§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.
|
Observations:
Based on review of facility policy, tour of the facility, and staff interview it was determined that the facility failed to make certain that a posted grievance policy and procedure was met federal guidelines for two out of two nursing units (Front hall nursing unit and back hall nursing unit).
Findings include:
The facility "Grievance procedure" policy dated 9/28/23, indicated that the facility encourages residents and their family members to make known to the facility any concerns. The facility has developed grievance procedure that will address all such concerns. The grievance official will be responsible for overseeing the grievance process.
During a tour on 2/27/24, at 9:25 a.m. observations of the facility did not find a posted grievance policy, grievance official e-mail and business address.
During a tour on 2/28/24, at 9:13 a.m. observations of the facility did not find a posted grievance policy, grievance official e-mail and business address.
During a tour on 2/28/24, at 11:45 a.m. observations with Assistant Nursing Home Administrator/Director of Social Services Employee E1 did not find a posted grievance policy, grievance official e-mail and business address.
During an interview on 2/28/24, at 11:47 a.m. the Assistant Nursing Home Administrator/Director of Social Services Employee E1 confirmed that the facility failed to make certain that a posted grievance policy and procedure was met federal guidelines as required.
28 Pa. Code 201.29(1) Resident rights
28 Pa. Code 201.18(e)(4) Management
| | Plan of Correction - To be completed: 04/19/2024
1. Upon notification of the alleged deficient practice, the facility NHA posted the federally required grievance policy components on front hall unit and back hall unit, to ensure these units had access to the grievance policy, grievance official email address, and business address.
2. Upon review the facility identified that the residents residing on front hall unit and back hall unit at the time of this survey had potential to be affected by this alleged deficient practice.
3. Everest Operations support provided education to the new facility NHA on ensuring facility compliance with federal guidelines to make certain there is posted grievance policy and procedures to include grievance official email address and business address on front hall nursing unit and the back hall nursing unit.
4. Facility NHA or designee will audit compliance with this plan of correction by conducting walking rounds to check for grievance policy postings on front hall nursing unit and back hall nursing unit as follows: 3 walking rounds weekly X4 weeks. Any trends identified in this monitoring will be reported to the QAPI committee monthly and this plan of correction may be modified to address those trends as necessary.
5. Allegation of compliance: 4/19/2024
|
|
