Every finding on record at Tlc Hospice LLC

Based on record review and interview the agency failed to follow procedures and thoroughly investigate complaints/grievances and communicate resolution to patients and/or representatives for 3 (P [patient] 1, P3, P5) out of 7 (P1-P7) patients. --- A. Record review of agency policy titled, ";Complaint/Grievance Process" dated October 2014 on page 1 under ";Procedure" it states, ";1. The organization staff member receiving the complaint will discuss, verbally and in writing, the grievance with a supervisor within five (5) days of the alleged grievance. The supervisor will investigate the grievance within five (5) days after receipt of such grievance and will make every effort to resolve the grievance to the patient's satisfaction. Response to the patient regarding the complaint will occur within ten (10) days of receipt. . . . 6. Resolution information will be communicated in writing to the patient or his/her representative filing the complaint." B. Record review of the agency document titled, ";[Name of facility] Complaint Log" reveals a complaint involving P1 dated 06/09/22 the complaint is logged as, ";Abuse allegation by CNA [Certified Nursing Assistant] and DON [Director of Nursing] @ [at] [name of facility]." The date resolved is 06/13/22 the resolution states, ";Investigation by police – unsubstantiated." C. During an interview on 03/01/2023 at 12:15 PM with Staff (S)1, DON (Director of Nursing) when asked if there was any communication with patient or representative regarding the complaint on 06/09/2022 involving P1 it was stated, ";No, we werent allowed to talk to the daughter or the patient." S1 confirmed that there was no written communication to the patient or representative regarding a resolution to the complaint. No evidence of written communication was produced. D. Record review of the agency document titled, ";[Name of facility] Complaint Log" reveals a complaint involving P3 dated 01/16/23 the complaint is logged as, ";Pt [patient] missing wallet and check books" The date resolved is 01/20/23 the resolution states, ";Son states – pt has wallet." E. During an interview on 03/01/2023 at 12:15 PM with S1, DON when asked if there was any follow-up regarding the complaint on 01/16/23 involving P3 it was explained that the patient calls the cops, and the cops notify the facility. S1 confirmed there was no written communication to the patient or representative regarding a resolution to the complaint. No evidence of written communication was produced. F. Record review of the agency document titled, ";[Name of facility] Complaint Log" reveals a complaint involving P5 dated 08/08/22 the complaint is logged as, ";Do not want nurse [nurses name] in home." The date resolved is 08/09/22 the resolution states, ";Family discharged per their request." G. During an interview on 03/01/2023 at 12:15 PM with S1, DON when asked if there was any follow-up regarding the complaint on 08/08/22 involving P5 it was confirmed there was no written communication to the patient or representative regarding a resolution to the complaint. No evidence of written communication was produced.

Based on record review and interview the facility failed to conduct performance improvement projects based on needs of the hospices population and reflect the scope, complexity, and past performance of the hospices services. This failed practice could cause a negative effect on patient care and outcomes for all patients. --- Findings are: A. Record review of facility policy titled ";Improving Organizational Performance, Policy No. 5-001.1" revised November 2021, states, ";Procedure: 1. Senior management will: F. Assure that each performance improvement activity contains the following elements: 1. Description of the indicator(s)/activities to be conducted. 2. Frequency of activities. 3. Designation of responsible party. 4 Method(s) of data collection. 5. Acceptable limits for findings. 6. Who will receive the report. 7. Follow-up plans if findings fail to meet acceptable limits including plan(s) of correction." B. Record review of facility policy titled ";[facility name] 2022 QAPI [Quality Assessment Performance Improvement] PROGRAM" dated July 28, 2022, states ";QAPI Program: 13. QAPI activities must include a performance project, an ongoing monitoring of at least one important aspect related to the care provided. C. Record review of ";Worksheet to Create a Performance Improvement Project [PIP] Charter" dated 08/01/2023. ";Project Overview, Name of Project: Comprehensive pain assessment completed and individualized care plan in place for every patient on admission and reviewed at IDG [Interdisciplinary Group] meeting. Problem to be solved: Every patient will have a care plan in place at admission which addresses pain. .. Background leading up to the need for this project: Audit completed. Updated care plans addressing pain not addressed every 14 days. Team members: none listed. Project Approval: No names or signatures listed." D. During an interview with Staff (S)1 on 03/01/2023 at 11:41 am, when asked to provide meeting minutes for PIP in place none could be provided. When asked to provide any further documentation of PIP, none could be provided.

