HospitalInspections.org

Based on staff interviews, admission packet review, and policy and procedure review it was determined the facility failed to inform patients how to contact the State Agency as part of their grievance process.

The findings were:

The facility's admission packet was reviewed in the morning of 1/9/13. Within the admission packet was a booklet titled, "Patient Service Guide." The Guide which included patient rights information failed to contain a phone number or address for lodging a grievance with the State Agency.

The facility's risk manager/compliance officer was interviewed regarding how the facility informs patients of the grievance policy on 1/9/13 at approximately 5:00 p.m. The manager directed the survey team to the "Patient Service Guide" but after reviewing the guide, she acknowledged the State Agency address and phone number were not included. The manager also acknowledged the State Agency's grievance information was not provided in any other form throughout the facility.

The facility's policy titled, "Customer Service Policies and Procedures" was reviewed on 1/9/13 and included the facility's grievance policy. The policy did not contain the phone number or address for lodging a grievance with the State Agency.