Don’t Let CMS Grievance Standards Give You Grief: Put Your Policy In Place

CMS grievance requirements

Nobody’s perfect—including your hospital staff. Patients will complain. But you have a responsibility to your patients and to your hospital to comply with the grievance requirements called for by the Centers for Medicare and Medicaid Services (CMS), the Office for Civil Rights (OCR), and the Joint Commission—and your accreditation organization.

Watch out: The third most common problematic standard for hospitals is CMS grievance requirements! A recent report found that more than 1,000 U.S. hospitals were out of compliance with conditions of participation (CoPs)—don’t let this happen to your facility!

You must comply with CMS—and other agencies—grievance standards and establish a properly prepared grievance committee, asserts healthcare compliance expert Sue Dill Calloway. In her audio conference for ProfEdOnDemand, “Grievances: Ensure Hospital Compliance with CMS, OCR & Joint Commission Standards,” Calloway details the federal laws affecting hospitals, explains which are enforced by which agencies, and walks you through the standards of compliance you must heed.

The Not-So-Grievous Requirements?

Grievances are complaints or disputes—such as but not limited to improper care and unsafe hospital conditions—that your patients can file to express their dissatisfaction either orally or in writing. Then what?

CMS regulation §482.13(a)(2) states “The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance.”

For the most part, that’s pretty straightforward. Your patient has a problem and you need to make the patient happy. But your hospital is required to have a specific grievous plan in place in order to participate in Medicare and Medicaid.

“The hospital’s governing body must approve and be responsible for the effective operation of the grievance process, and must review and resolve grievances, unless it delegates the responsibility in writing to a grievance committee.”

That’s a tall order. Your grievance process must include a way for you to refer patient concerns in a timely fashion to the appropriate parties. Who are these appropriate parties?

The Joint Commission isn’t interested that your patients received cold food during their hospital stay, but they are interested in patient safety. Likewise, according to Medicare, If your patients received improper care or experienced unsafe conditions, they should contact your state survey agency which is part of the state department of health.

The Office of Civil Rights is interested in your patients’ grievances regarding civil right violations, including race, color, national origin, disability, age, sex, and religion.

In The Event Of A Survey

Is your hospital prepared for a CMS survey? You can be if you know what the agency is looking for. If a surveyor shows up at your hospital’s door tomorrow, you can expect him/her to ask these the survey questions :

  • Do your hospital’s policies and procedures encourage all personnel to alert appropriate staff concerning any patient grievance?
  • Does your hospital adhere to its policy/procedure established for referrals?
  • Do patients (or their legal representatives) know how to file a complaint and with whom? (Expect the surveyor to interview patients.)
  • Is your hospital following its grievance policies and procedures?
  • Does your hospital’s process assure timely resolution of grievances involving situations or practices that place the patient in immediate danger?
  • Does the patient or the patient’s representative know that he/she has the right to file a complaint with the state agency, as well as or instead of utilizing the hospital’s grievance process?
  • Has your hospital provided the telephone number for the state agency to all patients/patient representatives?
  • Are beneficiaries aware of their right to seek review by the Quality Improvement Organization (QIO) for quality of care issues, coverage decisions, and to appeal a premature discharge?

Put A Policy In Place

To remain in compliance you can’t afford not to have a grievance policy in place. Don’t wait until you get a complaint to figure out how to handle it. Some considerations when creating your plan should include, according to Calloway:

  • A way to respond to grievance complaints made through an interpreter or by a person with low health literacy,
  • A way to respond to both written and verbal grievance complaints, and
  • Information readily available for patients about how to contact a quality improvement officer.


The ECRI Institute offers these action recommendations for creating your hospital grievance policy:

  • Design a process to capture and address all complaints and grievances.
  • Ensure the involvement of the organization’s governing body or its designated grievance committee.
  • Implement policies, procedures, and processes for investigation and resolution of patient complaints and grievances.
  • Educate all physicians and staff on grievance processes.
  • Train all staff to listen effectively and manage patient and family expectations.
  • Use dedicated staff to solve small problems before they escalate.
  • Employ a proactive approach to customer service.
  • Empower frontline staff to act as the first line of defense against complaints.
  • Track complaints, grievances, and patient satisfaction surveys and implement improvement initiatives to address trends identified.
  • Verify that the grievance process is effective.

Learn How To Create A Grievance Policy

Bottom line: Your hospital must create and implement guidelines necessary for meeting CMS grievance requirements and follow those grievance procedures in a way that satisfies CMS regulations.

Calloway’s conference will give you the know-how to create and follow a policy handling grievances and complaints. You’ll be able to help your facility close the gap between what you’re currently doing and what you’re required to do.

To join the conference or see a replay, order a DVD or transcript, or read more

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