§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, review of select facility policy and resident interviews, it was determined that the facility failed to make information available regarding the facility's grievance/complaint process and the residents' rights to file a grievance in prominent locations on the nursing units.
A review of the facility's policy entitled "Grievance Policy" and the "Grievance Posting Policy" last reviewed by the facility March, 2020, indicated that it is the policy that grievances will be afforded prompt investigation and resolution by the facility administration. The policies failed to indicate where the residents or family members may obtain a grievance form.
During an interview with the Director of Social Services on February 26, 2020, at 10:00 AM, it was acknowledged that grievance postings were not placed in prominent locations on each unit of the facility and the policies failed to indicate where grievances can be obtained.
During a group interview conducted on February 25, 2020, at 1:00 PM with eight residents who regularly attend the monthly Resident Council Meetings (Residents 136, 102, 139, 86, 42, 22, 54 and 35) the residents stated that they were not aware how to file a grievance, the location of grievance forms or the identify of the facility's designated Grievance Offical. All the residents in attendance were unaware of the location of any grievance postings in the facility, which comprised of four nursing units, which detailed the facility's grievance process.
Observations conducted on the days of survey of all four nursing units, from February 25, 2020, through February 28, 2020, revealed the postings of the availability of grievance forms was written in small print posted on the back of a clipboard. The forms were difficult to read due to the size of the print and format and were not found in prominent locations for access by resident and family members. The grievance postings failed to include pertinent information regarding contacting and/or role of the local area Ombudsman.
28 Pa. Code 201.18(e)(1) Management
Previously cited 1/25/19
28 Pa. Code 201.29(a)(b)(i) Resident rights
Previously cited 1/25/19
| ||Plan of Correction - To be completed: 03/31/2020|
The Jewish Home of Eastern Pennsylvania (the "Home") submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges are deficient under State and Federal regulations relating to long-term care. This Plan of Correction should not be construed as either a waiver of the Home's right to appeal or an admission of past or ongoing violations of State and Federal regulatory requirements.
Elements detailing how the facility will correct the deficiency as it relates to the individual residents.
Information on the grievance process including, how to file a grievance, location of grievance forms and the identity of the Grievance Official will be provided to identified residents (136,102,139,86,42,22,54 and 35).
Indicate how the facility will act to protect residents in similar situations.
Information on the grievance process including, how to file a grievance, location of grievance forms and the identity of the Grievance Official will be reviewed with residents a monthly resident council meetings.
The measures the facility will take or the system it will alter to ensure that the problem does not reoccur.
Grievance policy will be reviewed and updated as needed. The grievance posting will be updated to include location of grievance forms and any additional information required. The grievance posting will be displayed in prominent locations such as the bulletin board and in close proximity to the concern boxes located on each floor. The grievance posting will be displayed in 12 pt. font or lager.
How the facility plans to monitor its performance to make sure that solutions are sustained.
Grievance posting placement will be audited for prominent placement for 3 months.