Nursing Investigation Results -

Pennsylvania Department of Health
Patient Care Inspection Results

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Inspection Results For:

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LIFECARE HOSPITALS OF PITTSBURGH SNF UNIT - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on an abbreviated complaint survey completed on February 21, 2019, it was determined that Lifecare Hospitals of Pittsburgh SNF Unit was not in compliance with the following Requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

 Plan of Correction:

483.10(j)(1)-(4) REQUIREMENT Grievances:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
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.
Based on review of facility policies and documents, observations and resident and staff interviews, it was determined that the facility failed to notify residents of the procedure for filing a grievance including the name and contact information of the grievance official, the time frame for responding to grievances and the procedure for anonymous grievances to be filed for residents on one of one nursing units (skilled nursing unit).

Findings include:

A review of the facility policy, "Resident Complaint Process" review date unknown, indicated that resident and family members would be able to make complaints to the facility and that the procedure for filing a grievance would be included in the admission packet.

A review of the admission packet did not include instructions for filing a grievance, the name and contact information of the grievance official, the time frame for responding to grievances and a procedure for anonymous grievances to be filed at the facility.

During observations on 2/21/19, from 2:00 p.m. to 2:30 p.m. of the resident rooms, hallways and the information located on a main bulletin board did not include instructions for filing a grievance, the name and contact information of the grievance official, the time frame for responding to grievances and the procedure for anonymous grievances to be filed at the facility.

During an interview on 2/21/19, at 2:40 p.m. the Nursing Home Administrator (NHA) and the Director of Nursing (DON) confirmed the above findings that the facility failed to notify residents of the grievance procedure.

28 Pa. code 201.18(e)(4) Management.

28 Pa. Code 201.29(i) Resident rights.

 Plan of Correction - To be completed: 03/29/2019

No residents were directly affected by the findings.

Policy for Resident Complaint Process was reviewed and revised. The policy was renamed "Resident Grievance and Complaint Process." The policy is updated to include, the name and title of the identified grievance official, timeframe for responding to grievances and the procedure for filing anonymous grievances.

Postings of this procedure will be located in the main bulletin board located at the main entrance to the Transitional Care Unit along with blank forms and box to file anonymous grievances.

The revised process will be included in all new admission packets and will verified for placement by the Nursing Home Administrator.

Education was provided by the Director of Nursing Services and the Nursing Home Administrator to nursing staff and the interdisciplinary team. Residents currently residing on the unit were re-educated on the process by the facility Activity Assistant.

Audits will be conducted a minimum of three times per week for two weeks for sign placement and blank grievance forms. Audits will then be conducted weekly thereafter.

Audits for new admissions receiving orientation to the process will be conducted three times per week for two weeks and then weekly thereafter.

Audits will be reviewed monthly to identify areas of opportunities for improvement. The results of audits will be reviewed at least quarterly at the facility Quality Assurance Process Improvement meeting. Any further actions needed as a result of tracking and trending will be taken to assure compliance.

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