Observations:
Based on review of facility policies and procedures, review of facility documents, review of medical records (MR), and staff interviews (EMP), it was determined the facility staff failed to all applicable Federal regulations.
The facility was found to be non-compliant with the following Federal regulation:
CFR 482.13(a)(2)(ii) The grievance process must specify time frames for review of the grievance and the provision of a response.
This standard has not been met as evidenced by:
Based upon a review of facility policies and procedures, facility documents, and staff interview (EMP), it was determined that the facility failed to ensure patients received a written response to grievances in a timely manner for two of four patient grievances reviewed (MR1 and MR2).
Findings include:
On June 10, 2024, a review of the facility's "Patient Complaint Management and Grievance Process," revealed, "......C. Grievance Process: 4. Response to Grievances a. If the PRC receives the grievance verbally from the patient/family, discussions occurring at that time will serve as acknowledgement of the grievance. c. On average a written response addressing resolution of the grievance will be sent to the patient/family within 7 business days of receipt of the grievance ... There are occasions when a grievance is complicated and may require an extensive investigation. If a grievance will not be resolved or if the investigation is not or will not be completed within 7 days ... the PRC should inform the patient or the patient ' s representative of the need for additional time. Ideally, the grievance will be resolved in twenty-one (21) business days. However, there may be times when a longer response period is appropriate....".
On June 10, 2024, a review of MR1's grievance revealed that the grievance was received in person by EMP4 on January 12, 2024. The review also revealed no notification to the patient that additional time was needed to complete the investigation. Additionally, the final letter was dated May 11, 2024, four months after the acknowledgement of the grievance.
On June 10, 2024, a review of MR2's grievance revealed that the grievance was received on April 4, 2024. Further review revealed that a letter was sent to the patient on April 25, 2024, acknowledging the need for additional time to investigate. The letter was sent 21 days after the grievance was reviewed, exceeding the (7) business days, as per facility policy.
EMP1 confirmed the above findings on June 11, 2024, at approximately 11:45 AM.
| | Plan of Correction - To be completed: 08/10/2024
The deficiency was immediately reviewed with the Vice President of Operations and the Director of Patient Relation to address the identified deficiency.
Completed: June 17, 2024
Education:
The deficiency was reviewed with the Vice President of Operations and the Director of Patient Relations in our 1:1 meeting to address the deficiencies on June 17, 2024
Education will be provided to all Patient Relations team members at Shadyside and Presbyterian hospital regarding the policy titled Patient Compliant Management Grievance process PR-01. The Education will emphasis the segment of the policy indicating that on average, a written response addressing resolution of the grievance will be sent to the patient/family within seven business days of receipt of a grievance. There are occasions when a grievance is complicated and may require an extensive investigation. If a grievance will not be resolved or if the investigation will not be completed within seven business days, the Patient Relations personnel should inform the patient or the patient ' s representative of the need for additional time. Ideally, the grievance will be resolved in twenty-one (21) business days. Additionally, Education will include an emphasis on ensuring written response letters are completed within seven business day of the date the grievance was received. Furthermore, education will be including the need to respond to all triggers and grievances as this is required by policy. Education will be completed by Director of Patient Relations in our next staff meeting with a PowerPoint Presentation and sign off during staff meeting. Director of patient relations will conduct the education.
Completion date: July 19, 2024
Monitoring:
The Director of Patient Relations will monitor for dates that a grievance was originally filed, dates the extension letters are sent and the date a final completion letter is sent to ensure that each stage in the process is being done with in the timeline allotted to patient relations based on our policy titled Patient Compliant Management Grievance process PR-01. The Director of Patient Relations will review the results and take appropriate action with staff as needed.
Random audits of four grievance response letters per week will be reviewed for a period of 3 months or until sustained compliance of 90% is maintained.
Reporting
On a weekly basis, audit results will be shared Vice President of Operations and the Director of patient relations will review and follow up with staff.
On a bi-monthly basis, compliance result will be shared at PUH/SHY Quality & Safety Surgical Cabinet and PUH/SHY Quality & Safety Medicine Cabinet meetings and with the Executive Management group weekly.
The person responsible for overseeing the correction of this deficiency will be The Director of Patient Relations
Overall Completion date: August 10, 2024
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