Every finding on record at In Home Comfort

Upon observation, there was no evidence the Emergency Plan communication plan includes all of the following: • Names and contact information for the following: • Hospice employees • Patients' physicians Corrected on site.

Upon observation, there was no evidence the Emergency Plan communication plan must includes a primary and alternate means for communicating with hospice's employees. Corrected on site.

Upon patient record review, 5 of 5 (Patient #1, #2, #3, #4, #5) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient 1, 2, 3, 4, 5: The Notice of rights and Election statement are included in a packet, they are not individually signed, however they are included on a Receipt of info consent form as being explained and given to the patient.

Upon observation, there was no evidence the hospice discussed the policies and procedures for managing the safe use and disposal of controlled drugs with the patient or representative and the family in a language and manner that they understand to ensure that these parties are educated regarding the safe use and disposal of controlled drugs. There is documentation in the SN SOC that disposal of controlled medications is a teaching need, but there was no evidence of documentation in the patient record that the policy was discussed.