Every finding on record at Comfort Care Hospice

Observed in Emergency Management Session. The organization did not evaluate the effectiveness of its Emergency Operations Plan. During the Emergency Management Session, it was noted the organization had implemented its Emergency Operations Plan (EOP) in response to actual emergencies, but had not completed and documented an evaluation of its EOP. This was reveiwed and confirmed with the Administrator/Director of Patient Care Services. Observed in Emergency Management Session. The organization did not complete/document the evaluation of all emergency response exercises and/or responses to actual emergencies, including the identification of deficiencies and opportunities for improvement. This was reveiwed and confirmed with the Administrator.

Observed in Infection Control System Tracer. The organization did not identify risks for acquiring and spreading infection based on analysis of its surveillance activities and other infection control data. During the infection control tracer discussion, it was noted the organization had an established policy, process, and template for conducting an Infection Control Risk Assessment annually. Leaders indicated the risk assessment/analysis had not been completed and documented according to organizational policy. This was reviewed and confirmed with the Administrator/Director of Patient Care Services.