INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on February 13-14, 2024 by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Tadiso Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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715.22(a) LICENSURE Patient grievance procedures
(a) A narcotic treatment program shall develop and utilize a patient grievance procedure.
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Observations
Based on a review of facility policy & procedures and patient records, the facility failed to document they are following their patient grievance policy.
The facility policy states that "The Director of Social Services will keep a log of all submitted grievances along with a brief contact note indicating the follow up that has been taken and the final determination. Copies of the grievance and follow-up will be scanned into the patient's electronic record."
The facility grievance binder was reviewed for the period of May 2023 - February 2024. There were no grievances observed to be scanned into the electronic patient record.
There were a total of seven patient grievances filed that did not include documentation of determination or follow up. These are as follows:
Patient # 1 - grievances filed on May 16, 2023; however, no response from facility staff documented.
Patient # 2- grievance filed on May 18, 2023; however, no response from facility staff documented.
Patient # 3 - grievance filed on November 14, 2023; however, no response from facility staff documented.
Patient # 4 - grievance filed on November 17, 2023; however, no response from facility staff documented.
Patient # 5 - grievance filed on December 21, 2023; however, no response from facility staff documented.
Patient # 6 - grievance filed on December 29, 2023; however, no response from facility staff documented.
Patient # 7 - grievance filed on December 30, 2023; however, no response from facility staff documented.
In addition, there were two grievances filed that included a written determination and plan on the grievance form; however, there was no follow up documentation to show that the plan was followed.
Patient #8 filed grievances on October 20 & October 22, 2023. There was a determination documented that included follow up with the Director of Security. There was no documentation that the Director of Security was contacted, nor any outcome.
These findings were reviewed with facility staff during the investigation process.
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Plan of Correction
Once the grievance has been discussed, and a follow up shared with the patient, the patient will then sign the grievance form confirming they have met with the social service supervisor for a follow up, the social services administrative assistant will scan the completed grievances into the F drive titled "Grievances and Incident complaint forms."
A social service supervisor will document discussed outcomes via a grievance note after meeting with the patient within 7 days. If applicable, the patient will receive a written notification of actions taken to address the complaint.
The Assistant Director of social services will keep a binder of all submitted grievances along with a brief contact note indicating that the follow up was discussed including the final determination. A grievance note will be placed in the patient's file by the Assistant Social Service Director describing the steps taken and any resolution if applicable which require follow-up. The Director of social services will audit the grievance binder every quarter for corporate compliance.
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715.22(b) LICENSURE Patient grievance procedures
(b) The procedure shall permit aggrieved patients a full and fair opportunity to be heard, to question and confront persons and evidence used against them and to have a fair review of their grievances by the narcotic treatment program director. If the grievance is filed against the narcotic treatment program director, the review of the case shall be conducted by either a multi-representative group of the narcotic treatment program or a subcommittee of the governing body instituted for the express purposes of grievance adjudication.
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Observations
Based on a review of policy & procedure and client records, the facility failed to document that aggrieved patients were permitted a full and fair opportunity to be heard, and to question and confront persons and evidence used against them.
The facility policy states that "The Director of Social Services will keep a log of all submitted grievances along with a brief contact note indicating the follow up that has been taken and the final determination. Copies of the grievance and follow-up will be scanned into the patient's electronic record."
The facility grievance binder was reviewed for the period of May 2023 - February 2024. There were no grievances observed to be scanned into the electronic patient record.
There were a total of seven patient grievances filed that did not include documentation of determination or follow up. These are as follows:
Patient # 1 - grievances filed on May 16, 2023; however, no response from facility staff documented.
Patient # 2- grievance filed on May 18, 2023; however, no response from facility staff documented.
Patient # 3 - grievance filed on November 14, 2023; however, no response from facility staff documented.
Patient # 4 - grievance filed on November 17, 2023; however, no response from facility staff documented.
Patient # 5 - grievance filed on December 21, 2023; however, no response from facility staff documented.
Patient # 6 - grievance filed on December 29, 2023; however, no response from facility staff documented.
Patient # 7 - grievance filed on December 30, 2023; however, no response from facility staff documented.
These findings were reviewed with facility staff during the investigation process.
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Plan of Correction
The Assistant Director of social services will keep a binder of all submitted grievances along with a brief contact note indicating that the follow up was discussed with the patient which includes the final determination of the grievance. A grievance note will added in the patient's file by the Assistant Social service Director describing the steps taken and any resolution if applicable which require a follow up. The Director of social services will audit the grievance binder every quarter for corporate compliance.
Once a grievance has been submitted by the patient, a social service supervisor will contact the patient to discuss within 7 days and document a grievance note including the nature of the grievance and determination if applicable.
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