§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 observations, resident group response interview, and staff interview it was determined that the facility failed to ensure each resident the right to anonymously file a grievance/concern based on interviews held with the resident council group participants during the onsite survey.
Findings Include:
Review of the facility's corporate standard of practice titled "Grievances/Concerns", recently revised February 7, 2017, reads "The resident and/or his/her interested party have the right to voice grievances regarding treatment and/or services, which have been provided or not provided."
The standard continues "The resident or interested party may voice a concern to any team member or may report a concern anonymously."
An interview with members of the facility's Resident Council, during a meeting held on April 20, 2022, at 1:00 PM, revealed residents are instructed to request the grievance/concern form from the Life Enrichment Coordinator, complete the grievance/concern form, and return.
The interview also revealed there are no areas within the facility to obtain a grievance/concern form anonymously or without the assistance or participation of other staff.
Observations during the onsite survey confirmed no areas within the facility providing access to residents and/or family members to obtain the forms anonymously.
An interview with the Nursing Home Administrator, on April 21, 2022, at 8:45 AM, revealed grievance forms are now available in resident areas in order to file a grievance/concern in an anonymous fashion.
28 Pa. Code 201.29 (a) Resident rights
| | Plan of Correction - To be completed: 05/30/2022
1.At the next Resident Council meeting the resident will be informed on how to file an anonymously.
2.Residents will be educated at the Resident Council Meetings of their right to file an anonymous grievance or concern and of the process to do so.
3.A new office door file has been hung in a common area with grievance forms and a new lock box for resident to file of grievance/concern forms has been hung and labeled for grievances. IDT will be re-education on the residents right to file an anonymous grievances and location of the new lock box for placement of grievances.
4.The Director of Social Services/designee will make rounds 2x/week x1 month, then weekly x2 months to ensure forms are available. Findings will be reported monthly to the Quality Assurance Performance Improvement Committee for review and recommendations.
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