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Kelly’s Regulatory Corner 

This month we will be looking at one of the tags in the Resident Rights regulatory group, F585 Grievances.

What’s Required

Per SOM Appendix PP F585, residents have the right to voice grievances to either the facility or other entity/agency that hears grievances without fear of discrimination or reprisal (or actual discrimination or reprisal). Areas that could be grieved are comprehensive, but per the regulation, include:

  • Care and treatment provided
  • Care and treatment not provided
  • Staff behavior
  • Behavior of other residents
  • Other concerns regarding the resident’s stay at the facility

Once the resident makes a grievance, it is their right to have it resolved promptly. The facility is required to make “prompt efforts to resolve” the grievance, which includes the facility acknowledging the complaint/ grievance and actively working towards a resolution.

The Grievance Officer

The Grievance Officer is the individual who is designated to oversee the entire grievance process. That includes receiving and tracking grievances from initial complaint(s) through resolution. This person is also responsible for conducting any investigations related to the grievance, if necessary. At Mission Point, our Grievance Officer is the facility Administrator.

How to File a Grievance

The regulation states that residents should be notified individually or through prominent postings in the facility of their right to file grievances orally or in writing, and that the grievance can be filed anonymously. Contact information for the Grievance Officer must be included, as well as contact information for independent entities that can hear a grievance, such as the State LTC Ombudsman Program or State Survey Agency. Residents must also be informed of their right to obtain a written decision regarding their grievances, and what the expected time frame for reviewing the grievance is.

Please consider posting this information on all unit resident information bulletin boards not just in the lobby area – not everyone can leave their unit to go to the lobby area. Another idea that works well is near the elevator or in the elevator itself if you have an information board there.

Mission Point has a draft “contact information” form on SharePoint for facilities to personalize and post throughout the facility. Mission Point also uses “Concern Forms” to document grievances and a “tracking log” to track them for compliance – both documents are also available on SharePoint > Policies & Procedures.

Reporting Requirements

This regulation states that all alleged violations of neglect, abuse and/or misappropriation of resident property will be immediately reported, consistent with the reporting requirements at F609 and per State law.

Written Grievance Decision

Providing the written grievance decision is where many teams forget to close the loop. There are specific items per regulation that need to be included in the document, including:

  • Date grievance received
  • Summary statement of resident’s grievance
  • Steps taken to investigate
  • Summary of pertinent findings/conclusions regarding the concerns raised by the resident
  • Statement as to whether the grievance is confirmed or not confirmed
  • Any corrective actions to be taken as a result of the grievance
  • Date the written decision was issued

If completed in its entirety, the Mission Point “Concern Form” will prompt all the above information.

Don’t forget – the results of all grievances must be retained for at least 3 years.

The intent of this regulatory requirement is to ensure that teams have a process in place that addresses the residents right to voice their concerns and have any grievance be acknowledged and processed by the facility in a timely manner. It’s important to complete this process within appropriate time frames and provide information regarding the outcome to the resident.


-Kelly Dines, VP of Clinical Operations