Every finding on record at Camino De Luz Hospice Care

Based upon an Emergency Preparedness Program (EPP) survey performed on 10/23/2024 from 10:30 AM to 2:45 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to maintain an updated emergency preparedness plan. --- Findings include: During the review of the facilities Emergency Preparedness Program with the Clinical Supervisor (employee #1) on 10/23/2024 it was noted that the facility failed to develop and maintain an emergency preparedness plan that must be updated at least every 2 years. Emergency Plan presented to Surveyor was dated 11/10/2021.

Based upon an Emergency Preparedness Program (EPP) survey performed on 10/23/2024 from 10:30 AM to 2:45 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to include a process for cooperation and collaboration with local, tribal, regional, State and Federal emergency preparedness officials effort to maintain an integrated response during s disaster or emergency situation. --- Findings include: During the review of the facilities Emergency Preparedness Program with the Clinical Supervisor (employee #1) on 10/23/2024 it was noted that the facility failed to include a process for cooperation and collaboration with local, tribal, regional, State and Federal emergency preparedness officials as required under §418.113(a)(4) of the Emergency Preparedness.

Based upon an Emergency Preparedness Program (EPP) survey performed on 10/23/2024 from 10:30 AM to 2:45 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to develop procedures to follow up with on- duty staff and patients to determine services that are needed, in event that there is an interruption in services during or due to an emergency. The hospice must inform State and local officials of any on-duty staff or patient that they are unable to contact. --- Findings include: During the review of the facilities Emergency Preparedness Program with the Clinical Supervisor (employee #1) on 10/23/2024 it was noted that the facility failed to have written procedures to follow up with on- duty staff and patients to determine services that are needed, in event that there is an interruption in services during or due to an emergency, also the hospice must inform State and local officials of any on-duty staff or patient that they are unable to contact as required under §418.113(b)(1).

Based upon an Emergency Preparedness Program (EPP) survey performed on 10/23/2024 from 10:30 AM to 2:45 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to develop procedures to inform State and local emergency preparedness officials about patients in need of evacuation from their residences at any time due to an emergency situation based on the patients medical or psychiatric condition and home environment. --- Findings include: During the review of the facilities Emergency Preparedness Program with the Clinical Supervisor (employee #1) on 10/23/2024 it was noted that the facility failed to have written procedures not notify State and local emergency preparedness officials about patients in need of evacuation from their residences at any time due to an emergency as required under §418.113(b)(2).

Based upon an Emergency Preparedness Program (EPP) survey performed on 10/23/2024 from 10:30 AM to 2:45 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to ensure policies and procedures to facilitate the support of volunteers and other healthcare professionals in an emergency. --- Findings include: During the review of the facilities Emergency Preparedness Program with the Clinical Supervisor (employee #1) on 10/23/2024 it was noted that the facility failed to stablished policies and procedures to ensure and facilitate the support of volunteers and other healthcare professionals in an emergency as required under §418.113(b)(4).

Based upon an Emergency Preparedness Program (EPP) survey performed on 10/23/2024 from 10:30 AM to 2:45 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to develop and maintain policies and procedures related with the role of the facility under a waiver declared by the Secretary in accordance with section 1135 of the Act in the provision of care and treatment. --- Findings include: During the review of the facilities Emergency Preparedness Program with the Clinical Supervisor (employee #1) on 10/23/2024 it was noted that the facility failed to include policies and procedures which outline the facility's role in the provision of care and treatment under section 1135 waivers during a declared public health emergency in alternate care sites as required under §418.113(b)(6)(C)(iv).

Based upon an Emergency Preparedness Program (EPP) survey performed on 10/23/2024 from 10:30 AM to 2:45 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to develop primary / alternate means for communication with staff, Federal, State regional and local emergency management agencies in compliance with Federal, State and local laws. --- Findings include: During the review of the facilities Emergency Preparedness Program with the Clinical Supervisor (employee #1) on 10/23/2024 it was noted that the facility failed to provide evidence of the Emergency Preparedness Communication Plan that included primary and alternate means for communicating with the facility staff, Federal, State, regional and local emergency management agencies under §418.113(c)(3).

