Every finding on record at Hospicio Del Oeste Inc

Based upon an Emergency Preparedness Program (EPP) survey performed from 12/17/2024 through 12/18/2024 from 8:00 AM through 3:00 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 Manager (employee #1) and QAPI Director (employee #7) on 12/18/2024 at 10:30 AM 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 from 12/17/2024 through 12/18/2024 from 8:00 AM through 3:00 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 Manager (employee #1) and QAPI Director (employee #7) on 12/18/2024 at 10:30 AM, 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 from 12/17/2024 through 12/18/2024 from 8:00 AM through 3:00 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 Manager (employee #1) and QAPI Director (employee #7) on 12/18/2024 at 10:30 AM, it was noted that the facility failed to establish 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 from 12/17/2024 through 12/18/2024 from 8:00 AM through 3:00 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to develop and maintain an emergency preparedness training and testing program that is based on the emergency plan. --- Findings include: During the review of the facilities Emergency Preparedness Program with the Clinical Manager (employee #1) and QAPI Director (employee #7) on 12/18/2024 at 10:30 AM, it was noted that the facility failed to develop and maintain an emergency preparedness training and testing program based on the facility's risk assessment.

Based on the home visits (HV) conducted and the policy and procedures reviewed from 12/17/2024 to 12/18/2024, it was determined that the facility did not ensure that accepted standards of practice were followed to prevent the transmission of infections and the use of standard precautions for 2 out of 4 home visits. (HV #1 and HV#3). --- Findings include: 1.During the home visit conducted on 12/17/2024, the following was observed: a. On 12/17/2024 at 11:43 AM, it was observed at home visit # 1 that the registered nurse (employee # 10) did not use hand sanitizer on a glove change. 2.During the home visit conducted on 12/17/2024, the following was observed: a. On 12/17/2024 at 9:30 AM, it was observed at home visit # 3 that the humidifier tank connected to the H tank regulator had insects inside.

Based on the review of documents related to the volunteer program and interview with the Administrative Assistant (employee #9), it was determined that the facility failed specify day-to-day administrative and/or direct patient care roles performed by volunteers. --- Findings include: 1.On 12/17/2024 at 11:30 AM during the review of the volunteer program documentation, no documentation with specific duties performed by volunteers was presented by facility. 2. Hours performed by volunteers were kept by human resources personnel in a personal notebook, not in an official facility document.

Based on the review of documents related to the volunteer program and interview with the Administrative Assistant (employee #9), it was determined that the facility failed to provide the saving cost achieve by using the volunteers in different roles at the facility. --- Findings include: 1. On 12/17/2024 at 11:30 AM during the review of the volunteer program no evidence of the monthly cost saving using volunteer was found. 2. The facility failed to provide the saving cost achieve by using the volunteers in different roles at the facility for year 2024.

