Every finding on record at Wenatchee Hospice LLC

Upon observation, the Emergency Preparedness plan did not include a process for collaboration with tribal emergency preparedness information for an integrated response during a disaster or emergency situation. Corrected on site.

Upon observation, the communication plan did not include contact information for tribal emergency preparedness staff. Corrected on site.

Upon observation, the Emergency and communication plan did not include a primary and alternate means for communicating with tribal emergency management agencies. Corrected on site.

Upon personnel record review, 2 of 12 (Personnel #8 ad 9) did not have evidence Emergency Preparedness training including: • Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles • Demonstrate staff knowledge of emergency procedures • Provide emergency preparedness training at least annually • Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others • Maintain documentation of all emergency preparedness training

Upon patient record review, 1 of 18 (Patient #18) did not have evidence that the hospice obtained the patient's or representative's signature confirming that they received a copy of the Patient's Rights and Responsibilities.

Upon observation during home visit, the nurse did not follow acceptable standards of practice to prevent the transmission of infection and communicable diseases. Patient 4 during a dressing change for a nephrostomy tube, the RN did a dressing change and tube insertion site and tube placement check but did not change her gloves with a new pair after removing the soiled dressing. Nurse continued with the application of the new dressing wearing the dirty gloves.

Upon personnel record review, 1 of 12 (Personnel #9) did not have evidence the hospice employees and contract employees have received orientation on the hospice philosophy.

Upon personnel record review, 1 of 12 (Personnel #9) did not have evidence that the hospice employees have received orientation on their specific job requirements.

Upon patient client record review, 8 of 18 (Patient #2,3,5,7,8,12,17& 18) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patients #2,3,5,7, 8 & 17 there was no date for the effective date of the election statement to indicate the first day of hospice care for patients Patients 12 & 18 there was no Notice of election Form