Every finding on record at Gibraltar Hospice, Inc.

Observed in Emergency Management Session. The Surveyor noted that there was no written Delegation of Authority included in the Emergency Management Plan. This was validated with the Administrator Designee. Observed in Emergency Management Session. The Surveyor identified that there was no current written Order of Succession included in the Emergency Management Plan. This was validated with the Administrator Designee.

Observed in Emergency Management Session. The Surveyor noted that there was no current contact list for staff, physicians, other licensed practitioners, or volunteers included in the Emergency Management Plan. This was validated with the Administrator Designee.

Observed in Patient Home. In 2 of 3 home visits conducted, the organization did not conduct a patient specific reassessment that included the patients' needs for management for all areas of hospice care related to the palliation and management of the terminal illness and related conditions. For example, observed during RRHV#1 and during RRHV#3 the skilled nurse did not conduct a full skin assessment on the patients who were bedbound, had increased weakness, limited mobility, and were incontinent. This was validated with the Administrator Designee and Director of Patient Clinical Services following the home visits conducted.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization did not conduct an effective assessment of the patient's medication in accordance with organizational policy no. 3-002.2, 5) During subsequent hospice visits, the medication profile will be used . . .A)to evaluate the use of drugs in the home setting . . . Observed in RRHV#3, the skilled nurse did not utilize the medication profile to evaluate the patient's use and understanding of the medications, instead just picking up and reading each medication containers. This was validated with the Administrator Designee and the Director of Patient Clinical Services following the home visit.

Observed in Record Review. In 2 of 10 patient records reviewed, Identified during the record review for RRHV#3, and RRNHV#1, there were no documented Registered Nurse comprehensive assessments during the 6 weeks preceding the survey date. This was validated with the Director of Patient Clinical Services following the record review session.

Observed in Record Review. In 10 of 10 patient records reviewed, the goals developed did not reflect patient and family goals based on the problems identified in the assessments. For example, in RRHV#1, the psychosocial assessment documented the problem needs funeral arrangements, with a corresponding goal, MSW will facilitate resolution. In RRHV#2, the psychosocial problems documented were Patient is sad, and Patient gets frustrated with corresponding goals Social Worker will assist in providing resources, and Social Worker provided complement added resources and support. Additionally in RRHV#2, the Spiritual Care Coordinator documented the following assessed problem, spiritual distress with the corresponding goal, pt/cg to receive spiritual support during hospice care. In RRHV#3 the psychosocial problems identified included, Pt's appetite has declined, and Pt has more episodes of forgetfulness, with the corresponding goals, Social Worker will establish trusting relationship, and Social Worker will provide emotional support. In RRNHV#1, the psychosocial identified problem was Pt continues to struggle with anxiety, with a documented goal of Social Worker provided counseling. In RRNHV#2, the psychosocial problem identified was Pt lacks coping skills, with a corresponding goal of Social Worker will assist Pt in complementing added resources. In RRNHV#3, the psychosocial problem identified was Pt without funeral arrangements with a corresponding goal of Social Worker will educate Pt on the importance of mortuary arrangements. In RRNHV#4 the psychosocial problems identified included agitation, and Pt felt sadness due to illness progression, with corresponding goals of Social Worker will assist in providing resources and support as needed, and Social Worker will provide support. In RRNHV#5 the psychosocial problem identified was Pt is sad due to not being able to take long walks, with a corresponding goal of SW will assist Pt to share less stress and or acceptance. In RRNHV#6 the psychosocial problem identified was Pt is sad due to pression of illness, with a corresponding goal of SW will assist in complementary added resources and support as needed. In RRNHV#7 the Psychosocial problem identified was Pt continues to be confused with episodes of forgetfulness, with a corresponding goal of SW educated Pt daughter on the importance of having all community resources in place . . . This was validated with the Director of Patient Clinical Services following the record review session.

