Every finding on record at El Sinai Hospice and Palliative Care LLC

Upon observation of the Hospice's Emergency Preparedness Plan, there was not documented evidence that the Hospice had established strategies for addressing those emergency events, as identified by the Hazard Vulnerability Risk Assessment, as most likely to occur within the Hospice's services area(s); including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the Hospice's ability to provide care.

Upon patient record review, 1 of 5 (Patient #1) did not contain documented evidence that the Comprehensive Assessment included a Bereavement component, which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death.

Upon patient record review, 1 of 5 (Patient #5) did not contain evidence that the Plan of Care included all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. The Physician-signed Hospice Plan of Care included the following, "Patient has a 16F Foley Catheter in place". The order does not include the balloon size, when/by whom does the catheter need to be changed out, or any irrigation details, if any. The Plan of Care included the following, "Gastrostomy Tube. Patient is receiving IsoSource parenteral feedings 1/2 can T.I.D. per family report." There is no indication as to whether the site is to be left open to air, covered with a dressing requiring changing, nor who is responsible for monitoring the insertion site.

Upon patient record review, 1 of 5 (Patient #1) did not contain evidence that the Plan of Care included all services necessary for the palliation and management of the terminal illness and related conditions, to include equipment and supply needs. During the Surveyor-attended home visit on 08/09/22, the patient/caregiver reported a hospital bed and over-bed table, and a bed-side commode. None of these DME were included on the POC.

Upon patient record review, 1 of 5 (Patient #1) did not contain evidence that the IDG had ensured that the care and services were provided only in accordance with the Plan of Care. The SOC RN Assessment documented, "Nurse instructed patient/family on non-pharmacological pain relief measures, to include use of hot/cold packs." There was no order for this interventions on the Hospice Plan of Care to include the frequency of intervention, duration, or method of application.

Upon personnel record review, 1 of 8 applicable (Personnel #9) did not contain evidence that this Hospice employee had received an orientation on the Hospice Philosophy.