Based upon an Emergency Preparedness Program (EPP) survey performed on 10/23/2024 from 10:30 AM to 2:45 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to develop and maintain an emergency preparedness training and testing program. --- Findings include: During the review of the facilities Emergency Preparedness Program with the Clinical Supervisor (employee #1) on 10/23/2024 it was noted that the facility failed to develop and maintain an emergency preparedness training and testing program based on the facilities risk assessment.

Based on three home visit (H.V) with thirteen records reviewed (R.R), interviews and observations on 10/23/2024 through 10/24/2024, it was determined that the facility failed to ensure to inform the patient and family/caregivers of the Medicare number needed to file a complaint and the patient rights are promoted related to security, dignity and privacy 1 out of 3 home visits (HV#3). --- Findings include: During home visits with quality registered nurses (employee #2) and (employee #3), the following were observed: 1. HV#1 is a 78-year-old male with admitted 06/14/2024 with Malignant Neoplasm, Extrahepatic Bile Duct. It was noted in the medical record that the certification was going for the second of ninety. He was under the services for physician visit 1 month and as needed (PRN), social work 1 month and PRN, spiritual counselor 1 month and PRN, licensed practical nurse 5 days a week and the registered nurse 2 days a week and as needed. a. On 10/23/2024 at 10:39 AM, the licensed practical nurse (LPN) was observed leaving the side rail down to fix the bed. 2. HV#3 is a 95-year-old female with admitted 09/06/2024 with Cerebral infarction with Chronic Neurologic deficits. It was noted in the medical record that the certification was going for the six episodes. She was under the services of physician visit 1 month and as needed (PRN), social work 1 month and PRN, spiritual counselor 1 month and PRN, Home maker 5 days a week and registered nurse 2 days a week and as needed. a. On 10/24/2024 at 9:52 AM, during the ulcer treatment procedure, it was observed that the registered nurse (employee #5) left the patient uncovered for approximately 5 minutes while preparing the treatment materials.

Based on three Home Visit (HV) with records reviewed, ten records reviewed (RR), staff interview, it was determined that the facility failed to ensure that the clinical record contains current assessment and reassessments for each hospice patient related to nutritional and spiritual counselor. --- 1.Findings include: 1. RR # 2 is a 101-year-old female who was admitted on 9/17/2024 with a diagnosis of Chronic Obstructive Pulmonary Disease-COPD and Acute Respiratory Failure. According to the medical record review performed on 10/24/2024 at 2:00 PM. The plan of care performed by the physician included a nutritional assessment. The following was found during the record reviewed: a. During an interview with the nurse supervisor employee # 1 on 10/24/2024 stated that even when it was pending to attach the nutritional history document, the interdisciplinary team has a WhatsApp chat where the nutritionist sent the document of diet plan, dated on 9/19/2024. b. The facility failed to ensure a confidential clinical record and the protection of patient health information (PHI) as the WhatsApp is not HIPAA compliant and cannot be use to collect, receive or transmit PHI, lacks the control required to ensure the confidentiality, integrity and confidentiality of the PHI.

Based on three Home Visit (HV) with records reviewed, ten records reviewed (RR), staff interview, it was determined that the facility failed to ensure that the clinical record contains current assessment and reassessments for each hospice patient related to nutritional and spiritual counselor for 1 out of 10 records reviewed (RR#2) --- 1. RR # 2 is a 101-year-old female who was admitted on 9/17/2024 with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and Acute Respiratory Failure. According to the medical record review performed on 10/24/2024 at 2:00 PM. The plan of care performed by the physician included a nutritional assessment. The following was found during the record reviewed: a. No evidence was found of a nutritional assessment from the day of admission on 9/17/2024 through 10/24/2024 where the record was reviewed. b. During interview with the nurse on charge of the Interdisciplinary Group (IDG) process employee # 3 on 10/24/2024 stated that the patient was assessed by the nutritionist, but the related document (Nutritional History) was pending to attach in the medical record. c. The facility failed to ensure that the nutritionist made accessible and available their assessment document (Nutritional History) in the clinical medical record. d. The spiritual counselor conducted an initial bereavement assessment on 9/18/2024. During interview with employee # 3 on 10/24/2024 stated that, the follow up visit has a monthly frequency. The medical record did not present evidence of a follow up visit on 10/18/2024. Employee # 3 stated that the hospice provides time until the end of the month, even if the date of the follow up visit exceeds the 31 calendar days (one month). f. The facility failed to ensure that the spiritual counselor made accessible and available their follow up visit in the clinical medical record.

