Observations
The facility failed to inform clients of the grievance process. Interviewed clients reported that they were unaware of their right to file a grievance and they did not know the process.
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Plan of Correction
1. We will continue to follow our written Grievance Policy as we have in the past.
2. We will continue to include the grievance policy in the patient rights section in our Consent to Treatment. As we have in the past, Intake staff will continue to review the patient rights section with the patient on admission and the patient will initial that it was reviewed with them. As in the past, the patient will sign the full document at the end and staff will witness.
3. For our detox unit patients: We will add a statement to the Detox Core Expectations form explicitly advising the patient about their right to file a grievance including the policy around how to do that. The patient will sign the document once staff have reviewed it with the patient. This form is an electronic document found in our EMR. We will have the IT department add the revised version to the system by March 2, 2020. (Copy of revised form attached)
4. For our rehab unit patients: We will add a statement to the Rehab Core Expectations form advising the patient about their right to file a grievance including the policy around how to do that. The patient will complete the form at program orientation and will sign the document at that session. This has already been completed and implemented on 2/5/2020 (Copy of revised form attached).
5. All patient care staff will receive a re-training on the patient grievance policy and will sign in at the training as evidence of attendance. Due to the number of staff, this training will be held in a number of sessions. Staff must attend one session between February 24th and March 23rd, 2020.
6. Staff who conduct the new hire orientation will emphasize the grievance policy and procedure during that annual training. Documentation of the attendance at new hire orientation will continue to be placed in the employee's HR file.
7. Staff who conduct the staff mandatory annual training will emphasize the grievance policy and procedure during that annual training. Documentation of the attendance at new hire orientation will continue to be placed in the employee's HR file.
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