Every finding on record at Care Partners

Based on review of policy and procedures, it was determined the facility failed to include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. --- Findings:Review of the document titled, "EMERGENCY / DISASTER MANAGEMENT Policy Number: AD.E10" and dated last revised 05-2024, lacked evidence that a process for cooperating and collaborating with local, tribal, regional, State, and Federal emergency preparedness officials during a disaster or emergency situation is part of the agency emergency response.During interview with the Executive Director and Medical Director on 10/24/2025 beginning at 11:00 AM, the above finding was presented and acknowledge.

Based on personnel file review, and staff interview it was determined the hospice failed to ensure that an initial orientation and/or signed job description addressing the employee's specific duties had been documented for each staff member in 9 of 14 employee files reviewed. --- Findings:Review of the personnel files of employees #1, #2, #3, #4, #5, #6, #7, #8, #9, and #14 revealed that each personnel file was lacking documentation to reflect each employee received an initial orientation or had a signed job description of their specific job duties.Employee #1 record review revealed a hire date of 08/22/2025. At the time of the personnel file review conducted on 10/15/2025 and 10/22/2025, the file lacked evidence of a signed job description and an orientation for a new employee of their specific duties.Employee #2 record review revealed a hire date of 02/03/2025. At the time of the personnel file review conducted on 10/15/2025 and 10/22/2025, the file lacked evidence of a signed job description and an orientation for a new employee of their specific duties.Employee #3 record review revealed a hire date of 04/22/2024. At the time of the personnel file review conducted on 10/15/2025 and 10/22/2025, the file lacked evidence an orientation for a new employee of their specific duties.Similar findings were found in the employee files of employee #4, #5, #6, #7, #8, #9, and #14.During interview with the Executive Director and Medical Director on 10/24/2025 beginning at 11:00 AM, the above findings were discussed. The Executive Director acknowledged the employee files lacked orientation and on-boarding education, and/or competency and skill evaluations of Employees #1, #2, #3, #4, #5, #6, #7, #8, #9, and #14. The Executive Director stated, "We are adjusting to staff changes and I'm sure we have the records, but they can't be found right now."

Based on interview and medical record review, it was determined the hospice failed to include individualized measurable outcomes anticipated from implementing and coordinating the plan of care for 11 of 13 patient care plans reviewed (Patients #1, #3, #4, #5, #6, #7, #8, #10, #11, #12, and #13). Findings include: 1. Review of the document titled "Interdisciplinary Care Plan" for Patients #1, #3, #4, #5, #6, #7, #8, #11, and #13 revealed for each patient a problem of "Spiritual Supporting" with a goal of "Patient achieves feelings of spiritual comfort." The care plan lacked information regarding what "achieves" meant for each patient and how this would be measured. 2. Review of the document titled "Interdisciplinary Care Plan" for Patients #1, #4 and #11 revealed for each patient a problem of "Pain Management" with the goal of "Patient/family will express satisfactory control of symptoms." The care plan lacked information regarding what "satisfactory control " meant for each patient and how this would be measured. 3. Review of the "Interdisciplinary Care Plan" for Patients #6, #7, #8, #10, and #12 revealed for each patient a problem of "Altered Bowel Function" with the goal of "Patient will maintain optimum bowel functioning consistent with food intake and stage of disease process." The care plan lacked information regarding what "optimum" meant for each patient and how this goal would be measured. 4. Review of the "Interdisciplinary Care Plan" for Patients #3, #6 and #12 revealed for each patient a problem of "Spiritual And Emotional Support" with the goal "Patient/caregiver will feel needs are being met as they have defined." The care plan lacked information regarding what each patient's "needs" were and how this goal would be measured. During the exit conference on 9/19/2022 at 1:00 PM, the above findings were presented. The CEO, QCM, DON, DCP, CFO, DPSC, and HR Specialist were informed that during medical record review, it was noted that many care plans contained the same goal statements and lacked outcome statements of individualization and measurable components for each patient. The CEO, QCM, and DON acknowledged the above findings without question or comment.