Based on four home visits with record reviewed and fifteen records reviewed, it was determined that the facility failed to ensure that patient's records include the registered nurse, hospice aid and home makers clinical notes, for 5 out of 19 record reviewed (RR-H.V. #1, #2 and R.R. # 1, # 7 and #8). --- 2. HV # 2 is a 71-year-old male who was admitted on 06/27/2023 with a diagnosis of Age-related Cognitive Decline. The interdisciplinary group determined five visits per week for the Home Health Aid (HHA) and five visits per week for the Home Maker. According to the medical record review performed on 12/18/2024 at 1:00 PM, the following was found: No evidence was found of one of the visits for the HHA and Home Maker from week started on 09/02/2024 through 09/06/2024. . No evidence was found of one of the HHA visits from week started on 09/09/2024 through 09/13/2024. No evidence was found of one of the visits for the HHA and Home Maker from week started on 09/23/2024 through 09/27/2024. No evidence was found of two of the visits for the HHA and one of the visits for the Home Maker from week started on 10/14/2024 through 10/18/2024. No evidence was found of one of the visits for the HHA and Home Maker from week started on 11/04/2024 through 11/08/2024. No evidence was found of one of the visits for the HHA and Home Maker from week started on 11/18/2024 through 11/22/2024. No evidence was found of one of the visits for the HHA and Home Maker from week started on 11/25/2024 through 11/29/2024. During an interview with employee # 5 on 12/18/2024 at 1:00 PM it was stated that there was a holiday for the week started on 11/18/2024 through 11/22/2024 and the week started on 11/25/2024 through 11/29/2024. The document that evidences the HHA and Home Maker visits did not specify that there was a holiday and neither specified a notification to the patient caregiver or provisions made to compensate the absence of the HHA. The facility failed to ensure accessible and available evidence of the Home Health Aid (HHA) and Home Maker visits in the medical record. 3. RR # 1 is a 85-year-old female who was admitted on 06/26/2024 with a diagnosis of Congestive Heart Failure. In the certification period from 09/24/2024 through 12/22/2024 the interdisciplinary group determined five visits per week for the Home Health Aid (HHA). According to the medical record review performed on 12/18/2024 at 1:00 PM, the following was found: a. No evidence was found of one of the visits from week started on 10/14/2024 through 10/18/2024. a. No evidence was found of one of the visits from week started on 11/04/2024 through 11/08/2024. b. No evidence was found of one of the visits from week started on 11/11/2024 through 11/15/2024. a. No evidence was found of one of the visits from week started on 11/18/2024 through 11/22/2024. b. No evidence was found of one of the visits from week started on 11/25/2024 through 11/29/2024. c. During an interview with employee # 5 on 12/18/2024 at 1:00 PM it was stated that there was a holiday for the week started on 11/18/2024 through 11/22/2024 and the week started on 11/25/2024 through 11/29/2024. The document that evidences the HHA visits did not specify that there was a holiday and neither specified a notification to the patient caregiver or provisions made to compensate the absence of the HHA. d. The facility failed to ensure accessible and available evidence of the Home Health Aid (HHA) visits in the medical record. 