Failure to Provide Anonymous Grievance Filing
Penalty
Summary
The facility failed to ensure that grievance or concern forms could be filed anonymously by residents and their representatives. This deficiency was identified across five locations within the facility, including four nursing units and the lobby, where grievance or complaint forms are provided. The facility's policy, last reviewed on March 14, 2025, stated that grievances could be submitted orally or in writing and could be filed anonymously. However, during an observation on April 14, 2025, it was noted that there were no grievance boxes available in the facility. Instead, posted signage instructed individuals to provide completed grievance or complaint forms to social services, or to slide the document under the door if the office was closed. During an interview on the same day, the Nursing Home Administrator confirmed the absence of grievance boxes and acknowledged the facility's failure to ensure that grievance or concern forms could be filed anonymously. This lack of anonymous filing options was consistent across all five locations where grievance or complaint forms were available. The deficiency was noted under the regulation 28 PA Code: 201.18(e)(4) Management, indicating a failure to comply with the requirement to provide a means for residents to file grievances without fear of reprisal or discrimination.
Plan Of Correction
The facility will install secure, locked grievance boxes in each of the five locations where forms are provided (four dining rooms and the lobby). Each box will be clearly labeled and placed in a visible, accessible location. New signage will also be posted to inform residents and representatives that grievance/concern forms may be submitted anonymously through these boxes. A facility-wide check confirmed that no such boxes currently exist. Staff will be re-educated on the grievance policy, including the right to file anonymously, by the Social Services Director. The Social Services Department will check the boxes weekly to collect submissions and ensure functionality. Random monthly audits will continue thereafter. The Nursing Home Administrator is responsible for ensuring the implementation of this correction and compliance. Secure, locked grievance boxes will be installed in all five designated locations (four dining rooms and the lobby). Each box will be placed in a location that is visible and accessible to residents and representatives but positioned to maintain privacy, such as near unit entrances or in recessed wall areas obscured from direct staff oversight. Boxes will be clearly labeled and signage will be updated to inform residents and families that grievances may be submitted anonymously. On June 7, 2025, the Social Services Director provided an in-service training to the Administrator and Social Services staff responsible for grievance management. The training covered: - The policy and resident rights regarding grievance filing - The importance of maintaining anonymity - Protocols for monitoring and responding to submissions Training documentation is retained in the education file. To ensure timely attention to grievances, the Social Services Department will check each box daily, beginning June 9, 2025. A log will be maintained to document daily checks and response actions. Additionally, monthly audits will be conducted to confirm: - Each box remains secure and in proper working condition - Signage is in place and clear - Daily check logs are complete and up to date Audit results will be reviewed in the QAPI meeting each month to support continued compliance.