Every finding on record at Friendly Hospice Care, Inc.

Observed in Emergency Management Session. The organization’s continuity of operations plan did not identify in writing how and where it will continue to provide its essential business functions when the location of the essential or critical service has been compromised due to an emergency or disaster incident. This was discussed with the Administrator.

Observed in Emergency Management Session. The organization’s staffing plan did not address the management of all staff and volunteers as follows: reporting processes; roles and responsibilities for essential functions; integrating staffing agencies, volunteer staffing, or deployed medical assistance teams into assigned roles and responsibilities; verifying the identity and licensures of volunteer practitioners (such as nurses, respiratory therapists, physical therapists). This was discussed with the Administrator.

Observed in Patient Home. In 1 of 3 home visits conducted, The organization had not followed a written policy that addresses the security of health information, including access, use, and disclosure.the organization had not protected against unauthorized disclosure of health information. During RRHV#2, the nurse discovered that she had left the updated medication list for this patient at the home of RRHV#1 during that visit. This was discussed with the Administrator.

Observed in Record Review. In 1 of 6 patient records reviewed, the hospice had not conducted and documented a patient-specific comprehensive assessment that identified the patient’s need for hospice care and services. In the chart for RRHV#1, the patient's primary diagnosis was recurrent major depression, yet a depression assessment was not conducted nor was a suicide risk assessment conducted. This was discussed with the Administrator.

Observed in Record Review. In 1 of 6 patient records reviewed, the written plan of care was not based on the patient’s goals and the time frames, settings, and services required to meet those goals. In the chart for RRHV#1, the psychosocial goals were assessment statements, not measurable goals: Patient is undecisive regarding code status. Patient does not wish family involvement. Patient declined to discuss funeral arrangements. The patient was at risk for falls and had oxygen ordered during the admission visit. The plan of care did not include any goal related to the fall risk and oxygen safety risks. This was discussed with the Administrator.

Observed in Record Review. In 1 of 6 patient records reviewed, the plan of care did not include all services needed for the palliation and management of the terminal illness and related conditions, including the following: treatment necessary to meet the patient’s needs. In the chart for RRHV#1, the patient was found to be at risk for falls and oxygen was ordered upon admission. While education about oxygen safety and fall risk prevention was documented by the nursing staff, the plan of care did not include any interventions regarding these safety needs. This was discussed with the Administrator.

Observed in Patient Home. In 2 of 3 home visits conducted, the organization had not provided the patient with care, treatment, or services according to the patient's individualized plan of care. During RRHV#1, it was discovered that there were no comfort pack medications in the patient's home. They had been ordered upon admission to the organization more than six weeks prior to the survey. Upon review of records, it was discovered that the organization had never ordered the medications from the pharmacy as confirmed with the Administrator. During RRHV#2, it was discovered that the oral Tylenol, Tylenol suppositories and Bisacodyl suppositories ordered as part of the comfort pack medications were not in the patient's home. Again, it was confirmed with the Administrator that the medications had not been ordered from the pharmacy.

Observed in HR File Review. In 1 of 1 HR files reviewed, for a hospice aide, the supervisor had not evaluated the following areas by observing a home health or hospice aide's performance of the tasks with a patient or pseudo-patient as part of a simulation: - Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other staff - Reading and recording temperature, pulse, and respirations - Appropriate and safe techniques in personal hygiene and grooming that include bed, sponge, tub, or shower bath; sink, tub, or bed shampoo; nail and skin care; oral hygiene; toileting and elimination - Safe transfer techniques and ambulation - Normal range of motion and positioning. In the file for HR6, the competency evaluation for all of the required elements were documented as having been completed on the date of hire, prior to the organization admitting a patient. It was confirmed with the Administrator that the assessment was not conducted on a patient or pseudo-patient, rather a verbalization and demonstration in the office of the agency.

Observed in HR File Review. In 1 of 8 HR files reviewed, the organization had not obtained a criminal background check on the applicant as required by law and regulation or organization policy. A criminal background check was not documented in the file for HR4 as confirmed with the Administrator and Office Manager.