§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 on observations, resident and staff interviews, it was determined that the facility failed to prominently post the contact information of the grievance official with whom a grievance can be filed, his or her name, business address (mailing and email) and business phone number for one of four resident areas reviewed and during one Resident Council meeting held.
During the Resident Council group meeting, held August 13, 2019, at 10:05 AM, the residents in attendance revealed they are not aware of a grievance official identified by the facility.
Observations throughout the facility on August 11, 2019, August 12, 2019, and August 13, 2019, revealed no signs posted identifying the facility's grievance official or his or her contact information.
An interview with the Nursing Home Administrator (NHA) on August 13, 2019, at approximately 1:00 PM revealed her belief the grievance official information to be posted at a location observed over three days by the survey team.
An observation on August 13, 2019, at 1:13 PM revealed the receptionist (RC 1) attempting to post a framed sign with the name of the grievance official in the hall previously observed by the survey team.
An immediate interview withe RC 1 revealed she thinks the grievance official posting information must have "fallen off the wall."
28 Pa. Code 201.18(b)(2)(3) Management
28 Pa. Code 201.29(a)(b) Resident rights
| ||Plan of Correction - To be completed: 09/20/2019|
1. Social Service posted the Grievance Notification process on 8/12/19.
2. Social Service met with current residents on 8/12/19 and reviewed the grievance process.
3. Social Service will be educated by the Nursing Home Administrator on the importance of verifying grievance process is posted.
4. Social Service will interview five residents a week for twelve weeks to verify understanding of the grievance process. Social Service will visualize the grievance posting weekly for twelve weeks. Weekly reports of findings will be trended into a monthly report and presented to Quality Assurance Process Improvement Committee for three months.