Six questions to ensure your grievance process meets regulations.
Best Practices for Compliance
CMS has developed a Quality in Focus Program as a resource for all long-term care facilities nationwide. Using the Quality in Focus as the foundation, Polaris Group highlights best practices to help mitigate civil money penalties and lower high scope and severity citations related to FTag deficiencies.
F585 Grievances
The intent of this regulation is to support each resident’s right to express concerns, including those related to treatment, care, management of funds, lost clothing, or violation of rights, and to establish a procedure for addressing these grievances. Staff at the facility are responsible for promptly addressing and resolving grievances, while also keeping residents informed of the progress towards resolving their concerns.
During mock surveys, the majority of facilities are able to provide the Grievance Binder, which documents monthly complaints. However, Polaris Consultants have observed that 75% of these binders do not meet the essential requirements of F585, thus resulting in G and IJ Scope and Severity levels. To provide guidance on best practices and minimize the risk of citation under this regulation, here are some questions to help evaluate your process.
Ask These Questions to Ensure Your Grievance Process Meets Regulations
Where are your grievance forms located?
- Is there a secure way for families or residents to submit the grievance? (sealed envelope, pen/pencil readily available)
- Do you identify where to place the completed form? (under a manager’s door, in the locked grievance box)
- Do you assure in writing that the complainant that the information can be made anonymously?
Is your grievance policy current and included in the resident admission packet?
- Is your policy reviewed annually by the QAPI team?
- Is it posted in a prominent location in the facility?
- Is the name and contact information of the current grievance officer listed?
- How often do you check the location to identify if a grievance has been made?
What do you consider a reasonable time frame for completing the review of the grievance?
- Do all managers know what the facility time frame expectation is to address concerns?
- Who is assigned to initiate the response in the absence of the designated officer?
- Are all concerns reviewed at daily stand-up meetings to ensure prompt action is initiated?
Does your written grievance decision include the date the grievance was received AND the date the written decision was issued?
- Does your written grievance include all steps taken to investigate the concern?
- Does your written grievance include a statement as to whether the concern was confirmed or not?
- Does your written grievance include any corrective action taken or to be taken by the facility as a result of the grievance?
Do you take immediate action to prevent further violations of any resident right while the alleged violation is being investigated?
- Who are ‘like’ residents that the same issue could impact?
- Do you keep the resident/POA informed of the progress of the investigation? How is this documented?
- Do you ensure that your state agencies, including law enforcement, are notified in cases where a suspected violation of a resident's rights occurs, and again if the violation is subsequently confirmed?
- Do you promptly suspend the employee in question pending completion of the investigation, and do you refrain from transferring the implicated employee(s) to a different unit or wing?
Was the resident/POA satisfied with the way the concern was managed and resolved?
- Did you add the incident to the grievance log and include all information on the log?
- If appropriate, do you follow up on violation in general terms at the next Resident Council meeting?
- Do you maintain completed grievance forms for a period of no less than 3 years from the issuance of the grievance decision?
Our Polaris Consultants possess a range of resources to ensure compliance with every aspect of the Grievance regulation. If you believe that your current approach to managing F585 might be insufficient and you're uncertain about where to begin, contact us today.
