Grievances and Complaints: Ensuring Hospitals Compliance with the CMS CoPs

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

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 hospitals. The grievance standards are located in the patient rights section.

CMS has a new website to get the CMS manuals. CMS also a new email address to ask questions and information on both of these will be provided.

Come learn what you need to ensure compliance. Many hospitals are surprised at the number of regulations and the detailed requirements on what they need to do 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). This program will cover in detail the CMS requirements for hospitals to help prevent the hospital from being found out of compliance with the grievance regulations.

This program will talk about a federal law that is in effect now for hospitals and enforced by 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. The information must also be posted on a sign in the hospital.

This program will also discuss the Joint Commission standards on complaints and DNV Healthcare on grievances and how these crosswalk to the CMS grievance interpretive guidelines. This is a must-attend for any hospital. 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 on the policy. This program will cover what is now required to be documented in the medical record.

• 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 include 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.

This program will cover the following:

• Background on CMS CoPs
• How to find a 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 requested, are not from the patient
• Need to determine the 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
• 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
• Changes to the QIOs process
• P&P on grievances
• Written notice to patient requirements
• The 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 the complaint process
  • Policy required
  • Notice to patient
  • Grievance process
  • Appeal to CEO or board
  • Timelines for filing a grievance on discrimination
  • Job description for compliance person

• Consumer Advocates or Patient Advocate
• Chief Operating Officer (COO)
• All nurses with direct patient care
• All nurse managers
• Joint Commission Coordinator
• All department directors
• 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
• Staff Nurses
• 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 compliant standards