§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, and facility documents and staff interviews it was determined that the facility failed to document, resolve, and provide response to resident and/or their responsible party regarding concerns for ten of 13 grievances in March 2025.
Findings include:
Review of the facility "Resident Grievances and Concerns Policy" dated 3/10/25, indicated Time Frame: the grievance review will be completed in a reasonable time frame consistent with the type of grievance, but in no event will the review exceed thirty days.
Review of March 2025, facility provided Grievance log indicated there were a total of 13 resident entries and as of 5/15/25, at 2:00 p.m. ten had no date of parties informed of findings or disposition completed.
Interview on 5/15/25, at 2:00 p.m. the Nursing Home Administrator confirmed that the facility provided grievance logs indicated the facility failed to document, resolve, and provide response to resident and/or their responsible party regarding concerns for ten of 13 grievances in March 2025.
28 Pa. Code 201.14(b) Responsibility of licensee.
28 Pa. Code 201.18(b)(1)(e)(1) Management.
28 PA Code: 201.29(a) Resident rights.
| | Plan of Correction - To be completed: 06/05/2025
All outstanding grievances from March will be completed by 6/5/25 and documented as such on the facility grievance log. Follow up for grievance with the resident and/or reporting party will be documented on the grievance form and log.
A look back of April and May 2025 grievances will be completed and all outstanding grievances will be completed by 6/5/25 and documented as such on facility grievance log.
All future grievances will be completed per facility policy in the timeframe required. The NHA will review and sign off on all grievances to verify continued compliance with the timeframe involved and follow up per policy.
Facility Administrator will re-educate the IDT members on the policy and timeframe involved for completion of said grievances by 6/5/25.
Facility Administrator/designee will audit grievance log at the completion of the month to ensure proper follow up and timely completion with a report to the QA committee monthly X3.
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