Every finding on record at Divine Angels Hospice

Observed in Emergency Management Session. During a review of the organization's Emergency Operations Plan, it was noted that the emergency response contact list did not include the following organizations: 1) Entities providing services under arrangement, including suppliers of essential services, equipment, and supplies; 2) Relevant community partners (such as fire, police, local incident command, public health departments); and 3) Relevant authorities (such as federal, state, tribal, regional, and local emergency preparedness staff). This observation was reviewed with agency leadership.

Observed in Record Review. In 4 of 10 patient records reviewed, 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, during a review of the consent in the medical record for RRHV#2, the Line titled “Designation of Attending Physician” did not include the provider's complete name. Example #2: The organization did not ensure the patient’s right to choose an attending provider was implemented. For example, during a review of the consent in the medical record for RRNHV#2, RRNHV#4, and RRNHV#6, the Line titled “Designation of Attending Physician” was left blank. This observation was reviewed with agency leadership.

Observed in Record Review. In 1 of 10 patient records reviewed, it was noted that the organization did not ensure the plan of care goals included outcome measures for specific care activities. For example, a review of the medical record for RRHV#2, revealed that the patient’s terminal illness diagnosis was Senile Degeneration of Brain. The plan of care did not include a goal statement to evaluate the response to care, treatment, and services related to the diagnosis Senile Degeneration of Brain. This observation was reviewed with agency leadership.

Observed in Record Review. During a review of 1 of 2 Bereavement records it was noted that all requirements were not implemented. For example, a review of RRBR#1, revealed that a Bereavement plan of care that included specific, individualized interventions, and the timing and frequency of those interventions was not completed. This observation was reviewed with agency leadership.

Observed in Individual Tracer. During 1 of 4 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, an individualized disaster/emergency management plan was not identified. This observation was reviewed with agency leadership.