And now, I would like to introduce our speaker to get us started today. Ms. Laura Dixon most recently served as the Director of Risk Management and Patient Safety for the Colorado region of Kaiser Permanente. Prior to joining Kaiser, she served as the Director of Facility, Patient Safety, and Risk Management and Operations for COPIC from 2014 to 2020. In her role, Ms. Dixon provided patient safety and risk management consultation and training to facilities, practitioners, and staff in multiple states. Ms. Dixon has more than 20 years of clinical experience in acute care facilities, including critical care, coronary care, perioperative services, and pain management. Prior to joining COPIC, she served as the Director, Western Region, Patient Safety and Risk Management for the Doctors' Company in Napa, California. In this capacity, she provided patient safety and risk management consultation to the physicians and staff for the Western United States. As a registered nurse and attorney, Laura holds a Bachelor of Science from Regis University, a Doctor of Jewish Prudence from Drake University College of Law, and a registered nurse diploma from St. Luke's School of Professional Nursing. She is licensed to practice law in Colorado and in California. Thank you so much for being here with us this morning, Laura. I invite you to go ahead and get us started. Okay. Thank you very much, Lindsay, and welcome, everyone. We're talking on a topic today, grievances and complaints. And really, it's the same thing. It just depends on, are you going through CMS? Are you going through Joint Commission? Which one are you going through? But essentially, it is the same thing. And so when you do get one, whether it's written, verbal, from a patient, the representative, CMS has decided we need to take certain steps in order to address that issue and then follow up with the patient. By the way, the information I'm providing today is strictly that. It's informational only. It is not meant to serve as any legal advice or establishing an attorney-client relationship. Please reach out to your counsel, your in-house counsel, your representative, whoever it happens to be, for any specific issue as it relates to your case or your situation. Well, I want to do just a brief introduction. And those of you who've had an opportunity to listen through Georgia Hospital Association, you know why we're here today. And that's so we don't get one of these. And that is the statement of deficiencies where you have to do the plan of correction. That's the one you send back to CMS, and they take a look at it. And no provider, whether it's physician, dentist, hospital, no one wants to be notified. They've been involuntarily terminated from the agreement. And this usually happens because, well, there's a multitude. One, you don't allow them access. But as far as sending in that statement of deficiencies, plan of correction, if it's not sufficient, doesn't meet the main ones or the ones that they identify in that statement, or you just didn't do one, they can say, okay, we're done. You had an opportunity. And that's a huge financial hit for those. How does this thing work? Well, the regulation, what we're covering today, those topics, they start in the Federal Register, and then CMS has a couple jobs. One, they have to put that regulation out to their surveyors so that they know this is new, and that's called a transmittal. They also have to develop the interpretive guidelines or rationales and survey procedures for those changes. And then they're to update the manual. There are three types of surveys, certification, when you're starting out, validation, if, say, you had an accrediting organization come around and do a survey, they may come around also, or to go back and see how you did after a plan of correction. And then, of course, the complaint survey. Those usually happen when they get notice from a member or a QIO that, hey, this happened, and it was pretty bad, and so that's when they would be out. Keeping up with the changes, and they're having some multiple changes. I'm surprised how many we've had in the past year. In fact, one just came out yesterday, and it affects hospitals that provide OB services. Well, how do we keep up with them? First off, if this is your job, you're in compliance, I would subscribe to that federal register because then you can gain access to what those new regulations are. You want to make sure you have the most recent manual. STRS came out in 86, and multiple updates since then. And if there is a new manual, I'll show you what's called the transmittal page. And the transmittal page takes you right to where there is a listing of what's new, revised, or deleted. So you don't have to go through the massive 400-some page for the acute, or you don't have to go to the 360-some for a critical access hospital. And finally, I would check that what's called survey and certification website, because again, that's where they'll put out notices of their memos. And check it monthly. That's more than sufficient to keep you up to speed with what's going on. This happens to show the appendix for the entire manual, shows what CMS has responsibility to address and regulate. We're talking mainly appendix A today, because criticals don't have so much in that respect. Surprisingly, I really am surprised they don't. But criticals, you are appendix W, by the way. And another one you want to keep an eye on is appendix Q. That's immediate jeopardy. And again, when they have a complaint that is really concerning to them, or they feel it's an immediate jeopardy to health well-being of patients, they will be out within three days. And so you want to follow that, because that's a pretty rigid manual. And that's when they will really start to take action quickly. So for you, for appendix A, your last manual came out in April of this year. You'll see that blue lettering, transmittals. When you are on site, you will click that to get to the actual transmittal page. And yes, appendix W, you have the same resource. Unfortunately, your manual hasn't come out since 2020. And I've reached out to CMS to say, hey, when are we going to be getting a new one? Because there's been changes and responsibilities that aren't in here. And some folks are missing out on some critical information. So that's what it would look like when you hit that transmittal link. It will tell you the date it came out, what it applied to. Again, it will show you what's revised, what's new, and what's been deleted. Anytime a new manual comes out, this is the first place I go to. So I know what are they addressing. Memos, that's how that page would look like. I have the link here. It's on slide number 14 for those of you who are listening only. It will tell you what's the title, who does it apply to, and then the date it came out. This is what that would look like. Again, it will tell you the date it was issued and the subject. Now this happened to be only to acute hospitals, and that is QAPI, talked about that. And it finally, and I mean finally, came out with the interpretive guidelines and survey procedures for QAPI. When they did the new manual back in 2020 for acutes, they didn't have them in there. And so they had to pull this memo out. It took them a few years, took them three years to get it done, but they finally did. Criticals years are still pending. So that's how long it's been. I want to talk about deficiency reports. As I mentioned at the beginning, no one wants to get a notice of deficiencies. You can access it. You can go in and pull it up. Usually what happens is after CMS and the surveyors have been out, they come out and they upload all of their deficiencies from a particular visit onto this site. Now this thing is multiple pages long because it goes back to when they first started doing it back in around 2010. Now it doesn't have the plan of correction. You can ask for it. It has a name, the address, and then a brief description of what they found, but it would also include the tag number. So if you're trying to do some research, you're new to your role, and you want to find out where have we been facing before, or you want to do maybe some benchmarking, see what everybody else is facing, what you'll do is you'll go to this site and scroll to the bottom where it says downloads, and it's a huge Excel document. They do split it up now. It's now 2010 to 16, 2017 to current, and again, updated quarterly. So you'll see the name, address, tag number, and then a brief description of what they found. No names. They won't put any names in there, but they will put just some examples. So I pulled up some of them that I found to be unfortunately quite common. So first off, they didn't post the instructions telling the patient their rights to file agreements. They didn't post the state hotline number so that a patient or their representative can call up and voice this grievance. They didn't get the contact telephone number at your hospital to file agreements. Yes, you have to give the name and telephone for the contact at your facility so that a patient knows who to go to. They didn't make sure grievances were even documented. It was in the occurrence reporting system and thoroughly investigated. Now, if you put those in your occurrence reporting, okay, but you have to thoroughly investigate those grievances. That is a requirement. They didn't make sure there was a process for prompt resolution and that it was effective. In other words, we looked into it. Thank you. That was pretty much what it was. They didn't make sure any inpatient complaints that had to have further investigation were even seen as grievances. They didn't make sure the grievance policy was followed or there was documentation of the process. Now, if you're not going to follow your policy, CMS is going to issue you a citation on that. Didn't investigate grievances in a timely manner. Yes, there is a certain amount of time that's recommended. It's not hard, fast, but it is recommended. They didn't give a written final resolution and notify the patient or notify the