2. 4. RR # 7 is a 84-year-old female who was admitted on 11/05/2024 with a diagnosis of Disease of Liver. In the certification period from 11/05/2024 through 01/03/2025 the interdisciplinary group determined two visits per week for the Registered Nurse (RN). According to the medical record review performed on 12/18/2024 at 1:00 PM, the following was found: a. During interview with employee # 1 on 12/18/2024 at 1:30 PM and revision of the current policy and procedure named Documentación Clínica, Clinical Documentation, it was stated that nursing clinical notes must be integrated in the clinical record no more than 48 hours after the care is offered. b. No evidence was found of one of the nurses notes reassessments from week started on 11/24/2024 through 11/30/24. c. No evidence was found of the two nurses notes reassessments from week started on 12/01/2024 through 12/07/2024. d. The facility failed to ensure accessible and available nurses reassessments in the medical record. 3. 5. RR # 8 is a 88-year-old female who was admitted on 09/20/2024 with a diagnosis of Chronic Subdural Hemorrhage. In the certification period from 09/20/2024 through 12/18/2024 the interdisciplinary group determined two visits per week for the Registered Nurse (RN). According to the medical record review performed on 12/18/2024 at 1:00 PM, the following was found: a. During interview with employee # 1 on 12/18/2024 at 1:30 PM and revision of the current policy and procedure named Documentación Clínica it was stated that nursing clinical notes must be integrated in the clinical record no more than 48 hours after the care is offered. b. No evidence was found of one of the nurses notes reassessments from week started on 09/22/2024 through 09/28/24. c. No evidence was found of the two nurses notes reassessments from week started on 09/29/2024 through 10/05/2024. d. No evidence was found of the two nurses notes reassessments from week started on 12/01/2024 through 12/07/2024 and week started on 12/08/2024 through 12/14/2024. e. The facility failed to ensure accessible and available nurse's reassessments in the medical record. 3 Findings include: 1. H.V. #1 is an 80-years-old male, admitted to the facility on 11/15/2024 with a diagnosis of Alzheimer. During the record review performed on 12/17/2024, it was found that in the certification period 5 of 60 days, the interdisciplinary group stablish in the plan of care: Registered Nurse (RN) services 2 visits per week (wk) and as needed (PRN). The facility policy DOCUMENTACIÓN CLÍNICA, Clinical Notes evaluated on 12/18/2024 at 12:00 PM, state that the clinical notes must be documented in no more than 48 hours after the patient visit. a. During the week of 11/24/2024 thought 11/30/2024, no evidence was found of two visits notes of the RN. b. During the week of 12/01/2024 thought 12/07/2024, no evidence was found of one visit note of the RN, the RN visit on 12/06/2024. c. During the week of 12/08/2024 thought 12/14/2024, no evidence was found of one visit note of the RN, the RN visit on 12/09/2024.

