Every finding on record at Holy Rosary Healthcare

Observed in Emergency Management Session. It was identified during the review of the Emergency Operations Plan for hospice services, and in discussion with the Hospice Manager, the organization had not described the roles and responsibilities of leaders and staff during an emergency. This was reviewed and validated with the Hospice Manager and Hospice Director.

Observed in Emergency Management Session. It was identified during the review of the Emergency Operations Plan for hospice services, and in discussion with the Hospice Manager, the organization had not made arrangements with another hospice organization in the event that it cannot serve its own customers as the result of an emergency. This was reviewed and validated with the Hospice Manager and Hospice Director.

Observed in HR File Review. In 1 of 9 hospice personnel charts reviewed, there was no evidence that staff competence was assessed and documented in the last three years. Identified in the review of the personnel chart for HR3, there was no competency assessment completed in 2020, 2021, or 2022. This was reviewed and validated with the Hospice Manager.

Observed in Tracer Activities. The organization did not provide education and training to the patient based on condition and assessed needs. During the review of the hospice admission packet, it was identified that there was no symptom management education provided to patients/patient caregivers. This was reviewed and validated with the Hospice Manager.