Observed in Record Review. In 2 of 10 patient records reviewed, the organization did not include all services needed for the management of the terminal illness and related conditions. For example, identified during the record review for RRHV#1, the patient was assessed to have a high risk for falls, yet there was no care plan developed to address this problem. Identified during the record review for RRHV#2, the patient was assessed to be at a high risk for aspiration, being nutritionally compromised, have impaired skin integrity due to being paralyzed, incontinent and suffering from basal cell carcinoma, and have ongoing pain issues, yet there were no care plans developed to address these problems.

Observed in Record Review. In 3 of 10 patient records reviewed, the organization did not ensure that the hospice interdisciplinary group (IDG) reviewed, revised, and documented the individualized plan no less frequently than every 15 calendar days. Identified during the record review for RRHV#2, there was no documentation to support that the hospice IDG reviewed the plan of care during the 20 days following the patient's admission date/initial IDG date. Identified during the record review for RRNHV#3, there was no documentation to support that the hospice IDG reviewed the plan of care during October 2025, December 2025 and January 2026. Identified during the record review for RRNHV#5 there was no evidence to support that the hospice IDG reviewed the plan of care during October 2025, December 2025 and January 2026. This was validated with the Administrator Designee following the record review session.

Observed in Record Review. In 2 of 10 patient records reviewed, the organization did not provide the patient with care, treatment, or services according to the individualized plan of care. Identified during the record review for RRHV#2, there was no documentation that the ordered weekly Licensed Vocational Nurse (LVN) visit was completed one week prior to the survey date. Identified during the record review for RRNHV#5, there was no documentation to support that two LVN visits were conducted during the sixth month prior to the survey month. This was validated with the Director of Patient Clinical Services following the record review session.

Observed in Patient Home. In 2 of 3 home visits conducted, the organization did not ensure that accepted standards of practice were met to prevent the transmission of infections. Observed in RRHV#1 the Skilled Nurse did not perform hand hygiene following the assessment and palpation of the colostomy site, instead doffing gloves and immediately returning to the inside of the clinician supply bag. Additionally, the Skilled Nurse did not clean the equipment used to assess patient RRHV#1, before returning the equipment to a gallon size zip lock bag and placing it into the clean area of the clinician supply bag. In the following home visit conducted, the same Skilled nurse used the same reusable medical equipment to assess RRHV#3 and again did not clean the reusable medical equipment before returning it to the plastic zip lock bag located in the clinical supply bag. This was validated with the Administrator Designee and the Director of Patient Clinical Services following the home visits conducted.

Observed in Tracer Activities. The governing body/leadership did not ensure that the following conditions of participation were met as determined through observations, documentation, and staff interviews: 418.54 and 418.56. These were reviewed and discussed with the Administrator Designee. Observed in Patient Home. In 2 of 2 staff interviews, it was identified that the organization does not provide clinical staff with resources needed to maintain safe, quality care, treatment or services. For example during the three home visits conducted with two different clinical staff, the Surveyor noted the different types of equipment and supplies were being used by each. The clinicians validated that the Personal Protective Equipment, disinfecting supplies, barriers, and reusable medical equipment was purchased by themselves and were not provided by the organization. This was verified with the Administrator Designee following the home visits.

Observed in Medication Management Tracer. In 2 of 3 patient records reviewed, the organization did not ensure that the patient's record contained information that reflected the patients' care, treatment, or services. Observed during the home visit for RRHV#2, there were medications in the home that were not listed in the medical record including: Morphine Sulfate 10mg/0.5ml prefilled syringes, Ativan 0.5mg/0.25ml prefilled syringes, over the counter stool softener DS 100mg, and Tylenol 325mg tablets. Observed during RRHV#3, the patient did not have supplemental oxygen, yet the medical record included oxygen in the Plan of Care. Additionally the patient's hospital bed had full side rails not the half rails as documented in the medical record. This was validated with the Administrator Designee and the Director of Patient Clinical Services.

Observed in Patient Home. In 1 of 3 home visits conducted, where the patient had a hospital bed, there was no evidence that the family caregiver received instructions in the safe use of durable medical equipment. Observed during the home visit conducted for RRHV#3, the patient was in a hospital bed with full side rails. Upon reviewing the record there was no documentation to support that the family caregiver was informed of risks associated with full bed rails. This was validated with the Administrator Designee and Director of Patient Clinical Services following the home visit.