Based on the review of nineteen personnel credential files (C.F.) on 12/18/2024 at 9:00 A.M. with the facility human resources assistant (employee #6) it was determined that the facility failed to ensure that 1 out of 19 employees record reviewed providing services have the criminal background check. --- Findings include: On 12/18/2024 at 9:00 A.M. during review of the credential files it was identified the following: a. Licensed practical nurse (LPN) #4, no evidence was provided of the certified negative criminal background check (Ley 300).

Based upon home visit (HV) to patients residence performed on 12/17/2024 approximately at 9:30 AM it was determined that the facility failed to address real or potential threats to the health and safety of the patients, others, and property for 1 out of 4 home visits. (HV#3) --- Findings include: During home visit (HV) #3 no "oxygen in use" sign was observed in the entrance of the residence, nor on the patients room.

Based on a recertification survey, observations made during three home visits (H.V), it was determined that the facility failed to follow acceptable standards of infection control during the procedures of a ulcer care and bath care for 2 out of 3 home visits (H.V #1 and #2 ) related with hand washing, glove changes and cross contamination. Findings include: 1. H.V #1 is an 80 years old female admitted on 08/30/2021 with a diagnosis of Age-related cognitive decline, Hight Blood Pressure, Cholesterol, Mayor Depression and Alzheimer early onset. The patient was visited on 01/25/2022 at 1:10 PM accompanied by facility Clinical Nursing Supervisor (employee #2) to observe bath in shower. The following was observed related to infection control during the bath care procedure and services furnished by the Home Health Aide (HHA) nurse (employee #3): a. The employee #3 did not performed the COVID - 19 screening questions and assessment before to start the batting process. b. The HHA employee #3 performed the hand washing and put a pair of gloves and takes the vital signs to the patient at the end of the process of taking vital signs, when she finished, one ear plug of the stethoscope fells on the floor, she picked it up from the floor she placed it on the stethoscope then she took a gauze pad she sprayed alcohol on it and disinfected it, then she placed it inside the briefcase, removed the gloves and discarded. However, the HHA did not change the gloves, which shows that there was cross contamination from the beginning to the end of the procedure. 2. H.V #2 is a 79 years old female admitted on 11/26/2021 with a diagnosis of Alzheimer Disease with late onset. The patient was visited on 01/25/2022 at 10:30 AM accompanied by facility Clinical Nursing Supervisor (employee #2) to observe ulcer care. The following was observed related to infection control procedures during ulcer care of H.V. #2 and services furnished by the registered nurse (RN) (employee #4) at 10:30 AM: a. The RN employee #4 did not performed the COVID - 19 screening questions and assessment before to start the batting process. b. The RN employee #4 wash hands with soap and water eighteen seconds, dry and then put a pair of gloves to take the patient's vital signs, then discarded the gloves, disinfected hands with alcohol and put on another pair of gloves and prepared the materials to clean the patient's ulcer on the sacral area. c. The RN employee #4 removed the dry gauzes, removed her gloves and discarded, disinfected with alcohol and puts a pair of gloves. Performed the patient's ulcer care of the sacral area and cleaned the area three times with wound cleanser, removed her gloves disinfected with alcohol and puts a pair of gloves, then dried the area and took ulcer measurement removed her gloves, discard and disinfected with alcohol, not having gloves, the nurse went to her briefcase, took out gloves and puts them on, took a gauze, wrapped it around her thumb, and introduce her finger inside the cavity of the sacral ulcer to measure depth. Then she took her finger out of the sacral ulcer cavity and measured with a metric tape. She removed gloves discard, disinfected hands with alcohol and puts a pair of gloves. Then took a sterile gauze and put it inside the cavity of the sacral ulcer with hydrogel, then covered with adhesive gauze and fixed. d. The RN employee #4 accommodated the patient assisted with her family caregiver. She removed her gloves, discarded and disinfected hands with alcohol, however, did not have gloves, the nurse went to her briefcase, took out a pair of gloves and gloved her hands. She disinfected the hydrogel tube removed her gloves discarded, did not disinfected her hands, the nurse went to her briefcase, took out gloves and put them on. She removed gauze pads from the patient's left arm , removed gloves, discarded, disinfected hands with alcohol and went to her briefcase, took out gloves and puts them, disinfected the alcohol pot removed her gloves disinfected her hands and then removed her coat and discard, then she performed the hand washing with soap and water per ten seconds but she did not bring napkins to dry her hands and the patient's relative provided her with napkins. e. During ulcer care the RN failed to wash hands before and after performing ulcer care according with the established time of 20 seconds. f. The RN failed to change gloves when the dirty procedure ended and before initiating the clean procedure. g. The facility failed to ensure that nursing personnel use appropriate techniques when handling gauze and hydrogel during the ulcer care. h. Failed to ensure that nursing personnel prepare and maintain necessary material to be used during ulcer treatment procedures. i. Failed to ensure that nursing personnel use appropriate techniques of hand washing between glove changes. The facility failed to ensure that nursing personnel use appropriate techniques of infection control. All procedures observed shows that there was cross contamination from the beginning to the end. j. The employee #4 fails to follow the Protocol for Hand Hygiene and Glove Use of the Centers for Disease Control and Prevention (CDC).

Based on a recertification survey, interview and credential file reviewed, it was determined that the facility failed to ensure that core services, are provided directly by hospice employee related to social worker and spiritual counseling. Findings include: 1. During interview on 01/27/2022 from 3:00 PM the Board of Directors President employee #7 state that the facility has 13 Registered Nurse, that only 9 were facility employee, they have 2 social worker and were also contract, they have 3 spiritual counselor that was contract and have 5 physician that only one was employee of the facility. 2. The facility failed to provide core service Social Worker and spiritual Counselor directly by hospice employees.

