§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.
Based upon observation and interviews with residents and staff, it was determined that the facility failed to establish a grievance policy, failed to display in a prominent locations the residents' right to voice a grievance, how to file a grievance and the contact information of the facility's grievance official with six of forty-nine residents interviewed, (Resident R13, R27, R60, R61, R71 and R100).
A review of facility policy "Resident/Patient Bill of Rights," undated, stated that the resident has the right to object to any treatment or care which has been furnished as well as that which has not been furnished with the assurance that there will be no reprisals or voicing a grievance.
Observation of the facility throughout all the days of the survey, revealed that the facility failed to prominently post throughout the facility the residents' rights related to filing a grievance, including instructions on how to file a grievance as well as the facility's grievance official's contact information.
A group interview conducted with six residents (Resident R13, R27, R60, R61, R71 and R100) on August 28, 2019, at approximately 10:00 a.m. revealed that all six residents indicated that they did not know how to file a grievance if they chose to do so.
Interview with the Nursing Home Administrator on August 29, 2019 at approximately 1:30 p.m. revealed that the facility had not developed a grievance policy. Further interview with the administrator confirmed that the facility failed to place the grievance postings throughout the facility as required.
The facility failed to establish a grievance policy and failed to post information related to the residents' right to file a grievance.
28 Pa. Code: 201.29(a)(b)(c)(i)(j) Resident rights
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The facility established a grievance policy.
Residents R13 ,R27, R60 ,R61, R71 and R100 were informed of this policy and their right to voice a grievance and the process to file a grievance as well as the contact information of the facilities grievance official.
Signs were posted in prominent locations throughout the facility detailing residents right to voice a grievance as well as the process needed to file a grievance.
Residents will be educated on the process of filing a grievance upon admission and by quarterly care conferences as well as during monthly Resident Council meetings.
The Social Service Director or designee will interview random residents to ensure they are aware of the grievance process.
This will be done weekly for the first 4 weeks and then monthly for the next 3 months.
Results of audits will be shared with the monthly Qapi meeting and then reviewed by the quarterly Quality Assurance Committee which will make recommendations based on the outcome of the audits.The administrator will monitor performance to ensure sustainable solutions for ongoing compliance.