DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		 (X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER		 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED
101537 A. BUILDING __________
B. WING ______________ 		10/29/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
EMERALD COAST HOSPICE 401 E 23RD ST, STE C, PANAMA CITY, FL, 32405
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation
LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE

 TITLE

 (X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
(X4) ID
PREFIX
TAG		 SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY SHOULD BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
L0505      
37965 Based on record review and interview, the hospice failed to respond and resolve grievances or complaints made to hospice staff by patients or patient representatives for 5 of 5 patients reviewed. (1, 2, 3, 4 & 5) The findings include: On 10/29/19 at approximately 7:53 AM, an interview was conducted with the daughter of patient #1 during which she stated the resident had an incident on 10/16/19 in which he sustained a skin tear to his right wrist. She stated that she had complained to the case manager (Employee D) about the Hospice Health Aides (HHA) (staff members A & C) being rough and had requested the hospice not allow the home health aides to return to the patient home. She stated she also spoke with the nurse supervisor (Staff member E) and requested to file a formal complaint against the two aides involved in the incident however was told "no". She was informed the hospice would change the staff who were providing bathing assistance for her father. She stated she did not hear back from the hospice before her father passed away. On 10/29/19 the hospice was asked to provide a list of complaints that had been filed by patients or their representatives in the last 90 days. Review of the Event Summary report provided by the Manager of Clinical Practice failed to reveal a complaint filed by the daughter of resident #1. Further review of the document revealed 3 complaints related to the home health aides being rough (resident #2 on 10/23/19; resident #3 8/21/19; and 4 on 8/12/19) and 1 complaint related to the aide being "loud and rude" (#5 on 8/9/19). Of the complaint reports reviewed none offered documentation of follow up as evidenced by the "Follow Up Comments" section of the forms being left blank. On 10/29/19 at approximately 12:52 PM, an interview was conducted with staff member D, a registered nurse Case Manager during which she stated the resident's family had complained to her about staff members A & C, both HHA, being rough with resident #1 which she reported right away to staff member E, a supervisor. She stated the HHAs did not go back to the house after the incident. She further stated that complaints against staff are not put into the electronic reporting system only falls and antibiotics. She stated that when there is a complaint about hospice staff she calls the office and the supervisors handle it from there. On 10/29/19 at approximately 1:48PM, an interview was conducted with the two Clinical Managers (staff members E & F, both RNs) during which they stated that when a family member or caregiver calls the office with a complaint against staff the supervisor taking the complaint puts it into the system however if the family voices the complaint to field staff the employee hearing the complaint should put it into the computer reporting system. The staff have been told about the need to put the complaints in themselves when they encounter issues however this continues to be a problem. The issue involving resident #1 was addressed on the incident log related to the skin tear however the family's complaint about the HHA's being rough was not put into the system. Both managers stated they were aware of the situation and the family's concerns with the two HHAs however neither of them put into the system or followed up with the family. They reported the HHAs assignments were changed but the resident passed away shortly after the change was made. They further reported that after a complaint is received the hospice team meets immediately to follow up and discuss the issues. They do not have a process in which the family is contacted regarding their satisfaction with the resolution. On 10/29/19 at approximately 3:41 PM, an interview was conducted with the Manager of Clinical Practice. She stated that she reviews the complaint report daily and had not seen the complaints related to the HHAs being rough until today. She further stated that staff should bring complaints to the supervisors, then the supervisors need to come up with a plan to fix it in a timely manner. Currently the complaint form is generated by the managers after the field staff call the office with the complaint however the supervisors should be telling the staff to put the concerns into QI events - the electronic reporting system. She reported that she is aware that the complaints are not being put in and that she has sent e-mails and offered to train anyone who is unsure how to access the system. She reported they have staff meetings monthly and this issue has been discussed stating "I bring this up a lot". She further stated that she was aware of resident #1's family concerns with the HHA but that there is no complaint documented, clarifying "It has not been done". She stated that these need to be done immediately and that the manager or anyone on the management team should follow-up and resolve the family's or patient's concerns. Currently there is nothing in writing for any of the complaints being addressed or resolved but "there should be". Review of the Policy No 2-006 "Complaint/Grievance Process" states that the hospice staff member who has received a complaint related to patient care will discuss, verbally and in writing, the grievance with a supervisor. The supervisor is then to investigate the grievance within 5 days and make every effort to resolve the grievance to the patient's satisfaction. Response to the patient regarding the complaint will occur within 10 days. The policy goes on to state that a record of complaints received will be kept with documentation to include: the name of the complainant, the relationship to the patient, the nature of the complaint and the action taken to resolve the complaint.