Based on a recertification survey performed on 01/25/2022 through 01/27/2022, sixteen records reviewed (R.R.) with three home visits (HV) with record review and three records of patient death, it was determined that the facility failed to ensure that the physician reviews and complies with the policies and procedures related to patient care for 3 out of 16 records reviewed. (Death patient R.R #1, RR #2 and RR #3). Findings include: 1. R.R #1 is a 95 years old male patient admitted on 03/24/2021 with a diagnosis of Alzheimer Disease. According of the nurse note the following was found; a.The progress note performed by the register nurse (employee # 13) on 04/23/2021 at 9:40 PM provide the following: '' On March 23, 2021 at 8:04 PM. the registered nurse (RN) employee #13 received a telephone call from the patient relative who referred '' My dad stopped breathing". '' The nurse visit the patients' home at 8:40 PM. and wrote on her progress note that the relatives look sad. Patient does not respond; we proceed to take vital sings which are not present. Resource refers at 8:00 PM found patient like this. At 8:55 PM a call is made to physician (employee #14) who certifies death of patient with time 8:00 PM. A call is made to the police department who say their intervention is not necessary. A call is made to the funeral arrangements. Members of the interdisciplinary group. Funeral home staff are notified to remove the corpse. Emotional support is offered to relatives of the patient. '' b. The progress note performed by the physician (employee # 14) on 04/23/2021 at 8:50 PM provide the following: '' I was notified by the nursing staff that the patient had no vital sings, Blood Pressure: 0, Pulse: 0, Saturation: 0, or no respiration or heart sounds. Death was certified at 8:00 PM on April 23, 2021.'' c. According of the physician progress notes causes of death are: Coronary Artery Disease, Malignant Hypertension and Alzheimer Disease. d. The nurse notes reveled that she provided emotional support and transfer the patients' body to the funeral agent. The nurse note revealed that the patient death was at 8:00 PM and she notified the death by telephone call to the physician (employee #14) at 8:55 PM however, no evidence of a Face to Face visit made by the physician to the patient's home to certify the death. The physician (employee #14) never visit the patient home to declare the patient death. e. Members of the interdisciplinary group was notified by the nurse and no evidence of visit to offer emotional support to patient relatives. 2. R.R #2 is a 92 years old male patient admitted on 02/23/2021 with a diagnosis of Age-related cognitive decline. According of the nurse note performed on May 11, 2021 at 10:25 AM the following was found; a. The progress note performed by the register nurse (employee # 15) on 05/1/2021 at 10:25 AM provide the following: ''At 5:05 AM received a telephone call per the nursing home personnel who indicates '' Patient does not present vital sings. ''The nurse visits the patient at the nursing home at 9:55 AM. and proceeds to estimate vital sings witch he presented: 0, for which she notified physician (employee #16) for certification of death. Members of the interdisciplinary group was notified. Funeral arrangements will be made by Maricao Funeral Home. A call is made to the daughter of a patient deceased and emotional support is given. '' b. The progress note performed by the physician (employee # 16) on 05/11/2021 at 12:50 PM provide the following: '' A call is received at 10:05 AM by the nurse (employee #15) was notified that the patient had no vital sings. The patient is evaluated, vital signs are absent. The death of patient is certified. Hour of death 4:42 AM. '' c. The nurse note did not revealed the hour at the patient death. Only provide the hour when received the call 5:05 AM and was at 8:00 PM and she notified the death by telephone call to the physician (employee #14) at 8:55 PM however, no evidence of a Face to Face visit made by the physician to the patient's home to certify the death. The physician (employee #14) never visit the patient home to declare the patient death. 3. R.R. #3 is a 95 years old male who was admitted on 07/05/2021 with a diagnosis of Chronic Kidney Disease Stage 3, Essential Hypertension, Diabetes Mellitus Type 11 and Alzheimer Disease. During the record review on 01/26/2022 at 10:10 AM related to management of the terminal illness and death process the following was identify: a. The nurse note written by the register nurse (employee #15) on 07/09/2021 reveled: '' Register nurse receives a telephone call at 4:50 AM to notify the patient of death at 4:50 AM. The interdisciplinary group is notified including the physician (employee #14) to certify death. A home visit is made, vital signs are confirmed and the nasal canula oxygen and urinary catheter was removed to the deceased. Emotional support is provided to the resource in the nursing home.'' b. The physician progress note written by the physician (employee #14) on 07/09/2021 at 6:40 AM reveled: '' Notify by the nursing personnel that the patient did not respond and did not present vital sings. Blood pressure 0, Pulse 0, Saturation 0, Respirations 0, no heart sounds. Death was certified at 4:40 AM on July 9, 2021. '' c. The physician progress note written on 07/09/2021 at 6:40 AM lacks the hour when she received the nurse call to notify the patient status. The physician documented '' proceed to certify death at 4:40 AM on July 9, 2021,'' however, no evidence when the physician goes to the patient home to certify the death. 4. In an interview with the Clinical Administrator (employee #1) and the President of the Board of Directors on 01/26/2022 at 1:15 PM, she refers that most of the contracted doctors have several jobs and when the nurse receives calls from patients caregivers from patients who are in the process of death or who have died, notify the physician if the physician cannot go home, she certifies by phone because they are in private offices or providing services in emergency rooms. This has been difficult for us because they resign and there is a shortage of physicians. 5. During Records Review performed on 01/26/2022 at 10:00 AM thru 3:00 PM, it was found that the facility failed to comply with Local Law Number 24 from April 22, 1931 which establishes that the physician is responsible of declaring and certifying patient's death at home.

