Every finding on record at Solace Care LLC

Observed in Emergency Management Session. The Emergency Operations Plan did not describe the following: How the organization will obtain and replenish nonmedical supplies (including food, bedding, and other provisions consistent with the organization’s plan for sheltering on site) that will be required in response to an emergency. This was confirmed by the administrator.

Observed in Emergency Management Session. The Emergency Operations Plan did not describe the following: The organization's arrangements with other organizations in the event that it cannot serve its own customers as the result of an emergency. This was confirmed by the administrator.

Observed in Emergency Management Session. Management and staff did not evaluate all emergency response exercises and all responses to actual emergencies. During the emergency systems tracer it was reported that the community disaster drills did not have an evaluation documented. This was confirmed by the administrator.

Observed in Data Tracer. The organization did not protect the privacy of health information. During review of the process for providing medical supplies to the patients, it was reported that supplies were delivered to patient's homes by Amazon. There was no contract and no HIPAA business associate agreement in place for this process. This was confirmed by the Administrator.

Observed in Data Tracer. The organization did not compile and analyze data. During the data systems tracer, it was noted that a process for compiling data, such as spread sheets was not in place. This was confirmed by the Administrator.

Observed in Individual Tracer. The organization did not implement the infection prevention and control activities it has planned. During home visit 3 it was observed that the social worker washed her hands after entering the home in the patient's bathroom. She did not carry paper towels with her to dry her hands and there were no paper towels in the patients bathroom. She used toilet tissue to dry her hands and then placed the used toilet tissue in the pocket of her bag because the trash can would not open. This was discussed with the Administrator.

Observed in Record Review. In 2 of 2 patient records reviewed, The organization did not provide a written discharge summary to the patient’s physician in accordance with law and regulation. For hospices that elect to use The Joint Commission deemed status option: Law and regulation require that the hospice inform the attending physician of the availability of a discharge summary. The discharge summary is provided to the physician upon the physician’s request and includes the patient's medical and health status at the time of discharge . During record review, it was noted that in records 4 and 5 there was no documentation of the discharge summary being sent to the physician or the physician being made aware of it's availability. This was confirmed by the Administrator.

Observed in Leadership Session. The written agreement for inpatient care did not includes the following: - That the hospice furnishes the inpatient provider with a copy of the patient’s plan of care and will specify the inpatient services to be provided - That the inpatient provider has policies that are consistent with those of the hospice and that it agrees to abide by the patient care protocols established by the hospice for its patients - That the record will include documentation of all inpatient services and events and that a copy of the discharge summary and, if requested, a copy of the record will be provided to the hospice - The party responsible for the implementation of the provisions of the agreement - That the hospice retains responsibility for appropriate training of the personnel who provide hospice care under the agreement - That the hospice documents a description of the training provided along with the names of those providing the training. During review of the contract for inpatient services, it was noted that the requirements listed above were not included in the contract. This was confirmed by the administrator.

Observed in Leadership Session. The organization did not have in place a stipulation that the outside agency will complete criminal background checks on contracted employees who provide direct patient care or have access to patient records. During review of contracts it was noted that the staffing contract did not require that criminal background checks be performed on contracted staff being provided to the hospice. This was confirmed by the administrator.