Observed in Record Review. In 1 of 4 patient records reviewed, During RR# 3's patient record it was noted the organization had not ensured the patient's plan of care included interventions to manage symptoms. For example: review of RR# 3's start of care RN comprehensive assessment revealed documentation of a wound to the left heel that was open and had a history of osteomyelitis with every other day dressing changes. However, review of the initial plan of care and current Interdisciplinary Group/Plan of Care update revealed no documentation of a wound. This was reviewed, discussed, and validated with the Director of Patient Care Services.

Observed in Record Review. In 2 of 4 patient records reviewed, During RR# 3 and RR# 4's patient records it was noted the organization had not ensured the plan of care included measurable outcomes anticipated from implementing and coordinating the plan of care. For example: review of RR# 3's start of care RN comprehensive assessment revealed documentation that RR# 3 had an open wound to the left heel with a history of osteomyelitis and wound dressing changes every other day. However, review of the initial plan of care and current Interdisciplinary Group/Plan of Care update revealed no goal for the wound. Review of RR# 4's plan of care and subsequent Interdisciplinary Group/Plan of Care updates revealed a pain goal that the patient would report reduced pain to a tolerable level. However, there was no indication what a tolerable level was for RR# 4. This was reviewed, discussed, and validated with the Director of Patient Care Services.

Observed in Record Review. In 2 of 11 patient records reviewed, the organization had not collected assessment data as required by organizational policy. In the chart for RR#1, there were no wound measurements for this patient who has been on service for more than 6 months, during which time, the documentation indicated he had a wound for at least 4 months. The organization's wound care policy indicated that measurements wound be part of the initial comprehensive assessment and weekly after. In the chart for RR#3, the patient was admitted approximately 6 weeks prior to the survey with a stage 3 pressure ulcer on the coccyx. There were no wound measurements in the chart. This was confirmed with the DPCS.

Observed in Record Review. In 1 of 11 patient records reviewed, the POC did not include a detailed statement of the scope and frequency of the services necessary to meet the patient’s and family’s needs. In the chart for RR#6, the MSW evaluation visit/frequency was not on the hospice POC. This was discussed with the DPCS.

Observed in Record Review. In 6 of 11 patient records reviewed, the plan of care (POC) did not include all services needed for the palliation and management of terminal illness and related conditions. During HV#1, the PCG confirmed that she tests the patient's blood sugar daily; the hospice nurse test the blood sugar during SN visits, and the patient is taking Insulin. Daily blood glucose monitoring was not included on the hospice POC. Additionally, the patient was receiving wound care to multiple wounds. These treatment orders were received from an outside consulting physician and not added to the hospice POC. The nutritional supplement did not include a frequency. Additionally, SN and MSW both documented the patient seemed depressed.The MSW screened for depression and suicidal ideation as a result of this assessment. The plan of care was not updated to include this potential problem. In the chart for HV#2, the nutritional supplement was missing the frequency. During the home visit, it was confirmed with the RN and PCG that the patient was not using a Foley catheter nor a condom catheter, and had not for a long time, which by chart review appears to have been more than 7 months ago. The POC still included orders for both Foley catheter changes routinely with prn flushes as well as Condom catheter supplies. In the chart for RR#1, the order for for the wound vac which was present upon admission to the organization in mid-2022 was not included on the POC. The only order on the POC was for SN twice weekly for wound care. There was a supplemental order dated 9/14/22 Left Heel Wound - Cleanse with Normal Saline. Pat dry, continue application for Xeroform to left heel, cover with abdominal and bandage with kerlix. Change dressing every other day. Maintain foot off loaded with soft pillows to avoid pressure. Patient will be seen next week by ….. which was end dated 9/28/22. The patient continued to have wound care documented for another 2 months for which there was no order. In the chart for RR#2, the Basaglar order was incomplete and stated per sliding scale as ordered, however did not include that scale. In the chart for RR#6, the left chest tube care order was missing the frequency of the dressing change and read Cleanse wound with normal saline solution, pat dry then cover site with sterile dressing, requires drainage with PleurX drainage kit every 8 days. In the chart for RR#7, the patient had two medications, Tramadol and Tylenol both ordered prn for pain without further clarification as to when to take which medication. This was discussed with the DPCS.

