Every finding on record at Mount Sinai Hospice, Inc.

Observed in Emergency Management Session. The organization did not ensure that the emergency response exercise sufficiently stressed its emergency Operations Plan to identify weaknesses in key areas of safety. For example, the 2019, 2020 and 2021 emergency response exercise(s) did not include a description of how patient acuity assignment and tracking procedures were activated and tested. In addition, there was not a description of how key care, treatment, or service processes were activated and tested.

Observed in Document Review. A review of the admission packet, and documents provided to patient and family showed that the organization did not provide a copy of its written policy and procedure related to management and disposal of contolled medication. This finding was observed during survey activity, but corrected onsite prior to the surveyor’s departure. The corrective action taken needs to be included in the organization’s Evidence of Standards Compliance submission.