§483.10(j)(1) The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay.
§483.10(j)(2) The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have, in accordance with this paragraph.
§483.10(j)(3) The facility must make information on how to file a grievance or complaint available to the resident.
§483.10(j)(4) The facility must establish a grievance policy to ensure the prompt resolution of all grievances regarding the residents' rights contained in this paragraph. Upon request, the provider must give a copy of the grievance policy to the resident. The grievance policy must include:
(i) Notifying resident individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number; a reasonable expected time frame for completing the review of the grievance; the right to obtain a written decision regarding his or her grievance; and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system;
(ii) Identifying a Grievance Official who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances, for example, the identity of the resident for those grievances submitted anonymously, issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations;
(iii) As necessary, taking immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated;
(iv) Consistent with §483.12(c)(1), immediately reporting all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator of the provider; and as required by State law;
(v) Ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued;
(vi) Taking appropriate corrective action in accordance with State law if the alleged violation of the residents' rights is confirmed by the facility or if an outside entity having jurisdiction, such as the State Survey Agency, Quality Improvement Organization, or local law enforcement agency confirms a violation for any of these residents' rights within its area of responsibility; and
(vii) Maintaining evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision.
Based on review of facility policy and admission packet, observations, and resident and staff interviews, it was determined that the facility failed to notify residents of the grievance process on three of four nursing units (Gardenside, Countryside and Woodside nursing units).
A review of the facility "Grievance Policy Form and Log" policy dated 11/9/18, indicated that the procedure to file a grievance would be prominently displayed at the facility, and that the facility would make an effort to promptly resolve resident grievances.
During a group interview on 2/26/19, at 11:00 a.m. 10 of 10 residents (Resident R300, R301, R302, R303, R304, R305, R306, R307, R308 and R309) indicated they did not know who the grievance official was, where to find a grievance form, or the specific process for filing a grievance.
A review of the admission packet, given to each resident upon admission, did not include the correct information on how to file a grievance, including the name and contact information for the Grievance Officer, information on providing a written response to residents and information on how to file an anonymous grievance.
During observations on 2/28/19, from 2:30 p.m until 2:45 p.m, the information board at the main entrance of the facility did not include the name or contact information for the grievance official, a time frame for grievance resolutions, information on providing a written response to residents and instructions for how to file an anonymous grievance. Information for residents and families on the Gardenside, Countryside and Woodside nursing units did not include instructions for the grievance procedure, accessible grievance forms, or instructions for how to file an anonymous grievance.
During an interview on 2/28/19, at 2:45 p.m. the facility Nursing Home Administrator (NHA) was informed that the facility had failed notify residents of the facility grievance process.
28 Pa. Code 201.29(i) Resident rights.
| ||Plan of Correction - To be completed: 04/16/2019|
The administrator reviewed the facility grievance policy for accuracy and completion. The grievance policy addresses all components required by the federal regulation.
Since all residents and family members have the potential to be affected by the alleged aberrant practice of not effectively communicating the grievance policy. All signage was reviewed for consistency and updated more detailed instructions on how to file a grievance. Grievance forms will be updated to a bright color green for easy visibility. The admission agreement was updated to include the updated grievance information in relation to the most recent grievance policy.
All residents received an updated grievance procedure form for their room and residents will be re-educated about our grievance policy at the next resident council meeting. The updated grievance information will be sent to family members and staff via the facility newsletter.
The administrator / grievance official will audit the publicly displayed information daily 5 days each week for 4 weeks to ensure the information is appropriately displayed.