Based on three home visit (HV) with records reviewed , ten records reviewed (RR) on 10/23/2024 through 10/24/2024, it was determined that the facility failed to follow the frequency of services necessary to meet the specific needs according to each patient's individualized plan of care 1 out of 13 (HV-RR #3). --- Findings include: 1. HV#3 is a 95-year-old female with admitted 09/06/2024 with Cerebral infarction with chronic neurologic deficits. Was noted in the medical record that the certification was going for the six of sixty. He was under the services of physician visit 1 month and as needed (PRN), social work 1 month and PRN, spiritual counselor 1 month and PRN, Home maker 5 days a week and registered nurse 2 days a week and as needed. a. On 10/24/2024 at 1:13 PM, during the record review observation it was found that on the days 10/13/2024 to 10/26/2024 no visits from the home maker were found.

Based on review of the manual of infection control with Institutional Programs (employee #4) on 10/24/2024 at 4:32 PM, it was determined that the facility failed to ensure the maintenance and documentation of an infection control program that protects patients, families, and hospice staff through infection prevention and control with this condition Not Met. --- Findings include: During the review of the infection control manual with institutional program (employee #4) on 10/24/2024 at 4:32 PM, the following was found: The manual did not contain a program of policies and procedures for the prevention and control of infectious transmissions, and it was observed that the hospice did not have a plan in place for an infection prevention and control education program for the staff.

Based on three home visit (H.V) with thirteen records reviewed (R.R) interviews and observations on 10/23/2024, it was determined that the facility failed to ensure follow accepted standards of practice to prevent the transmission of infections and communicable disease for 1 out of 3 (HV-RR#1). --- Findings include: During home visit with quality registered nurse (employee #2) on 10/23/2024 at 10:20 AM, the following was observed: 1. HV#1 is a 78-year-old male with admitted 06/14/2024 with Malignant neoplasm, Extrahepatic Bile Duct. It was noted in the medical record that the certification was going for the second of ninety. He was under the services of physician visit 1 month and as needed (PRN), social work 1 month and PRN, spiritual counselor 1 month and PRN, licensed practical nurse 5 days a week and registered nurse 2 days a week and as needed. a. During the home visit it was observed that the licensed practical nurse (employee #6) did not use soap and water or hand sanitizer at each glove change. b. During the patient's bed bathing procedure, the licensed practical nurse (employee #6) did not perform the 3 water changes and did not ask him if he wanted to wash his head and mouth.

Based on interview with Nursing Supervisor (employee # 1) on 10/23/2024 at 8:25 AM, it was determined that the facility failed to ensure core service are provide directly by hospice employee with counseling services which makes this Condition Not Met. --- Findings include: During the interview with the nursing supervisor (employee #1) on 10/23/2024 at 8:46 AM she stated that the spiritual counseling staff was under contracted services. The facility did not ensure that the spiritual counselor was part as an employee of the facility.

