§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 documents and staff interviews, it was determined that the facility failed to document the date the grievance was received, a summary statement of the resident's grievance, steps taken to investigate the grievance, a summary of findings/conclusions regarding the resident's grievance, whether the grievance was confirmed or not confirmed, corrective actions implemented, and the date of written decision issued for one of one resident's (Resident R1) allegation of neglect. (Resident R1)
Findings include:
A review of facility "Grievance/Complaints, Filing" policy dated 2/20/25. revealed upon receiving a resident grievance or complaint the facility Grievance Officer will submit a written report of the findings of the Administrator.
A review of a facility reported document dated 4/5/25, to the State Agency contained an allegation of neglect by Resident R1. The report contained evidence that Resident R1 made an allegation that facility staff allowed her to lay on the floor for an hour after a fall.
A review of facility Grievance Log for the month of April failed to provide documented evidence that the facility documented a summary of the resident's allegation, investigate the allegation, document a summary of findings/conclusions, if the allegation was substantiated or unsubstantiated, corrective actions implemented by the facility, and the date the decision was issued.
During an interview on 5/7/25, at 10:56 am the Administrator in Training Employee E2 confirmed that the facility's April 2025 Grievance Log failed to provide documented evidence that the facility implemented and completed the grievance process which inclued properly documenting the resident's allegation, investigate the allegation, complete a summary of findings, draw a conclusion of substantiated or unsubstantiated and provide a date when a decision was issued.
Pa Code:201.29 (a) Resident Rights
| | Plan of Correction - To be completed: 06/03/2025
IA: Grievance for R1 was completed during the period of time when the state surveyor was here on the complaint visit. Audit of grievance log will be completed for the past 30 days to ensure all grievances were addressed.
Education: The NHA, DON, and SW were educated on the grievance policy. Staff were educated on the grievance policy for assisting residents/families with concerns.
Audits: Grievances will be reviewed twice weekly times 2 weeks, weekly times 2 weeks and monthly times 1 month. Results of the audits will be reviewed through the QA/QI process.
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