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

Event Information
Product Format
Prerecorded Event
Sue Dill Calloway, RN, MSN, JD
90 minutes
Product Description

How Hospitals Can Comply with CMS Grievance Regulations

The CMS grievance requirements are a frequent source of investigation, and CMS perennially identifies them as problem areas for hospitals.

Many hospitals are confused at the number of regulations and the detailed compliance requirements for this problematic standard. Most hospitals that accept federal reimbursement must be in compliance with the CMS Conditions of Participation (CoPs). Hospitals must have a grievance procedure and a compliance coordinator to investigate any grievances alleging noncompliance, including discrimination. There must be a process to promptly resolve any grievance under Section 1557, and hospital staff must follow the hospital grievance and complaint policy, which should be approved by the board.

Join this informative webinar by expert speaker Sue Dill Calloway, RN, MSN, JD, to learn about the CMS, The Joint Commission (TJC) and Office of Civil Rights (OCR) standards for grievances and complaints. Sue will also explain the OCR requirements under Section 1557 of the Affordable Care Act (ACA) and what you need to ensure compliance.

Further, you’ll learn about the TJC standards on complaints and how these crosswalk to the CMS grievance interpretive guidelines. Additionally, Sue will cover what is now required to be documented in the medical record. This live webinar is a must-attend for staff from all hospitals.

Session Highlights

  • Why all hospitals that receive reimbursement for Medicare patients must follow the CMS conditions of participation on grievances
  • Review CMS’s regulations regarding grievance committees
  • Discuss TJC’s complaint standards in the Patient’s Right (RI) chapter
  • TJC standards on complaints and how these crosswalk to the CMS grievance interpretive guidelines
  • What is now required to be documented in the medical record
  • How patients must be provided with a written notice that includes the steps taken to investigate the grievance, the results and the date of completion
  • OCR’s requirement for hospitals to have a process to handle grievances related to discrimination under Section 1557

Session Agenda

  • A look at the Medicare state operations manual
  • Updated data deficiency reports
  • Patient Rights standards under CMS Grievance CoPs
  • Limited English proficiency resources available through OCR
  • Certification CHI and core CHI
  • Compliance with OCR Section 1557 of the ACA
  • Compliance with Notice of Patient Rights
  • Insight into the grievance process
  • Beneficiary & Family Centered Care QIOs
  • Hospital grievance procedure, 7 day rule
  • DNV Healthcare NIAHO on grievances
  • Sample grievance policy

Who Should Attend

  • 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 complaint standards

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About Our Speaker

Sue Dill Calloway - Hospital Coding Expert

Sue Dill Calloway, RN, MSN, JD, is the president of Patient Safety and Healthcare Consulting and Education company with a focus on medical-legal education especially Joint Commission and the CMS hospital CoPs regulatory compliance. She also lectures on legal, risk management and patient safety issues. She was a director for risk management and patient safety for five years for the Doctors Company. She was the...   More Info
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Dear Valued Customers


We regret to announce that ProEdTech LLC and all its affiliate brands will cease operations on April 1, 2019.


We are no longer able to fulfill online orders. We will fullfill all DVD and book orders already placed.


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