|§483.10(f)(5) The resident has a right to organize and participate in resident groups in the facility.|
(i) The facility must provide a resident or family group, if one exists, with private space; and take reasonable steps, with the approval of the group, to make residents and family members aware of upcoming meetings in a timely manner.
(ii) Staff, visitors, or other guests may attend resident group or family group meetings only at the respective group's invitation.
(iii) The facility must provide a designated staff person who is approved by the resident or family group and the facility and who is responsible for providing assistance and responding to written requests that result from group meetings.
(iv) The facility must consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility.
(A) The facility must be able to demonstrate their response and rationale for such response.
(B) This should not be construed to mean that the facility must implement as recommended every request of the resident or family group.
§483.10(f)(6) The resident has a right to participate in family groups.
§483.10(f)(7) The resident has a right to have family member(s) or other resident representative(s) meet in the facility with the families or resident representative(s) of other residents in the facility.
Based on facility policy and documentation, resident and staff interviews interview, it was determined that the facility failed to demonstrate response to grievances from resident council for eight of eight months ( July 2021, August 2021, September 2021, October 2021, November 2021, December 2021, January 2022, and February 2022).
Review of the facility policy "Grievance/Concern Resolution" dated 11/10/21, indicated to resolve resident concerns in a timely manner, facility utilizes a grievance form to identify concerns and track via a monthly log.
A review of resident council meeting minutes indicated the following concerns:
July 2021: develop cleaning area for common area to stay tidy, request of variety of additional activities, workshop classes for internet and technology services, additional phones, remotes and batteries, and clock, more advertisement on laundry services.
August 2021: residents request vehicle to be able to go out to appointments
September 2021: more art activities, casino night in place of being able to go out to the casino, residents would like an accommodation or starfish program setup to acknowledge staff that go above and beyond, would like evening snacks to be offered and not having to ask
October 2021: residents want to have more choice in their meal orders, residents would like laundry cleaned and returned faster.
November 2021: celebrate birthdays with a small cake, residents suggested having a liaison to collect concerns and bring them to the next resident council.
December 2021: tarp or some sort of protection from the elements on the back porch, request for more phones, remote controls, and batteries.
January 2022: more options on menu, request of more phones, TV remote controls, batteries, weatherization of smoking area, faster turnaround in laundry.
February 2022: turnaround time for laundry, clocks for each unit lounge, request for more frequent linen changes.
During an interview on 3/9/22, at 10:30 a.m. and 10:50 a.m. Residents indicated that residents' concerns are not being addressed and are on-going.
During an interview on 3/9/22, at 2:28 p.m. Director of Social Services Employee E16 confirmed that residents have on-going concerns and the facility is not using concern forms to follow upon resident council and could not produce documentation showing they addressed the residents' concerns.
28 Pa. Code 201.18 e(1)Management.
Previously cited 12/23/19, 9/23/21
| ||Plan of Correction - To be completed: 04/13/2022|
1. All request and concerns from July 2021 thru Feb 2022 at the residents council, were written up on the facilities grievance forms by the Director of Social Services or designee, and was addressed and discussed with the resident council president, on 3/10/2022 and was resolved on 3/11/2022
2. Resolved concerns will be addressed in the resident council meeting on 3/30/2022 by the Director of Social Services or designee.
3. Remotes, batteries, clocks and phones were purchased and received by the Maintenance Director or designee and given out to those residents that did not have remotes or phones. Batteries were used to replaced those that needed to be replaced.
4. Extra staff were hired by the Housekeeping Director to assist faster turn around of linen and personal belongings
5. The facility housekeeping will continue to clean the lounge areas and the Housekeeping Manager or designee will assess area through out the day to insure the area is still clean.
6. The Activity Department will discuss with the residents to see who has the interested or the ability to participate in a workshop or class for internet and technology services. If enough interested is mentioned a workshop will be set up.
7. The request for a vehicle to be able to go out to appointments, The facility is contracted with a medical transport service to provided transportation services for appointments.
8. The request for casino night have been placed on the activity calendar by the Activity Director or designee for the month of March.
9. The facility recognizes outstanding employees with the employee of the month program. Residents will been informed by the Activity Director or designee during the resident council meeting for March, of any staff member they would like to be acknowledge that go above and beyond.
10. All Pantry's are stocked with snacks by the Dietary staff or designee. Nursing staff will be educated by the Director of Nursing or designee to offer snacks to all residents in the evening shift hours.
11. New dietary management system has been in place to offer residents more choices in their meals. (optima solutions) by the Dietary Manager
12. A monthly birthday party for all residents with a birthday in that month is celebrated once a month by the Activity Director or designee.
13. At the March resident council meeting, residents will be informed by the Activity Director or designee that they can address concerns individual or can act as a liaison for their floor.
14. The request for a tarp of some sort of protection from the elements on the back porch is unable to be accommodated for safety reasons. The patio is used as a smoking area and for outdoor activities as weather is permitted.
15. The Activity Director and social service director has been educated by the Administrator on grievance forms and when a residents has concerns during the resident council meeting.
16. The Activity Director or designee and director of Social Services, will meet after the residents council meetings to audit concerns or request from the residents monthly. The concerns or request will be reviewed and placed on the facilities grievance forms and addressed with the appropriate departments for resolution.
17. The concern or grievance forms addressed by the Activity Director or designee and Director of Social Services will be reviewed at the facilities quality assurance meeting monthly by the Administrator or designee, for the next three meetings.