Every finding on record at Pacific Home Care Associates, Inc

Based on interview and review of documentation, it was determined the hospice agency failed to review and update the emergency preparedness plan policy and procedure at least annually. --- Findings: Review of the agency's policy and procedure titled, "Emergency Prepared Plan/Acuity" revealed the policy was last revised on 3/12/2018. During an interview with Employee #10 on 9/17/2019 at 4:00 PM, Employee #10 acknowledged there was no documented evidence of the policy revision since 2018, and they will be working on it.

Based on interview, review of the hospice's required annual education courses and review of emergency preparedness documentation, it was determined the agency failed to provide hospice staff emergency preparedness training at least annually. --- Findings: Review of the agency policy and procedure titled "EMERGENCY MANAGEMENT PLAN" revised on 4/2018 reflected "The training and testing program is reviewed and updated at least annually." During an interview with Employee #10 on 9/17/2024 at 4:00 PM, Employee #10 confirmed the hospice staff did not participate in any annual EP training. The agency failed to present documentation of annual EP training.

Based on interview and review of emergency preparedness documentation, it was determined the agency failed to maintain the required documentation of participation in an annual drill and tabletop exercise during the preceding year. --- Findings: Review of emergency preparedness documentation revealed the information provided lacked documentation of participation in, analysis and review of an emergency preparedness drill and tabletop exercise during the prior year. During an interview on 9/17/2024 at 4:00 PM, Employee #10 was asked if the agency had participated in a drill or tabletop exercise during the prior year. Employee #10 stated they have not had any drill or tabletop exercises done. No further information was provided regarding a drill or tabletop exercise.

Based on interview, it was determined the hospice failed to document the cost savings achieved through the use of volunteers. --- Findings: During an interview on 9/16/2024 at 4:06 PM, Employee #8 was asked to provide documentation of the cost savings achieved through the use of volunteers. Employee #8 stated "We don't really have a cost savings at the moment." During the exit interview Employees #9, #10, and #11 was made aware of the findings. No further information was provided.