Observed in Data Session. The QAPI program did not include issues related to palliative outcomes. This was confirmed with the QAPI Nurse.

Observed in Record Review. In 1 of 11 patient records reviewed, the organization had not implemented its infection prevention activities including surveillance. In the chart for HV#1, the patient developed a wound infection approximately 2.5 months prior to the survey for which the patient was started on oral antibiotics. There was no infection surveillance report filed. This was discussed with the DPCS.

Observed in Data Session. The organization did not have a goal for limiting the spread of infections associated with procedures. The goal was an intervention, Limiting the spread of infections associated with procedures by providing in-service on hand-hygiene to 100% of field staff and providing competencies on hand hygiene on hire. Observed in Data Session. The organization did not have a goal for limiting the spread of infections associated with the use of medical equipment, devices, and supplies. The goal was an intervention, Limiting the spread of infections associated with the use of medical equipment, devices, and supplies by providing in-service to 100% of field staff on proper sanitizing DME and devices at least annually. This was discussed with the QAPI Nurse.

Observed in Record Review. In 1 of 2 patient records reviewed, in which an aide was ordered, the RN did not prepare complete instructions for the aide. In the chart for RR#3, the aide was assigned to take vital signs at each visit, however did not include any parameters outside of which the aide was to notify the RN. This was discussed with the DPCS.

Observed in Tracer Activities. There was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by Condition level observations at 418.56, 418.104.

Observed in Record Review. In 7 of 11 patient records reviewed, the patient record did not include complete information that clearly documented the course and result of the patient's care, treatment and services. In the chart for HV#1, the SN notes documented that wounds were present, orders were present and the caregiver was re-instructed at visits, however there was no documentation the SN actually provided wound care during the visit, and if so, what that care entailed though there were orders for the SN to provide wound care twice weekly. In the chart for HV#2, Finesteride was duplicated on the POC/medication profile. In the chart for RR#1, an example was at the initial SN visit, the documentation was unclear regarding if any care was actually performed at the visit or if information from the referral was being documented as it read Skin assessment done. Patient has I&D on Left foot wound vac in placed. Change wound vac dressing twice weekly with black foam on -125 mmhg pressure. Will continue to monitor. On another visit in October 2022 a nurse documented an incomplete note reading Proper wound care was done aseptically on the patient`s wound on left foot Further described wound vac was present. Same visit, the nurse also wrote Upon skin assessment, gangrenous wound on left foot was noted with a wound vac running to low suction -125mmhg. Minimal serosanguineous drainage was observed. Cleanse with Normal Saline. Pat dry, continue application for Xeroform to left heel, cover with abdominal and and bandage with kerlix. Change dressing every other day. There is only one documented wound for the patient, yet this documentation seems to indicate there is a left foot wound AND a left heel wound for which there is differing treatment. In the span of 2 SN visits, subsequent to the previous notes, the documentation went from the patient having a wound vac on his left foot with a dressing on the left heel, to having no wounds present at all with no explanation. In the chart for RR#3, the LVN documented Wound of unknown origin on left frontal head noted. Wound treatment provided with no specification as to what actual care was provided to the patient. In the chart for RR#6, in the admission visit, if care was provided by the RN, the documentation was not clear and read patient has left chest tube to left chest covered site with sterile dressing, requires drainage with PleurX drainage kit every 8 days. Reinforced on keeping the site clean and dry at all times. If care was provided, the documentation did not include all steps of the dressing change order which included cleansing with normal saline. In the chart for RR#8, approximately 2 weeks post admission, the RN obtained an order for weekly visits for wound care, however there was no documentation that a wound had developed, the POC had not been updated with any interventions/goals for a wound. In the chart for RR#3, the admission documentation of care was unclear and read Patient noted with sacral wound pressure ulcer stage 3. MD order to apply silver alginate cream Topical to sacral area every other. Reminded PCG to always keep the skin clean and dry at all times. PCG verbalized understanding. Will keep monitoring. This was discussed with the DPCS.