Every finding on record at Care and Comfort Hospice Inc

Upon personnel record review, 3 of 11 (Personnel #1, 3, 4) did not have evidence Emergency Preparedness training including: • Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles • Demonstrate staff knowledge of emergency procedures • Provide emergency preparedness training at least annually • Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others • Maintain documentation of all emergency preparedness training Personnel 1, 3, 4: No evidence of training for emergency preparedness.

Upon personnel record review, 3 of 11 (Personnel #1, 3, 4 ) did not have evidence the hospice employees and contract employees have received orientation on the hospice philosophy.

Upon contract review, 1 of 4 (Alt MD) did not have evidence of a contract to fulfill the role of medical director or alternate medical director, if applicable. Upon arrival there was no Medical Director Designee and/or contract. The agency corrected this and a contract was in place and personnel file available for review.

Upon patient client record review, 5 of 5 (Patient #1, 2, 3, 4, 5) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient #1, 2, 3, 4, 5: The Election Statement utilized by the agency does not clearly identify the effective date. The agency reportedly practices the patient signature date as the date of the election. The Election Statement does not identify patient's choice of physician. The choice of physician was recorded on a separate form.

Upon patient client record review, 1 of 5 (Patient #2) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #2: 11/28/22 MSW Visit note is conflicting. Included in narrative "Patient is calm and relaxed at the time of the home visit. Patient has suicidal ideations at the time of the home visit." .... "Patient is not presenting any crisis at the time of home visit." DPCS reports that MSW must have meant that patient has NO suicidal ideations.

Upon observation, there was no evidence the organization follows their policies and procedures to maintain the the patient's clinical record in confidential manner. During home visit to patient #2, noted that Medication profile for Patient #1 was in patient information packet there. The list was not used by caregiver.

Upon client record review, 1 of 5 (Patient #3) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed. Patient #3: The signature pages for verification of policies/procedures for managing controlled drugs was not signed/date by patient.

Upon observation, there was no evidence the organizational chart matches the hospice's information submitted to CMS and/or State licensing agencies for ownership and management personnel. There was no evidence the HSP furnish updated information to CMS, state agencies and ACHC at intervals between recertification, or re-enrollment, or contract renewals, within 30 days of a written request or change in authority, ownership or management. Current Administrator/DPCS is not consistent with License application.