| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 017024 | (X3) Date Survey Completed 12/29/2021 |
| Name of Provider or Supplier Southeast Alabama Homecare, Llc | Street Address, City, State 3813 Ross Clark Circle, Suite 300, Dothan, AL | |
| For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency. | ||
| (X4) ID Prefix Tag | Summary Statement of Deficiencies
(Each deficiency should be preceded by full regulatory or LSC identifying information) |
| G0432 | Make complaints to the HHA CFR(s): 484.50(c)(3) Make complaints to the HHA regarding treatment or care that is (or fails to be) furnished, and the lack of respect for property and/or person by anyone who is furnishing services on behalf of the HHA; This ELEMENT is not met as evidenced by: Based on review of agency policy and procedure and interviews with staff, it was determined the agency failed to follow their policy for complaint investigation and documentation of complaints, their investigation and follow-up through resolution. This affected 1 of 1 Medical Record (MR) reviewed with Intravenous (IV) administration and wound care who was discharged for cause. This affected MR # 1 and had the potential to affect all patients who are admitted to this home health agency. Findings include: Agency Policy: Grievance Procedure, Patient Complaints Policy Number: 1.007 Revised date: 11/1/21 Purpose: To establish a process for patient, caregivers...to communicate areas of concern in regard to patient care and services as well as an internal process to investigate, address findings and follow-up with the individual who initiated the concern. Policy ...The agency will investigate complaints made by the patient, legal representative, caregiver, and/or family... Procedure: 1. Staff receiving complaints either in person, by phone, or through the mail shall document the patient complaint. Agencies will document the complaint with the information system: the Executive Director or Clinical Director will receive an automated workflow regarding the complaint for follow-up. 2. The Executive Director or Clinical Director interviews the patient, family, and involved staff or other individuals and takes appropriate actions to resolve the issue. ...5. After the investigation and analysis is completed, but no later than 30 days after the complaint/grievance filing, the Executive Director or Clinical Director will follow-up with the patient and/or complainant and document within the information system... 6. Agencies can access the complaint report within the information system. Any supporting documentation regarding the complaint should be kept in a confidential file. 1. The surveyor was provided the agency complaint log on 12/28/21 by Employee Identifier (EI) # 1, Executive Director. Review of the agency complaint log on 12/29/21 revealed no documentation of a complaint related to MR # 1, a patient admitted to the agency on 7/31/21, recertified for continued care from 9/29/21 to 11/27/21, who had been receiving Intravenous infusion and wound care services from the agency and was discharged for cause on 10/24/21. An interview was conducted with EI # 1 who was asked if the agency had received a complaint involving MR # 1. EI # 1 stated, "I think the mother/father called and there was an email to return his/her call. Then it escalated. I think she/he would call continuously... I think (EI # 6, Office Manager) talked to him/her since I was out of the office. EI # 1 was asked if there was documentation of the call. EI # 1 stated, "No, I never talked to her/him." An interview was conducted with EI # 6 who was asked if the agency had received a complaint involving MR # 1. EI # 6 stated, "Yes...about discharge from service. I told her/him she/he would need to speak to (EI # 1 Identified), she/he was in the (another agency location identified), she/he was talking about she/he couldn't understand why we called DHR (Department of Human Resources). She/He talked to me about (agency nurse identified), she thought (agency nurse identified) was a friend, she told me about the drinking and she/he could only take a sip or two and would be intoxicated. She/He said she was going to call state. She/He called several times, that day was after the DHR complaint and she/he was mad. She/He was on her/his way to meet DHR at the house." EI # 6 was asked what happened with the complaint after then. EI # 6 stated, "I told her/him I would reach out to EI # 1 and let him/her know what the complaint was....I called EI # 1 and let him/her know everything that had been said on the call. EI # 6 was asked if the complainant verbalized she/he wanted to speak with EI # 1 during the call. EI # 6 stated, "yes." Due to the call not being documented there is no documentation of the date of the complainant's call. . |