Every finding on record at Hospicio Amor & Tranquilidad, Inc.

Observed in Emergency Management Session. On review of the organizations Emergency Exercises, the organization did not review and evaluate any exercises or actual emergency incidents that they had done in 2024, 2023, or 2022. The organization completed drills and actual emergencies to test there plan but did not document an evaluation to identify opportunities for improvement, or recommend action to take to improve the emergency management program. This finding was reviewed with the owner.

Observed in Record Review. In 9 of 10 active patient records reviewed, Hospice surveyor noted goals in patient records were not measurable and specific to the patient. On RRHV #2, goals were not measurable for example secretions will be managed with medication. On RRHV #3, it was noted that goals were not measurable and specific to the patient, for example, patient is a high fall risk and there is no goals for fall. Also goals not measurable with an example of “will carry out good hygiene”. In addition, RRNHV #1, RRNHV #2, RRNHV #3, RRNHV #4, RRNHV #5 and RRHNV #6 and RRNHV #7 has goals that were not measurable and specific to the care of the patient with examples of report that pain has been reduced to a personally acceptable level of complete relief effective oxygen therapy, optimal cardiac function, “have decrease in bladder function”, and optimal fluid control. This finding was reviewed with the owner and DCPS.

Observed in Data Tracer. On review of the organizations QAPI program, the organization did not identify the frequency and detail of data collection associated with all measures in the QAPI plan and therefore the governing body could not approve it. This finding was reviewed with the owner.

Observed in Data Tracer. On review of the organizations QAPI, the organization had not documented what performance improvement projects were being conducted, the reasons for conducting these projects, and the measurable progress achieved. The organization had documented on each item that they were collecting a rationale for the measurement but there were not formal performance improvement projects in place. On interview with the QAPI coordinator, she was new to the position and did not fully understand what the requirement for a performance improvement plan. This finding was reviewed with the QAPI coordinator and owner.

Observed in Competency Session. On review of the HR files for the organization, the organization did not define the skills that were to be assessed during the competency for the chaplain, medical director and MSW. This finding was reviewed with owner and HR.

Observed in Record Review. In 3 of 3 patient records with aide services, the patient record was missing documentation of the aide visits. On RRHV #3, RRNHV #2, and RRNHV #4 it was noted that there was no documentation of the aide visits that specified what tasks they performed. The documentation in the record was a visit date and time in and out with a signature of the patient. On discussion with the owner, they have the visit notes for aides but somewhere along the line that form was stopped and only the visit date/time/patient signature was collected. This finding was reviewed and validated with the owner. Observed in Patient Home. On 1 of 3 Home visits conducted the medication list was inaccurate. On RRHV #1, on review of medications that the nursing facility had the patient was no longer taking the Meclizine and metoprolol for the past couple of months and the electronic medical record had not been updated to reflect the changes. This finding was reviewed with the owner and the nursing director.

Observed in Record Review. In 1 of 1 discharged patient records reviewed where patient revoked from service, a discharge summary for care and treatment was not sent to the attending provider. On review of RRDC #1, the discharge summary was not created because their EMR does not have a way to create a discharge summary in program and the organization was not aware this was the requirement. This was reviewed and validated with the Administrator.