§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 facility document review, group interview, observations and staff interview, it was determined that the facility grievance policy does not include all required elements pertaining to identification and contact information of grievance official.
A review of facility policy "Grievance Policy" last reviewed 1/1/19, revealed that the contact information for the facility designated Grievance Official Name, Business address, Email address, and Business phone are blank.
During the resident group meeting on 2/26/19, at approximately 2:00 p.m. Residents R600, R601, R602, R603, R604, R605 and R606 expressed that they were unaware of whom the facility's grievance officer is.
During an interview 2/28/19, at 2:00 p.m. Director of Nursing confirmed that the facility policy did not identify a designated grievance officer, as required.
28 Pa. Code: 201.18(a)(b)(e)(1) Management
28 Pa. Code: 201.29(a) Resident rights
| ||Plan of Correction - To be completed: 04/22/2019|
The grievance officer's name and contact information (business address, email address and phone number) have been provided to the seven residents cited (R600, R601, R602, R603, R604, R605, R606). At the next three resident council meetings the grievance officer will be identified and the means of contacting the grievance officer reviewed. This includes business mailing address, email address and phone number. Additionally, the facility will post this information for other interested parties in areas throughout the building.
The Administrator or designee will check monthly for three months to ensure that the survey books are up to date and remain in place in all locations. The QAPI Committee will review the Resident Council Meeting minutes for three months to ensure compliance as well as monthly checking for three months the posting of the grievance officer notification. Any deficient practice will be immediately corrected. The need for additional monitoring will be determined by the committee. (see also F574)