Volume 2025 | No. 2
SURVEYOR
DMEPOS
DRX2-4C Frequency of the citation: 18%
DRX2-4B Frequency of the citation: 16%
Overview of the requirement: At the time of admission, the organization provides the client/patient with documentation detailing its process for receiving, investigating, and resolving complaints. The documentation includes how to contact the supplier, ACHC, and, when required by the state, the appropriate state agency. Comment on deficiencies: Compliance is assessed through review of client/patient records, new client/patient admission packets, and policies and procedures. Most deficiencies resulted from missing elements in the complaint information and inadequate documentation of receipt. Examples of ACHC Surveyor findings: ■ Client/patient records do not contain proof of receipt of the organization’s complaint process. ■ Complaint information provided to clients/patients does not include: ٝ Telephone number. ٝ Contact person. ٝ The process for receiving, investigating, and resolving grievances/complaints. ٝ Information on how to contact ACHC with a complaint. Compliance tips for:
Overview of the requirement: When handling Medicare beneficiary complaints, the organization follows the process outlined in the CMS Quality Standards for DMEPOS suppliers. Within five business days of receipt, complaints are acknowledged and investigations begin. Beneficiaries are notified with a written response within 14 days. Comment on deficiencies: Surveyors assess compliance through review of grievance/complaint records and by interviewing staff. Most deficiencies were cited due to lack of compliance with required time frames.
Examples of ACHC Surveyor findings:
■ There is no evidence that Medicare beneficiaries: ٝ Receive written notification of the results of the investigation of their complaint within 14 days. ٝ Are notified within 5 days that their complaint has been received and is being investigated. ■ The manager and performance improvement (PI) coordinator were not aware of the required time frames and methods for responding to Medicare beneficiaries after being informed of a grievance/ complaint/concern. Compliance tips for:
■ CMS Quality Standards require supplier organizations to notify beneficiaries of two key phases of a complaint investigation: ٝ The complaint is acknowledged and investigations are under way (within five business days of receipt.) ٝ The investigation has an outcome and a written response (within 14 days). ■ The organization maintains records of all grievances/complaints, client/patient notifications, investigations and outcomes. This information is reported to leadership through the performance improvement (PI) committee.
Nerd Newbies (understand the requirement)
■ The organization provides all clients/patients with information listing a telephone number, contact person, and the organization’s process for receiving, investigating, and resolving grievances/complaints about its services/care. ■ ACHC’s telephone number must be provided. (This requirement is not applicable to an organization if this is its first ACHC survey.) ■ At least annually, review information provided to new clients/patients to ensure that the complaint information is current with ACHC Standards. ٝ Check specifically for details on how to file a complaint with the organization or ACHC. ■ Audit client/patient records to ensure that there is documentation of receipt of how to file a complaint.
Nerd Newbies (understand the requirement)
Nerd Apprentices (audit for excellence)
■ Routinely audit complaint records to ensure that: ٝ Timeframes are being met.
Nerd Apprentices (audit for excellence)
ٝ All complaints received by personnel are properly documented, investigated, and communicated to clients/patients. ■ Are all personnel responsible for handling complaints are aware of the requirements? ■ Check for compliance frequently. ■ Educate to ensure retention.
■ Reeducate personnel on the importance of:
Nerd Trailblazers (prepare the path for others)
ٝ Providing compliant information to clients/patients. ٝ The policy for handling complaints. ■ Review the client/patient intake process. Is there a way to document provision of complaint information in the client/patient record?
Nerd Trailblazers (prepare the path for others)
achc.org | (855) 937-2242 | 11
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