Based on a recertification survey, three (3)Home Visits (H.V) with Record Review and ten Records Review (R.R), review of policy and procedure , it was determined that the facility failed to ensure that the clinical record contain complete clinical past and current findings for each hospice patient related to weakly ulcer measure, Home Health Aide (HHA) visit, glucose level (Dextrostix) and Frequency of visit for 7 out of 13 records review (R.R #2, #3, #5, and #6 and H.V. with record review #1, #2 and #3). Findings include: 1. R.R. #2 is an 87 years old male who was admitted on 10/02/2019 with a diagnosis of Alzheimer Disease, Parkinson, Age Related Cognitive Decline. During the record review on 01/25/2022 at 1:24 PM, it was found that Interdisciplinary group (IDG) plan of care performed on 10/12/2019 establish the following frequency to the core services in the Visit Calendar: Registered Nurse Services (RN) 2 visits per week and as necessary (PRN), Physician Services: indicated 1 visit per month and PRN., Social Worker Services 1 visit per month and PRN, and the Counseling Services 1 visit per month and PRN. During the record review the following was found: a. The electronic medical record does not provide evidence of the RN visit since 11/28/2021 to 12/28/2021, during the week from 01/02/2022 thru 01/08/2022, lack of 1 visit of RN, from 01/16/2022 thru 01/2/2022, lack of 1 visit of RN. b. During interview with the Clinical administrator (employee #1) on 01/25/25022 at 2:00 PM state that she downloads the patient medical record in the electronic record, however no evidence was found of the RNs missing note. 2. R.R. #3 is a 100 years old male who was admitted on 10/01/2020 with a diagnosis of Alzheimer Disease, High Blood Pressure (HBP), Pulmonal Fibrosis, and Prostatic Cancer. During the record review on 01/26/2022 at 12:13PM, it was found that Interdisciplinary group (IDG) plan of care performed on 11/29/2021 establish the following frequency to the core services in the Visit Calendar: Registered Nurse Services (RN) 2 visits per week and as necessary (PRN), Physician Services: indicated 1 visit per month and PRN., Social Worker Services 1 visit per month and PRN, and the Counseling Services 1 visit per month and PRN. During the record review the following was found: a. Evidence was found that the HHA provide services and has task assignment since 09/24/2021 with a frequency of 5 visits per week for complete bed bath and since 12/13/2021 Home Maker (ALL) 5 visits per week for patient assistant, however, it was not ordered in the IDG Plan (Visit Calendar). 3. R.R. #5 is a 74 years old male who was admitted on 12/14/2021 with a diagnosis of Alzheimer Disease, and Parkinson. During the record review on 01/26/2022 at 2:52 PM, it was found that Interdisciplinary group (IDG) plan of care performed on 12/14/2021 establish the following frequency to the core services in the Visit Calendar: Registered Nurse Services (RN) 2 visits per week and as necessary (PRN), Physician Services: indicated 1 visit per month and PRN., Social Worker Services 1 visit per month and PRN, and the Counseling Services 1 visit per month and PRN. During the record review the following was found: On 12/17/2021 the social worker assigns the service of Home Maker (ALL) 5 visits per week, however, it was not ordered in the IDG Plan (Visit Calendar). 4. R.R. #6 is a 70 years old male who was admitted on 12/01/2020 with a diagnosis of Alzheimer Disease, and Parkinson. During the record review on 01/26/2022 at 3:15 pm, it was found that Interdisciplinary group (IDG) plan of care performed on 12/14/2020 establish the following frequency to the core services in the Visit Calendar: Registered Nurse Services (RN) 2 visits per week and as necessary (PRN), Physician Services: indicated 1 visit per month and PRN., Social Worker Services 1 visit per month and PRN, and the Counseling Services 1 visit per month and PRN. During the record review the following was found: On 12/14/2020, the task assignment for HHA stablish frequency for 5 visit per week, however, it was ordered in the IDG Plan (Visit Calendar). 