Encompass Health Rehabilitation Hospital of Kissim

“PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES CFR(s): 482.13(a)(2)(ii) At a minimum: The grievance process must specify time frames for review of the grievance and the provision of a response. This Standard is not met as evidenced by: 50929 Based on interview, and record review, the facility failed to ensure a process for prompt resolution of grievances, for 1 of 4 sampled patients, (#1). Findings: Patient #1 was admitted to the facility on 3/07/25 at 6:22 PM. The chief complaint was generalized weakness with a plan to continue medical management and medical oversight to improve patient’s functional independence. Patient #1 was transferred to an acute care facility on 3/14/25 at 11:40 AM, with concern for stroke, after a hypotensive (abnormally low blood pressure) episode, that required fluid resuscitation (emergent restoration of fluid volume). On 3/24/25 at 10:21 AM, patient #1’s husband sent an email to the facility’s Chief Executive Officer (CEO) regarding concerns his wife experienced while admitted to the facility. The email included concerns for poor patient care, lack of communication and family involvement in care and treatment. No additional emails were sent and patient #1’s husband was not contacted regarding the decision/resolution to the grievance. On 6/02/25 at 11:30 AM, the Chief Nursing Officer reviewed the grievance logs for March, April, and May of 2025 and stated there was only one formal grievance which was not from patient #1. On 6/03/25 at 10:44 AM, the System Director Quality & Risk Management stated, she pulled the grievance log for 2025 and did not see a grievance for patient #1 listed. On 6/03/25 at 1:27 PM, the System Director Quality & Risk Management explained patient #1’s concerns were not processed as a grievance, but should have been. She said they were unable to provide a copy of the original email sent by the complainant nor copies of any correspondence to patient #1’s husband. She acknowledged the facility was supposed to reply to the grievance within seven days and follow up in writing within 30 days. The System Director Quality & Risk Management confirmed in this case, the follow up was not done. The hospital’s polices/procedures “Patient and Customer Complaint or Grievance Policy” (Policy #8) with revision date of 8/16/24, noted the facility’s guidelines required that a “written response should be complete within seven calendar days of receipt of grievance ...if hospital CEO or designee determines the investigation is not or will not be complete within seven calendar days, he/she must provide patient/family with a verbal progress report. Hospital CEO or designee must maintain ongoing communication and complete written response within 30 days.””

“PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION CFR(s): 482.13(a)(2)(iii) At a minimum: In its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. This Standard is not met as evidenced by: 50929 Based on interview, and record review, the facility failed to notify the patient of the decision pertaining to his grievance, for 1 of 4 sampled patients reviewed for grievances, (#1). Findings: Patient #1 was admitted to the facility on 3/07/25 at 6:22 PM. The chief complaint was generalized weakness with a plan to continue medical management and medical oversight to improve patient’s functional independence. Patient #1 was transferred to an acute care facility on 3/14/25 at 11:40 AM, with concern for stroke, after a hypotensive (abnormally low blood pressure) episode, that required fluid resuscitation (emergent restoration of fluid volume). On 3/24/25 at 10:21 AM, patient #1’s husband sent an email to the facility’s Chief Executive Officer (CEO) regarding concerns his wife experienced while admitted to the facility. The email included concerns for poor patient care, lack of communication and family involvement in care and treatment. No additional emails were sent and patient #1’s husband was not contacted regarding the decision/resolution to the grievance. On 6/02/25 at 11:30 AM, the Chief Nursing Officer reviewed the grievance logs for March, April, and May of 2025 and stated there was only one formal grievance which was not for patient #1. On 6/03/25 at 10:44 AM, the System Director Quality & Risk Management stated she pulled the grievance log for 2025 and did not see any grievance for patient #1 listed. On 6/03/25 at 1:27 PM, the System Director Quality & Risk Management explained patient #1’s husband’s concerns were not processed as a grievance. She said they were unable to get a copy of the original letter sent from patient #1 nor copies of any correspondence sent back to patient #1’s husband. She acknowledged the facility had not followed up with the husband by notifying him of the grievance decision as required. The hospital’s polices/procedures “Patient and Customer Complaint or Grievance Policy” (Policy #8) revised 8/16/24, noted the facility’s guidelines required that a “written response should be complete within seven calendar days of receipt of grievance ...if hospital CEO or designee determines the investigation is not or will not be complete within seven calendar days, he/she must provide patient/family with a verbal progress report. Hospital CEO or designee must maintain ongoing communication and complete written response within 30 days.””