§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 observations, review of select facility policies and procedures, and resident and staff interviews, it was determined that the facility failed to make information available regarding the facility's grievance/complaint process and the residents' rights to file a grievance in prominent locations on all five nursing units (Blue Jay Way, Pheasant Ridge, Country Lane, Chestnut Trail, and Bison Boulevard; Residents 22, 30, 48, 83, and 150).
During a group interview conducted on April 17, 2019, at 10:30 AM with five alert and oriented residents (Residents 22, 30, 48, 83 and 150) revealed that the residents were not aware of a formal process to voice a grievance in writing, verbally, or anonymously. All five residents in attendance stated that there were no postings in the facility, comprised of five nursing units, regarding the facility's grievance process or how to file a grievance anonymously.
Observations of all five nursing units and the front lobby on April 16, 2019, at 9:46 AM and again on April 17, 2019, at 12:45 PM, revealed no evidence of postings of the procedural information, including how to file anonymously - with the contact information of the grievance official with whom a grievance can be filed; to include a business address (mailing and email) and a business phone number; the right to obtain a written decision regarding his or her grievance; and a reasonable expected time frame for completing the review of the grievance.
The policy entitled "Senior Living Grievance Process" last revised by the facility on November 13, 2018, indicated that grievance forms can be obtained by contacting the executive director or a department head. It further indicates that the forms are available at the nurse's station. Observations of the nursing stations on April 17, 2019, at 12:45 PM revealed that the grievance forms are behind the closed and locked doors of the nursing stations, and only available to a resident if they ask for the form. There was nothing contained in the policy about how a resident would file a grievance anonymously.
Interview with the Administrator and Director of Nursing on April 18, 2019, at 2:00 PM confirmed that the residents do not currently have the means to anonymously access grievance forms and that there are no postings throughout the facility regarding the facility's grievance process.
Previously cited 10/3/18
28 Pa. Code 201.18(e)(1) Management
Previously cited 10/3/18 and 5/4/18
28 Pa. Code 201.29(a)(b)(i) Resident rights
Previously cited 10/3/18
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All nursing units and the front lobby will have information on the grievance policy including how to file anonymously readily available. Information will also include contact information for the grievance official.
All nursing units and the front lobby will have the necessary forms for filing a grievance as well as the method by which to submit the information anonymously to a grievance official.
Staff will be educated on the process for residents/families to file a grievance including anonymously. During resident council the residents will be re-educated on the process for filing grievances, the location of grievance forms to complete as well as the grievance officer contact information. The education will include the policy entitled, "Senior Living Grievance Process."
Weekly audits times four and monthly times three will be completed by the Nursing Home Administrator or designee to ensure proper notification of grievance procedures are accessible on all nursing units and the front lobby. The results of the audits will be reviewed at the monthly QAPI meeting.