5. H.V. #1 is an 80 years old female who was admitted on 08/30/2021 with a diagnosis of Age-related cognitive decline, Hight Blood Pressure, Cholesterol, Mayor Depression and Alzheimer Disease. During the record review on 01/27/2022 at 9:10 AM, it was found that Interdisciplinary group (IDG) plan of care performed on 08/30/2021 establish the following frequency to the core services in the Visit Calendar: Registered Nurse Services (RN) 1 visit per week and as necessary (PRN), Physician Services: indicated 1 visit per month and PRN., Social Worker Services 1 visit per month and PRN, Counseling Services 1 visit per month and PRN and Nutritionist one presential visit and then PRN and following was found during reviewed the patient record: a. The record was reviewed on 01/27/2021 at 9:10 AM. and provide evidence that the plan of care for the license practical nurse ( LPN) was performed and signed by the register nurse (RN) employee #10 on 08/30/2021 however, does not have the signature of the LPN ( employee #3 ). b. The record was reviewed on 01/27/2021 at 9:10 AM. and provide evidence that the LPN (employee #3) did not performed five patient visits to provide bath care on week 01/16 till 01/22 of 2022 however, no evidence of nurse's notes. c. The record was reviewed on 01/27/2021 at 9:10 AM. and provide evidence that the ALL (employee #12) did not performed one patient visit on week 01/02 till 01/08 and 01/09 till 01/15 of 2022 however, no evidence of nurse's notes. The home maker service (ALL) performed her notes, however, lacks the signed, the date and the social worker license number. No evidence when the social worker evaluated the ALL service. 6. H.V. #2 is a 79 years old female who was admitted on 11/26/2021 with a diagnosis of Alzheimer Disease with late onset and secondary diagnosis of Diabetes, Hypertension and Hypothyroidism. During the record review on 01/26/2022 at 1:30 PM, it was found that Interdisciplinary group (IDG) plan of care performed on 11/30/2021 establish the following frequency to the core services in the Visit Calendar: Registered Nurse Services (RN) 2 visits per week and as necessary (PRN), Home Health Aide services (HHA) 3 visits per week and as necessary (PRN), Physician Services: indicated 1 visit per month and PRN., Social Worker Services 1 visit per month and PRN, and the Counseling Services 1 visit per month and PRN and following was found during reviewed the patient record: a. The record was reviewed on 01/26/2021 at 1:30 PM. and provide evidence that the register nurse (employee #4) visit the patient to provide care on 01/03, 01/05, 01/10, 01/13 and 01/18/2022 however, the nurses notes did not provide evidence of Destrostix (measure patients glucose) performed by the patient caregiver during the visits. b. The patient record provide evidence that the patient has a pressure sacral ulcer stage 111 register nurse (employee #4) visit the patient to provide care on 12/13, 12/19, 12/25, 12/26/2021, 01/02, 01/03, 01/05, 01/10, 01/13,01/18 and 01/21/2022 however, the nurses notes did not provide evidence of ulcer measures during the visits performed by the register nurse. c. The patient record provide evidence that the Social Worker (employee #8) performed the initial assessment by telephone on 11/27/2021 and she wrote that the patient received alimentation by PEG, however the initial assessment performed by the register nurse, the physician and the nutritionist reveled that the patient has poor appetite and recommended mechanical soft diabetic diet 1600 kilocalories. The patient record provide evidence that the social worker performed the next visits on 12/28/2021 and 01/11/2022 by telephone call and did not provide evidence of the patient status. 