§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 review of facility policy and facility documentation, observations, resident and staff interviews, it was determined that the facility failed to make certain residents were aware of the procedure for filing a concern/grievance (written or verbal, the procedure to file a grievance anonymously), and make certain concern forms are easily located and accessible to all residents and/or representatives on four of four nursing units (A, B, C, D).
Findings include:
Review of the facility policy entitled, "Grievance Policy" last reviewed 12/14/23, indicated that: all persons will be provided with an opportunity to present their complaints through a formal grievance procedure; the grievance procedure will be reviewed with all residents at the time of admission, and posted in the Manor; if filing a written grievance, the forms are located in the Administrator's office, must be submitted in writing and signed by the resident or person filing the grievance on behalf of the resident, and lacked guidance related to filing an anonymous grievances.
Observation on 2/12/24, at 11:00 a.m. revealed a green sample grievance form in flip chart at the entrance with a round wooden table blocking access to the chart, and no blank forms for resident use, or a box to anonymously place completed grievance forms.
During an interview on 2/13/24, at 10:15 a.m. Resident Council Members confirmed that they tell someone if they have a complaint, and do not know if there is an official form or where to get it.
During an interview on 2/14/24, at 1:11 p.m. the Nursing Home Administrator confirmed there was no postings of grievance procedures and no way for residents/family to anonymously submit a grievance.
28 Pa. Code 201.29(a)(b)(c) Resident rights 28 Pa. Code 201.18(e)(4) Management
| | Plan of Correction - To be completed: 04/15/2024
Edinboro Manor has placed a grievance submission box and forms in the soda shoppe for residents/representatives who wish to file an anonymous grievance. Forms are also located in designated areas of each hall.
By March 22 the administrator/designee will educate all staff and resident council on the anonymous grievance process and location of submission box and forms. There will be follow up at each resident council meeting to ensure all residents understand the steps to submit an anonymous grievance.
The administrator/designee will audit 3X a week for 3 weeks then 1X per week for 3 weeks then 1X per month for 2 months to ensure availability of grievance forms in designated areas.
Audit results will be reviewed by the Quality Assurance and Planned Improvement Committee to ensure Grievance forms are posted in prominent places and that all education has been completed.
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