|(a) Written policies, procedures, and actual practices
shall demonstrate that there is a formal grievance process to address
residents' complaints about their treatment and facility services.
(b) The formalized grievance process shall include
the following policy, procedural, and practice elements:
(1) Staff members shall not deny a resident the opportunity
to submit a grievance upon request, unless doing so would interfere
with the safety and security of the facility.
(2) Residents shall have full access to the grievance
process, including forms and methods of submission. If the resident
cannot read or otherwise understand the grievance process, a staff
member or translator shall read and explain the process to the resident.
(3) A written response and resolution shall be provided
to the resident no later than:
(A) 10 calendar days after the date the grievance is
received by pre-adjudication staff; or
(B) 30 calendar days after the date the grievance is
received by post-adjudication staff.
(4) Documentation of the resident's acknowledgment
of the resolution shall be maintained.
(5) Grievances shall be confidential, with access limited
to those involved in providing responses and administrative review.
Retaliation against residents for filing a grievance shall be prohibited.
(6) At least one grievance officer shall be designated
(7) Residents shall be provided at least one level
of appeal to a supervisory-level or above staff person or to an administrative-level
appeals board or panel. A supervisory-level staff person who provided
the initial response or who is named in the grievance shall not provide
the appeal response.
(8) Residents shall have the ability to participate
in the resolution of a grievance, including the use of an intermediary
and the ability to request witnesses.
(9) A supervisory-level or above staff person shall
conduct periodic formal reviews of the grievance process and dispositions
and maintain documentation of this review.
(10) The facility shall maintain a tracking system
and grievance log that documents:
(A) each grievance submitted;
(B) the grievance disposition;
(C) whether the grievance was appealed; and
(D) the appeal disposition, if applicable.
(11) The facility administrator or designee shall review
any unresolved grievances submitted by residents who have been released
to determine if any action is needed.