patient if it's going to take longer than seven days. We're going to touch on all of these issues as I go through them. Again, those are just some of the deficiencies that I found that were pretty repetitive, and especially not getting back to the patient, not following their own policy, and not notifying them, hey, this is how you file a grievance. I'm going to move right into the conditions of participation. If you take Medicare and Medicaid, you must follow these conditions for each and every patient. It doesn't matter if it's Medicare, Blue Cross Blue Shield, Cigna. It doesn't matter. Now, these are in patient rights section for Appendix A. There's only a few tag numbers, but it's, they're pretty involved. That's what we're going to be covering today. This has the minimum protection for the rights of a patient. For example, just giving a notification of what their rights are and that they can exercise them. Privacy, confidentiality, free from unnecessary restraints, occlusion, sometimes that's the basis of the complaint. Have advanced directives followed, who will visit them? Again, these are just some of the basic rights that we have to notify patients. Again, it applies to all hospitals that participate in Medicare and Medicaid. You know, that's except, of course, the VA and all parts of the hospital. Doesn't matter if it's ER, OB, if you have an inpatient behavioral health unit, still doesn't matter. And it applies to all type of hospitals, whether it's psychiatric, rehab, and critical access doesn't matter. And again, it also applies regardless of who your accrediting organization is. Those are the ones that have deemed status also with joint, with CMS. There was a time there with CMS was really closely following two of them because they were having some concerns with, are they really following up and meeting the expectations we have under our conditions of participation? On criticals, I mentioned there was no similar requirement in your conditions of participation. In other words, we don't have this really nice sections that give you what you have to do and the expectations and what they'll look at. But you should have something, some policy, procedure, education for your staff on what to do. And by the way, the restraint and seclusion section for Appendix W, even though it's an Appendix A for you under patient rights, it's in the swing bed section for Appendix W. Now, I want to point out something. If you are a critical access hospital, you're listening to this program. If you have a distinct rehabilitation or behavioral health unit, you are surveyed under Appendix A. So, what I'm talking about today will apply to you. And that's those distinct units because some of you do have those. They won't, excuse me, they won't use W, they use Appendix A. Lindsay mentioned we have a few polling questions. This gives me just some information also as far as future topics that I can talk on. But I'm going to have her put this one up first. Lindsay. Hey, absolutely. Let me see. I don't know if I put the actual question in here or just that last part. So, I may have to read that first part to you, but let's see here. I did put the whole thing. Perfect. Okay. So, this first question says, Hospital A is a 200-bed facility in a multicultural area. To save paper, used patient rights are posted at the main entrance and in English only. Will Hospital A be subject to a citation failure to provide adequate notice of patient rights? Your options here, yes, no, or not sure. Give you just a second to put in your response there. For those of you who joined us maybe a few minutes late, as we go through the webinar, there'll be several of these polling questions that you'll have the opportunity to answer. But we'll also pause to address any questions that you have for Laura up to that point. So, please go ahead and type in your questions into the Q&A option found there at the bottom of your Zoom window. Or if you don't see that, you can, of course, type in your questions there in the chat. We'll make sure that we bring those questions up for Laura as we go throughout the webinar as well. Okay. We've gotten a pretty consistent response here, Laura. Great, great, okay. In that one and share those results. Okay, very good. And you're not graded on these, by the way. Right. Lindsay doesn't keep track. No, not at all. Your answers are always anonymous. And it's a good way to, if nothing else, start a conversation within your hospital or your team if that's what you, if you're part of the agreements committee. Yes, I'm talking about that. All right. First, notice of rights. We have to tell each patient of what those rights are in advance of doing anything for them. And that's also included discontinuing care when possible. And that's outpatients too. Of course, we know in writing is best because the idea is we want to inform them so we can protect them. And we have to have policy and procedures to make sure patients do have that information. This is how we're going to do it. Grievance requirements should also appear in the written copy of the patient report. So here's an example. This is that registration patient's going to be admitted, say, for a knee. Well, they initial four sections that are required to show, yes, indeed, this information was given. And here are the four sections. One, who do they contact at the hospital? Number two, they can also contact what's called a quality improvement organization or the state agencies if they have any concerns or complaints. And of course, we know the state agency is those folks who come out and do the surveys. Third one, you have a right to have people visit you. And you have a right to determine who those visitors will be. And then patient has a right to discharge planning. The admitting nurse would cover that information with the patient and then document it. So one gives it and one usually covers it. It doesn't have to be that way. However, it works best within your facility. Here's a couple other suggestions. One, put it on the back of their general admission for consent for admission. And an acknowledgment or their privacy practices. So you can do it a couple of ways. Include a sentence in there. I have received these rights and I've had an opportunity to ask questions and then have them initial it. If they refuse to initial that, your staff can document a patient refused to initial and then they can initial it. Include the information of visitation and that they were also given to their representative. Patients don't always have to have a representative. But sometimes it's nice to ask, do you have anyone who's with you? You want to serve as your representative while you're here? Because they can ask questions, remember things to ask when it's time, be there, be prepared for discharge planning, et cetera. So if they have someone, document that you've given them a copy of those rights also. So as far as the notice to the patient representative, take reasonable steps to determine who that is. It can be, of course, a minor. It's most likely going to be the parent, grandparent, their legal guardian. Maybe durable power of attorney when you have an incapacitated patient or incompetent patient or what they call a patient advocate. That's how joint commission refers to is a patient advocate. It can be a care partner, whoever that happens to be. If the patient is not incapacitated and still has that representative, we give it to both of them. We give it to the patient and we give it to the representative. And the patient can tell you orally or in writing. I recommend that you do get it in writing. Because if a couple more people show up and come, no, no, I'm not representative. You have it in writing on who that is. And that's the person you would want to reach out to. Incapacitated patients and incapacitated and incompetent where they've been declared incompetent. If someone comes in, they have an advanced directive. You have your incapacitated patient. We give that information to them. If they're incapacitated and you don't have the luxury of those advanced directives, you give it to whoever comes in and says, I am that person. I am the representative. And we can't discriminate between same-sex spouses, domestic partner. We can't do that. Whoever comes in and says, I am the representative. Now, if you get two people claiming the same thing and you don't have anything in writing and the patient's incapacitated, then, yes, you can ask for supporting documentation to show that. What that would be, that could vary. And sometimes, I'll be honest, it may not exist. So if you have something or the person has something to show, I've been taking care of them. I've been living with them. I've been paying their bills. I'm always around. Something that shows that, yes, indeed, they are the one to take precedent, great. But if they have a living will, a copy of the will that shows they're the representative or the executor of the estate, something like that, that helps you. So, again, just don't be surprised if they don't have anything to support it. Then if they start to argue between themselves, then you might need to bring in risk management. If you're risk management, you may need to bring in higher powers or even the ethics committee to say, okay, who is this person going to be? I mentioned spouse does include same-sex. There are two CMS memos that recognize the rights of such an individual. And they have equal rights as opposite-sex marriages. We must honor it no matter where the couple resides. And the Supreme Court ruling says every state still has to recognize it, even though that may not be legal in your state. You do also want to follow any other specific state laws. They can have a procedure to determine who is the representative when they're incapacitated. Have your policies addressed it so that they don't have to wake up at 2 in the morning if you're that person who they would reach out to. Train them on what the laws, the policy, and procedures are. If you do, if there is a reason to refuse to recognize that person as the representative