§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 the facility policy, observations, Resident group meeting and staff interview, it was determined that the facility failed to provide residents access to grievance forms, failed to provide the right to file grievances anonymously, and failed to post the name of the Grievance Official for residents to file a grievance orally (meaning spoken) for 155 of 155 residents at the facility.
Findings include:
A review of the facility "grievance procedure" policy last reviewed on 1/23/24, with a previous review date of 7/19/23, indicated that all concerns can be written and placed in the concern form collection box and five locations identified or residents can seek out Administration team or staff member with concerns. Concerns presented to the Administrator is typically responded to within 72 hours. The posted procedure indicated the second previous Administrator as the grievance officer. Review of the facility "Resident Admission Packet" indicated that the facility follows the resident rights of being able to file a grievance.
During an observation on 3/19/24, from 9:00 a.m. through 10:00 a.m. throughout the facility there was no grievance forms found in the bins identified as the grievance forms in any of the identified areas on the grievance procedure.
During a group interview on 3/20/24, at 10:15 a.m., Residents R100, R101, R102, R103 and R104 indicated they did not know how to file a grievance and were never told they could, where the forms are or how to file an anonymous grievance.
During an interview on 3/20/24, at 12:40 p.m., the Nursing Home Administrator and Director of Nursing indicated that the facility currently has no grievance officer information posted and forms are not available to file a grievance.
28 Pa. Code: 201.18(e)(4) Management.
28 Pa. Code: 201.29(a)(j) Resident rights.
| | Plan of Correction - To be completed: 05/09/2024
On 03/20/24 Administrator ensured that grievance forms were available at designated locations. Postings include information on who is the Grievance Officer and how to file an anonymous complaint.
Social Services/designee will conduct interviews with all cognitive residents and resident representatives for those without cognition for any outstanding grievance(s).
Residents will be educated at the resident council on who is the grievance officer and how to file an anonymous grievance, the grievance process and who the grievance offer is. Staff will be educated at the resident council on who is the grievance officer and how to file an anonymous grievance, the grievance process and who the grievance offer is. Administrator will receive education from the Market President on the same.
Grievance officer posting and Grievance forms availability will be monitored by the Administrator 3x a week x 2 weeks; weekly x 2 weeks; then monthly thereafter with reporting through Quality Assurance and Process Improvement Committee for review and/or recommendation ongoing.
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