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.
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
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.
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
Agenda
- 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
Speakers
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.
