§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 review of facility policy, review of the facility grievance log, and resident interviews, it was determined that the facility failed to document and follow grievance procedures for grievances brought up at two of four Resident Council meetings (September and October, 2021).
Findings include:
Review of the facility's policy entitled "Grievances" dated 3/2/21, indicated that grievances may include a resident verbalized complaint to facility staff and that the facility will acknowledge complaints and grievances and will actively work toward resolution of that complaint or grievance.
During an interview on 11/6/21, at 12:35 p.m., Residents R50 and R51 stated that several residents had brought up issues about lengthy call bell response by staff and issues about the quality and palatability of the evening meal at Resident Council meeting held on 9/2/21 and 10/28/21.
Review of the Resident Council meeting minutes recording form indicated that that the documentation for new business concerns (any issues or concerns) is done as follows: the concern is to be recorded and show of attendees obtained and should be documented on Department Response Form or referred to appropriate department in the case of a single resident concern).
Review of the Resident Council meeting minutes documentation for the meetings dated 9/2/21 and 10/28/21, indicated that there was "no new business" brought up by the residents in attendance.
During an interview on 11/6/21, at 2:30 p.m., the Nursing Home Administrator confirmed that there were no resident grievances documented regarding the quality and palatability of the food and the untimely response to call bells by staff.
28 Pa. Code 201.29(j) Resident rights.
Previously cited 1/11/21.
| | Plan of Correction - To be completed: 12/17/2021
0585 Grievances:
The deficiency will be corrected by education to the dietitian, dietary manager, and activity director as follows: Minutes from Resident council and food committee must include any concerns brought up by the residents in the meetings and appropriate grievance forms should be completed in order to ensure follow up and follow up documentation. Minutes from the food committee need to be written in a logical format and maintained in a binder. Concerns noted in the food committee meeting must also be formally addressed using the grievance form and handled in a reasonable time frame.
The process as above noted will protect residents in similar situations as all department managers will also be re-educated on the grievance process and will be responsible for updating their individual staff members. Re-education will include the grievance process, the importance of timely reporting and follow up. Grievances are tracked and trended monthly with QAPI. Re-education regarding the grievance process was provided by the NHA. The dietary manager was educated about the keeping of minutes for the food committee. (Minutes were kept by the previous manager but were not formally typed or reviewed by NHA or QAPI)
Department heads/leadership will document any grievances on grievance forms or offering blank forms to those that are capable during weekly Guardian Angel rounds. Grievances will then be managed by the Social Services Director who will review in stand up meetings and disseminate to appropriate departments.
Weekly audits will be conducted interviewing 5% of residents (interviewable residents) to determine if they have any concerns that they have reported and asking what type of follow up occurred. These results will be compared with reported grievances to ensure documentation of the grievance and that follow up is occurring timely. These results will also be tracked and trended and reported during monthly QAPI meetings.
Corrective action is in process and will be completed by December 17th.
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