§483.10(h) Privacy and Confidentiality.
The resident has a right to personal privacy and confidentiality of his or her personal and medical records.
§483.10(h)(l) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident.
§483.10(h)(2) The facility must respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service.
§483.10(h)(3) The resident has a right to secure and confidential personal and medical records.
(i) The resident has the right to refuse the release of personal and medical records except as provided at §483.70(h)(2) or other applicable federal or state laws.
(ii) The facility must allow representatives of the Office of the State Long-Term Care Ombudsman to examine a resident's medical, social, and administrative records in accordance with State law.
|
Observations:
Based on review of facility policy and interviews with residents and staff, it was determined that the facility did not ensure that an appropriate process was in place for distributing mail to residents within 24 hours of delivery to the facility, including on the weekends for four of eight residents reviewed (Resident R3, R4, R6, and R7).
Findings include:
Review of facility policy titled "Resident Mail Handling Policy", most recently revise in February 2026, revealed that "Incoming mail should be distributed to residents within seventy-two (72) hours of receipt by the facility".
Interviews were conducted on June 17, 2026, with alert and oriented residents.
An interview with resident R3 at 10:45 a.m. revealed that mail is delivered "through the administrator at his discretion", but that it isn't delivered on weekends when the administrator was not in the building. She further revealed that she has been waiting on a letter which should include a payment, and that not having it yet has caused her some distress.
An interview with resident R4 at 10:57 a.m. revealed that mail delivery is delayed and that "I was told it's kept up front so the administrator can go through it" before delivery but specified that the mail had not been opened on delivery.
An interview with resident R6 at 11:10 a.m. revealed that she was expecting a letter from the social security office for "a couple of months", but that it still has not been delivered to her.
An interview with resident R7 at 11:19 a.m. revealed that he was also waiting for a letter from the social security office which "should be here" but had not yet been delivered to him by the facility.
In interview with employee E1, the Nursing Home Administrator, at 2:00 p.m. on June 17, 2026, he confirmed that he had implemented a mail delivery system wherein the received mail is given to him so that he can sort it before delivery to the residents. He stated that there "is typically a 24-hour turnaround" for delivery, but that any mail delivered over the weekend when he is not working would be delivered to the residents the following Monday, which was outside of the required 24-hour window.
28 Pa. Code201.14(a)Responsibility of licensee
28 Pa. Code201.29(a)Resident rights.
| | Plan of Correction - To be completed: 07/24/2026
F583 — Personal Privacy/Confidentiality of Records
1. All residents have been made aware of the new policy regarding mail delivery.
2. The Administrator/designee completed an audit of the resident mail to ensure current mail has been delivered timely.
3. The VP of Operations will educate the Administrator/designee on:
- Residents' rights regarding personal mail and privacy, the revised resident mail policy, required timeframes, and maintaining confidentiality.
The facility's Resident Mail Handling Policy was revised to require that all incoming resident mail be delivered within 24 hours of receipt, including mail received on weekends and holidays.
The revised mail distribution process was immediately implemented to ensure timely delivery of resident mail and will be reviewed at Resident Council.
4. The Administrator/designee will audit the resident mail delivery weekly × 4 weeks to ensure the mail is delivered timely.
- The audits will be forwarded to the QAPI committee who will determine the need for further audits.
|
|
