Observations
Based on a review of patient records, internal investigations, the Grievance and Appeal Procedures, and the employee Compliance Handbook, the facility failed to follow its written procedures for the management of treatment and rehabilitation services.
Per the Grievance and Appeal Procedures, a decision will be rendered in writing as soon as possible within 48 hours after filing the complaint. The patient shall be given a copy of the complaint and final decision, and a copy shall be filed in the patient's record.
Per the Compliance Handbook, the Chief Compliance Officer has a responsibility to investigate compliance risks or misconduct, develop corrective action plans, and refer employees involved in misconduct or compliance breaches for disciplinary action.
Patient # 3 was admitted on April 8, 2026, and discharged on May 1, 2026. A grievance was found in the patient record involving an allegation of a breach of confidentiality. There was no written decision documented in the patient record. Nor was there documentation of an internal investigation being conducted into the alleged compliance risk.
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Plan of Correction
On August 6, 2026, all staff responsible for receiving, investigating, and resolving grievances will be re-educated on the facility's Grievance Policy. Education will emphasize the requirements to:
- Conduct and document an internal investigation for all grievances involving potential compliance concerns.
- Document all investigative findings.
- Provide and maintain a written grievance decision in the patient's record, when applicable.
- Ensure all grievance documentation is completed in accordance with facility policy and regulatory requirements
The Executive Director is responsible for ensuring that the corrective action plan is implemented and maintained.
The Administrative Assistant is responsible for tracking all grievances using the facility's grievance tracking Smartsheet to ensure each required step in the grievance process has been completed, including investigation, documentation, written grievance decision (when applicable), and case closure. If any required step is incomplete or overdue, the Administrative Assistant will immediately notify the Executive Director and the appropriate leadership team members for prompt follow-up and corrective action.
To ensure this deficiency does not recur, the grievance tracking Smartsheet will be monitored on an ongoing basis, and leadership will review grievance completion and compliance during routine quality oversight meetings. Any identified deficiencies will be addressed promptly through corrective action, additional staff education, and continued monitoring to ensure sustained compliance with facility policy and regulatory requirements.
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