as the representative, there has to be a documented rationale for that refusal. Maybe they've got experience in the past with that person. Or maybe there is a concern that they're not really related to them, say, in the issue of human trafficking. Or say it's in the issue of a parent who has taken the child when they don't have custodial rights to do so. Or even elder, you have a concern with elder. And you really have those concerns. They have to be a nondiscriminatory reason and rationale for doing so. Quickly on Medicare beneficiaries, it's called the I am notice. And that just stands for important notice. That's all it means, important message from Medicare. Now, you have to give this information. And I have an example of what it is in the appendix for you, by the way. And that important message talks about, you know, these are what your responsibilities are under Medicare. Now you're not required for those who aren't admitted, like observation patients, because they're not admitted. It's a standardized form, by the way, you cannot alter that form, you just fill it out. And you have to give a copy of the signed important message before discharge. And that means not more than two calendar days before they're expected to go home. The sooner you can give it, the better. And it just pretty much says, hey, these are your rights under Medicare. If you're observation, you're not admitted, just be aware of that as far as when Medicare would kick in. So now the agreements process. Again, CMS calls them agreements, Joint Commission calls them complaints. You have to have a process for prompt resolution of agreements. You have to inform the patient, this is who you contact at our hospital. Who that is, is up to you. If you want it to be the consumer advocate, the risk manager, whoever it is, your choice. But you give them the phone number and contact name. Patients have a right and they should, should have a reasonable expectation of safe care and service. And if they have a concern about it, they should be able to have those addressed in a timely, reasonable and consistent manner. CMS does give us a definition. I would include it in your policy. They also, it's the same thing used by what's called DNV healthcare. We do touch on DNV while we're here, but they really quite follow word for word for what CMS says. Joint Commission doesn't have a definition in their glossary for some reason, they don't have it. I would use CMSs. If you have deemed status or if you're accredited simply through also with Joint Commission, you might want to combine your policy and procedures. It's in the right section. Now the difference here is instead of a representative, Joint Commission uses the phrase family. So the patient and family have a right to have these grievances reviewed. And there is in there also on the right section, a way to handle those grievances. For CMS, here's the definition. It's a formal or informal, verbal or written complaint. And it shows you about here. That's usually what it is about. It could be anything from my food is cold to I'm not getting my pain meds, they're ignoring me, I fell and no one came, those type. It's a huge gamut of what a complaint could be. Now, when you have a verbal complaint and it's about care that is not resolved at the time by staff present, that's a complaint. It could be by the patient or the representative. I mentioned it involves the gamut of care. It could be also abuse or neglect. Anything that touches on your compliance with CMS conditions that could be failure to do discharge planning or discharge evaluation. Could also be a Medicare billing complaint, but it relates to the rights and limitations in that section. I don't go into billing issues. So just be aware that is one of the items that the quality improvement organizer, something that, okay, that they could have taken care of. The staff present could have resolved. Like my linens are filthy. Could we get them changed? Yes. Maybe it's, again, the food is cold. Can you warm it up for me? In those cases, excuse me, where it could be done timely, like right then and there, it doesn't require a written response. It only rises to the level of agreements when it cannot be resolved at the time by the staff that are present. Or maybe it means more action, like an investigation. If that's the case, door number two then, you have to have all of the requirements for agreements met. And again, it can be the patient or their representative who makes this grievance. If it's not the patient and maybe they've gone home and the representative calls back and says, I got a bone to pick with you, contact the patient. Make sure, yes, indeed, they are authorized to act as the representative. Now, if not, it's still maybe considered a complaint under joint commission. So let's say you get ahold of the patient and they're good with it. They're satisfied with what happened and they have no issue. But the representative is not happy. Under CMS, it is not considered a grievance. Even if that person is an authorized representative, do the same steps in the previous slide. Talk to the patient and get their, talk to them, make sure it's okay to talk to them because you may have to disclose protected health information. And also document, yes, you can talk to them. The patient said, yeah, go ahead and talk to them. But again, if the patient is fine with everything that happened and says, I don't want anything done, I'll talk to that person. You don't have to do it. Your processes can say, no matter what, we're gonna do it, that's fine. You can't, because you may pick up on something. But if the patient says, I'm happy, don't do anything, don't talk to her, don't listen to them, you don't do it. Just document it. Don't do it, just document it and put it in there, what happened. I would also put it in your risk management file so that it's clear that you did do what you were supposed to do. Billing. And we had talked about this just a little bit ago. Generally, they're not a grievance unless it relates to the quality of care. So for example, I was in, I had this really bad infection. I kept complaining, please change my dressing, it stinks, et cetera. Nobody did it and then I got billed for it. That would be a quality of care issue. So yes, you would wanna treat it. Otherwise, a written complaint is considered a grievance. Doesn't matter if it's inpatient or outpatient care. If they email you or fax it over, it's still considered a written grievance. If it's in a patient satisfaction questionnaire or survey, generally not, unless the patient in there has said, I had this problem and I want somebody to look into it, then yeah, you do have to consider that a grievance. Otherwise, if you wanna treat patient satisfaction, complaints or issues as a grievance, fine. CMS isn't gonna argue with it. It's up to you if you want to do that. It's just, again, in those surveys, you're not required unless they ask for a resolution. What if they telephone it in? It's still a grievance. Anything on abuse, neglect, where there's been patient harm, always consider that a grievance because you need to take care of it. Now, there is a very minor exception and it's in tag 118. And I would look at it very narrow. So you've had, the patient's gone home, you're doing some follow-up. And let's say it happens to be a nurse who's called the patient to see how they're doing follow-up and they get this verbal communication. That normally, that's a complaint that would have been routinely handled by the staff. It's then again, not a complaint. But be very careful in that interpretation because it's an extremely narrow exception. So again, you're on the phone, you're just doing follow-up care, say anything else. And they say, yeah, my room temperature was freezing cold. Well, we could have taken care of that at that time. But if it involves abuse, neglect or harm, it is a grievance. That is a very narrow exception to you. The patient wants you to treat as a grievance, it's always a grievance, unless they say it is not a grievance. Then follow what they wish and document it. And we know the patient doesn't have to use that magic word grievance. They say, you know, I got a beef to run past you. I have an issue with the care I received. That's how you can term it. Again, if it is resolved at that time, it is not a grievance. You may want to do some work with your staff. You know, keep up that good customer service and PR. Get the staff to deal with it timely, give them that authority to handle things. And you're less likely to have anything like a grievance if the patients have a good positive experience afterwards. You know, they could say, you know, I haven't heard from my doctor in a few days and I've been waiting to see him and get some questions answered. Hopefully they are coming around. And the nurse can go, hey, let me get on that right away. And then the physician shows up or contacts them. It's not a grievance, but you have to give the staff the authority to do so. Otherwise monitor your patient satisfaction surveys. You may find some things in there that, oh, I didn't like that. Or all of a sudden you've realized they've contacted CMS directly. Maybe they've gone to the Department of Health or their QIO. And we'll give you some insight into what are the trends out there with your people. What will the surveyor do? Well, first they wanna see your policy. They wanna make sure it does have in there, we encourage all staff to alert your supervisor, whoever it happens to be, when a patient or a family member representative issues or talks to you or gives you a written complaint. You can do it by education during orientation and annual skills lab. You can put it out memos, put it up in their lunchroom if you want, just so they're aware that you take these issues seriously. And also the surveyor is gonna verify how you make sure grievances that do involve issues of immediate danger to the patient are done really quickly. Those go to the top of the pile and those are resolved timely. They will also interview patients, by the way. Do