The CMS grievance requirements are a frequent source of investigation, and CMS perennially identifies them as problem areas for hospitals. Therefore, it is important to understand why all hospitals that receive reimbursement for Medicare patients need to follow the CMS conditions of participation on grievances.
Complying with CMS Grievance Regulations
Many hospitals are confused by 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.
CMS Hospital CoPs and Patient Rights
You can find the interpretive guidelines on the CMS website under the state operations manual (SOM). In order to stay compliant, hospitals need to check the CMS transmittals once a month for changes; critical access hospitals have a separate manual under Appendix W.
In advance of furnishing or discontinuing care, a hospital needs to inform every patient of his or her rights. It is the hospitals’ duty to protect and promote every patient’s rights, and hospitals should have P&P to ensure that patients receive this information. The best way to inform all patients, both inpatients and outpatients, of their rights is by doing it in writing. The grievance requirements must appear in the written copy of the patient rights.
Role of CMS, TJC and OCR standards
ProfEdOnDemand recently hosted a live webinar “Grievances and Complaints: What Hospitals Should Know About the CMS and Joint Commission, DNV Standards and OCR” with expert speaker Sue Dill Calloway, RN, MSN, JD, where Sue discussed the interplay of CMS, TJC and OCR standards for grievances and complaints. She discussed TJC standards on complaints and how these crosswalk to the CMS grievance interpretive guidelines. Additionally, Sue covered what is now required to be documented in the medical record.
This session also reviewed CMS’s regulations regarding grievance committees and discussed TJC’s complaint standards in the Patient’s Right (RI) chapter. Sue explained how to comply with OCR’s requirement for hospitals to have a process to handle grievances related to discrimination under Section 1557, and 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.