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5/24/2010 Survey Tag 0765 Detail for:
PIKES PEAK DIALYSIS CENTER
Wednesday, October 23, 2019 12:17 AM

Survey Date: 5/24/2010

Regulation Number:0765

Regulation Title: GOV-INTERNAL GRIEVANCE SYS ID/IMPLEMENTED

Regulation Description: The facility's internal grievance process must be implemented so that the patient may file an oral or written grievance with the facility without reprisal or denial of services. The grievance process must include- (1) A clearly explained procedure for the submission of grievances. (2) Timeframes for reviewing the grievance. (3) A description of how the patient or the patient's designated representative will be informed of steps taken to resolve the grievance.

Surveyor Findings:


Based on review of facility documents and staff interviews, the facility failed to keep a record of patient grievances. This failure created the potential for not addressing patient's issues, and violating the patient's rights.

The findings were:

On 5/20/10 at approximately 10:45 a.m., an interview was conducted with the facility administrator. S/he stated that the facility hasn't kept records of patient complaints since 2008. S/he explained that this was due to a change in administration and was improving since April, 2010.

A review of the facility's patient grievance log took place on 5/20/10 at approximately 10:30 a.m. The earliest entry available was for 4/1/10 and was one of two grievances that made up the entire patient grievance log for 2009 and 2010.

Facility Plan of Correction:

V765
All teammates were in-serviced on the grievance policies #3-01-06 “Patient Grievance”, #3-1-06A “Addressing Patient Grievances: DaVita Teammates” and #3-01-6B “Patient Grievance Procedure” on 06/10/2010 with instructions on how to address and document these issue. Grievances logs are now located at the North RN station, South RN station, SW office and FA office. All individual grievances will be addressed by the FA or designee within 10 days of receipt. Findings will be discussed by the IDT at weekly core team meetings and also reviewed and documented in QIFMM. FA is responsible for ongoing compliance with POC.


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Colorado Department of Public Health and Environment
Health Facilities and Emergency Medical Services Division
4300 Cherry Creek Drive South
Denver CO 80246-1530
Email us or phone 303.692.2800 main

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