they know how to file agreements? Do you know that you can also notify the state agency? I understand patients may not remember that when they're being admitted, but the surveyors usually are pretty good about, so do you get a notice or anything is signed about what you can do if you have a problem here? They also wanna find out how do you handle phone, how do you give out phone numbers? And who do you give the numbers? What numbers are you giving is what I'm trying to say. Do you give them the QIO? Are you providing the department health so that they know who to contact, wherever that happens to be? There is a suggestion. You don't have to do this by CMS. You might wanna think about doing audits of records and taking a course through QAPI, your Quality Assurance Performance Improvement. Make sure you're doing what your grievance policy and procedure says. You wanna get in trouble with CMS, that's one way to start, not following your policy and procedures. Another thing you have to have is how are you gonna resolve this issue? So of course, a process for prompt resolution. Tell the patient who they contact if they do wanna file it, that is the name, their telephone number. Yes, we do have to do that. And include the patient representative when you're doing that so that they're also familiar with it. What if they come in by phone? Does your operator know where to send those calls? Do they go to risk management or is there someone else they go to? Is there an electronic form that your staff can fill out and then hit send and it automatically goes to where it needs to be? And these don't have to be elaborate forms. It's just something very simple and 100 words or less, tell me what was the patient's concern. Governing body, also known as a governing board. They have a lot of responsibility. They are responsible for everything that occurs in the hospital, all of the processes. So they have to approve and they're responsible for this grievance process. Now they can delegate that responsibility, but they have to do in writing and it must go to a committee. And that must include what's the process to address these complaints timely and then make sure that within this delegation, all that data goes into QAPI because we need to know if there's an opportunity for improvement. That's why the data on grievances is just one element of your QAPI program. They also have one thing, they can either themselves review and resolve grievances, this is the board, or they can delegate that in writing to the committee to do that. A lot of the boards in the larger hospitals will do that because just the size that may occur. Again, they're still though responsible for the operation of that process and to make sure that that process is reviewed and analyzed through QAPI, not just the complaints, but the process also. So the committee, it is more than one person, it must be. How you do that, who you include is up to you, but there has to be an adequate number of qualified members. These are the people who are going to review and resolve these issues. And CMS won't say what their function is, how many times they have to meet, that depends on how many you get. Maybe it's the size of your hospital, maybe you meet monthly, maybe you meet weekly, depending on what the size is. And again, as far as the composition, you get to determine that. You may want housekeeping, food service, may want medical records involved, nursing, medicine, ancillary services, wherever that is, it just can't be one person on this committee. And they have to know what their responsibilities are and how they're going to resolve them. So we're up to question number two, Lindsay. Okay, let's get that one up here on the screen for everybody. I do see several questions that have come in, Laura. So we'll address those in just a few seconds as well. Great. Okay, so this question says, our grievance committee, you can check all that apply here to your organization. Includes members from various departments, includes only C-suite members and legal, includes risk management only, responds to complaints in a timely manner, needs work or not sure that we have one. Give you just a couple of seconds here and while you're doing that, let's see. This first question asks, Laura, I know intake forms are recommended. Do intake forms need to be stored or kept for seven years like other medical documents? Yes, you keep it for the same amount of time you would a medical record because that's part of the record. Okay. And then here, are all complaints that are telephoned in required to follow the grievance process regardless of the subject? No, it depends on, again, if during the phone call, it's something that the staff who were there at the time could have taken care of, that's that narrow exception to a grievance. So that does not have to. Now your policy can say, if patient complains, we wanna know about it, we're gonna deal with it. Okay. But that is the one very narrow exception. If it could have been handled at the time it was made by the staff who were present, it is not a grievance under CMS. I would just, again, make a quick note on however you're doing that when it's telephoned in that this is what it was. We could have taken care of that at the time and the patient understands, you're done. Then you don't have to. Those are, again, please be careful because those could be narrowly construed by CMS. Just make sure that the person taking that call is very comfortable in that, yeah, we could have done that. Like the food's cold, the room's cold. Can I get a blanket? Something like that. Perfect. Do critical access hospitals need a grievance committee? Again, this is one where critical access hospitals for some reason, they didn't include this requirement in there. But if you are, you know, getting complaints, grievances, however you wanna call them, you might wanna think about developing something because your governing body or person still is responsible. And if there are issues going on that involve safe care or quality of care, they need to be addressed. Usually you're going to put that through your QAPI, but they have not made this requirement spelled out in for critical access hospital. I can't stress enough that it's probably a really good idea to have some type of process to deal with it. Those folks aren't usually there that long, you know, on the majority of time, the length of stay limitations, but you could still get some complaints from the patients. Mm-hmm. Okay, and then a couple of, a little bit more specific situations here. And I know you mentioned earlier that you're gonna cover DNV, but it does follow CMS guidelines here. So this question says, we are using DNV for our accreditation and we had our survey this week. I was told that the standards of DNV have been approved by CMS. However, the surveyor stated that the timeframe is seven to 10 days, calendar and holidays and weekends count. And it says, we adhere to the seven business days. And this is also stated in, we were in compliance and always have been. However, I have been doing this for 13 years and this is the first time I've ever heard of anything other than seven days. I was a little shocked by the 10 day standard that was quoted to me by DNV. What are your thoughts on that? You're absolutely correct. And I talk about that when I hit the DNV standards. DNV, yeah, they do give you a little bit more leeway. And CMS doesn't have the seven day hard fast rules. What they're saying is most complaints should be or could be resolved within seven days. So I'll talk about that if you don't mind. I'd like to talk about that so everyone has the benefit of hearing it and seeing the regulation. Great. Perfect. And then the last one here before in this polling question says, kind of a hypothetical situation. If an adolescent in a behavioral health unit gets discharged, and the family member calls two days later with a complaint, but you cannot verify if they're family or not, you get little demographic information from the receiving facility, what would the best action be here? Yeah. That one, it's up to you how you wanna handle it. Because first off, again, you have to get the consent of the patient to talk to this person unless, you know, like a minor, you mentioned a teenager, an adolescent. Adolescents can still be considered adults at a certain age, given their circumstances. But I'd be, I'd just reach out and say, this person called in to complain or talk to us. They had an issue. May we talk to them? You don't have to, unless you could find out who is calling this in. Because if you can't act on it like an anonymous complaint, CMS says you don't have to address those as a complaint. You don't have to go through the processes. It's up to you if you wanna do that. And you could just investigate it. And, you know, you're not required then to get back to the patient. But unless that individual who's making that complaint gets you more information or, you know, I need to talk, know who you are, what, et cetera, and they won't do it. I said, well, there's not much I can do. But you may wanna look at it internally. Okay, great. And I just shared those results there. It looks like we have a close tie between the first and what, the fourth option there? Yeah, and I like that you're getting various departments involved because it's not always just one department. There are many people who are always involved in it. All right, continue with our survey. The surveyor will look to determine has the board approved the process? In other words, they're gonna go through the board minutes. Is it signed off on the process by someone who was on the board? Or have they delegated that responsibility? And it must be, again, in writing to the committee. They will determine how effective it works. In other words, are things getting done timely? That was probably one of the major deficiencies I noticed, that these things weren't addressed timely. Patients weren't informed of the results. That was another one. There was no letter or communication back to the patient. And there was a