Patient Complaint Grievance Investigation

CMS-compliant inspection template for documenting patient complaint and grievance handling, including acknowledgment, investigation, written response, and resolution.

Case Intake and Complaint Classification

• Complaint/grievance was logged in the designated tracking system
• Date and time of receipt were documented
• Source of complaint was documented
• Issue was classified as complaint or grievance per policy
• Primary concern category was identified

Acknowledgment and Timeliness

• Initial acknowledgment was documented
• Acknowledgment date/time was recorded
• Acknowledgment occurred within policy/CMS timeframe
• Patient or representative was informed of next steps and contact person

Investigation and Documentation

• Investigation was initiated and documented
• Relevant records, interviews, or event reports were reviewed
• Findings were documented objectively and clearly
• Root cause or contributing factors were identified when applicable
• Any immediate patient safety risk was escalated promptly

Written Response and Resolution

• Written response was issued
• Written response date was documented
• Written response addressed the concern, findings, and resolution
• Resolution status was documented
• Patient was informed of any appeal or follow-up process if applicable

Corrective Action, Closure, and Attestation

• Corrective action plan was documented when needed
• Follow-up completion date was documented
• Case was formally closed in the tracking system
• Inspector attestation