§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 resident group meeting, resident and staff interview, review of facility policy and procedures, it was determined that the facility failed to ensure that the grievance forms were available and accessible to residents on four of four nursing units (Second, Third, Four and Fifth Floors).
Findings include:
A review of the facility policy and procedure, titled, "Grievances" stated "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 grievance 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 reasonably expected time frame for completing the review of the grievance."
During a resident group meeting on June 15, 2022, at 10:30 am., Residents R6, R7, R16, R22, R55, R67, and R94 were identified as being alert and oriented, revealed that the residents were unaware of where the grievance forms were located. The residents were unaware of any location of grievance/concern submission boxes to submit an anonymous grievance. Residents also were not aware of who is grievance officer at the facility.
Interview on June 15, 2022, at 11:05 a.m. with Nursing Home Administrator confirmed that grievance forms were not available to residents. The Nursing Home Administrator further reported, "grievance forms only available electronically to staff, residents make a call to any staff or call the front desk and guest service will interview the resident".
A tour was conducted with the Nursing Home Administrator of the Second, Third, Four and Fifth Floor and it was confirmed there was no grievance procedure nor contact name, or telephone number of the grievance officer posted on all nursing units.
28 Pa. Code 201.14(a)Responsibility of licensee
28 Pa. Code 201.18(b)(3) Management
28 Pa. Code 201.18(e)(1) Management
28 Pa. Code 201.29(a)(d)(i) Resident rights
| | Plan of Correction - To be completed: 08/09/2022
F-0585 Residents R6, R7, R16, R22, R55, R67, and R94 have been notified where the grievance forms are located. Current residents will be notified of the grievance forms and how to submit them anonymously upon admission. Facility staff have been educated on grievance forms and how pts can submit them anonymously by ADON/GSD/designee. Guest services will check that concern forms are accessible on each unit on an ongoing basis. Guest services will interview 5 patients weekly x4 weeks to ensure that they are aware of the grievance forms and how to submit them anonymously. A review of the findings of the Grievance audit will be brought to Quality Assurance committee monthly. The committee will determine the need for further audits.
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