Grievances and Complaints: What Hospitals Should Know about the CMS, Joint Commission, DNV and OCR Standards?

Why Should You Attend:

If a CMS surveyor showed up at your hospital tomorrow would you know what to do? Are you sure you are in compliance with the entire grievance requirements by CMS, OCR, and the complaint standards by the Joint Commission or your accreditation organization? Do you have a grievance committee? Do you provide a written response as required by CMS? The CMS grievance requirements have recently been a frequent source of investigation. In fact, it was the third most common problematic standard for hospital. The grievance standards are located in the patient rights section.

This online training will talk about the Office of Civil Rights requirements under Section 1557 of the Affordable Care Act. The hospital must have a grievance procedure and compliance coordinator to investigate any grievances alleging noncompliance with this law including discrimination. There must be a process to promptly resolve any grievance prohibited by Section 1557.

This training program will also discuss the CMS Hospital CoPs, the Joint Commission and DNV Healthcare standards on complaints and grievances. How these cross walk to the CMS grievance interpretive guidelines will also be discussed. This is a must attend for any hospital. Staff should be aware and follow the hospital grievance and complaint policy. The policy should be approved by the board. Staff should be educated on the policy. This program will cover what is now required to be documented in the medical record.

Learning Objectives:

• Discuss that any hospital that receives reimbursement for Medicare patients must follow the CMS Conditions of Participation on grievances. (This is true whether the hospital is accredited by Joint Commission, HCFA, CIHQ, DNV Healthcare or not)
• Identify 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 in most cases the patient 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

Areas Covered in the Webinar:

• Background on CMS CoPs
• How to find current copy
• CMS deficiency memo
• How to find changes in the hospital CoPs
• Issuance of final interpretive guidelines
• OCR grievance requirements under Section 1557
• TJC standards
• Recent standing order memo
• Preprinted order sheet changes
• Federal Register, interpretive guidelines, survey procedure
• P&P requires to ensure patients have information on rights
• Prompt resolution of grievances
• CMS definition of grievance
• Definition of staff present
• TJC definition and six elements of performance on complaints
• P&P with all the required elements
• Form to collect information
• HIPAA requirements if request not from patient
• Need to determine person is authorized representative
• Billing issues and information on patient satisfaction
• Telephone complaints after discharge
• Customer service and complaints
• Audits and PI required
• Policy to encourage staff
• 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
• Changes to QIOs process
• P&P on grievances
• Written notice to patient requirements
• Time frame for responding to grievances
• 7 day rule
• System analysis approach
• What should critical access hospitals do?
• DNV Health NIAHO standards on grievances
• OCR Section 1557 on complaint process
• Policy required
• Notice to patient
• Grievance process
• Appeal to CEO or board
• Time lines for filing grievance on discrimination
• Job description for compliance person

Who Will Benefit:

• Consumer Advocates or Patient Advocate
• Healthcare Consumer Advocates
• Chief Operating Officer (COO)
• All nurses with direct patient care
• All nurse managers
• Joint Commission Coordinator
• Chief Executive Officer (CEO)
• Chief Nursing Officer (CNO)
• Chief Medical Officer (CMO)
• Chief Financial Officer (CFO)
• Board Members
• Quality Improvement Coordinator
• Risk Managers
• Legal Counsel
• Nurse Educator
• Patient Safety Officer
• Emergency Department Manager
• Nurse Managers/Supervisors
• Compliance Officer
• Clinic Managers
• Medical Department Nurse Manager
• Surgery Department Nurse Manager
• OR Nurse Director
• ICU Nurse Director
• CCU Nurse Director
• Outpatient Director
• HIPAA Privacy and Security Officer
• Director of Business Office
• Lab Director
• Policy and procedure committee
• Ethicist
• Anyone involved in the implementation of the CMS grievance, DNV, OCR, or Joint Commission complaint standards

Sue Dill Calloway
chief learning officer, Emergency Medicine Patient Safety Foundation

Sue Dill Calloway is a nurse attorney, a medical legal consultant and the past chief learning officer for the Emergency Medicine Patient Safety Foundation. She is the immediate past director of Hospital Patient Safety and Risk Management for The Doctors Company. She is currently president of Patient Safety and Health Care Education and Consulting. She was a medical malpractice defense attorney for many years and a past director of risk management for the Ohio Hospital Association. She was in-house legal counsel for a hospital in addition to being the privacy officer and compliance officer.

Ms. Calloway has done many educational programs for nurses, physicians, and other health care providers. She has authored over 102 books and numerous articles. She is a frequent speaker and is well known across the country in the area of healthcare law, risk management, and patient safety. She has taught many educational programs and written many articles on compliance with the CMS and Joint Commission restraint standards.

Topic Background:

CMS issued their first memo summarizing noncompliance and grievances were a top problematic standard. A recent report by CMS found 902 hospitals out of compliance! Don’t let this happen to your hospital. Come learn what you need to ensure compliance. Many hospitals are surprised at the number of regulations and the detailed requirements to comply with this problematic standard.

Most every hospital in the US that accepts Medicare or Medicaid reimbursement must be in compliance with the CMS Conditions of Participation (CoPs).

Note: That Critical Access Hospitals (CAH) have a separate set of hospital CoPs and there is no corresponding restraint standard and the only mention of restraints is in the swing bed section. However, CAH are expected to have some system of grievance and complaint resolution. Therefore, many CAH adopt most of the requirements. This program will be helpful in determining suggested practices for policy implementation. CAH hospitals that are in systems should know the differences in the two sets of CoPs and may find the program of interest for that reason.

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