Standard Grievance Procedures

Background

The Code of Federal Regulations states that: AAll patients are encouraged to understand and exercise their rights. Grievances and recommended changes in policies and services may be addressed to facility staff, administration, the Network Council, and agencies or regulatory bodies with jurisdiction over the facility, through any representative of the patient's choice, without restraint or interference, and without fear of discrimination or reprisal.@ (Subpart U - Conditions for Coverage of ESRD Services, Section 405.2138.)

Purpose

Grievance procedures protect patient rights and establish a reasonable mechanism for resolving problems and complaints. With the establishment of grievance review procedures, the Network encourages open communication between the patient and staff of the ESRD facility, including transplant units, and fosters speedy resolution of complaints and problems at the local level. Further, it provides a means whereby patients can bring problems before an objective outside authority without intimidation, fear of discrimination or reprisal.

Standards

1.The Network requires that all member facilities adopt written policies and procedures covering the rights and responsibilities of patients, the purpose of which is to encourage patients to understand and exercise their rights. All facilities must establish a Grievance Committee. There must be displayed, in a prominent place in the dialysis facility, a notice highlighting the grievance mechanism of the facility, names of committee members, and the address and phone number of the Network.

Patients may bring grievances to any member of the facility Grievance Committee and may ask for assistance in formulating complaints from any staff member of choice.

All patients should be made familiar with the grievance policy of their facility and the designated individuals to whom a complaint may be addressed.

2. The Network Grievance Committee is composed of representatives from nephrology, administration, social work, nursing, nutrition and patients.

3. Inquiries, grievances and complaints may be brought to the Network for resolution by patients, families, facility personnel and other interested parties. Grievances may be addressed to facility staff, administration, the Network and agencies or regulatory bodies with jurisdiction over the facility.

4. Patient grievances that are received via telephone or in person should be confirmed by the patients or their representatives in writing. The Network may commence its investigation of a complaint while awaiting written notice.

Determining Grievances for Network Involvement

 The Network may receive complaints about a wide variety of issues concerning the medical/surgical services received in the unit or the physician's office. If the Network determines that the complaint deals with reimbursement or is related to survey and certification of the facility, the complaint will be immediately referred to the Centers for Medicaid & Medicare Services (CMS) Regional Office.

CMS Region II Office
Certification & Enforcement Branch
26 Federal Plaza
New York, NY
Sherry Mohamed: 212-616-2475
Gwendolyn Taylor: 212-616-2484

CMS Region I Office
Kathleen M. Egan, RN, MSN
Project Officer
Division of Quality Improvement
Boston Regional Office
JFK Federal Building
Boston, Ma 02203
Tel: 617-565-1268
Fax: 617-565-4835
E-Mail: KathleeEgan@cms.hhs.gov

New York State Department of Health
Centralized Hospital Intake Department
Hedley Park Place
433 River Street, 6th Floor
Troy, NY 12180-299
800-804-5447

Designating a Patient Representative

A patient may designate whomever he/she chooses as a representative. The written complaint submitted by the representative must include the patient's designation of the representative.

Use of Facility Grievance Process

All ESRD treatment facilities are required to have grievance procedures. Although it is not mandatory that patients utilize their facility grievance process before contacting the Network, patients should be encouraged to utilize the facility grievance procedure prior to referring a grievance to the Network. The Network will act as a facilitator or mediator between the two parties in an effort to arrange for a settlement at the facility level.

Network will evaluate all grievances. If the Network determines that a complaint would be more appropriately handled at the facility level, that recommendation may be made to the patient. If the patient refuses, the Network is obliged to handle the complaint.

If the patient feels that an unsatisfactory solution has been reached at the facility level, then the patient may bring the grievance to the attention of the Network Grievance Committee.

Timing of Network Activity

 When a written grievance is received, the Network will provide written acknowledgment to the complainant within 15 calendar days. If the Network can determine, based on the content of a patient's grievance, or after a conversation with the patient, that it does not involve the quality of professional medical/surgical services and it is not a Network issue, or is more appropriately handled by another agency, the patient is to be so informed. The letter will inform the patient of the reason for the disposition and direct the patient to the appropriate party. All Network efforts at mediation and resolution of the grievance should be concluded within 90 calendar days of receipt of the inquiry and a response submitted to the patient detailing the results of the Network's efforts and any other options which the patient may pursue if he/she is not satisfied with the outcome. The patient will be advised of his/her right to pursue his/her grievance with the Regional Office and/or the State Survey and Certification Agency. The facility will be afforded the opportunity to review and comment on the Network findings prior to patient notification.

If the findings and recommendations of the Network Grievance Committee are not satisfactory to the patient and/or the facility, the matter may be referred to the Executive Committee of IPRO.

Both the IPRO Executive Committee and Network Grievance Committee may decline to investigate a grievance for which legal action is pending.

Life-Threatening Situations

 If the grievance presented to the Network appears to be of an immediate life-threatening nature, the grievance will be immediately forwarded to the CMS Regional Office to the attention of the Associate Regional Administrator, Division of Clinical Standards and Quality. The initial contact (within 24 hours) will be by telephone, followed by written confirmation. The Network will detail the nature of the grievance and state that it appears to be of an immediate life-threatening nature. The Network shall inform the patient that his/her grievance has been forwarded to the CMS Regional Office for review. At the instruction of the Regional Office the Network will serve as consultant and begin an investigation, which will be completed within 60 days.

Conflict of Interest

 The Network will ensure that a conflict of interest or a potential conflict of interest does not exist among members of its Grievance Committee, Medical Review Board, or Executive Committee involved in the investigation and resolution of grievances. Any individual who has direct involvement with the complainant or the provider under investigation, either financial, professional or personal, will be excluded from participation in the investigation and resolution of the grievance.

Reference: Code of Federal Regulations, Subpart U, Conditions for Coverage of Suppliers of End Stage Renal Disease (ESRD) Services 405.2138 (e) Standard: grievance mechanism

Home
Fistula First