Every finding on record at Cima Hospice of the Valley LP

(THIS IS A CONTINUING VIOLATION FROM SURVEY MF3Q11 EXIT DATE 06/03/22) Based on record review and interview, the Agency’s 1 of 1 written emergency preparedness and response plan failed to include a continuity of operations business plan that addressed emergency financial needs, essential functions for client services, critical personnel and how to return to normal operations as quickly as possible for 2023 and currently in 2025. This failure could place the Agency’s active clients at risk of harm if the Agency was unable to function following an emergency or disaster. --- The findings included: On 05/14/25 at 09:00 a.m., the Adm provided Agency Emergency Preparedness Binder 2024.  Record review of the Agency’s Emergency Preparedness Binder included an organizational chart that documented the Adm as the first point of contact and the Alt Adm/DON as the second point of contact. Continued record review of the Agency’s Emergency Preparedness Binder revealed the Agency’s Emergency Preparedness policies titled, “RM.007 Emergency Preparedness Plan (EPP)”, that documented an effective date of 06/02/21, quoted in part, “[Agency] has an identified EPP (“the plan”) that describes a comprehensive approach to meeting the health, safety and security needs of our staff and client population during an emergency or disaster situation that disrupts [Agency] services…Continuity of Operations – Ensuring that the Agency continues to operate during a public health emergency. This includes but is not limited to:… Identify and prioritize essential functions and operations…Establish lines of succession…Delegation of authority…Resource Management to prioritize medical resources to meet critical needs during a public health emergency/Emerging Infectious disease…Roles and Responsibility to ensure the Agency is compliant with all applicable laws and regulations during a public health emergency/Emerging Infectious Disease (EID)…Safety and Security…Supply Chain evaluation and planning for disruptions in supply chain…” Record review of the Agency’s Emergency Preparedness Manual included an Emergency Preparedness Manual (1 of 47, 1, title page, not included), dated 01/04/24, that documented “Continuity of Operations…” This document was 47 pages in length and contained information on the Agency would return to normal operations as quickly as possible following a disaster, including the Agency’s financial needs and the essential functions for client services and critical personnel for 2024. Record review of the Agency’s Emergency Preparedness Manual failed to include a Continuity of Operations for 2023 or 2025. In a telephone interview on 05/19/25 at 03:35 p.m., the Adm identified herself as the Disaster Coordinator. The Adm stated she “did not see anything for 2023” related to the continuity of operations. The Adm stated there was nothing other than what was in the binder and that there was no excuse. The Adm stated the Agency updated the continuity of operations annually. The Adm stated the continuity of operations for 2024 was updated on 01/04/24. The Adm stated the Disaster Coordinator or the Adm who was responsible for ensuring there was a continuity of operations updated each year. The Adm stated she was not there at the beginning of 2023, but she was assigned towards the end of year. The Adm stated not having a continuity of operations could negatively affect client safety and the continuity of care. The Adm stated not having a continuity of operations could also mean the client’s safety was at risk. The Adm stated it was important to have a review of the system yearly because it could negatively affect it in a lot of ways. The Adm stated she could not “speak for why it was missing”, but it was a detriment to the Agency’s entire organization, the safety of its clients and staff. The Adm stated the continuity of operations had information that included evacuation plans, staff’s responsibilities, listed who the Disaster Coordinator and who the Alternate Disaster Coordinator was. The Adm continued to list information included on the continuity that included procedures such as response, recovery, mitigation, and implementation, communication methods with clients and staff, local contacts, and the Agency’s support system.  The Adm stated, “I know it is on me, but I don’t know where it is”.  In a simultaneous record review and interview on 05/20/25, the DON stated she was assigned as the Alt Disaster Coordinator and 2nd on the call tree in the Agency’s Emergency Preparedness in March 2025. The DON identified the Adm as the Disaster Coordinator.  The DON identified the Agency’s Emergency Preparedness Binder 2024 as the Agency’s Emergency Preparedness Plan. The DON stated the Agency used the Agency policies as the Emergency Preparedness Plan. The DON stated the continuity of operations was updated on 01/04/24. The DON stated she did not know if the Agency had a continuity of operations for 2023. The DON stated, “I could not find one for 2023, it was before my time”. The DON stated she did not know who was assigned for the position at that time. The DON stated she did not know if one was made. The DON stated the Agency was using the 2024 continuity of operations in 2025. The DON answered, “No” the continuity of operations has not been updated. The DON stated not having a continuity of operations would negatively affect client and the agency because it would be hard to organize everyone during an emergency and to make sure everyone was contacted. The DON stated, “sure it would affect client care, maybe visits could be missed, needs would be unmet, the need for oxygen, that is my first concern”. The DON stated it was the Adm to ensure the continuity of operations was completed and implemented. In a follow up telephone interview on 05/20/25 at 09:20 a.m., the Adm stated the Agency did not have an updated continuity of operations for 2025. The Adm stated she “thought” it had been updated prior to today and could updated it “now”. No further information was presented upon exit.