7. H.V. #3 is a 77 years old male who was admitted on 11/02/2021 with a diagnosis of Cerebral Infarction due to Unspecified occlusion or Stenosis of left cerebellar artery and secondary diagnosis of Dementia, Hight Blood Pressure secondary to Cholesterol, Hemiplegia Right Side and Pressure areas of left hip and right foot. During the record review on 01/26/2022 at 2:30 PM, it was found that Interdisciplinary group (IDG) plan of care performed on 11/02/2021 establish the following frequency to the core services in the Visit Calendar: Registered Nurse Services (RN) 1 visits per week and as necessary (PRN), Physician Services: indicated 1 visit per month and PRN., Social Worker Services 1 visit per month and PRN, and the Counseling Services 1 visit per month and PRN and one Nutritionist initial visit and then PRN (as needed) and following was found during reviewed the patient record: a. The patient record provide evidence that the Nutritionist (employee #11) did not performed the initial visit to identify nutritional problems and establish a nutritional plan for the patient until December 2021 to date, no evidence of nutritionist notes. b. The record was reviewed on 01/27/2022 at 9:10 AM. and provide evidence that the register nurse (employee #9) did not performed patient visits to provide care on week 11/14 till 11/20, 11/21 till 11/27, 11/28 till 12/04 of 2021 and 01/02 till 01/08/2022 however, no evidence of nurses notes. c. The record was reviewed on 01/27/2022 at 9:10 AM. and provide evidence that the Spiritual Adviser (employee #10) did not performed patient visit on December /2021 however, no evidence of note. d. The record was reviewed on 01/27/2022 at 9:10 AM. and provide evidence that the patient received home maker service (ALL) employee #12 on December 2021 to January 2022. The record provide evidence that the patient caregiver signed the exoneration service on November 19/2021. However, the record provide evidence that the patient receive service on December 9/ 10/ 13 and 14/ 2021 and on January 10/ 12/ 14 and 19 of 2022. The ALL weekly report of visits was signed by the ALL however lacks the date and Social Worker signed. No evidence when the social worker evaluated the ALL service.

Based on unannounced recertification survey, review of thirty (30) credential files (C.F) with the Human Resources (employee #5), performed on 01/27/2022 from 11:30 AM thru 1:30 PM, it was determined that the facility failed to ensure that employees who have direct contact or access to patient records obtain and maintain criminal background check required under federal law and accordance with State requirements, Law 300 for 2 out of 30 files evaluated. (Physician CF #1 and #5). Findings include: Two out of six Physician C.F. reviewed on 01/27/2022 from 11:30 AM thru 1:30 PM, no evidence was found criminal background check. (Physician C.F. #1, and #5).

Based on a recertification survey, review of thirty credential files (C.F) with the Human Resources (employee #5), performed on 01/27/2022 from 11:30 AM through 1:30 PM, it was determined that the facility failed to ensure an update credential related to updated Influenza Vaccine, and Law 300 of 1999 Ley de Verificación de Historial Delictivo' , Criminal Background Check for 3 out of 30 credential files (Physician C.F #1, #2, and #5). Findings include: Review of thirty (30) credential files of the personnel of the hospice on 01/27/2022 from 11:30 AM thru 1:30 PM provided evidence of the following: 1. The Physician C.F (P.C.F.), it was found the following: a. One out of six physicians C.F, did not contain evidence of updated Influenza vaccine (P.C.F. #2). The last influenza vaccine was on 12/09/2019. b. Two out of six physicians C.F (P.C.F.), did not contain evidence of ' ' Ley 300 de 1999 Ley de Verificación de Historial Delictivo'' Criminal Background Check (P.C.F #1 and #5).