time of the complaint or who can quickly be at the patient’s location to resolve the patient’s complaint.
  • If a verbal patient care complaint cannot be resolved at the time of the complaint by staff present, is postponed for later resolution, is referred to other staff for later resolution, requires investigation, and/or requires further actions for resolution then the complaint is a grievance. A complaint is considered resolved when the patient is satisfied with the actions taken on his or her behalf.
  • Billing issues are not usually considered grievances for the purposes of these requirements. However, a Medicare beneficiary billing complaint related to rights and limitations provided by 42 CFR 489 is considered a grievance.
  • A written complaint is always considered a grievance, whether from an inpatient, outpatient, released/discharged patient or their representative regarding the patient care provided, abuse or neglect, or the hospital’s compliance with CoPs. An e-mail or fax is considered “written.”
  • Information obtained with patient satisfaction surveys does not usually meet the definition of a grievance unless an identified patient writes or attaches a written complaint on the survey and requests resolution. If the patient does that but without requesting resolution, the hospital must treat the complaint as a grievance if it would usually treat such a complaint as a grievance.
  • Any verbal or written complaints regarding abuse, neglect, patient harm or hospital compliance with CMS requirements is considered a grievance.
  • Whenever patients or their representatives request that their complaint be handled as a formal complaint or grievance, or when the patient requests a response from the hospital, the complaint is a grievance and all the requirements apply.