L0560      
37965 Based on interview and record review, the hospice agency failed to develop, implement and maintain a Quality Assurance and Performance Improvement (QAPI) program to identify and investigate concerns, and develop, monitor and evaluate interventions to improve patient care and services. The findings include: On 10/29/19 the hospice was asked to provide a list of complaints that had been filed by patients or their representatives in the last 90 days. The Manager of Clinical Practice provided a copy of the Event Summary report for the dates of 8/30/19 to 10/29/19. The review revealed of the 11 complaints filed 3 complaints related to the home health aides (HHA) being rough (resident #2 on 10/23/19 - HHA A); resident #3 8/21/19 and 4 on 8/12/19 - HHA B and C) and 1 complaint related to the aide being "loud and rude" (#5 on 8/9/19 - HHA B). Of the complaint reports reviewed none offered documentation of follow up as evidenced by the "Follow Up Comments" section of the forms being left blank. On 10/29/19 at approximately 3:41 PM an interview was conducted with the Manager of Clinical Practice. She stated she started her position in July and there had only been one Quality Assurance Performance Improvement (QAPI) meeting since she started her position. She stated that she reviews the complaint report daily and had not seen the complaints related to the HHAs being rough until today. She stated there is not a performance improvement plan in place for the concerns however they are planning a meeting with the HHAs next week and will be offering some on-line trainings. She further stated that staff should bring complaints to the supervisors, then the supervisors need to come up with a plan to fix it in a timely manner. Currently the complaint form is generated by the managers after the field staff call the office with the complaint however the supervisors should be telling the staff to put the concerns into QI events - the electronic reporting system. She reported that she is aware that the complaints are not being put in and that she has sent e-mails to address the need to put complaints in timely and has offered to train anyone who is unsure how to access the system. She reports they have staff meetings monthly and this issue has been discussed stating "I bring this up a lot". She further stated that she was aware of resident #1's family concerns with the HHA but that there is no complaint documented, clarifying "It has not been done". She stated that these need to be done immediately and that the manager or anyone on the management team should follow-up and resolved the family's or patient's concerns. Currently there is nothing in writing for any of the complaints being addressed or resolved but "there should be". Review of the national Hospice and Palliative Care Organization (NHPCO) Hospice Stands of Practice retrieved from www.nhpco.org/hospice-care-ocerview/hospice-stands-of-practice/ revealed that "Patients and families have the right to have their complaints heard and addressed."; "The hospice has a process in place that is initiated whenever a complaint is received to work toward a resolution of the complaint. The hospice documents this process and resolution, including follow-up performed with the patient/family/caregiver." And that "Complaints are tracked and regularly reviewed to identify any patterns or tends." "Staff members are educated about the complaint resolution process and accept responsibility for helping to identify and address complaints."