Based on three (3) Home Visits (H.V.) with record reviewed, ten (10) Records Reviewed (R.R), review of policy and procedure, it was determined that the facility failed to ensure that the clinical records contain the Initial plan of care, initial assessment, comprehensive assessment, updated comprehensive assessment, and clinical notes. One (1) of thirteen (13 ) records review (R.R. #6). --- Findings include: R.R. #6 is an 78 year- old old female was admitted on 03/06/2024 with a Diagnosis of Alzheimer Disease End Stage Late Stage, Bedridden, Severe Dysphagia with PEG #22, Stiffness of upper and lower limps, Urinary and Fecal Incontinence, Sacral pressure area and left heel, Dehydration, Weight loss and Appetite. According to the medical record review performed on 10/24/2024 at 1:05 P.M. provided evidence that patient was plan of care performed by the physician and the Interdisciplinary group on 03/07/2024 and establish that nursing service provide 2 visit per week an as necessary (PRN), the Physician 1 visit per month and PRN, the Social Worker 1 visit per month and PRN and the Spiritual counselor 1 visit per month and PRN. The following was found during the record reviewed: a. No evidence was found related to '' Initial Evaluation performed by the Spiritual Counselor on 03/06/2024. b. According of the patient record the first monthly visit performed per the Spiritual Counselor was 07/18/2024 and them on 08/29/2024 twelve days later. No evidence of monthly visits on 09/18/2024 and 10/18/2024. c. During interview with the Nurse Supervisor employee #1 on 10/24/2024 at 1:30 P.M. she stated: '' The Spiritual Counselor submitted the resignation with effective date on March 11/2024.'' The facility lacks Spiritual Counselor until June 2024.

Based on review of fifteen (15) credential files (C.F) with the nurse supervisor (employee #1) performed on 10/23/2024 from 9:30 AM, it was determined that the facility failed to ensure that 6 out of 15 employees who provide services have updated credential files related to Register Nurses (RN), Practical Nurse, Dietitian, Speech Therapy, Occupational Therapist and Physical Therapist, lack of Influenza Vaccines, Annual Membership and Annual Evaluation. (CF#7,#9, #10, #11, #12,#13). --- Findings include: 1. Review of fifteen (15) credential files (C.F) of the hospice on 10/23/2024 from 9:30 AM till 2:30 PM provided evidence of the following: a. Five out of fifteen (15) credential files did not contain evidence of updated Annual Evaluation (Dietitian C.F #9, Respiratory therapist C.F #10, Speech therapy C.F #11, Occupational therapist C.F #12 and Physical therapist C. F #13 ). b. One out of fifteen (15) credential files did not contain evidence of updated Health Certificate expired on 07/20/2024, ( Occupational therapist C.F #12). c. Two out of fifteen (15) credential files did not contain evidence of updated Influenza Vaccines, (Speech Therapist C.F #11 and Physical Therapist C.F #13). d. Two out of fifteen (15) credential files did not contain evidence of updated CPR ( Practical Nurse C.F. #7 expired on 10/21/2024 and Speech Therapy C.F #11 expired on 07/2024 ).

Based on recertification survey, the review of fifteen personnel credential files (C.F) on 10/23/2024 at 10:00 AM with the facility nurse supervisor it was determined that the facility failed to ensure that 1 out of 15 employees providing services, have the criminal background check. ( R.N. #2). --- Findings include: On 10/23/2024 at 10:00 A.M during review of the credential files it was identify the following: a. Register Nurse Credential File (RN) #2, no evidence was provided of the certified negative criminal back ground check (Ley 300)

Based on an Emergency Preparedness (EP) survey performed on 10/21/2021 at 9:30 AM, it was determined that the facility failed to develop and maintain an emergency preparedness plan that include a process for cooperation and collaboration to maintain a respond during a disaster or emergency situation. Findings include: During the EP survey performed on 10/21/2021 at 9:30 AM, it was found that the facility did not provide evidence of the facility's efforts to be in contact and participation in the state health coalitions.

Based on an Emergency Preparedness (EP) survey performed on 10/21/2021 at 9:30 AM, to evaluate emergency preparedness requirements, it was determined that the facility failed to develop and maintain an emergency preparedness training program. Findings include: 1. No evidence of initial training in emergency preparedness policies and procedures to all new and existing facility employees and individuals providing services under arrangement, consistent with their expected roles. 2. No evidence of documentation related to if the staff demonstrate knowledge of emergency procedures.

Based on an Emergency Preparedness (EP) survey performed on 10/21/2021 at 9:30 AM, to evaluate emergency preparedness requirements, it was determined that the facility failed to conduct exercises to test the emergency plan. Findings include: 1. Facility did not have evidence of participation in a second full-scale exercise that is community-based or facility based. 2. Facility did not have evidence of a tabletop exercise that includes a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge their an emergency plan. During the survey the facility participated in a full scale exercise.

