Every finding on record at Creative Hospice Care, Inc

Based on review of complaint log, staff interviews, and review of the policy titled, ";Resolution of Patient Conflicts, Grievances or Complaints" it was determined that the Administrator failed to provide adequate oversight, monitoring and ensuring the agency managed and maintained a complaint log. --- Findings include: Review of the policy titled "Resolution of Patient Conflicts, Grievances or Complaints " RI.25, dated 01/2022. revealed the following: Procedure IV. The Hospice will follow State guidelines for documentation of the receipt of the complaint/grievance and the initiation of a complaint investigation. VI. Documentation will include, but not limited to the names, address and phone number of the person filing the complaint, the nature of the complaint, and the remedy /relief the person is seeking. VII. the hospice will complete the investigation and documentation of the resolution per state guidelines upon receipt of the complaint. VIII. The hospice will involve the patient, caregiver, representative and /or the patients healthcare provider as appropriate to reach a resolution. XII. all actions taken, and follow-up performed will be documented on the complaint form as well as reported to the management staff. The agency failed to provide a complaint log which was requested on 5/28/2024. A telephone interview was conducted with Clinical Manager (CM) on 5/29/2024 at 10:45 am, revealed that a request was brought to CM's attention by CNA AA. CM verbalized that they do not have evidence of any complaints recorded in the electronic record nor in the actual complaint binder. CM verbalized that an investigation was not conducted on CNA AA's request. On 5/29/24 at 12:51 pm., a telephone interview was conducted with CNA BB, who verbalized that an allegation on CNA AA was reported to the Administrator and CM several times in the month of April 2024. CNA BB stated that an office visit was made on 5/2/2024 with the Administrator and reported the allegation. An onsite interview was conducted on 5/29/2024 at 2:00 p.m., with the Administrator and the Regional Administrator. During the interview it was revealed that the agency did not have a complaint log and the Administrator verbalized that they do not have evidence of any complaints recorded in the electronic record nor in the actual complaint binder. The Administrator additionally verbalized that CNA BB reported an allegation, and they did not investigate the reason for CNA AAs request. An allegation that was brought to their attention was not investigated as per complaint policy.

Observed in Emergency Management Session. EOP did not have a process for cooperation and collaboration with the local, state, tribal, regional and federal emergency preparedness officials

Observed in Emergency Management Session. The organization had not participated in a full-scale exercise that was community -based in past two years.

Observed in Record Review. the surveyor found that wound measurements had not been documented per organization policy. For example wound measurements had been recorded on 12/11/23 and then not again until 1/6/24 and then not again until 2/20/24. The issue was discussed and confirmed with organization leadership.

Observed in Document Review. the surveyor found that the organization had not begun to collect data on hand hygiene. The organization had set goals for hand hygiene, but had never collected or analyzed any data on hand hygiene. This was discussed and confirmed with organization leaders.

Observed in Tracer Activities. In 2 of 3 patient records reviewed, for bereavement the surveyor found that bereavement care plans had not been developed and documented to include specific, individualized interventions, and the timing and frequency were the same exactly for all levels of bereavement risk. The bereavement coordinator informed surveyor that the organization had been without bereavement coordinator from June 2023 til he was hired in September of 2023 and while mailouts for bereavement occurred during that time frame care plans did not and nothing but mailouts occurred .

Observed in HR File Review. The organization had not provided documentation of orientation of two contracted staff RNs hired 1/2024 related to specific job duties. The two contracted RN's had been working unassisted with hospice patients for weeks. The issue was discussed and confirmed with organization leadership.

Observed in HR File Review. In 2 of 9 HR files reviewed, the surveyor found that competencies had not been documented. The surveyor observed that 2 contracted RN staff members hired 1/2024 and actively working in field with patients did not have initial competencies documented. The issue was discussed and confirmed with organization leadership.

Observed in Record Review. the surveyor found that the organization had not sent discharge summary to the hospital the revoked patient was sent to for broken hip. The surveyor discussed and confirmed with organization leadership that no documents had been sent to the hospital the patient was transported to for broken hip.