§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 facility policy review, observations and resident and staff interviews, it was determined that the facility failed to provide an anonymous process to file a concern/grievance on one of six units (3B nursing unit) and failed to make grievance forms and a labeled receptacle available on three of three nursing floors (Second, Third and Fourth nursing floors).
The facility policy "Concerns/Complaints/Grievance" dated 2/7/19, indicated that the resident shall be encouraged and assisted throughout the period of stay to exercise his/her rights and voice 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 ot other residents and other concerns regarding their stay. The facility maintains confidentiality of all information associated with grievances including the identity of the resident for those grievances submitted anonymously.
During an observation on 10/23/19, at 10:15 a. m. on the 3B secured nursing unit it was noted that no concern/grievance forms and a receptacle to place the concern/grievance forms anonymously was provided.
During an interview on 10/23/19, at 10:23 a. m. when Resident R31 was asked how she would file a concern/grievance with the facility, she indicated that she did not know of a process and would just tell a nurse, the social worker or the Ombudsman.
During an interview on 10/24/19, at 11:10 a. m. Nurse Aide (NA) Employee E12 indicated that concern/grievance forms are kept at the nurse's station and they give them to residents when they ask. NA Employee E12 confirmed that there are no forms or box for the forms available on the nursing unit.
During an interview on 10/24/19, at 11:36 a. m. Social Service (SS) Supervisor Employee E13 indicated that the concern/grievance receptacles are located in each floor's recreation rooms and confirmed that by residents of the secured unit needing to ask to leave the unit to go to the recreation room, SS Supervisor Employee E12 confirmed there is no anonymous process in place.
During an observation on 10/25/19, of the Second, Third and Fourth floor recreation rooms revealed no concern/grievance forms and no labeled receptacle to place an anonymous concern/grievance form.
During an interview on 10/25/19, at 10:45 a. m. SS Supervisor Employee E13 confirmed that by not labeling the receptacle and not having concern/grievance forms available, there is no comprehensive grievance process in place.
28 Pa Code: 201.29 (d) (i) (j) Resident rights.
| ||Plan of Correction - To be completed: 12/17/2019|
The Grievance officer/designee delivered a blank grievance form to each of the resident rooms on 3B
R-31 was educated by the Director of Nursing /Designee on how to file a grievance anonymously
E-12 was educated by Social Service Director/Grievance officer on where to direct residents to obtain a blank grievance forms and how to submit anonymously
E-13 was re-educated on the process of submitting a resident grievance anonymously by the Central Corporate Compliance Officer.
Resident council to be held Nov 13, 2019. The Central Corporate Compliance and Grievance officer will address resident council. The Central Corporate Compliance officer and Grievance officer will conduct a separate education on 3B as to the process of submitting a grievance anonymously as some may choose not to attend resident council. The process has been in place prior to plan of correction that the grievance officer will go throughout the facility to communicate/educate and ensure that residents have anonymous forms in their night stand drawers.
Grievance officer /designee will be responsible for delivering a blank grievance form to each resident room.
Grievance officer /designee will secure boxes on each floor including 3B and the lobby with signage providing information on submitting a grievance anonymously.
Grievance officer /designee will provide an area on each floor for residents to obtain blank grievance forms anonymously. RCC/Social Service Staff/Designee will be responsible for refilling resident drawers with blank grievance forms on a PRN basis.
The process on submitting a written grievance anonymously will be discussed with new admission on new admission orientation by the Social Service Department.
The Central Corporate Compliance Office will Educate the Director of Social Service (The grievance officer) and his staff on the process of submitting resident grievances anonymously.
ADON Educators/designee will educate the 3B staff on the submission of submitting grievance's form anonymously.
Compliance of submitting the resident grievance forms on unit 3B anonymously will be audited weekly for one month, bi-monthly X two months and monthly X two months. All results will be reviewed by the Quality committee for compliance. Grievance official will present audit results to the Quality committee for compliance