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 over 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 about 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.
Recall that the CMS regulations under grievances include the requirement to have a grievance committee.
Discuss that the Joint Commission has complaint standards in the patient’s rights (RI) chapter and DNV grievance standards 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 requirements 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 the patient
Issues surrounding a person as an authorized representative
Telephone complaints after discharge
Audits and PI required
Process for prompt resolution
The requirement to inform each patient on how to file grievances
Board’s responsibility in the grievance process
Grievance committee required
Referral to QIO and State Department of Health
QIOs process
P&P on grievances
Written notice of patient requirements
The time frame for responding to grievances
7-day rule
System analysis approach
Information for critical access hospitals
TJC compliant 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 a grievance on discrimination revised
Resources and Internet links

Who Should Attend?

Consumer Advocates or Patient Advocates
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-compliant standards