§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 policy 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 the nursing units, which consisted of three nursing units.
During a group interview conducted on January 16, 2019, at 10:00 AM with seven alert and oriented residents (Residents 96, 60, 33, 79, 41, 73 and 135) the residents relayed that grievance forms can be obtained from the nurses station kept in a folder. All seven residents in attendance stated they were not aware of postings in the facility, regarding the facility's grievance process, they were unaware of who the grievance official is, how to file a grievance anonymously, that they can obtain a written notice, or contact information to file a complaint outside of the facility.
Observations conducted on the days of survey of all three nursing units, from January 15, 2019, through January 18, 2019, revealed no evidence of postings that contained procedural information, including how to file anonymously, where to obtain grievance forms, 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.
There was no evidence provided by the facility of a facility established grievance policy/procedure which was confirmed by the Director of Nursing during interview on January 15, 2019, at 10 AM.
During an interview with the Nursing Home Administrator (NHA) on January 15, 2019, at 10:00 AM the NHA confirmed that the residents do not currently have means to anonymously file grievance forms and that postings throughout the facility, do not include all pertinent information regarding the facility's grievance process.
28 Pa. Code 201.18(e)(1) Management
Previously cited 12/27/18, 7/14/17
28 Pa. Code 201.29(a) Resident rights
Previously cited 12/27/18, 2/9/18, 7/14/17
28 Pa. Code 201.29(b)(i) Resident rights
| ||Plan of Correction - To be completed: 03/06/2019|
1.A resident group meeting is scheduled for 2.8.2019 and led by the grievance officer/designee to inform residents R96, R79, R73 and R135 about the grievance/concern process including who the grievance official is, how to file a grievance anonymously, that they can obtain written notice, or contact information to file a complaint outside of the facility and where the posters are located in the facility.
2.Current residents are invited to attend the resident group meeting led by the Grievance officer to discuss the concern/grievance process including who the grievance official is, how to file a grievance anonymously, that they can obtain written notice, or contact information to file a complaint outside of the facility by whom and when. New admissions will be educated on the grievance process during the admission process. "The Grievance process will be posted in the facility on each nursing unit and will be added to the monthly activity calendar for residents to review."
3.The interdisciplinary team will be educated by the Grievance officer/designee on the "Concern/grievance form process" and the "QAPI manual" by the date of compliance 3.6.2019.
4.The "resident Interview" tool from the QAPI manual will be utilized to randomly interview 10 residents/week x 4 weeks on call lights, interviews will be conducted by the NHA/designee. Trends will be reviewed with QA&A.