Every finding on record at Los Angeles Hospice, Inc.

Based on interview and record review, the hospice agency (HA) failed to ensure the emergency preparedness plan/drill for field staff were completed in an annual basis. This failure had the potential for the staff to lack the knowledge to respond effectively during a emergency/disaster situation. Finding: During a review of the emergency preparedness plan of the HA, on 4/28/22 at 11:30 a.m., the HA did not have evidence of Emergency Preparedness training/disaster drill for all field staff. During an interview with the Administrator and Director of Patient Care Services Designee, on 4/28/22 at 11:35 a.m., they stated they could not provide evidence of the field staff receiving Emergency Preparedness training/disaster drill training. The HA's undated policy and procedure titled, "Emergency Management Policy No. 7-001.8," indicated the agency conducts an additional exercise every 2 years, on the year opposite of the full scale community-based exercise or individual facility-based functional exercise which includes a mock disaster drill.

Based on observation, interview, and record review, the hospice agency failed to implement COVID-19 (an acute respiratory illness) procedures and policy. This failure had the potential to spread infection. Findings: During an observation, on 4/26/22, at 3 p.m., upon entrance to the hospice agency there was no screening for COVID-19 signs and symptoms, and no temperature check. An interview was conducted with the Administrator, on 4/26/22, at 3:30 p.m., she stated that there is no screening done for visitors but will start to implement it. During an interview with the Director of Patient Care Services Designee (DPCSD), on 4/28/22 at 11 a.m., she stated she did not know if all staff were fitted for N-95 masks ( a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) and did not have evidence of fit testing (used to test any tight-fitting respirator, ensuring that there's a proper seal to protect the user). A review of the agency's undated policy and procedure, "Infection Control Plan," indicated the organization will address surveillance, prevention, identification, control and reporting of infections, utilizing current scientific methods and epidemiologic principles.