question of whether or not it had been reviewed and analyzed, the process itself through QAPI. So on the timely referral, you have to have a way so that we can get these patients' concerns on quality of care to the appropriate QIO, Quality Improvement Organization. That can also include, by the way, premature discharge. Every state has one, whether it's Kepro or Viltana, and they have to review the appropriateness and quality of care given to Medicare beneficiaries in a hospital setting. I, again, have in the appendix where your state would fall, and I'm sorry, I don't recall right off the handle where Georgia would fall, but they're called Beneficiary and Family Centered Care, and they manage all complaints and quality of care reviews. And the reason they do that is that it helps ensure consistency in the process, but it also takes into account local factors that might be beneficial. Are you in a large metropolitan area where a lot of resources could be available? Are you in a smaller area where you might not have the benefit of some of those resources that a patient can utilize? So that's why they have split them up by states to find out, okay, what's going on here? Is it Denver? Is it Atlanta? Where is this patient being taken care of? They always will make you aware if they get a complaint, and that can be a couple things, whether it's quality of care, premature discharge, whatever it happens to be. A patient can have you, they can ask you to forward the complaint to the QIO. So don't be surprised if they do that. If you do, you have to send it on. You don't have to, again, unless the patient specifically requests it. So you may want to add that in your notice of rights. We'll be happy to forward this on to the QIO if you so request it, but we must have your request. It doesn't have to be in writing. It can be verbal. That's an example of what it happens to be. Lieutenant, it looks like you folks would be in Kepro also. And I like it because they include the regions and the telephone numbers where they can, or you can, send the information. Next thing we have to do is have a clear procedure, clearly explained procedure, so a patient knows how to do this. The surveyor will look at how that, how does that spell out? Does it tell the patient how to submit a verbal or written grievance? They will talk to patients. Did you get this information at any time on how you do it? By the way, don't forget limited English proficiency patients. You have to make that accommodation for them. Timeframes. The grievance process has to spell that out, or review the grievance and giving that response. That means you have to get the grievance, you have to review it, investigate it, and then come up with a resolution. And those that endanger their patient, that, again, goes to the top of the list. They get immediate review. Document also, if it is so complicated that it may take extensive investigation. You know, it could be a patient has many people on their list, or the naughty list, so to speak, and you've got to get a hold of them. Maybe some are on vacation, whatever it happens to be. Or maybe it does involve more investigation that you have to do. The seven-day rule. So let's talk about that. The interpretive guidelines offer it as being acceptable. But there may be times when it takes longer. Again, it may take more than seven days. They don't say in the interpretive guidelines for CMS, that working days, business days, or calendar days. They don't say that. But they do say most complaints are usually not so complicated and don't require extensive investigation. I could take 10 days, but tell the patient, I'm working on it. We're going to get back with you. Bear with us because so-and-so is out of town, so-and-so is ill, whatever it is. We are working on it and we'll get you that written response. The surveyor wants to see those timeframes you have established in your policy and procedure. And are they clearly explained to the patient? And again, if they're in the policy, are you adhering to them? So when we get to DNV, I'll go through that difference. But CMS says, yes, seven days looks pretty good to us. But they don't delineate business days to calendar days. Your procedure, again, and you have to give them a written notice of your decision. And that means you include the contact person, what you did to investigate, what was the result of that investigation, and when you closed it out. So you may not come to a resolution that meets what the patient maybe stated, this is what I want. I want that person hired. But you say, this is what we found. I'm going to urge you here to work with counsel on that response, if that's practicable. Your professional carrier also may have individuals who have done this or are familiar with it, and can help you with some of the wording. Maybe not, but some of the carriers do provide that service. Because you don't want to provide anything in there that could be used against you and if there is ever litigation. For example, yeah, we know about the doctor's bad acts in the past, and we're trying to work with them and get it done. So we put them on probation. That's not something you want to include in there. And if it ever goes to lawsuit, your attorney will probably grow two heads because of it. So you can just say we've investigated it. We have established some education processes in order to make staff more aware of what their responsibilities are, something like that. And so as of this date, we're considering the matter resolved and closing the file. You're done. Contact person. I've had a couple emails that came through and asking about, you know, with the issue of patients who kind of have a temper or are satisfied and may feel retaliatory, that giving the name and telephone number really puts that person at risk. So I did send it off to CMS and asked, you know, hey, is there some other way they can do it? Maybe their designation? But no. You know, you does require the contact person and their information for direct communication. I was a little disappointed in that response, but unfortunately, that's how CMS did say we did have to give the name and contact information for that individual. The written notice communicated, again, in a language and a way they understand. So don't forget low health literacy or get it translated into their native language. You may need additional tools to resolve. Meet with the family. That's perfectly acceptable. Again, as long as you're comfortable with it and whoever's going to be there. But you do have to respond to each and every substance of that grievance. If they have three or four things that upset them or they weren't happy about, you have to respond to each and every one of them. On your procedure, again, if they email it, you can email it back as long as your policy permits it. I've noticed some hospitals do have those firewalls that protect them. So if your policy says, yeah, we'll respond, we'll do it. And it's considered resolved when one of two things, patient's happy with it, or you've taken reasonable steps to resolve it. And I'll get to that here in the next slide. So that's why you have to have that policy on grievances. Specify in the timeframe to review and respond to that grievance. So resolution, if you have taken appropriate and reasonable action, it's considered resolved. But if the patient and or representative, yeah, that's not good enough. Keep documentation of what you've done. So you can show, yes, indeed, I have met all my requirements. And you can still close the file. Says, well, I don't like that answer. I want that person fired. We understand you're still not happy. However, we've taken every step reasonable to resolve this issue. We feel it's resolved, and therefore we're closing it out. Now, you're not required to include, as I mentioned, anything that could result a legal action in a written response. But just give enough information that you've done what you can to address that complaint and resolve it. Surveyors will look at your written notices to make sure that they comply with the questions. Now, one thing I never was clear on is, if surveyors ever want to see those letters, sometimes they will want to look at them to see, did you indeed review it? And that's what I noticed in reviewing some of the deficiencies. A review of the medical records and the letters sent to the patient noted their grievance was not addressed. So don't be surprised if they want to see those letters you sent out. Okay, critical access hospital. Again, and this is in the swing bed section where we talk about patient rights, freedom from abuse, neglect, exploitation. So you have to have a way. And that's in response to these three issues. You have to have a way to respond and investigate each one of those allegations. And you must report to the administrator, excuse me, or other like state agency. And you have five working days to do that abuse, neglect, exploitation. If there is harm to a patient, you have like 24 hours, I think, to notify the administrator. So you got to jump on that one quick if there is injuries. But if the patient, their family representative, whoever it happens to be, does file a grievance, you have five working days in that situation. And that's in the swing bed section for critical access hospital. Okay, joint commission. Let's talk about those folks for a while. If you have deemed status, that's great. That means you normally would not have to undergo a survey. Not that CMS wouldn't, but normally would not have to. The complaint standards in the right section. And again, I mentioned it's the patient and family have that right as opposed to the designated representative as put out in CMS. Joint commission does call them complaints or write straightforward and said, this is what it is. CMS calls them grievance. So in the right section, the patient or family have a right to have that complaint reviewed. So what you have to do is again, establish a resolution process and tell the patient, their family about it. This is also in the medical staff section and in the