Grievances and Complaints: Ensuring Compliance with the CMS and OCR Requirements in 2025

Hospitals that accept Medicare or Medicaid reimbursement must comply with the CMS Conditions of Participation. The CMS grievance requirements have been a frequent source of deficiency citations. 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.

The federal law enforced by the Office of Civil Rights requirements under Section 1557 of the Affordable Care Act will also be discussed. A hospital must still have a grievance procedure and a designated person to investigate any grievances alleging noncompliance with this law, including discrimination.

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 in the policy. This program will cover what is now required to be documented in the medical record.

Learning Objectives:-

• Discuss that any hospital that receives reimbursement for Medicare patients must follow the CMS Conditions of Participation on grievances.
• Recall that the CMS regulations under grievances include the requirement to have a grievance committee.
• 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.

Agenda:-

This program will cover the following:

• Introduction
• CMS deficiency reports
• P&P requires ensuring patients have information on their rights
• Prompt resolution of grievances
• CMS definition of grievance
• P&P with all the required elements
• HIPAA requirements if the request is not from the patient
• Issues surrounding a person as an authorized representative
• Telephone complaints after discharge
• Audits and PI required
• Process for prompt resolution
• Requirement to inform each patient on how to file grievances
• The board’s responsibility in the grievance process
• The grievance committee required
• Referral to QIO and the State Department of Health
• QIOs process
• P&P on grievances
• Written notice to the patient requirements
• Time frame for responding to grievances
• 7-day rule
• System analysis approach
• Information for critical access hospitals
• OCR Section 1557 on the complaint process and recent changes
  • Policy required
  • Grievance process
  • Appeal to the CEO or the board changed
  • Timelines for filing a grievance on discrimination have been revised
• 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
• Ethicist
• Anyone involved in the implementation of the CMS grievance or OCR requirements.