Every finding on record at Falcon South Plains Hospice LP

Based on observation, record review, and interview the agency failed to provide each patient with a written statement on how to exercise his/her right to voice grievances that informed the patient, as required, on how to contact HHSC, and if applicable agency staff for 1 of 4 patients (Pt #1- only interviewable patient) for which home visits were conducted (Patient #1, #2, #3 & #4) in that: The agencys policy given to patients was inaccurate on what state agency to file a grievance/complainant with. This failure placed Patient #1 as well as other patients at risk of being unable to file a complaint due to confusion regarding the correct state entity to report complaints and would delay resolving a patients complaint leaving them at risk of abuse, neglect or exploitation. --- Findings Included: Review of the clinical record for Patient #1 revealed a start of care date of 10/13/20203. The plan of care was reviewed for the certification period 08/08/2024 – 10/06/2024. During a concurrent home visit and interview with Patient #1 on 12/3/2024 at 11:15 a.m. Pt #1 was interviewed, and surveyor asked if she had a complaint regarding the agency or agency staff what would she do. Pt #1 stated, ";I dont know. I guess call them (agency)." Surveyor asked if she received an admission booklet with information about how to file complaints. Pt #1 stated ";Yes, but I dont know where it is. My daughter probably has it." Review of the agencys new client admissions documents contained a booklet that read, ";CONSUMER COMPLAINT REPORTING- By signing below, I acknowledge that I have been informed that I may register a complaint about (Agency) and/or its employees, including complaints concerning the advance directive requirements to the: Texas- Department of Aging and Disability Services at 1-800-458-9858." Review of the agencys online policies and procedures read, ";PATIENT RIGHTS & RESPONSIBILITIES ADDENDUM, Section 1.0 HOS-FED-TX, 06172024. At the time of admission, an agency must provide a client (patient) who receives licensed home health services, licensed and certified home health services, hospice services, or personal assistance services, with a written statement that informs the client that a complaint against the agency may be directed to HHCS Complaint and Incident Intake, P.O. Box 149030, Austin, Texas 78714-9030, toll free 1-800-458-9858." During an interview on 12/2/2024 at 11:25 a.m. with the Alternate Administrator and Area Director of Clinical Operations, the new patient admission packet was reviewed. The Alternate Administrator and Area Director of Clinical Operations acknowledged the patient rights information up to date. Alternate Administrator confirmed all clients received the same information booklet regarding where to file complaints. During a telephone interview on 12/10/204 at 4:08 p.m. with the Alternate Administrator, surveyor asked when the patient admission booklet was created, and distribution began. The Alternate Administrator stated, ";January 2023 was when we began using this booklet."