leadership where they spell out the governing body has this responsibility to make sure there's an effective operation of that process. Unless of course they delegate it in writing to a committee. The review and resolution, they're considered done when in, when possible, when you review them, that you've gotten it here, they say acknowledge the receipt of the complaint. Also tell them if you can't take care of it right away. Notify the patient once you've got your followup done. Once you're finished with it. You also have to give the patient, the person they file with the state. Again, same as CMS, who do you file this complaint with? And the notice of the decision, very similar. You give them a written notice of your decision, name of the contact person, what you did to resolve it, investigate it. This is the result of that process. And when we're closing it out, again, same as CMS, nothing different. Here on the timeframe, this is joint commission. You determine the timeframe for grievance and review. This is under deemed status. So essentially you're going to consider strongly that seven day timeframe. The process includes referral of those concerned to the QIO, whether it's a complaint of care or premature discharge. And again, they can ask you to forward it to the QIO if possible. Here are my suggestions. Have a policy so you can hit all of those elements. I have examples in the appendix. Use a form so that if it is telephoned in, the staff know this is what you need to ask or what you need to take down. And again, might want to think about reaching out to a professional carrier. They may have help for you on doing that response. If they don't, maybe if you have in-house counsel that could help with that, it could be very beneficial. And I believe this will take me to my third question. Lindsay. Apologies. Laura, can you hear me? Yes, I'm sorry. I had to get a sip of water. You're good. Okay. Just wanted to make sure that I came off of mute all the way. Okay, perfect. All right. Let me get this one up on your screen. Perfect. You should all see this one now that says, hospital sees grievance coordinator maintains a separate file for all complaints and grievances that he receives. Although most grievances are resolved, there have been a few situations where a patient retains an attorney and files a lawsuit. What should the grievance coordinator do at this point? First, continue to work with the patient to resolve the issue or call the patient and offer that they drop the complaint. The hospital will offer a monetary settlement or possibly close the grievance file and work with assigned professional counsel going forward. It looks like we do have, I think, just one question here, Laura. It asks, do you have to have specific or do you have to be specific, excuse me, on the corrective actions? No. No, you don't. No. You can put them in generalities if possible, just so the person who made the complaint knows this is what you did. You know, we investigated this complaint and I'm trying to think of one that came across. Darn it, what was it? The patient wasn't happy about the outcome, I think is what it was. He had had surgery and was having repeated infections and felt that the staff didn't listen to him when he kept reporting it hurts, it hurts, it hurts. And so he had an extended stay because he had to go back to surgery. And so what they did in that response is that they put in there and said, we reviewed your file and realized that we will go back and talk to and educate our staff on the importance of listening to what a patient is reporting and then further education on identifying perhaps what needed to be done or notifying the physician. That's how it was that, you know, listen to the patient and notify the physician when that happens. And that was it. That's all they did. They cut it off and said, we've now done that. We think we've resolved this issue and, you know, we wish you the best in the future, blah, blah, blah, and close the file. So you don't have to go into specificity. It just, you know, we've looked at it, we investigated it. Here was our process in doing so. That's mainly what they're looking at. Talk to staff, talk to the physician, reviewed the records. And then you can say, you know, we've instituted one more process. You don't have to do that, but that's what they want to know. What did you do in the resolution? Perfect. Okay. I don't see any other pending questions on that issue, that complaint. Right. Okay. Okay. And there we go. Good. All right. So let's talk about patient not happy. And now they go get a lawsuit. Okay. Those who file a lawsuit, if they do that, note it in the file. And usually it happens when, no, patient says, I'm going to go get an attorney. Okay. Let me know when you have done that. And in the meantime, you can still work with them. You can, if your policy allows that. And your board said, yeah, keep doing it. See what happens. Because a patient may do that out of frustration, anger, whatever it is. Or if they, you all of a sudden get served with those wonderful papers that say, notice of lawsuit, something like that, then you're done. Then yes, they have filed the lawsuit. Note it in the file, the date you were served with the papers and close the file. You cannot continue. Once you get that service, you cannot continue to have unilateral discussions with the patients anymore. Notify your risk manager. If you're the risk manager, then of course you would follow your normal steps. You would probably notify your carrier, whoever it happens to be. The attorney who is assigned to defend the case will then have an opportunity to look at whatever information shared, discussed, communicated with, whatever it is, with that patient. Up until the time you got the, you sent notice that, hey, you filed a lawsuit. I'm done with you. We're finished, more or less. And say, we have received your papers. We're closing our grievance file and have referred it on to counsel. You're done. That's it. So again, if that happened, if they just say, well, I don't like this. I'm going to go talk to my attorney or I'm going to go get an attorney. Not that any of us have ever heard that, but if that's all they have said, you can ask them, do you have an attorney? Yes or no? Okay. Let me know what your decision is. Until then, I will continue to work on the grievance until I have further notice. That is okay. Now, if that does happen, the patient's, I'm going to get an attorney, tell your risk manager, they may have a different step and just follow what those steps are. But normally, yes, you can continue until you get notice a lawsuit is filed. Then you stop. Now we're up to DNV. It's also, it's through NIOSH on the grievances. It's in the patient rights section. And the wording, again, it's the exact same. They do split it out for critical access. So I got to hand it to DNV. They did take that extra step that CMS hadn't done it. The hospital has to have a formal grievance written procedure. Governing body has to approve it. And it provides the same thing. In that process, who do they contact? Who does the patient contact to file a complaint and the resolution and review? What is the process? Now here it says again, governing body shall review it unless it's delegated in writing to a committee. That process has to include that way you refer it to the quality of care, but it could also be if it's going to utilization review, peer review, quality management as appropriate. CMS did not separate out peer review and the others. Specifications on timeframe for review and response. And the resolution has to be in writing, has to go back. Same requirements, name of the person at your organization, the steps you did to investigate, the results of that process, and it should be data completion. I apologize for that typo there. Has the same definitions as CMS for agreements. Address it timely. And here's the difference. So for that requester that did ask, written notice for initial acknowledgement within seven to 10 calendar dates. And again, CMS says seven days. So steps you took to resolve, the results of that resolution, that could be we've adjusted our policy and procedure. So we talked to the staff, we've adjusted our policy and procedures and trained all those who need to know. And now we're done with that. We're closing the file. Same thing. If you can't get it done, tell the patient you continue to work on it. Likewise, if it's a minor request, you could have immediately taken care of, it doesn't have to be in writing. It does not. Same process to refer a Medicare patient to the quality improvement organization. If they request it, appeal a discharge or disagreement with the coverage decision. The surveyor, again, wants to see your policy and procedure. Also, is it encouraging the staff to report if it is agreements? Have you defined, by the way, to your staff, what is agreements? What would you consider agreements? And what would you do? Who would you report it to? Verify that information is given to the patient. Make sure you have that response in writing within your time frame. And you have that time frame explained to the patient. Because again, you may need to get additional input and folks are on vacation or they're at a conference, whatever it is, and you can't get to them. Same thing on abuse and neglect and mistreatment theft. You have to, again, review those no matter what. Then we give information to the patient on the state agency. Who do they contact? Also, you can complain to the hospital, the QIO, or they can ask you to forward it. Timeframes, again, clearly explained, and it must explain the hospital's grievance process. They spell out in telemedicine complaints. Let's see, I have to get one of those. CMS doesn't, other than in the telemedicine section where if you do get a complaint about the care given through a telemedicine provider, you do have to act on it, just don't say the process. Essentially, it's the same process. So for acutes and criticals, you have evidence of all complaints you have received about that physician