The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

Based on staff interview and review of facility documents, it was determined that facility staff failed to ensure that the facility's complaint and grievance policy was followed related to the written response grievance resolution process for thirty-four (34) out of one hundred and eighty-one (181) reported grievances.

Findings included:

A review of the facility's complaint and grievance log for the time period from 7/1/19 through 1/21/2020 revealed one hundred and eighty-one (181) reported grievances. Nine (9) of the grievances on the log which had not been documented as resolved were still within the 21 day response timeframe. Fifty-eight (58) of the remaining grievances on the log did not have a documented resolution date which fell within the 21 day timeframe. Of the aforementioned fifty-eight (58) grievances which had not been resolved within 21 days, twenty-four (24) were related to billing issues. Thirty-four (34) grievances which were not related to billing issues fell outside the 21 day timeframe for resolution, as described in the facility's policy and procedure.

Staff Member (SM) #1, Patient Safety Director, was interviewed on 1/28/2020 at 9:00 a.m., and the surveyor held a discussion related to the number of grievances which had exceeded the 21 day resolution timeframe, as specified in the facility's complaint and grievance policy. SM #1 replied that the facility has realized that grievances are not always closed within 21 days as specified in the policy, but that "the investigations are robust, and physicians sometimes also review, depending on what needs to be reviewed". SM #1 also added that billing information doesn't "drop" for six (6) weeks, so those complaints can not be resolved in the specified time frame. SM #1 told the surveyor that staff "communicates with the complainant throughout the process, and do our best to document that communication".

The surveyor randomly selected a grievance from the log and walked through it with SM #1. SM #1 was able to demonstrate that, although the grievance was not resolved within the 21 day timeframe, there was documentation of communication with the complainant throughout the facility's investigative process. SM #1 told the surveyor that that they review all letters before they go out to complainants, and that SM #31, Patient Advocate, talks with the family and or patients, and that SM #1 bridges the gap.

Concerns related to the grievance policy time frame expectation not being met with a large number of cases on the grievance log were discussed with SM #1 as noted above, and with SM #7, Vice President of Quality, on 1/30/2020 at approximately 2:30 p.m.

The facility's complaint and grievance policy, last revised 10/17/17, was reviewed and included the following information, in part, related to the grievance resolution process: "...2. Upon receipt of a grievance, the Patient Advocate shall confer with the appropriate department manager to review, investigate and resolve with the patient and/or patient representative within seven (7) days of receipt of the grievance with the exception of complaints that endanger the patient (i.e., abuse or neglect). These grievances should be reviewed immediately given the seriousness of the allegations and the potential for harm to the patient. A representative of the administrative staff will oversee and assist with the resolution process as needed. Medical staff leadership may be involved as needed to resolve physician delivery of care issues. 3. Occasionally, a grievance is complicated and may require an extensive investigation. If the grievance will not be resolved, or if the investigation is not or will not be completed within seven days, the complainant should be informed that the facility is still working to resolve the grievance and that the facility will follow-up with a written response within 21 days...".