§483.10(j) Grievances.
§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.
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Observations:
Based on a review of facility policy, facility grievances, and resident representative and staff interviews, it was determined that the facility failed to resolve a resident representative's grievance concerns related to care/treatment for one of 31 residents reviewed (Resident R1).
Findings include:
The "Concerns-Grievances" policy, dated 12/28/23, revealed "the facility will honor the resident's right to voice concerns and/or grievances without discrimination or reprisal. Such concerns and/or grievances will include, but not limited to, treatment which has been furnished as well as that which has not been furnished and instances of behavior of other residents. Other forms of grievances could include management of funds, lost items and/or violation of rights. This process will provide a method of documenting Concerns/Grievances and resolutions. These processes combined will promote customer satisfaction with the facility care and services and identify areas of improvement. Social Services will be responsible for coordinating orientation and in-service training to ensure all facility staff are knowledgeable of the facility's Concern process and that they understand their role in providing responsive customer service to residents and their families in concern resolutions. Social Services Director will coordinate the facility system for collecting concerns and tracking concerns for timely and appropriate response. Social Services will instruct facility staff to submit to the Social Service Director that all concerns received will be investigated within seventy-two hours (72 hours) following receipt of the concern. Within seven (7) days following the receipt of the concern, the facility will inform the complainant with the results of the investigation."
A review of facility grievances from the months of January through March 2024, revealed no grievances from Resident R1's family member.
During an interview with Resident R1's resident family member on 3/19/24, at 6:00 p.m. it was indicated that a letter of concern was written by Resident R1's family member in February 2024, and provided to Employee E1 regarding care and treatment concerns for Resident R1.
During an interview with Employee E1 on 3/20/24, at approximately 4:55 p.m. it was revealed that he/she did receive a letter of concern from Resident R1's family member in February 2024, but failed to provide it to any further facility staff to address the concerns.
An interview with the Director of Nursing on 3/20/24, at approximately 6:00 p.m. confirmed that he/she was unaware of Resident R1 family member's care and treatment concerns and further confirmed that the above noted letter of concern regarding the care and treatment concerns were not addressed timely as per the facility grievance policy as stated above.
28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(1)(3) Management
28 Pa. Code 201.29(a) Resident rights
| | Plan of Correction - To be completed: 04/17/2024
Plan of Correction 0585
No residents have been negatively effected by deficiency.
R 1's family member was contacted by phone on 3/20/2024 by DON to discuss concerns and address issues written in letter received by DON on 3/19/2024. Concern report was properly completed, with resolutions, and provided to Social service Director as Per facility policy.
1. Staff will be educated by social service or designee of facilities' concerns and grievances policy by 4/12/2024.
Staff will attend in-service and sign to attest to understanding policy and procedure to be followed by all staff.
2. Upon admission, Social Services/designee will inform residents of their right to voice concerns with respect to treatment received, as well as lack of treatment received, during their stay in the facility. The residents will be educated to process that Social Services Director has established.
a. Review of information provided to residents and or designee will be documented in each morning clinical meeting for 4 weeks. Audit of reviews and corrections as needed, will be documented by social service director, and provided to DON or Designee weekly with IDT for 4 weeks to ensure all new admissions have been educated to concern/grievance policy and process.
b. The Concern Form will be utilized for each Resident Council meeting when concerns are brought forth. Any concerns identified will be addressed per policy, as established by Social Service Director.
c. DON will audit weekly concerns and discern follow up performed properly with social services director, during weekly "RISK" meetings with IDT. Concerns will be addressed with plans to correct as presented. This will continue as part of standard procedure for weekly meeting.
d. NHA or designee will audit resident council meeting minutes x 4 to ensure processes is compliant.
3. Results reviewed Monthly (QAOI) review of concern/ grievance process will be discussed Continuing education will be determined, monthly, to ensure Compliance and evaluate need for further audit.
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