§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, observations, and resident and staff interviews, it was determined that the facility failed to provide concern forms assessable to resident ' s and visitor ' s from a wheelchair on two of three nursing units (fifth, and sixth floor nursing unit), failed to have a grievance box and forms accessible on one of three nursing units (fourth floor) and failed to provide residents with the grievance official contact information (name, business address, email address, and business telephone number) on three of three nursing units (fourth, fifth, and sixth floor nursing units)
Findings include:
A review of the facility policy "Grievance/Concern Resolution" reviewed 10/1/22 and 10/2/23, indicated the facility utilizes a grievance form to identify concerns and track via a monthly log.
During an observation on 2/8/24, at 8:42 a.m. revealed the grievance box and concern forms were not accessible due to two dining chairs placed in front of the grievance box and the grievance official information was not posted.
During an observation on 2/8/24, at 8:44 a.m. revealed the concern forms were not accessible by wheelchair, and the grievance official information was not posted.
During an observation on 2/8/24, at 8:47 a.m. revealed the concerns forms were not accessible by wheelchair. The grievance official information was posted in 10 font print, and not easily accessible to residents.
During an interview on 2/8/24, at 8:55 a.m. Social Worker Employee E3 confirmed the boxes were not at a level that was accessible to residents and visitors in a wheelchair, and the facility failed to post the grievance official contact information on the fourth, fifth, and sixth floor nursing units.
28 PA Code: 201.18(e)(4) Management.
28 PA Code: 201.29(a)(b)(c) Resident rights.
| | Plan of Correction - To be completed: 04/04/2024
1. Grievance forms were placed, and official contact information postings were immediately updated at all grievance boxes on all floors upon identification by surveyor. Grievance boxes have been lowered on all units to make them accessible from a wheelchair. 2. Residents will be notified and reoriented to the grievance procedure, grievance official, grievance box accessibility and availability of forms at the next scheduled resident council meeting. Residents who do not attend resident council will be notified of the grievance procedure by DOSS or designee. 3. Education was provided to the Social Worker and Activities Director by NHA on ensuring forms are available, proper height of grievance boxes, and posting of the grievance official. 4. Audits will be completed by the NHA or designee weekly x 4 weeks, then monthly x 2 months to ensure boxes, postings and forms are available for resident use. 5. Audit results will be reviewed through the monthly QAPI process/meeting.
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