HospitalInspections.org

Based on review of policies and procedures, review of Quality Management/Performance Improvement Plan 2012-2013 and interview, it was determined the facility failed to assure QA/PI (Quality Assurance/Performance Improvement) activities were conducted for grievances. The failed practice prevented the facility from identifying trends in grievances and prevented formulating plans to improve or reduce the number of grievances. This failed practice had the potential to affect all persons admitted to the facility. Findings follow:

A. Review of policy, "Complaints about Patient Care and/or Service (and Grievances)" revealed, "The Quality Advisory Committee will function in the capacity of Grievance Committee, as a portion of the meeting will be dedicated to reviewing grievances and recommending activities to improve/ensure safety and quality for patients".

B. Review of "Quality Management/Performance Improvement Plan 2012-2013" revealed, "The Board of Directors formally delegates to the organization's leadership and appropriate committees the review of the Quality functions. These functions include: ...grievance process."

C. During an interview with the Director of Quality on 02/01/13 at 0850, she verified there were no QA/PI activities conducted for grievances.