or practitioner. They'd still follow CMS requirements. I wanna talk about Office of Civil Rights, and I know we've talked about this in the past, the Affordable Care Act, in particular, Section 1557 of that, because there may be complaints you get that might not necessarily address medical care, but other issues. It's still considered a grievance. So in the patient rights section, it pretty much follows what this Section 1557 says. They amended it in 2020 in the hospital permit rule. They also said the same thing with this, but they said, we're not going to add anything to the manual, thank you, CMS, that are already in this section. They can, if CMS comes around and finds a violation of one of those protected classes rights, a grievance, they can actually send that over to the Office of Civil Rights, because there is so much overlap, not only with care and a grievance on care for the protected class, but low health literacy and the limited English proficiencies. And non-discrimination, we know that prohibits the discrimination of those classes, race, color, national origin, age, sex, disability. And this previously, by the way, had said you had to have a coordinator to handle grievances if you had 15 or more employees. Okay, the 2020 rule repealed that. In other words, it's saying, I don't care if you have 15 or 500 employees, you have to have a specific procedure to address these complaints and especially discrimination. And now it is sufficient if there are appropriate and responsible procedures in place. So that's what they're looking for. If there is complaint on discrimination that used to be 15 or more, they wiped that out. Now you have to have a process no matter how many employees you have. They did say, we're not going to put it in there because it's duplicative. And also, we also know section 1557 has undergone some changes in the last couple of years. And especially in response to some of the cases, the lawsuits that have come out. So for discrimination and non-discrimination, sex discrimination, pregnancy related conditions, gender identity, sex stereotypes. So that is included in that non-discrimination law. However, there is an out, I should say, or an option that they will not require a hospital or a provider to do an abortion or sex change operation if it goes against their religious beliefs. So they do have that conscious objective. On language assistance, we still have to provide it, whether it's limited English proficiency if they only speak Spanish, auxiliary aids. Don't forget those that if you have, what about if you have a blind person, maybe you have to do braille. Qualified readers for that person. Maybe you have optical readers. Health and Human Services, they add a few more in there that go quite a bit extensive. Voice, text, video-based telecommunication, electronic and IT, computerized assisted transcription services. If any of you have a cell phone and you're texting and you use the microphone, those things have really come a long way and they're very efficient and they get the spelling right usually. So that's an example of what that computerized assisted transcription service is. And you have to train your staff on what these laws are and make sure that they know what your policy and procedures are. We've talked about this in the past. You have to put up taglines, something with those 15 languages that say, if you don't speak English, you get services at no charge. There are five, well, five states total, D.C., Colorado, Maryland, Rhode Island, Virginia. You have to have 17. There is a list for each state and I have that in the appendix. So you'll wanna go through there. I've got the information on how you find that list. This is through your census and they determine what's your top 15 and then break it down. You may just wanna go ahead and have someone to handle the grievances and be done with it. There are two other federal laws that talk about a grievance process, Title II, Title IX. OCR said that, again, it would not affect independent obligations that those of you who are covered under Section 5057, you still gotta comply with them, meaning you have a written policy and process to handle grievances and especially those that allege discrimination of those protected classes. Under OCR, a patient must file a grievance within 180 days of the last act of discrimination, that's six months. So if they're in your hospital, they go home two months later, they have that, they're still within their timeframe to file that grievance with OCR and then OCR will step in. Of course, we can't retaliate against them or anybody who participates in the investigation but here the grievance must be in writing. These are the ones going to OCR. They must be in writing. They have to document who is filing that complaint, can't be anonymous, they can't act on them and they have to state what is the problem and what do they want done to fix this. So to file a complaint, I put the email link in here if you're interested and wanna go see what it looks like. The coordinator must investigate that complaint and they also have to maintain files and records of the complaint and the investigation. Anyone who is involved in that care, they have to have an opportunity to give evidence, give their side of the story on what happened. After that, the coordinator issues a written decision, tell the patient in that decision that you can pursue further legal remedies if you so desire and again, they can file at any time as long as it's within that six month window of time. So if it's two years after the fact, OCR probably isn't gonna act on it. They do have a section how they file a complaint, however they send it in, that's up to them and they're instructed to, okay, who is this against? Who were they believed had this violation? It doesn't help when it's a very non, I went to this hospital in say Dallas, Texas and they didn't treat me very nicely. Well, we need a little bit more information on that. So that's why it's in there and what to file and why it's so important that we move forward with an investigation. So we're gonna end just a few minutes early. So we have just a couple of takeaways. Remember to give patients their information on their rights and how to file agreements at admission. Make sure there's enough information also to the representative if that's incapacitated or incompetent person. Now, granted they have a lot on their plate, especially if they've been taking care of this individual, but you've done your due diligence. Train the staff, what is a grievance? Who do you go to, to let them know about this grievance? What steps? And yes, it may be at the end of the day, like, oh yeah, they complained about that. Just let them know, please submit it, we need to look into this. Make sure staff can address those issues that they can take care of then and there. Right then and there, give them that empowerment to do so. Get your governing body know, keep them informed that these grievances, they may all want to know. We've had seven complaints about this issue. We've had two complaints. We had four last month, we've had two this month, and we're all concerned about it. Have a policy, you have to have that on grievances and who's responsible to respond and the method. If you have any doubt, put it in writing back to the patient. The coordinator, they keep files, records of these grievances. I would keep them for as long as you would keep your normal business records and qualified interpreters available. So if a patient calls in, they're trying to verbally give a complaint that you can get in touch with an interpreter very quickly so that it is not, again, a qualified interpreter. Which brings me to my last little discussion. I'll go ahead and read this then I'll have Lindsay put up the questions. We have a small facility farming community and of course they have trouble getting physicians, especially orthopedic surgeons. We have a physician who's been on staff for six years, but again, multiple complaints filed against them due to bad outcomes. These are lawsuits, that's what those were. He was under medical staff requirement to disclose his success and or failure rate with certain procedures, including femoral neck and hip fracture repairs. He had to tell the patient, this is what I've had good, what I've had bad. So we have a patient coming in through ER. She was in a bike accident, femoral head fracture, scheduled for an ORIF, open reduction internal fixation. Dr. Z's on call and meets with her in the ER and provides a brief introduction, explanation of the proposed surgery. Now, when he did this, of course, our patients got some good drugs on board. They've got Demerol IV for pain and was loggy during the explanation. Now with the nurse present, she was there and this conversation was going on. The nurse did state that the patient said, can you wait, my son will come in and you can tell him, I can't do this right now. Well, Dr. Z, of course, didn't agree with that. And no, we need to get this done quickly, but does leave the ER bay and goes up and schedule surgery, schedules an OR. The son does arrive 30 minutes later. Dr. Z talks to him briefly and said, this is what I want to do, but he doesn't disclose his success and failure rate. So the patient goes through surgery but ends up with a significant link discrepancy between the right and left leg. And that of course resulted in a quite an altered gait. One that was outside the normal parameters for such an outcome. Yes, there is always going to be some discrepancy when you replace a hip and especially when you have a femoral neck fracture because they really have to go in and change that. But this was outside those acceptable parameters. The patient and the son both filed agreements with the hospital regarding this surgery. So here's the questions. Well, first, the grievance goes to the committee. After 10 days, it's still crickets from the hospital. The patient and their son do file a complaint with the state QIO, it happens to be QPRO, and also with the state. The board recommends no