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

Laura A. Dixon
Recording Webinar Available @All Days
Recorded Webinar


Grievances and Complaints: Ensuring Hospitals Compliance with the CMS CoPs, Joint Commission, DNV Standards and OCR
Hospitals that accept Medicare or Medicaid reimbursement must comply with the CMS Conditions of Participation. 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.

Also to be discussed is the federal law enforced by the Office of Civil Rights requirements under Section 1557 of the Affordable Care Act.  A hospital must still have a grievance procedure and compliance coordinator 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 crosswalk 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:-

  • 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.


This program will cover the following:

  • Background on CMS CoPs
  • CMS conditions of participation – grievances
  • Application of Conditions
  • Notices required
  • Incapacitate patient
  • Spouses and same-sex marriages
  • Grievance process
  • CMS definition of grievance
  • Governing Board responsibilities
  • Grievance committee
  • Grievances and referrals
  • Timeframes
  • Referral to QIO and State Department of Health
  • QIOs process
  • P&P on grievances
  • Information for critical access hospitals
  • DNV Health NIAHO standards on grievances
  • OCR Section 1557 on complaint process and recent changes
    • Policy required
    • Grievance process
  • Interpreters
  • 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
  • Anyone involved in the implementation of the CMS grievance, DNV, OCR, or Joint Commission-compliant standards

Training Options

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