Based on a recertification survey, three Home Visit (H.V) with Record Reviewed and ten Record Review (RR), review of policy and procedure, it was determined that the facility failed to ensure that the clinical record contain correct clinical past and current findings for each hospice patient related to Registered Nurse (RN) visits, Home Health Aid (HHA) visits, 2 out of 13 records review (R.R #3 and #8) Findings include: 1.R.R. #3 is an 86-year-old female who was admitted on 12/17/2019 with a Diagnosis of Rheumatoid Arthritis End Stage. According to the medical record review performed on 10/21/2021 at 1:00 PM provides evidence that: patient was total dependent of activity daily living (ADL), alert, Dysphagia, disoriented, bedridden, extremity contracture and muscles weakness. The plan of care performed by the physician and the Interdisciplinary group on 09/29/2021 of the recertification establish that nursing service provide 2 visit per week an as necessary (PRN), Home Health Aid (HHA) 5 visit per week, the Physician 1 visit per month and PRN, the Social Worker 1 visit per month and PRN and the Spiritual counselor 1 visit per month and the homemaker (ALL) 5 visit per week. The following was found during the record reviewed: a. No evidence was found related to HHA visit from 08/30/2021 until 10/21/2021. b. During interview with the nurse supervisor employee #2 on 10/21/2021 at 1:30 PM stated that the HHA on charge of this patient employee #7 was sick on 09/30/2021 she was retired with medical justification and suppose to return to work on 10/28/21. The nurse Supervisor state that the facility policies and procedure was that the personnel will deliver the documentation between 24-48 hours of the visit. That the HHA did not submit the notes prior to her illness 08/30/2021 through 10/21/2021. c. The facility failed to ensure that HHA made accessible and available their home visit note in the clinical medical record. 2. R.R. #8 is an 86-year-old female who was admitted on 12/08/2020 with a Diagnosis of End Stage Alzheimer. According to the medical record review performed on 10/21/2021 at 11:30 AM. The visit frequency is nursing service 2 visit per week an as necessary (PRN), Home Health Aid (HHA) 5 visit per week, Physician 1 visit per month and PRN, Social Worker 2 visit per month and PRN and Spiritual counselor 2 visit per month. The following was found during the record reviewed: a. No evidence was found related to HHA visit since 08/28/2021 until 10/21/2021. b. During interview with the nurse supervisor employee #2 on 10/21/2021 at 1:30 pm stated that the HHA on charge of this patient employee #8 was sick on 09/30/2021 she was retired with medical justification and suppose to return to work on 10/28/21. The nurse Supervisor stated that the facility policies and procedure was the personnel will deliver the documentation between 24-48 hours of the visit. That this HHA did not submitted the notes prior to her illness 08/30/2021 through 10/21/2021. c. The facility failed to ensure that HHA made accessible and available their home visit note in the clinical medical record.

Based on a re-certification survey, the review of thirty (30) credential files (C.F) with the Hospice secretary (employee #8 ) performed on 10/21/2021 from 1:30 PM, it was determined that the facility failed to ensure that 9 out of 30 employees who provide services have updated credential files related to Register Nurses (RN), Director, Physicians, Social Worker (SW), Spiritual Advisor (SA), related to the lack of Health Certificate, Influenza Vaccines, and Law 300 ( Director C.F#1, Physician C.F #2 and #3, RN C.F's #11, #12 and #20, Social Worker C.F #28 and Spiritual Advisor C.F #29). Findings include: 1. Review of thirty (30) credential files (C.F) of the hospice on 10/21/2021 from 1:30 pm till 2:30 pm provided evidence of the following: a. Five out of thirty (30) credential files did not contain evidence of updated Law 300, (Director C.F #1, Physician C.F #3, RN C.F #12 and #21, and SA C.F #29). b. One out of thirty (30) credential files did not contain evidence of updated Health Certificate, (SA C.F #29). c. Four out of thirty (30) credential files did not contain evidence of updated Influenza Vaccines, (Physician C.F #2, and #4, RN C.F #11 and SW C.F #28).