Home Events Grievances and Complaints: What Hospitals Need to Know for CMS CoPs, TJC, DNV Standards & OCR

Grievances and Complaints: What Hospitals Need to Know for CMS CoPs, TJC, DNV Standards & OCR

NDHA is an approved provider of continuing education by the North Dakota Board of Examiners for Nursing Home Administrators.

Date: 3/8/2022

9:00 – 11:00 AM Central time


Registration fees:       $175 per NDHA member  |  $225 per non-member

Target Audience

Chief Medical Officer, Chief Nursing Officer, Compliance Officer, Emergency Department Personnel, Joint Commission Coordinator, Medical Records, Quality Improvement personnel, Risk Manager, Legal Counsel.


Hospitals that accept Medicare or Medicaid reimbursement must comply with the Centers for Medicare & Medicaid Services (CMS) Conditions of Participation (CoPs). This program will cover the CMS requirements on grievance regulations and will explain how hospitals can comply.

This program will review a federal law that is enforced by the Office of Civil Rights requirements under Section 1557 of the Affordable Care Act. Hospitals must still have a grievance procedure and compliance coordinator to investigate any grievances alleging noncompliance with this law, including discrimination.

This webinar will also cover the Joint Commission standards on complaints and the DNV Healthcare on grievances, indicating how each of these standards cross walk to the CMS grievance interpretive guidelines. Hospital staff should follow the hospital grievance and complaint policy, which should be approved by the board. This is a must-attend session for all hospitals.

Learning Objectives

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

  • Recite that any hospital receiving reimbursement for Medicare patients must follow the CMS CoPs on grievances.
  • 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 rights (RI) chapter and DNV grievance standard in the patient rights chapter.
  • Explain 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.



Laura A. Dixon is the president of Healthcare Risk Education and Consulting. She previously served as the Director, Facility Patient Safety and Risk Management and Operations for COPIC from 2014 to 2020.  In her role, Ms. Dixon provided consultation and training to facilities, practitioners and staff in multiple states.

Ms. Dixon has more than twenty years of clinical experience in acute care facilities, including critical care, coronary care, peri-operative services and pain management.  Prior to joining COPIC, she served as the Director, Western Region, Patient Safety and Risk Management for The Doctors Company, Napa, California.  In this capacity, she provided consultation to the physicians and staff for the western United States.As a registered nurse and attorney, Laura holds a Bachelor of Science degree from Regis University, a Doctor of Jurisprudence degree from Drake University College of Law, and a Registered Nurse Diploma from Saint Luke’s School Professional Nursing.  She is licensed to practice law in Colorado and California.

This speaker has no real or perceived conflicts of interest that relate to this presentation.



Mar 08 2022


9:00 am - 11:00 am

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