Complaint vs. Grievance per CMS Guidelines

Complaint – verbal communication to the hospital by a patient, or the patient’s representative, regarding the patient’s care or non-care issue that can be resolved immediately by the staff present.Examples:-Food is cold-Room needs to be cleaned

What is Considered a Complaint?

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.

Grievance – is a formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient’s representative, regarding the patient’s care (when the complaint is not resolved at the time of the complaint by staff present), abuse or neglect, issues related to the hospital’s compliance with the CMS Hospital Conditions of Participation (CoP), or a Medicare beneficiary billing complaint related to rights and limitations.It's a Grievance when..... A verbal 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 investigations, and/or requires further actions for resolution A written complaint is always considered a grievance (email and fax are considered "written") The complaint involves allegations of abuse, neglect, patient harm or hospital compliance with CMS requirements Whenever a patient or the patient's representative requests their complaint to be handled as a formal grievance or when the patient requests a response from the hospital Billing issues are not usually considered grievances, however billing issues can become a grievance if the patient states they will not pay because of a care or treatment issue Information obtained from a patient satisfaction survey is not a grievance unless the patient writes or attaches a written complaint on the survey Post hospital verbal communications regarding patient care is considered a grievance if the complaint cannot be handled at the moment the patient is communicating the concern to patient relations, CEO, etc.

What is Considered a Grievance?

CMS Grievance Guidelines

c24bea82-d226-4eb5-8eec-294bc94f7e97 (image/png)

Caption: :

9e68ceeb-d3a5-4dc7-91b9-89f930a60b72 (image/png)

7c333a16-3c4b-4d78-8965-dd85c6d8e5d7 (image/png)

Caption: : Organizations typically delegate the grievance process to a patient relations department, the "committee" can be defined to be a collaboration of the patient advocate handling the grievance along with the related managers, or a formal oversight committee.

Grievance Process CMS Guidelines

e4f15744-7da1-46c1-9123-35d2e65db997 (image/png)

Caption: : A written response of acknowledgement/progress on resolution needs to be sent to the patient within 7 days if more time is needed to resolve the grievance. This letter needs to include a stated number of days in which the patient will receive a follow-up written response (number of days depends on each hospital's grievance policy).

71cecd88-47ab-41b2-a7f2-8067d384e673 (image/png)

Grievance Process CMS Guidelines

A grievance is considered resolved when the patient is satisfied with the actions taken on their behalf. In situations where the hospital has taken reasonable actions on the patient's behalf to resolve the patient's grievance and the patient remains unsatisfied, the hospital can consider the grievance closed, but the hospital must maintain documentation