further action be taken against Dr. Z because it's only one of two surgeons on staff. What would you recommend the hospital do? Do they have immediate contact? Yank the privileges? Continue wait for a lawsuit? Anything else you wanna do that? Usually it's a single choice, but if you have any other suggestions for this hospital, what would you wanna tell them? And I guess, Lindsay, you'll have them put that in the chat section? Yes, that'd be great. Right, okay. All right, so we covered quite a bit and I'll wait to see if anyone has any additional questions. Perfect, thank you, Laura. While y'all are still putting in your responses, here's this final discussion question. If you do have any final questions for Laura, please go ahead and be typing those into the Q&A option there at the bottom of your Zoom window, or of course, if you don't see that, you can type your questions into the chat as well. So one question says, for that 1557 annual notice to patients requirement, is it sufficient that patients receive the notice at their first visit after 11-24, and then again on a yearly basis, or is it required that all patients receive the notice by 11-24? You mean the notice for patient rights? I guess I need to have a little bit more explanation. Would you repeat that for me, Lindsay? Yeah, the 1557 annual notice? Oh, yeah, mm-hmm, yeah. That can be when they come in for care. That's usually when it's gonna apply. And now, if you're talking about a patient who comes in more often, it's whenever they come in. Usually you just have to do it at least annually, let them know, hey, this is out there, that this is what we have to do. If I'm reading the question or hearing the question correctly, and that may be one, if you want to email it to me, Lindsay, happy to respond back. Yep, it came in anonymously, but the requester did say thank you, so I think they probably got there, their response. But as Laura just mentioned, if anybody does have maybe a more specific question that you think is just very applicable to your organization, you can always reach out to us at education at gha.org, and I'm happy to get those questions over to Laura. And she is always wonderful about going above and beyond in her thorough and timely response. And we just so appreciate her for doing that. Thank you. So just additional comments here to the final discussion saying submit for peer review. Let's see. Add that the hospital will take action against the surgeon for his disregard of the rules and may contact patient and son, but also consult with the CMO to strongly request peer-to-peer review. And those are great suggestions. Those are fantastic suggestions. Definitely that peer-to-peer review. Now, again, he was under, they were close to putting him on a mentorship status to where, okay, you want to do this, you got to have somebody with you, which, you know, when you've been doing this for years, that kind of doesn't go over too well as some of you may know, but nonetheless, patient safety is our, that's it. That's the first thing we need to do, recognizing that I understand you don't like this, but now here we are again. And they did go ahead and take action against his privileges. They temporarily suspended his surgical privileges and did take him back through peer review again. They did contact the patient and the son. I believe it was a CMO that reached out to them and said, let's talk what's going on. Now we also have to remember, they were close to filing a lawsuit. And so the complaint was just, you know, hey, we're about, we've got an attorney, we've been talking to him, but they did reach out in time and they said, we are so sorry, this is what we want to do for you. Now the lawsuit was avoided and they were able to take additional steps to help the patient. Like they started to pay for, I guess they had an insert done, the shoes that the patient was wearing. They made sure the shoes were modified and they paid for having all of those done so her gait was even or acceptable range in that respect. Now the final outcome on here was that the physician finally did decide to retire and just went into a consultative basis only. He no longer did surgery. In fact, most of the hospitals that he had troubles getting privileges at anyway, but he just went to consultative and the hospital had to accept it and start looking for another surgeon to replace him. Yes, it is very small area. We understand they have problems, but that's what they ended up having to do because they knew this problem was out there and they didn't follow up close enough. I do want to show you just a few of the, excuse me, some of the resources that are down in here. That's the IM notice that we do have to provide. I have updated standards. This was from 2023 for CNV on critical access. Also the Office of Civil Rights, their website and other resources that are available. And that's the example of the policy and procedure. I don't endorse this one. It just seemed to cover everything in there. So if you want to use that one, it is there. That's the link and it's from the office. And then DOJ, they also talk about limited English proficiency, other websites on having a qualified interpreter and that HR can verify their status, by the way, if they do go, if you go through an outside company. So I guess that's it, Lindsay. We'll give a couple minutes back and thank you everyone for listening to the great questions. I always appreciate those. Thank you. And there's just a couple more that came in, Laura, as you were going over those kind of resources there. This question asks, when you mentioned family being able to file a complaint based on the joint commission standards, how do we do this while following HIPAA? That's the same thing you'd ask the patient. And you got to do it when the family's not there. So-and-so, your daughter reached out and asked, wants to file a complaint. Is that okay we communicate with her? If they say verbally, yeah, you just document it. Okay to talk to daughter. And that's where you go, following the HIPAA. It's the same thing as if, you know, like when they, I'm just thinking when they're in an outpatient office and they say, who can we communicate about your status? And they put down, you know, Joe Blow or whoever it happens to be, same thing. Okay, and then the final question I see here before I give some closing comments, is it a grievance if the Better Business Bureau or insurance resolution team reached out and tells the organization that the patient has filed a grievance with them? No, no, I would not. I do not see CMS seeing that as a grievance. You may want to investigate it. That's your call and your processes, but it's usually from the patient or the representative that files that complaint or grievance, however you want to call them. That's where it comes into because, you know, that's tough when you don't have that direct information. I would take that as almost an anonymous complaint, but you can handle it. You can still address it because we know when the insurance company does, it's going to be one. And especially if the state does it, yes. When they say, oh, by the way, we got this complaint about you. They will need to handle that. That would be my suggestion to you to handle that. What did, what happened? Perfect, okay. I don't see any other pending questions. I did just provide some final comments there for you all in the chat. Just as another reminder, you will receive an email tomorrow morning, but just note that it does come from educationnoreplyatzoom.us. And so because it's coming from that Zoom email account, it very well may get caught in your spam, quarantine, your junk folders. And so you may not see it in your inbox in the morning. And if you don't see it there, then I would first encourage you just to check those additional folders. And if it's still not there and you would just simply like to go back and access the recording of today's session, we do record these webinars as on demand, meaning that you can use that same Zoom link that you used to join us for today's live presentation to also go back and access the recording. And the recording will be available for 60 days from today's date. And we do have an additional security measure in place so that we're protecting Laura's intellectual property here. So when you click on that Zoom link, it will ask you to enter your information and that will prompt an email to come to us for approval. And we record those recording, we approve those recording access requests very quickly, typically within a few moments of receiving them. But we do ask that you just give us one business day to approve those requests. And then again, you'll have full access to the recording for 60 days from today's date. And then also included in that email tomorrow morning will be a link to the slides that Laura presented for you today. I did go ahead and provide that link there for you in the chat now as well, but that will be in the email tomorrow and then also a link to a survey. So if you're joining us, especially as a member of the Georgia Hospital Association, I do encourage you to pay special attention to that survey link. That is how you will obtain your continuing education credits for today's session. And if you're joining us as a member of a partner state hospital association, please reach out to your contact within your association to obtain any information regarding CEs that they may have for you. I see lots of comments here, Laura, just saying thank you. They always enjoy your webinars and the information that you present. And she is wonderful. We're so thankful for her. Thank you all for joining us today. And I hope you have a wonderful afternoon. You do see Laura's contact information here on the screen, because you can, again, always reach us at education at gha.org. And we're happy to work with Laura and get an answer back to you quickly. Thank you so much, Laura. I hope you all have a wonderful afternoon. Thank you, everyone. Thanks, Lindsay. Thank you, bye-bye. Bye-bye.

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