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Based on interview and record review, the facility failed to to promote and protect patient rights in 4 of 4 (P-1, P-3, P-28, P-29) sampled patients who had filed a grievance, resulting in the potential loss of patient rights for all 56 patients being treated at the facility. Findings include: See tag A-0118

Based on interview and record review, the facility failed to establish a process for prompt resolution of patient grievances for 4 of 4 (P-1, P-3, P-27, P-28) sampled patients, resulting in the potential loss of patient rights for all 56 patients being treated at the facility. Findings include:

Review of policy #8928673 effective 11/2020, demonstrated on p.1 of 6, "Grievance: All patient grievances require a written response." Page 3, paragraph 3 states " Most patient grievances should be responded to in writing within seven (7) working days. The response must include the substance of the grievance, the steps taken to investigate the
grievance, the results of the investigation and the date of completion. The response should
also include the Recipient Rights officer's name and telephone number."

On 10/31/23 at approximately 1500, during record review of 'Grievance log', it was determined that P-27 and P-28 did not receive communications from the facility regarding the grievance process. Patient identification numbers were used to identify grievance cases, and the Risk manager Staff D was requested to produce patient names.

On 11/01/23 at 0800, the grievance names were presented and it was again confirmed that no correspondence had been sent from the facility. At this time, it was determined that P-1 had also filed a grievance and had received no correspondence from the facility.

On 11/01/23 at 1000, an interview was conducted with Service Recovery manager Staff Y and CNO staff A. Staff Y explained that complaints and grievances had previously been handled by patients using a 'button' on the facility webpage, to provide 'feedback'. Staff Y stated that it was called 'Share your experience.' Additionally, that since July 2023, it has transitioned to 'Patient Relations/ Consumer and Patient Experience. Previously, the data was managed through 'RL Datix software Sales Force,' which was changed 1 year ago on Nov. 1, 2021.
Staff Y was questioned why P-1, P-27 and P-28 did not receive correspondence after grievance. Staff Y stated, "They were erroneously listed as complaints."
Staff Y was next questioned if the grievance policy was updated to reflect changes implemented a year ago. Staff Y stated that the policy is in the approval process currently, so the facility is using the outdated policy currently. CNO Staff A added that the policy was submitted 60 days prior. Staff A was questioned if complaints/grievances were reported to the Quality team meetings. Staff A stated, "not currently." Staff A was next asked if the board approved of the grievance process. Staff A replied, "it is in process, but not signed off."


48030

On 10/31/2023 at 0900 an interview with Staff D revealed the facility did not have a complaint or grievance filed for P-3 but did present an email dated 12/27/2021 which was sent to Staff D and Staff S. The email reveals attempts were made to contact P-3 on 1/5/2022, P-3 attempted to call the facility back on 1/14/2022 and requested a call back. The final email dated 1/17/2022 from Staff D to Staff S requested a phone call be made to P-3. The facility was unable to provide any further documentation regarding the complaint and Staff D stated she did not think the follow-up was completed. Staff D stated the facility implemented a system called Salesforce on 8/23/2023 which will be used for tracking complaints and grievances. Staff D stated the facilities previous system did not work effectively at tracking the status of complaints and grievances.

Based upon observation, interview, and record review the facility failed to provide and maintain adequate physical facilities for the safety and needs all patients and was found not in compliance with the requirements for participation in Medicare and/or Medicaid 42 CFR Subpart 482.41(b), Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care, resulting in the potential for negative outcomes up to and including death in the event of a fire. Findings include:

A-0710 - Failure to comply with applicable provisions of the 2012 edition of the Life Safety Code

Based upon observation, interview, and record review the facility failed to provide and maintain adequate physical facilities for the safety and needs all patients and was found not in compliance with the requirements for participation in Medicare and/or Medicaid 42 CFR Subpart 482.41(b), Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care, resulting in the potential for negative outcomes up to and including death in the event of a fire. Findings include

A-0710 - Failure to comply with applicable provisions of the 2012 edition of the Life Safety Code.

See K-0211, K-0345, K-0353, K-0781, and K-0921.