F585
§483.10(j) Grievances.
§483.10(j)(1) The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay.
§483.10(j)(2) The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have, in accordance with this paragraph.
§483.10(j)(3) The facility must make information on how to file a grievance or complaint available to the resident.
§483.10(j)(4) The facility must establish a grievance policy to ensure the prompt resolution of all grievances regarding the residents’ rights contained in this paragraph. Upon request, the provider must give a copy of the grievance policy to the resident. The grievance policy must include:
- Notifying resident individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number; a reasonable expected time frame for completing the review of the grievance; the right to obtain a written decision regarding his or her grievance; and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system;
- Identifying a Grievance Official who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances, for example, the identity of the resident for those grievances submitted anonymously, issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations;
- As necessary, taking immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated;
- Consistent with §483.12(c)(1), immediately reporting all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator of the provider; and as required by State law;
- Ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident’s grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident’s concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued;
- Taking appropriate corrective action in accordance with State law if the alleged violation of the residents’ rights is confirmed by the facility or if an outside entity having jurisdiction, such as the State Survey Agency, Quality Improvement Organization, or local law enforcement agency confirms a violation for any of these residents’ rights within its area of responsibility; and
- Maintaining evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision.
INTENT §483.10(j)
To support each resident’s right to voice grievances (such as those about treatment, care, management of funds, lost clothing, or violation of rights) and to ensure that a policy is in place to process grievances. Facility staff are responsible for making prompt efforts to resolve a grievance and to keep the resident appropriately apprised of progress toward resolution.
DEFINITIONS §483.10(j)
“Prompt efforts to resolve” include facility acknowledgment of a complaint/grievance and actively working toward resolution of that complaint/grievance.
PROCEDURES §483.10(j)
If a resident’s response indicates problems in voicing grievances and getting grievances resolved, determine how facility staff deal with and make prompt efforts to resolve resident complaints and grievances.
- With permission from the resident council president or officer, review resident council minutes.
- Interview staff about how grievances are handled.
- How does facility staff protect residents from discrimination or reprisal when a grievance is voiced?
- How does facility staff ensure the right of the residents to file a grievance anonymously is supported?
- Interview staff about communication with resident regarding progress toward resolution of complaint/grievance.
- Review facility grievance policy to see if compliant with necessary requirements as listed above.
- Determine how information on how to file a grievance is made available to the resident.
- Review grievance decisions to determine if required information was provided to residents and facility documentation was maintained for at least 3 years.
POTENTIAL TAGS FOR ADDITIONAL INVESTIGATION
If the facility failed to allow a resident to exercise his or her right to file a grievance, including the right to file an anonymous grievance, without interference, coercion, discrimination, or reprisal from the facility, see guidance at §483.10(b)(1), F550, Resident Rights and Dignity.
If facility staff failed to report all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, see guidance at §483.12(c)(1), (4), F609, Reporting of Alleged Violations.
KEY ELEMENTS OF NONCOMPLIANCE §483.10(j)
To cite deficient practice at F585, the surveyor’s investigation will generally show that the facility failed to do one or more of the following:
- Support the resident’s right to voice any grievance without discrimination, reprisal, or the fear of discrimination or reprisal; or
- Make prompt efforts to resolve the resident’s grievance; or
- Make information on how to file a grievance or complaint available to the resident; or
- Establish a grievance policy that includes:
- Notifying the resident individually or with prominent postings throughout the facility about:
- The right to file a grievance in writing or orally;
- The right to file a grievance anonymously;
- The reasonable timeframe the resident can expect a completed review of the grievance;
- The right to obtain the review in writing;
- The required contact information of the grievance official;
- The contact information of independent entities with whom grievances may also be filed; or
- Identify the grievance official; or
- Prevent any further potential violation of any resident right during the grievance review, if necessary; or
- Immediately report certain violations as required by State law to the Administrator; or
- Ensure written grievance decisions meets documentation requirements; or
- Maintain evidence of the result of all grievances for no less than 3 years from the date the grievance decision was issued.
