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Based on select document review and interview, it was determined the facility failed to provide a written notice of resolution for two (2) of four (4) grievances filed with the facility during 2012. More specifically, two (2) of four (4) grievance reviewed in the survey sample failed to have a documented resolution within an acceptable timeframe, Patient records #9 & 12.

The findings were:

The facility's Grievance Policy and Grievance log for September through December of 2012 were reviewed in a facility conference room on January 15, 2012 beginning at 3:50 PM.

The Grievance log contained 34 grievances for the above specified timeframe. Four grievances were reviewed in their entirety. Two grievances, (for patients #9 & 12), both of which were received during the month of October (2012), contained a documented initial contact with the complainant that occurred within seven (7) days of it's receipt but failed to have a resolution and also failed to contain a written acknowledgement to the complainant that explained the reason for the delay in resolving their grievance(s).

The facility's policy, "Patient Grievance/Complaint Resolution Policy," was reviewed in the facility's conference room on January 15, 2012 beginning at 3:50 PM. A portion of the policy read in part,
'G. Investigation and response to the grievance must be completed within seven (7) business days of knowledge of the grievance. If the grievance will not be resolved or if the investigation is not or will not be completed within 7 business days, the patient advocate will inform the patient that they are still working to resolve the grievance and will follow up with a written response within fourteen (14) business days or as soon as a resolution is reached."

In an interview with the facility's Patient Advocate on January 17, 2013 beginning at 1:15 PM, in one of the facility's conference room's, the Patient Advocate acknowledged that both grievances are not resolved and both complainants have not received written notification as of January 17, 2013, for the delay in resolving their grievance.