Grievances and Complaints Ensuring Hospitals Compliance with the CMS CoPs, Joint Commission, DNV Standards and OCR

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By - Laura A. Dixon, BS, JD, RN, CPHRM

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Hospitals that accept Medicare or Medicaid reimbursement must comply with the CMS Conditions of Participation. The CMS grievance requirements have been a frequent source of deficiency citations. The grievance standards for acute hospitals are in the patient rights section of the Conditions of Participation manual. Although there is no similar section for Critical Access Hospitals, and the requirements for acute hospitals do not apply to CAHs, those facilities should have policies and procedures to address patient rights, including any grievance or complaint.

The federal law enforced by the Office of Civil Rights requirements under Section 1557 of the Affordable Care Act will also be discussed. A hospital must still have a grievance procedure and a designated person to investigate any grievances alleging noncompliance with this law including discrimination.

This program will also discuss the Joint Commission standards on complaints and DNV Healthcare on grievances and how their standards cross walk to the CMS grievance interpretive guidelines.

Staff should be aware of and follow the hospital grievance and complaint policy. The policy should be approved by the board. Staff should be educated in the policy. This program will cover what is now required to be documented in the medical record.

Objectives:

Discuss that any hospital that receives reimbursement for Medicare patients must follow the CMS Conditions of Participation on grievances.
Recall that the CMS regulations under grievances includes the requirement to have a grievance committee.
Discuss that the Joint Commission has complaint standards in the patient’s right (RI) chapter and DNV grievance standard in the patient rights chapter.
Recall that patients must be provided with a written notice that includes steps taken to investigate the grievance, the results, and the date of completion.
Describe that the Office of Civil Rights requires hospitals to have a process to handle grievances related to discrimination under Section 1557.

Agenda

This program will cover the following:

Introduction
CMS deficiency reports
P&P requires to ensure patients have information on rights
Prompt resolution of grievances
CMS definition of grievance
P&P with all the required elements
HIPAA requirements if request not from patient
Issues surrounding person as an authorized representative
Telephone complaints after discharge
Audits and PI required
Process for prompt resolution
Requirement to inform each patient on how to file grievances
Board’s responsibility in grievance process
Grievance committee required
Referral to QIO and State Department of Health
QIOs process
P&P on grievances
Written notice to patient requirements
Time frame for responding to grievances
7-day rule
System analysis approach
Information for critical access hospitals
TJC complaint standards
DNV Health NIAHO standards on grievances
OCR Section 1557 on complaint process and recent changes
- Policy required
- Grievance process
- Appeal to CEO or board changed
- Timelines for filing grievance on discrimination revised
Resources and internet links

Who Should Attend:

Consumer Advocates or Patient Advocate
All nurses with direct patient care
All nurse managers
Joint Commission Coordinator
All department directors
Chief Executive Officer (CEO)
Chief Operating Officer (COO)
Chief Nursing Officer (CNO)
Chief Medical Officer (CMO)
Quality Improvement Coordinator
Risk Managers
Nurse Educator
Patient Safety Officer
Compliance Officer
HIPAA privacy and security officer
Policy and procedure committee
Ethicist
Anyone involved in the implementation of the CMS grievance, DNV, OCR, or Joint Commission complaint standards

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Webinar Type

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Speaker Detail

Laura A. Dixon recently served as the Regional Director of Risk Management and Patient Safety for Kaiser Permanente Colorado where she provided consultation and resources to clinical staff. Prior to joining Kaiser, she served as the Director, Facility Patient Safety and Risk Management and Operations for COPIC from 2014 to 2020. In her role, Ms. Dixon provided patient safety and risk management consultation and training to facilities, practitioners, and staff in multiple states. Such services included creation of and presentations on risk management topics, assessment of healthcare facilities; and development of programs and compilation of reference materials that complement physician-oriented products. Ms. Dixon has more than twenty years of clinical experience in acute care facilities, including critical care, coronary care, peri-operative services, and pain management. Prior to joining COPIC, she served as the Director, Western Region, Patient Safety and Risk Management for The Doctors Company, Napa, California. In this capacity, she provided patient safety and risk management consultation to the physicians and staff for the western United States. Ms. Dixon’s legal experience includes medical malpractice insurance defense and representation of nurses before the Colorado Board of Nursing. As a registered nurse and attorney, Laura holds a Bachelor of Science degree from Regis University, RECEP of Denver, a Doctor of Jurisprudence degree from Drake University College of Law, Des Moines, Iowa, and a Registered Nurse Diploma from Saint Luke’s School Professional Nursing, Cedar Rapids, Iowa. She is licensed to practice law in Colorado and California.