Every finding on record at Community Care Hospice LLC

Based on review of the Emergency Preparedness Program (EPP), the Hospice failed to develop and maintain an emergency preparedness plan that includes a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach and include strategies for addressing emergency events identified by the risk assessment. This deficient practice has the potential to place patients at risk for harm or injury during an emergency situation. --- Review of the Emergency Preparedness Program on 01/24/24 between 1:00 PM and 4:30 PM revealed that there was no documented, facility-based and community-based risk assessment, utilizing an all-hazards approach that included strategies for addressing emergency events identified by the risk assessment.

Based on policy review the Hospice failed to develop and maintain an emergency preparedness plan (EPP) that includes 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. This deficient practice has the potential to place patients at risk for harm or injury during an emergency situation. --- Review of the Emergency Preparedness Program policies and procedures on 01/24/24 between 1:00 PM and 4:30 PM revealed that the facility did not have a plan in place for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials. The facility did not have evidence that contact had been made with these entities at the time of survey.

Based on policy review the Hospice failed to develop and implement policies and procedures to track the location of on-duty staff and sheltered patients in the facilitys care during an emergency. This deficient practice has the potential to place patients and staff at risk for harm or injury during an emergency situation. --- Review of the Emergency Preparedness Program policies and procedures on 01/24/24 between 1:00 PM and 4:30 PM revealed that there were no policies and procedures in place to track the location of on-duty staff and patients in the facilitys care during an emergency at the time of survey.

Based on document review the Hospice failed to document Letters of Agreement with other agencies, facilities, and vendors for the continuation of care in the event of an emergency. This deficient practice has the potential to place patients at risk for harm or injury during an emergency situation. --- Review of the Emergency Preparedness Program on 01/24/24 between 1:00 PM and 4:30 PM revealed that there was no documentation available at the time of survey of Letters of Agreement with other agencies, facilities, and vendors for the continuation of care in the event of an emergency. During an interview on 01/24/24 between 2:30 PM and 4:30 PM, the Director, Director of Education, and the Director of Compliance revealed that proof of the hospice's arrangements with other agencies, facilities, and vendors for the continuation of care in the event of an emergency was available but would need to be located in the digital shared point drive, however the agency failed to provide the documentation.

Based on policy review the Hospice failed to develop and implement policies and procedures which included a communication plan which included the names and contact information for the hospice employees, entities providing services under arrangement, patients' physicians and other hospices. This deficient practice has the potential to place patients at risk for harm or injury during an emergency situation. --- Review of the Emergency Preparedness Program on 01/24/24 between 1:00 PM and 4:30 PM revealed that there was no documentation within the communication plan available at the time of survey which included the names and contact information for the hospice employees, entities providing services under arrangement, patients' physicians or other hospices for the Emergency Preparedness Program.