Grievances and Complaints 2024

1
Grievances and Complaints2024

• CMS Conditions of Participation
• Joint Commission, DNV, OCR, and More
• Presented By
• Laura A. Dixon, BS, JD, RN, CPHRM

2
Speaker

• Laura A. Dixon, Esq.
• BS, JD, RN, CPHRM
• President, Healthcare Risk Education, and
  Consulting, LLC
• 303-955-8104
• ldesq_at_comcast.net
• Email questions to CMS
  Critical Access Hospitals
  qsog_CAH_at_cms.hhs.gov. Acute
  hospitals qsog_hospital_at_cms.hhs.gov.

2
2
3
CMS Hospital CoPs

• Grievances

4
Patient Rights Standards

• Patients Rights section contains the grievance
  provisions in Appendix A
• Tags 118 - 123
• Establishes minimum protections and rights for
  patients
• Examples
• Right to notification of rights and exercise of
  rights
• Right to privacy and safety, confidentiality of
  medical records and to be free from unnecessary
  RS
• Right to have advance directives followed
• Right to pick who will visit them

5
To Whom Does This Apply?

• All acute hospitals that participate in the
  Medicare or Medicaid
• Most hospitals in this country except VA or army
  hospitals
• All parts and locations of the hospital
• Includes
• Short term surgical psychiatric
  rehabilitation long term care hospitals
  childrens substance use facilities
• Applies regardless of accrediting organization

6
To Whom Does It NOT Apply?

• Critical Access Hospitals no similar
  requirement in the CoPs
• Nonetheless CAHs should have policy and include
  most of these requirements
• RS requirements in the swing bed section
  Appendix W
• CAVAET CAHs with distinct Rehab or Behavioral
  Health units are surveyed under Appendix A so
  may apply

7
Joint Commission Complaint Standards
8
DNV Healthcare NIAHO on Grievances
9
Office of Civil Rights1557 of the ACA
10
Key Takeaways

• Provide information to patients on their rights
  regarding filing a grievance on admission
• Provide such information to representatives for
  incapacitated/incompetent patients
• Train all staff on what is a grievance and who to
  notify
• Empower staff to address issues that can be
  resolved immediately
• Keep Governing Board informed of grievances
• Have a policy and procedure on grievances
• Include who responsible to respond to a grievance
  and the method to respond
• When in doubt respond in writing
• Grievance coordinator to keep files and records
  of grievances
• Have qualified interpreters available

11
The End Questions???

• Laura A. Dixon, Esq.
• BS, JD, RN, CPHRM
• President, Healthcare Risk Education, and
  Consulting, LLC
• 303-955-8104
• ldesq_at_comcast.net

Register Now
11
11