Based on record review, staff interview and review of the agency's policies and procedures, the agency failed to ensure the patient's comprehensive assessment was completed by the Master Social Worker (MSW) and/or the Chaplain within five days of the patient's election of coverage for seven of nine record requiring completion of the assessment (Patient (P)2, P3, P4, P5, P6, P7 and P11). Failure to assess the psychosocial and/or spiritual/bereavement needs of each patient had the potential to cause an absence of interventions needed for the well-being and comfort of all 35 patients and family members currently receiving services from this agency. --- Review of P2's Electronic Medical Record (EMR) in the "Patient Profile" section revealed a date of election of coverage of 04/20/21. Review of the "Benefits Period Manager" for the initial period starting 04/20/21, under the "POC (Plan of Care)" tab showed Chaplain services were ordered for two to three times per month. Review of the "Benefits Period Management" section under the "Chaplain" tab showed the initial assessment was dated 04/27/21. Review of P3's EMR in the "Patient Profile" section revealed a date of election of coverage of 09/08/21. Review of the "Benefits Period Manager" for the initial period starting 09/08/21, under the "POC" tab showed MSW services were ordered for one to two times per quarter. Review of the "Benefits Period Management" section under the "MSW" tab showed the initial assessment was completed on 10/26/22. Review of P4's EMR in the "Patient Profile" section revealed a date of election of coverage of 11/30/22. Review of the "Benefits Period Manager" for the initial period starting 11/30/22, under the "POC" tab showed MSW services were ordered for one time per month. Review of the "Benefits Period Management" section under the "MSW" tab showed the initial assessment was completed on 12/06/22. Review of P5's EMR in the "Patient Profile" section revealed a date of election of coverage of 12/03/21. Review of the "Benefits Period Manager" for the initial period starting 12/03/21, under the "POC" tab showed MSW services were ordered for two times per month. Review of the "Benefits Period Management" section under the "MSW" tab showed the initial assessment was completed on 07/22/22. Review of P6's EMR in the "Patient Profile" section revealed a date of election of coverage of 08/02/22. Review of the "Benefits Period Manager" for the initial period starting 08/02/22, under the "POC" tab showed MSW services were ordered for one time per month and Chaplain services were ordered for one time per month. Review of the "Benefits Period Management" section under the "MSW" tab showed the initial assessment was completed on 08/24/22. Review of the "Chaplain" tab showed the initial assessment was completed on 08/22/22. Review of P7's EMR in the "Patient Profile" section revealed a date of election of coverage of 02/24/22. Review of the "Benefits Period Manager" for the initial period starting 02/24/22, under the "POC" tab showed MSW services were ordered for one to two times per month and Chaplain services were ordered for one to two times per month. Review of the "Benefits Period Management" section under the "MSW" tab showed the initial assessment was completed on 03/07/22. Review of the "Chaplain" tab showed the initial assessment was completed on 03/07/22. Review of P11's EMR in the "Patient Profile" section revealed a date of election of coverage of 01/13/22. Review of the "Benefits Period Manager" for the initial period starting 01/13/22, under the "POC" tab showed MSW services were ordered for one to two times per month. Review of the "Benefits Period Management" section under the "MSW" tab showed the initial assessment was completed on 02/14/22. During an interview with the Chief Executive Officer (CEO) and Director of Nursing (DON) on 01/13/23 at 12:15 PM, the above documentation was reviewed and found to be complete. The CEO and DON confirmed the comprehensive assessments required by the MSW and Chaplain were not completed in a timely manner as per agency expectation and policy. The most recent relevant agency policies were requested. Review of the agency policy titled, "Comprehensive Assessment," last revised November 2021, revealed, "A comprehensive patient assessment will be performed by the interdisciplinary group no later than 5 calendar days after the election of hospice care in consultation with attending physician." Review of the agency policy titled, "Interdisciplinary Group Membership and Responsibilities," last revised November 2021, revealed. "The hospice interdisciplinary group membership includes at a minimum: Physician (A doctor of medicine or osteopathy; Registered nurse; Social Worker; Pastoral or other counselor...The interdisciplinary group responsibilities include but are not limited to: Participation in the establishment of the plan of care for each patient admitted to the hospice service."

Based on record review, staff interview and review of the agency's policies and procedures, the agency failed to ensure services were provided as ordered in the Plan of Care (POC) for two of eleven patient records reviewed (Patient (P)2 and P5). Failure to provide services deemed necessary for the comfort and well-being of each patient had the potential leave patient needs unmet for all 35 patients currently receiving care from this agency. --- Review of the Electronic Medical Record (EMR) of P2, in the "Benefits Period Manager" section for the benefit period 12/11/23 through 02/08/23, under the "Nursing" tab, the "Aide Plan of Care" revealed the Home Health Aide (HHA) was scheduled to visit P2 for care twice a week. Review of the "Aide" tab revealed the HHA documented completed visits one time per week for the four weeks 12/11/23 through 01/07/23. No documentation was found indicating the reason for the missed visits. Review of the EMR of P5, in the "Benefits Period Manager" section for the benefit period 11-28-23 through 01/11/23, under the "POC" tab revealed the Skilled Nurse (SN) was scheduled to visit P5 two times a week, and the social worker (MSW) was schedule to visit P5 two times a month. Review of the SN visits under the "Nursing" tab revealed the SN visited P5 once weekly during the weeks 11/19/22 through 01/11/23. Review of MSW visits under the "MSW" tab revealed the MSW made no visits to P5 during the same benefit period. No documentation was found indicating the reason for the missed visits. During an interview with the Chief Executive Officer (CEO) and Director of Nursing (DON) on 01/12/23 at 12:25 PM, the above documentation was reviewed and found to be complete. The CEO and DON agreed the frequency of visits scheduled for P2 and P5 were not met as scheduled in the POC. The most recent agency policy was requested. Review of the agency's policy titled, "Scope of Services," last revised November 2021, revealed, "Routine home visits will be provided according to the plan of care including scope and frequency."