Health inspection·March 20, 2024

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on record review and interviews, the facility failed to ensure a response to a billing grievance was responded to for one (Resident #1) of two residents reviewed for grievance process of thirteen sampled residents. Findings included: An interview was conducted on 03/19/2024 at 12:09 p.m. with a family member of Resident #1. The family member stated she was able to review the Medicaid Access Portal, which showed the resident's patient liability to be $1751.07 per month. The family member stated she overpaid, and she wanted a refund for the overpayment and the facility was sending her bills. The family member stated she called Business Office Manager (BOM) (former) about the billing error. The family member said she e-mailed a copy of the Notice of Case Action to (BOM/former), she stated the date on the e-mail was January 8th, 2024. Continuing, she stated I have not heard back, but I received another bill yesterday for $58.37. A record review of the business account for Resident #1, the Activity Report, documented on 01/08/2024, recd (received) call from [family member], she feels that we have the incorrect pt (patient) liab (liability); checked flmmis (Florida Medicaid Management Information System) and it matches our system, she is reaching out to DCF (Department of Children and Families.) An interview was conducted on 03/20/2024 at 4:45 p.m. with the Regional Business Office Manager (RBOM). She confirmed Resident #1 was currently being sent a bill for $58.37. The $58.37 was for one day in September 2023. Resident #1's bed had been held while he was in the hospital, Medicaid had been billed, and the last day of the bed hold was 09/02/2024. The RBOM confirmed the resident's family member had called in 01/2024 and by the notes in the account activity, the family member had questioned the patient liability. The RBOM confirmed the patient liability had changed from 08/2023 to 09/2023, but she did not know the reason for the change. When asked if the business office writes grievances for billing issues, the RBOM stated, maybe if the resident was current and he states he does not understand his bill, but, typically the concern is taken care of in the business office notes. The RBOM stated the former BOM took her vacation and left two weeks ago, and the RBOM confirmed she could tell from the business activity notes if the family member had been followed up with. A review of the facility's policy and procedure, Complaint/ Grievance, N-1042, last revised 10/24/2024, documented the policy: the Center will support each resident's right to voice a complaint/ grievance without fear of discrimination or reprisal. The center will make prompt efforts to resolve the complaint/ grievance and informed (sic) the resident of progress towards resolution. Page 1 of 2 105587 105587 03/20/2024 Aviata at Countryside 3825 Countryside Blvd N Palm Harbor, FL 34684

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Grievances will be reviewed by the Quality Assurance Performance Improvement Committee .The Center will inform residents of the right to file a grievance orally and in writing, the right to file grievances anonymously, the contact information of the Grievance Officer, a reasonable time frame for completing the review of the grievance, the right to obtain a written decision regarding the grievance, and contact information of independent entities with who grievances may be filed (State agency, Ombudsman, Quality Improvement Organizations. The Executive Director will designate a Grievance Officer at the facility. Procedure: 1. An employee receiving a complaint/grievance from a resident, family member and/ or visitor will initiate a Complaint/ Grievance form . 2. Original grievance forms are then submitted to the Grievance Officer/ designee for further action. 3. The Grievance Officer/ designee shall act on the grievance and begin follow up of the concern or submit it to the appropriate department director for follow-up. 4. The grievance follow-up should be completed in reasonable time frame; this should not exceed 14 days. 5. The findings of the grievance shall be recorded on the Complaint/ Grievance Form. 6. The results will be forwarded to the Executive Director for review and filing. 7. The Grievance Official will log complaints/ grievances in Monthly Grievance log. 8. The individual voicing the grievance will receive follow up communication with the resolution, a copy of the grievance resolution will be provided to the resident upon request. 105587 Page 2 of 2