Every finding on record at Comfort Care Hospice, LLC

Observed in Emergency Management Session. During the Emergency Management session, a review of the organization’s Emergency Operations Plan (EOP) revealed that a staffing plan that included the following information was not developed: The management of all staff and volunteers reporting process, roles and responsibilities for essential functions, integrating staffing agencies, volunteer staffing, or deployed medical assistance teams into assigned roles and responsibilities, and verifying the identity and licensures of volunteer practitioners (i.e. nurses). This observation was reviewed with the agency leadership team. Observed in Emergency Management Session. During the Emergency Management session, a review of the organization’s Emergency Operations Plan (EOP) revealed that a staffing plan that included the following information was not developed: 1) Methods for contacting off-duty staff, 2) Acquiring staff from its other health care facilities, and 3) Use of volunteer staffing, such as staffing agencies, and those deployed as part of the disaster medical assistance teams. This observation was reviewed with the agency leadership team.

Observed in Emergency Management Session. During the Emergency Management session, a review of the organization’s Emergency Operations Plan (EOP) revealed that an emergency response contact list was not developed to include the following: 1) Staff, 2) Physicians and other licensed practitioners, 3) Volunteers, 4) Other health care organizations, 5) Entities providing services under arrangement, including suppliers of essential services, equipment, and supplies; 6) Relevant community partners (such as fire, police, local incident command, public health departments); and 7) Relevant authorities (such as federal, state, tribal, regional, and local emergency preparedness staff). This observation was reviewed with the agency leadership team.

Observed in Record Review. In 3 of 3 Individual Tracers, it was noted that the organization did not ensure that the Hospice Election and Consent Form(s) were completed as required. The organization did not ensure the patient's right to choose an attending provider was implemented. For example, a review of the consent form in the medical record for RRHV#1, RRHV#2, and RRHV#3, revealed that a section for the patient and or the patient’s caregiver to choose an attending physician was not present on the form. This observation was reviewed with the Administrator and the Director of Nursing.

Observed in Individual Tracer. In 3 of 3 Individual Tracers, it was noted that the organization did not ensure the plan of care goals included outcome measures for specific care activities. For example, during a review of the medical record for RRHV#1, the following goal statement(s) were noted, “Patient family needs to be met and coping appropriately”, and “Patient will maintain patent airway”. The goal statement(s) did not include a method to measure the effectiveness of problem interventions. Example #2: During a review of the medical record for RRHV#2, the following goal statement was noted, “Reducing the risk for falls. Reducing the risk for injury. Maintain a safe environment.” The goal statement did not include a method to measure the effectiveness of problem interventions. Example #3: During a review of the medical record for RRHV#3, the following goal statement was noted, “To provide care that gives the patient dignity and respect comfort and symptom management in the dying process. This observation was reviewed with the Administrator and the Director of Nursing.

Observed in Individual Tracer. In 3 of 3 Individual Tracers, the organization did not ensure that a copy of its written policies and procedures on the management and disposal of controlled medications was provided to the patient or the patient’s representative and family. For example, during RRHV#1, RRHV#2, and RRHV#3, it was noted that each patient was currently taking a controlled medication. A copy of the organizations written policies and procedures related to the management and disposal of controlled medications was not present in the home folder. This observation was reviewed with the Administrator and Director of Nursing.

Observed in Individual Tracer. During 3 of 3 Individual Tracers, the Hospice Surveyor was not able to validate that a plan to provide education regarding procedures to follow if care, treatment, or services are disrupted by a natural disaster or an emergency was established. For example, during a review of patient education information in the home for RRHV#1, RRHV#2, and RRHV#3, an individualized disaster/emergency management plan was not identified. This observation was reviewed with the Administrator and the Director of Nursing.