L0652      
37965 Based on record review and interview, the Hospice failed to provide Hospice Health Aide (HHA) services that are consistent with accepted standards of practice for 5 of 5 sampled patients as evidenced by: (1) failure to ensure that the complaints voiced by patients and caregivers were addressed and resolved; (2) failure to ensure that HHA treated residents with respect. (Residents #1, 2 3, 4, & 5). The findings include: On 10/29/19 at approximately 7:53 AM, an interview was conducted with the daughter of patient #1 during which she stated the resident had an incident on 10/16/19 in which he sustained a skin tear to his right wrist. She stated that she had complained to the case manager (Employee D) about the HHA (staff members A & C) being rough and had requested the hospice not allow the home health aides to return to the patient home. She stated she also spoke with the nurse supervisor (Staff member E) and requested to file a formal complaint against the two aides involved in the incident however was told "no" but was informed the hospice would change the staff who were providing bathing assistance for her father. She stated she did not hear back from the hospice before her father passed away. On 10/29/19 the hospice was asked to provide a list of complaints that had been filed by patients or their representatives in the last 90 days. Review of the Event Summary report provided by the Manager of Clinical Practice failed to reveal a complaint filed by the daughter of resident #1. Further review of the document revealed 3 complaints related to the HHAs being rough (resident #2 on 10/23/19 - HHA A); resident #3 8/21/19; and 4 on 8/12/19 HHA B and C) and 1 complaint related to the aide being "loud and rude" (#5 on 8/9/19 - HHA B). On 10/29/19 at approximately 1:48PM,, an interview was conducted with the two Clinical Managers (staff members E & F, both RNs) during which they stated that when a family member or caregiver calls the office with a complaint against staff the supervisor taking the complaint puts it into the system however if the staff get the complaint they should put it into the computer reporting system. The staff have been told about the need to put the complaints in themselves when they encounter issues however this continues to be a problem. The issue involving resident #1 was addressed on the incident log related to the skin tear however the family's complaint about the HHA's being rough was not put into the system. Both managers stated they were aware of the situation and the family's concerns with the two HHAs however neither of them put into the system. They reported the HHAs assignments were changed but the resident passed away shortly after the change was made. They have been talking to the HHAs about the need to slow down and be of the hospice mindset "you don't' have 30 patients you don't have to rush". Staff member E reported that she had observed the HHAs in the field and offered re-education to them regarding the need to slow down however she reported the observations and re-education is not documented but they have been doing it. After a complaint the hospice team meet immediately to follow up and discuss the issues. They do not have a process in which the family is contacted regarding their satisfaction with the resolution. They reported that there will be a training on Tuesday next week (11/5/19) called "tender touch" during the monthly HHA meeting. They are not a part of the QAPI meetings. On 10/29/19 at approximately 2:45 PM, an interview was conducted with staff member C, a HHA, during which she stated that she had not been called back to the office for in-services or to talk about being too rough with patients. On 10/29/19 at approximately 2:55 PM, an interview was conducted with staff member B, a HHA, during which she stated she has not been re-educated on care since she started in her position 4 months ago. She also stated that if a family does not want you to go back "you don't go back" but it was nothing she did wrong. On 10/29/19 at approximately 3:25 PM, an interview was conducted with staff member A, a HHA, during which she stated that she got a call from the office saying she was "going too fast" and was offered tips on providing care. But that was right after she stated, 5 months ago, and that she has not been told of any concerns since then. She stated she was told about a staff change related to resident #1 but that it was because of the skin tear not about her being rough. On 10/29/19 at approximately 3:41 PM, an interview was conducted with the Manager of Clinical Practice. She stated she started her position in July and there had only been one Quality Assurance Performance Improvement (QAPI) meeting since she started her position. She stated that she reviews the complaint report daily and had not seen the complaints related to the HHAs being rough until today. She stated there is not a performance improvement plan in place for the concerns however they are planning a meeting with the HHAs next week and will be offering some on-line trainings. She further stated that staff should bring complaints to the supervisors, then the supervisors need to come up with a plan to fix it in a timely manner. Currently the complaint form is generated by the managers after the field staff call the office with the complaint however the supervisors should be telling the staff to put the concerns into QI events - the electronic reporting system. She reported that she is aware that the complaints are not being put in and that she has sent e-mails to address the need to put complaints in timely and has offered to train anyone who is unsure how to access the system. She reports they have staff meetings monthly and this issue has been discussed stating "I bring this up a lot". She further stated that she was aware of resident #1's family concerns with the HHA but that there is no complaint documented, clarifying "It has not been done". She stated that these need to be done immediately and that the manager or anyone on the management team should follow-up and resolved the family's or patient's concerns. Currently there is nothing in writing for any of the complaints being addressed or resolved but "there should be". Review of the national Hospice and Palliative Care Organization (NHPCO) Hospice Standards of Practice retrieved from https://www.nhpco.org/hospice-care-overview/hospice-standards-of-practice/ revealed that "Patients and families have the right to have their complaints heard and addressed. Ethical Behavior and Consumer rights (EBR) 3.1 The hospice has a process in place that is initiated whenever a complaint is received to work toward a resolution of the complaint. The hospice documents this process and resolution, including follow-up performed with the patient/family/caregiver." EBR 4: The hospice acknowledges and respects each patient's and family/caregiver's rights and responsibilities. These include "Being treated with respect"