Every finding on record at Light of Life Hospice Care, LLC.

Observed in Document Review. Upon review of the documentation provided, the Surveyor noted the Emergency Operations Plan did not describe the patient population served by the organization or the extent to which additional populations may be cared for during an emergency. This was evidenced by the organization was not able to produce documentation at the time of survey. This was discussed and verified by the Administrator and Director of Patient Care Services.

Observed in Document Review. Upon review of the documentation provided and discussion with the Administrator and Director of Patient Care Services, the surveyor noted that the implementation of the organization's emergency operations plan and annual table top drills did not stress the plan sufficiently to identify weaknesses, deficiencies and opportunities for improvement. This was reviewed with the Administrator and Director of Patient Care Services.

Observed in Record Review. In 3 of 8 patient records reviewed, with aide services, the written patient care instructions did not specify the duties of the hospice aide. Upon review of HV#2, RR #5 and RR #6, it was noted the patient had oxygen therapy ordered as needed; however, on review of the aide plan of care, there were no specific instructions provided to the aide regarding oxygen precautions, whether it was continuous or as needed, or if it could be removed during personal care. Upon review of HV #2, it was noted the patient was on anticoagulant therapy; however, on review of the aide plan of care, there were no specific instructions provided to the aide regarding bleeding precautions. This was discussed with the Administrator and the Director of Patient Care Services.