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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 21, 2025
Corrected date: May 20, 2025
Citation Details Based on observations, interviews, and record review conducted during the Recertification Survey completed 9/30/22, it was determined that the facility did not post, in a manner accessible and understandable to residents and resident representatives, the pertinent contact information for the State Long-Term Care Ombudsman Program and the State Agency Complaint Hotline number, including a statement that the resident may file a complaint. The findings are: The Homestead Group Committee Meeting Minutes dated (MONTH) 15, 2022, (MONTH) 12, 2022, and (MONTH) 9, 2022, included that the Ombudsman contact information was provided, that pamphlets were available from Social Work and that posters (with the information) were located at entrances to the facility. During an interview on 9/28/22 at 11:17 a.m., the Resident Council President stated they were not allowed off their units, so they were unable to see the posters with contact information on them. When observed on 9/28/22 at 12:03 p.m., the required postings were not located at the entrance to the building on the ground floor. The State Agency Complaint Hotline number was located in the Administration hallway and the Ombudsman contact information was not located. When interviewed on 9/29/22 at 1:50 p.m., the Administrator stated that the required postings were available in two different parts of the building, the hallway outside of the Administration offices (not a hallway that resident's normally pass through) and outside of the Social Work office between units one and two. The Administrator also stated that the Ombudsman contact information was discussed monthly at the Resident's Council meeting. In an observation on 9/29/22 at 2:03 p.m., the area outside of the Social Work office did not contain any postings of the State Long-Term Care Ombudsman Program or the State Agency Complaint Hotline number. 10NYCRR 415. 3(d)(3) | Plan of Correction: ApprovedApril 11, 2025 I. Immediate Corrections ??? Grievances provided Resident #1's Emergency Contact. Written documentation was provided per request, and the concerns were addressed in alignment with the facility's Grievances Policy. Follow-up communications were also conducted to ensure the complainant was informed of the outcome and resolution. II. Identification of Other Residents ??? A full-house grievance audit was conducted. This review confirmed that all grievances submitted during the specified period were fully investigated, resolved, and appropriately closed out. ??? Interviews with residents and/or their emergency contacts confirmed satisfaction with the resolutions. ??? ??? Documentation was provided to those who requested it, demonstrating transparency and adherence to grievance protocol. III. Systemic Changes ??? The Facility Grievance Policy was reviewed, and no revisions were necessary. Upon review, it was determined that the policy remains comprehensive, current, and in full compliance with 42 CFR § 483. 10(j). Nevertheless, as a proactive measure, all facility Social Workers were re-educated on the policy to reinforce expectations regarding grievance documentation, resolution timelines, and communication with residents and families. IV. QA Monitoring ??? The Director of Social Work or designee will conduct a weekly audit for 4 weeks then a monthly audit for an additional two months to ensure that all grievances are completed in the appropriate time frame and if a copy of the grievance is requested it will be provided. ??? Audit results will be presented to the QAPI committee during the quarterly meetings. The QAPI committee will review the findings and determine if any further corrective action or policy enhancement is warranted. Person Responsible: Director of Social Services |