§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 observation and resident and staff interviews, it was determined that the facility failed to make information regarding the facility's grievance/complaint process and the residents' rights to file a grievance readily available in prominent locations on the nursing units.
During a group interview conducted on September 28, 2021 at 10:30 a.m. with eight alert and oriented residents (Residents R21, R22, R23, R30, R40, R46, R78 and R84), the residents stated that they were not aware of how to file a grievance with the facility anonymously. The residents were also unaware of who was the Grievance Official in the facility. All eight residents in attendance stated that they were unaware of any postings in the facility, which was comprised of four floors, regarding how to file a grievance.
Observations of the nursing unit and bulletin boards throughout the facility, conducted on the days of survey from September 27, 2021, through September 29, 2021, revealed only one posting, titled Grievance Procedure printed on 8 x 11" copy paper in a small print and posted about five feet off the ground on a crowded bulletin board on the third floor. There were no postings on the first, second or fourth floors related to how to file a grievance.
During an interview on September 28, 2021, at approximately 2:45 p.m, the Administrator acknowledged that the facility failed to post the grievance process in a print size and a height that residents in a wheel chair could easily read on every floor of the facility.
The facility failed to make information regarding the facility's grievance/complaint process and the residents' rights to file a grievance readily available in prominent locations on the nursing units.
CFR The facility must make information on how to file a grievance or complaint available to the resident.
28 Pa. Code 201.18(e)(1) Management
28 Pa. Code 201.29(a) Resident rights
28 Pa. Code 201.29(c)(d)(e) Resident rights
| ||Plan of Correction - To be completed: 11/05/2021|
Grievance information is posted on all units including grievance coordinator information. Anonymous grievances boxes are placed in accessible locations on each unit for residents.
Resident council meeting is attended by grievance coordinator, and will be recorded in meeting minutes
Social services to complete written monthly check of grievance information posting and check boxes.
Written monthly review to be reported to QAPI committee X3 months