Every finding on record at Comforting Home Hospice,Inc.

Observed in Emergency Management Session. On Review of the written Emergency Management plan it had been identified that the plan had not addressed/ described the patient population served by the organization and the extent to which additional populations might be cared for during an emergency based on the organization’s capabilities (staff, space, supplies, equipment). This was validated by the DON. Observed in Emergency Management Session. On review of the written emergency management plan it was identified that although the organization had defined a succession plan list, the plan had not addressed a delegation of authority that described the decisions and policies that could be implementer by the authorized successors during the emergency and criteria or triggers that would initiate this delegation. This was validated by the DON.

Observed in Individual Tracer. In 2 of 11 patient records reviewed, it was identified that the chaplain had not completed the spiritual assessment within the required five days. For example, for RR # 5 the assessment was done 8 days after the admit date. For RR # 7 the assessment was done 6 days after the admit date. There was no additional documentation to explain the delayed spiritual assessments. This was validated by the DON.

Observed in Individual Tracer. In 11 of 11 patient records reviewed, it was identified that the Chaplain had not developed a plan of care for the patients. On review of all eleven records no spiritual POC had been done after the assessment. This was validated by the DON.

Observed in Individual Tracer. In 1 of 11 patient records reviewed, it was identified that orders/IDG approval had not been obtained. On review of the record it was documented that the patient had a healing wound on their right eyebrow, and the nurse had performed wound care on two different weeks in March 2022. ( Cleanse with NS, pat dry, apply trip antibiotic and cover with kerlix and tap). There were no orders or IDG approval found for this wound care. This was validated by the DON.