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

April 4 @ 8:00 am - 10:00 am MDT

$160 – $320

Our speaker will discuss the federal law that is now in effect for hospitals and enforced by the Office of Civil Rights (OCR) requirements under Section 1557 of the Affordable Care Act (ACA). Hospitals must have a grievance procedure and compliance coordinator to investigate any grievances alleging noncompliance with this law. There should be a process in place to resolve any grievance prohibited by Section 1557 and this information should be visibly posted in the hospital.

The speaker will also review the Joint Commission (TJC) standards on complaints; the DNV Healthcare procedures on grievances; and how these crosswalk to the CMS grievance interpretive guidelines. Staff should be aware and follow the hospital grievance and complaint policy. There will also be a review of medical records documentation.

At the conclusion of this session, participants will be able to:

  • Describe how a hospital must follow the CMS Conditions of Participation on grievances if they receive Medicare reimbursement.
  • Identify the CMS regulations under grievances, including the requirement to have a grievance committee.
  • Explan the Joint Commission complaint standards in the Patient Rights (Rights and Responsibilities of the Individual (RI) chapter.
  • Explain the DNV grievance standard in the Patient Rights chapter.
  • Discuss how the hospital should provide the patient with a written notice that includes steps taken to investigate the grievance, the results, and the date of completion.

C-Suite, nurses with direct patient care, TJC coordinators, quality improvement coordinators, risk managers, patient safety and compliance officers, ED managers and hospital legal counsel.

Sue Dill Calloway, RN, JD, has been a nurse attorney and consultant for more than 30 years. Currently, she is president of Patient Safety and Healthcare Education & Consulting. She was previously the chief learning officer for the Emergency Medicine Patient Safety Foundation. Additionally, Calloway has authored over 100 books and numerous articles. The speaker has no real or perceived conflicts of interest that relate to this presentation.

March 28, 5:00 p.m. MDT


Tickets are not available as this event has passed.


April 4
8:00 am - 10:00 am (MDT)
$160 – $320
Event Category:


Toni Pugmire
(208) 489-1409