Source: CMS Interpretive guidelines §482.13(a)(2)

The patient should have reasonable expectations of care and services and the facility should address those expectations in a timely, reasonable, and consistent manner. Although §482.13(a)(2)(ii) and (iii) address documentation of facility time frames for a response to a grievance, the expectation is that the facility will have a process to comply with a relatively minor request in a more timely manner than a written response. For example, a change in bedding, housekeeping of a room, and serving preferred food and beverages may be made relatively quickly and would not usually be considered a “grievance” and therefore would not require a written response.

“Staff present” includes any hospital staff present at the time of the complaint or who can quickly be at the patient’s location (i.e. nursing, administration, nursing supervisors, patient advocates, etc.) to resolve the patient’s complaint.

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Domain I: Distinguish between a grievance and a complaint as defined by CMS