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Based on review of facility documents and employee interviews (EMP), it was determined that the facility failed to adhere to its established policy in the identification of complaints and grievances for six of ten complaints/grievances reviewed.

Findings include:

Review of the Sharon Regional Health System Administrative Policy NO: 83, "Patient Rights And Responsibilities," revised September 2013 revealed, "PATIENT RIGHTS: Patients should be encouraged to ask questions about any of the following rights that they do not understand. ... VIII. COMPLAINTS, CONCERNS AND QUESTIONS- Patient's and patient's family/guardian have the right to: A. Tell hospital staff about concerns or complaints regarding the patient's care. This will not affect the patient's future care. B. Expect a response to a complaint from the hospital. Complaints may be made in writing or in person. The hospital has a duty to respond to those complaints. To share concerns with the Health system, patients and families may contact the Patient Advocate at ..."

Review of the Sharon Regional Health System Administrative Policy NO: 91, "Patient Complaint/Grievance," revised August 2013 revealed, "DEFINITIONS: 1. Patient Grievance: As defined by CMS Interpretive Guidelines, ref 482.13(a)(2) A written or verbal complaint (when the verbal complaint about patient care is not resolved at the time of the complaint by staff present) by a patient, or the patient's representative, regarding the patient's care, abuse or neglect, issues related to the hospital's compliance with the CMS Hospital conditions of Participation (CoP) ... a. 'Staff present' includes any hospital staff present at the time of the complaint or who can quickly be at the patient's location (i.e.) nursing, administration, nursing supervisor, Patient Advocate, etc.) to resolve the patient's complaint. B. If a verbal patient care complaint cannot be resolved at the time of the complaint by staff present, it is postponed for later resolution, requires investigation, and/or requires further actions for resolution, then the complaint is a grievance for the purpose of these requirements ... g. All verbal or written complaints regarding abuse, neglect, patient harm or hospital compliance with CMS requirements, are to be considered a grievance for the purpose of these requirements. H. Whenever the patient or the patient's representative requests their complaint be handled as a formal complaint or grievance or when the patient requests a response from the hospital, then the complaint is a grievance and all the requirements apply. ... PROCEDURE: ... 6. It is expected that most grievances can be resolved within seven (7) days. In those situations that a resolution cannot be reached in that time frame, the patient or the patient's representative will be informed and given a date when the hospital will follow-up with a written response, not to exceed 30 days. All response letters will be made to the complainant who may or may not be the patient. ... 8. A provision for notifying the patient of the results of the grievance review exists. The notification must be made in writing and include 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. ... 9. ... C. Once the investigation is complete, a letter will be sent to the patient with required information."

1. On March 11, 2014, a review of the facility Complaint Log was conducted for complaints received between July 2013 and February 2014. The review revealed six of ten complaints reviewed (July 14, 2013, September 17, 2013, September 30, 2013, October 6, 2013, December 23, 2013, and February 11, 2014,) were not resolved at the time of the complaint by staff present.

2. On March 11, 2014, at 10:30 AM, EMP13 confirmed that complaints dated, July 14, 2013, September 17, 2013, September 30, 2013, October 6, 2013, December 23, 2013, and February 11, 2014, were not resolved at the time of the complaint by staff present, thus meeting the definition of a grievance.

3. On March 11, 2014, at 11:45 AM, EMP7 confirmed no letters were sent to the complainants for the identified "complaints" dated July 14, 2013, September 17, 2013, September 30, 2013, October 6, 2013, December 23, 2013, and February 11, 2014. EMP7 stated, "Because they were not identified as grievances, none would have received a letter."

Cross Reference:
§482.13(a)(2)(iii)

Based on review of facility documents and employee interviews (EMP), it was determined that the facility failed to provide 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 for six of ten grievances reviewed.

Findings include:

1. Review of the Sharon Regional Health System Administrative Policy NO: 83, "Patient Rights And Responsibilities," revised September 2013 revealed, "PATIENT RIGHTS: Patients should be encouraged to ask questions about any of the following rights that they do not understand. ... VIII. COMPLAINTS, CONCERNS AND QUESTIONS- Patient's and patient's family/guardian have the right to: A. Tell hospital staff about concerns or complaints regarding the patient's care. This will not affect the patient's future care. B. Expect a response to a complaint from the hospital. Complaints may be made in writing or in person. The hospital has a duty to respond to those complaints. To share concerns with the Health system, patients and families may contact the Patient Advocate at ..."

2. Review of the Sharon Regional Health System Administrative Policy NO: 91, "Patient Complaint/Grievance," revised August 2013 revealed, "... PROCEDURE: ... 6. It is expected that most grievances can be resolved within seven (7) days. In those situations that a resolution cannot be reached in that time frame, the patient or the patient's representative will be informed and given a date when the hospital will follow-up with a written response, not to exceed 30 days. All response letters will be made to the complainant who may or may not be the patient. ... 8. A provision for notifying the patient of the results of the grievance review exists. The notification must be made in writing and include 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. ... 9. ... C. Once the investigation is complete, a letter will be sent to the patient with required information."

3. On March 11, 2014, a review of the facility Complaint Log was conducted for complaints received between July 2013 and February 2014. The review revealed six of ten complaints reviewed (July 14, 2013, September 17, 2013, September 30, 2013, October 6, 2013, December 23, 2013, and February 11, 2014) were not resolved at the time of the complaint by staff present.

4. On March 11, 2014, at 10:30 AM, EMP13 confirmed that complaints dated, July 14, 2013, September 17, 2013, September 30, 2013, October 6, 2013, December 23, 2013, and February 11, 2014, met the definition of grievances and were not resolved at the time of the complaint by staff present.

5. On March 11, 2014, at 11:45 AM, EMP7 confirmed no letters were sent to the complainants for the identified "complaints" dated July 14, 2013, September 17, 2013, September 30, 2013, October 6, 2013, December 23, 2013, and February 11, 2014. EMP7 stated, "Because they were not identified as grievances, none would have received a letter."

Cross Reference:
§482.13(a)(2)