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Based on review of the complaint/grievance log, review of individual complaints/grievances, review of the complant/grievance policy and interviews with key personnel on September 17, 2014, at approximately 12:05 p.m., it was determined that the facility failed to comply with the Rules for the Licensing of Hospitals, 10-144 Chapter 112, 3.2 which states Patient Rights in Critical Access Hospitals. A critical access hospital must protect patient rights and comply with the conditions for patient rights contained in 42 C.F.R. 482.13, in two (2) of five (5) complaint/grievance documentation. (Grievances A and C)

Findings include:

1. 482.13(a)(2)(iii) states that in its resolution of the grievance, the hospital must provided the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion, in .

2. Five (5) complaints/grievances were reviewed on September 17, 2014. The written notice to the patient in (Grievance C) one (1) of the five (5) grievances did not contain the steps taken to investigate all the concerns that the complainant had shared with the hospital. Additionally, there was no documentation that the hospital actually investigated all the complainant's concerns. Grievance A one (1) of the five (5) grievances reviewed, did not contain the results of the grievance process.

3. Penobscot Valley Hospital policy titled, 'PATIENT COMPLAINT/GRIEVANCE' stated, 4.0 PVH will strive to resolve all complaints/grievances from receipt to final response within seven days. If this cannot be accomplished, the reason will be documented and the complainant notified.

4. Grievance A, one (1) of the five (5) reviewed, contained no documentation that the complainant had been notified that the investigation would take more than seven days.
The grievance was received by the hospital on January 7, 2014, and the letter sent to the complainant, after the date of completion, was dated January 30, 2014.

5. The above findings were confirmed by the Director of Nursing, who reviewed these findings with the surveyor on September 17, 2014, at approximately 12:05 p.m.

Based on observations and interviews with key personnel on September 16, 2014, it was determined that the facility failed to ensure that the CAH was maintained to ensure safety of patients at all times.

Findings include:

1. During a tour of the Rehabilitation and Wellness Outpatient Clinic, on September 16, 2014, it was observed that five (5) ceiling tiles in the utility room (located off the conference room), housing electrical/communications equipment, were stained with water damage, resulting in a potential safety issue.

2. The above finding was confirmed by the Ancillary Services Director on September 16, 2014, at approximately 10:30 a.m.