Every finding on record at Asana Hospice Cleveland, LLC

Based on review of emergency preparedness documents and staff interview, the agency failed to ensure the emergency preparedness plan included a combined facility-based and community-based risk assessment for the entire service area. This could affect all patients receiving services from the agency. The census was 87 patients. Findings include: --- Review of the emergency preparedness documents revealed an emergency preparedness plan and risk assessment for the parent office in Berea and the counties served from the parent office and a separate emergency preparedness plan and risk assessment for the Ontario multiple location office and the counties served from the satellite office. The findings were verified in an interview with Staff B on 12/14/22 at 3:30 PM. Staff B stated emergency preparedness was completed separately for each office and not done together for all locations.

Based on document review and staff interview, the agency failed to ensure all staff completed emergency preparedness training on hire and maintained documentation of the training for 11 of 41 staff and volunteers (Staff C, D, G, H, I, J, K, L, M, N, and O). This could affect all patients receiving services from the agency. The census was 87 patients. Findings include: --- Review of the emergency preparedness documentation revealed a lack of documentation of emergency preparedness training for Staff C, D, G, H, I, J, K, L, M, N, and O. In an interview on 12/15/22 at 2:00 PM, Staff B verified that the emergency preparedness training could not be located for the above staff. Staff B stated that these were all staff hired in the last year or volunteers. Staff B stated the emergency training was only verbal during orientation and was not documented.