HospitalInspections.org

Based on review of facility documents and employee interview (EMP), it was determined the facility failed to send complaint acknowledgement letters with in seven days for 17 of 20 complaint records (OTH1, OTH2, OTH3, OTH4, OTH5, OTH6, OTH7, OTH8, OTH9, OTH10, OTH11, OTH112, OTH13, OTH14, OTH15, OTH16, OTH17, OTH18, OTH19, OTH20).

Findings include:


"Patient Representation/Complaints" policy and procedure dated September 2010, was reviewed. The policy stated, "Investigation of a grievance should be initiated within 48 hours after notification and a preliminary or final response within 7 days. The Patient Representative will forward patient grievances with their documented investigation and resolution to the VP of Quality Improvement for Administrative team review. ...(In order to meet PA DOH and CMS regulations. ... Grievance is not resolved until a letter is sent to patient and attached to this form."


1) Review of twenty complaint records dated July 2010, through September 30, 2010, revealed that 17 of 20 complaints received by the facility did not have acknowledgement letters sent to the complainant within seven days upon receipt.

2) An interview with EMP2 on October 20, 2010, at 2:16 PM, confirmed that a letter is not always sent within seven days. EMP2 stated that the Administrative team meets to discuss complaints and the letter is generally sent after that meeting. An interim letter is sent if the complaint extends past seven days but that it depends on the seriousness of each individual case. Generally we do not send an interim letter.