§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 and staff interviews, it was determined that the facility failed to provide acknowledgement of a complaint/grievance and actively work toward resolution of that complaint/grievance for two of 19 residents reviewed (Residents R9 and R11).
Findings include:
Review of the facility policy entitled, "Pavilion Complaint/Grievance Policy," dated 12/28/23, revealed that the Pavilion grievance official will oversee the Pavilion grievance process, receive and track grievances through their conclusion, will lead any necessary investigation by the facility, will maintain confidentiality of all information associated with grievances, will be responsible in issuing written grievance decision to the resident/resident representative and will coordinate with state and federal agencies as necessary in light of specific allegations. The grievance official of the Pavilion will also take immediate action to prevent potential violation of any resident right while the alleged violation is being investigated.
During an interview on 1/03/24, at 10:00 a.m. Resident R9 indicated he/she discussed concerns with administrative staff about being left on the toilet for long periods of time. Resident R9 further indicated administrative staff implied the concern would be addressed, however, no resolve of the grievance had occurred.
During an interview on 1/03/24, at 1:00 p.m. Resident R11 indicated he/she discussed several concerns with administrative staff such as a brace for his/her right knee, a dental appointment, cell phone usage by staff during care, and urine collection device not being emptied. Resident R11 indicated further that no resolve of the grievances had occurred.
On 1/04/24 at 8:40 a.m., the Nursing Home Administrator (NHA) provided two complaints/grievances from residents/resident representatives for review and there was no evidence that the concerns were investigated, tracked through to a conclusion, and that a written grievance decision was provided to the resident/resident representative.
During an interview on 1/05/24, at 10:15 a.m. the Director of Nursing confirmed that the facility lacked evidence that the complaints/grievances for Residents R9 and R11 as noted above, were investigated, tracked through to a conclusion, and that a written grievance decision was provided to Resident R9 and Resident R11.
28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 201.18(b)(3)(e)(1)(3) Management
| | Plan of Correction - To be completed: 03/01/2024
The Administrator spoke to residents R9 and R11 post survey and neither wanted to fill out a grievance form at that time. Since conversation with administrator resident R11 has filed a grievance with other concerns. Resident R11's concerns were addressed and plans were put in place. R11 was satisfied with the results and signed the grievance form. Staff was educated on the importance of checking on residents while in the bathroom, call bells and cell phone usage. there were only 2 found grievances from 2023 and both were handled prior to survey. The Pavilion's Grievance process has been updated. The Social Service Director will be the new grievance officer going forward and will be responsible for handling any grievances appropriately and in a timely manner that are submitted and giving to the Administrator. The grievance form has been updated to reflect the changes, a new grievance log and binder will be kept. Residents will be notified of the change at the next resident council meeting scheduled for 1/24/2024. All staff education will be provided to ensure the new process is followed properly. Administrator/designee will conduct audits on the grievance log and grievance binder 2x/week for 2 weeks, weekly for 2 weeks and periodically thereafter until compliance is met. Findings will be discussed in QAPI.
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