Every finding on record at Condado Sales and Rental, Inc.

Observed in Record Review. In 1 of 14 patient records reviewed, the organization failed to respect the patient's right to participate in decisions about their care. For example: on review of HosRRHV#1 in the Hospice Election of Benefits the section for Patient Notification of Non-Covered Items, Services, and Drugs was left blank and did not indicate it the patient had elected the addendum. On further review the Addendum was created yet there was no patient/caregiver signature to indicate if and/or when the addendum was presented. This observation was reviewed with the Hospice Supervisor.

Observed in Record Review. In 14 of 14 patient records reviewed, the organization failed to ensure the plan of care reflect patient and family goals that were specific, measurable, and time-bound. Throughout all records reviewed there were goals that were not specific and measurable. All goals in each record were also noted to have mostly the same target/achieve by date. Examples were: in HosRRHV#1 it is expected to provide safety/security and reduce the possibility of accidents and it is expected that families will face the patient's crisis on or before (date), It is expected to maintain an adequate emotional state of the patient's crisis condition on or before (date). In HosRRHV#2 an example was It is expected to improve the patient's quality of life through good pain management in or before (date). In HosRRHV#3 and example was Caregiver is expected to know the management of the patient with gastrostomy in or before (date) and the patient is expected to maintain his good nutritional status at or before (date). Further examples on goals that were not specific and measurable were seen throughout records reviewed. These observations were reviewed with the President/Hospice Administrator.

Observed in Record Review. In 1 of 14 patient records reviewed, the organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness and related conditions. In HosRRNHV#9 there was an incomplete wound care order on the plan of care as it lacked a frequency the wound care was to be performed. This observation was reviewed with the Hospice Supervisor.

Observed in Record Review. In 2 of 14 patient records reviewed, The organization failed to ensure the plan of care included all services needed for the palliation and management of the terminal illness and related conditions. On review of HosRRNHV#7 the patient's primary terminal diagnosis was congestive heart failure yet there was no care plan for cardiovascular to guide the care. In HosRRNHV#9 the documentation noted the patient was diabetic and on two types of insulin yet there was no care plan for diabetes care reflected the issue on the plan of care. These observations were reviewed with the Hospice Nurse and the President/Hospice Administrator.

Observed in Record Review. In 7 of 7 patient records reviewed with hospice aide services, the organization failed to ensure written patient care instructions were prepared for the aide services to be performed. On review of HosRRHV#3 the patient had documentation of a g-tube for feeding yet its presence and any care instructions were not addressed on the Aide assignment. In HosRRHV#4 the aide assignment plan of care noted to change dressing yet there were no specific instructions on how and where to change the dressing. On HosRRNHV#5, HosRRNHV#7, HosRRNHV#8, HosRRNHV#11, HosRRNHV#14 there was a task assigned for Toma de signo or take signs yet there were no instructions to indicate which vital signs to take and parameters for reporting abnormal findings. These observations were reviewed with the Hospice Supervisor and President/Hospice Administrator.

Observed in Patient Home. In 1 of 1 Where medication reconciliation was conducted, the organization failed to ensure the patient record reflected the patient's care, treatment and services. On home observation at HosRRHV#1 it was noted during the medication reconciliation there were medications noted in the patient home that the caregiver stated the patient had been taking since prior to the hospice admission that were not part of the hospice plan of care such as Carbidopa/Levodopa 3 times a day, Metformin 2 times a day and Rotigotine transdermal. This observation was reviewed with the President/Hospice Administrator, and Hospice RN.

Observed in Record Review. In 3 of 3 patient records reviewed, for discharged patients the organization failed to ensure that if the patient revoked or was discharged from hospice care the attending physician was provided with a copy of the hospice discharge summary and a copy of the patient record if requested. On review of HosRRDC#1, HosRRDC#2, and HosRRDC#3 there was no documentation that the physician was sent the discharge summary. These observations were reviewed with the Hospice nurse and President/Administrator.

Observed in Record Review. In 2 of 3 patient records reviewed, for discharge patients, the organization failed to ensure the discharge summary include all required elements. On review of the discharge summaries reviewed HosRRDC#1, HosRRDC#2 not all required elements were documented on the discharge summary as they lacked a summary of the patient's stay including treatments, symptoms, and pain management, nor current plan of care. This observation was reviewed with the Hospice Nurse and the President/Administrator.

Observed in Tracer Activities. The organization's pharmacy contract did not include all required elements. This was evidenced by the lack of a stipulation that the outside pharmacy would complete a criminal background check on contracted staff who provide direct patient care or have access to patient records. This finding was discussed with the organization's leadership.

Observed in Data Session. There was no documentation that hospice had developed, implemented and maintained an effective on going data driven QAPI program that included patient satisfaction, infection control, adverse outcomes and medication errors as required by regulation for the present fiscal year. (fiscal year starts on 10/1). This was discussed with the CFO.

Observed in Data Session. There was no documentation that the agency collected, compiled or analyzed data for the present fiscal year (fiscal year starts on 10/1) . This was discussed with the CFO.

Observed in Data Session. There was no documentation that the governing board had developed or approved a quality improvement program for the present fiscal year. In discussion with the CFO. he stated that their quality nurse had retired last year and the organization was unable to find and hire someone for the position.

Observed in Data Session. There was no documentation that hospice leadership had set priorities for data collection, performance improvement activities, patient health outcomes, identified the frequency of data collection or re-prioritized performance improvement activities for the present fiscal year. ( fiscal year starts on 10/1 ). This was discussed with the CFO.

Observed in Patient Home. In 2 of 3 home visits conducted, both before using their equipment - blood pressure cuff, stethoscope, pulse oximetry device and thermometer - and after using them, the nurses cleaned their equipment with a Sani wipe. They did not leave the solutions on the equipment for the 2 minutes required for disinfection. This was discussed with the hospice DON and the hospice Administrator.. (HOSHV#1,2,3) Observed in Patient Home. During 1 of 3 hospice home visits, the registered nurse at home visit #2 did not change his gloves after examining the patient's feet before he returned to the patient's face and performed an oral exam. This was also observed by the agency staff accompanying this surveyor.

Observed in Leadership Session. The governing body/leadership did not ensure that the following Conditions of Participation for Hospice were met as determined through observations, documentation, and staff interviews : 418.58.

Observed in Patient Home. In 2 of 3 home visits conducted, the tube feedings that the two hospice patients were receiving were not list on the MAR (medication administration record) as required by agency policy. This was discussed with the hospice DON and the Administator.