Every finding on record at Hospicio Divinas Manos

Based on an Emergency Preparedness (EP) survey, and evaluation of the EP manual, performed on 11/10/2022 from 9:00 AM to 11:30 AM with the facility Medical Social Worker (employee 2) , it was determined that the facility failed to develop and maintain an emergency preparedness plan that include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. --- Findings include: During the EP survey performed on 11/10/18 from 9:00 AM to 11:30 AM with the facility Medical Social Worker (employee #2) she show evidence that facility assess every need that patients have in the event of an emergency. A risk assessment, utilizing all-hazards approach who include the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care, were not evidence during survey procedures. Facility fail to have in place an all-hazard approach through aa risk assessment that promote that them will have the capacity to address a broad range of related emergencies.

Based on an Emergency Preparedness (EP) survey performed on and evaluation of the EP manual, performed on 11/10/2022 from 9:00 AM to 11:30 AM with the facility Medical Social Worker (employee #2) ,to evaluate the emergency preparedness requirements, it was determined that the facility failed to develop and implement emergency preparedness Policies and Procedures which outline the facilitys role in the provision of care and treatment under section 1135 waivers. --- Findings include: The facility failed to have in place policies and procedures related to the role of the facility under the waiver declared by the Secretary in accordance with section 1135 of the ACT that address provision of care and treatment at an alternate site identify by the emergency officials.

Based on an Emergency Preparedness (EP) survey performed on 11/10/2022 from 9:00 AM to 11:30 AM and evaluation of the EP manual, with the facility Medical Social Worker (employee #2) , to evaluate the emergency preparedness requirements and review of policies and procedures, it was determined that the facility failed to develop and maintain an Emergency Preparedness communication plan that complies with Federal, State and local laws. --- Findings include: The facility failed to have in place a written communication plan that contain s how the facility coordinates patient care within the facility, across healthcare providers, and with state and local public health departments.

Based on an Emergency Preparedness (EP) survey performed on performed on 11/10/2022 from 9:00 AM to 11:30 AM and evaluation of the EP manual, with the facility Medical Social Worker (employee #2) ,and interview to evaluate the emergency preparedness requirements, it was determined that the facility failed to develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws. --- Findings include: The facility did not 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. Procedures regarding when and how alternate communication methods are uses, and who uses them were not include as part of facility emergency preparedness plan. During interview on 11/10/2022 at 11:20 AM Medical Social Worker (employee #2) stated that facility did not had pagers, radio transceivers ( walkies-talkies ) or satellite telephone communications systems. She stated that facility had cellular phones to be used during emergency situations, in the event that they experience difficulty using cellular phones on remote areas they proceed to implement a system were employees will appear in person in every patient home and coordinate communications between patients facility staff, Federal, State, regional and local emergency management agencies.

Based on a recertification survey, three home visits (HV) with records reviewed, fifteen records reviewed (RR), administrative documents review, policies and procedures (P&P's) review, interview with the Quality Assurance Performance Improvement ( QAPI) officer (employee #1), during a survey process performed from 11/08/2022 thru 11/10/2022, from 8:30 AM thru 3:00 PM, it was determined that the facility failed to promote that information from performance being achieved and published on the Medicare.gov Hospice compare is used to identify gaps in execution. --- Findings include: 1. During survey procedures performed from 11/08/2022 thru 11/10/2022, from 8:30 AM thru 3:00 PM: review of Quality Assessment Performance Improvement (QAPI) program activities, the surveyor requested to the facility's QAPI officer evidence of the medicare.gov Hospice compare data analysis, discussion and establishment of activities to improve in areas where the achievement does not compare favorably with the same industry. QAPI officer (employee #1), provides evidence on 11/10/2022 at 1:15 PM of activities performed by the facility. During the review of QAPI activities it was identified that facility does not include in their QAPI plan and indicators or activities related with the percentage of patients who received visits from a register nurse or medical social worker on at least 2 of the final 3 days of their life. Facility also did not have QAPI plan and indicators activities related with the compliance with Hospice Care Index. During interview on 11/08/2022 at 2:45 PM with the QAPI officer (employee #1), stated that facility did not include indicators or activities related with the percentage of patients who received visits from a register nurse or medical social worker on at least 2 of the final 3 days of their life and indicators or activities related with the compliance with Hospice Care Index as part of their QAPI plan.

Based on a recertification survey and observations performed on medical surgical storage room, on 11/09/2022 it was determined that the facility failed to follow acceptable standards of infection control. This deficient practice had the potential to affect 43 out of 43 admitted patients receiving services. --- Findings include: On 11/09/2022 at 2:00 PM medical surgical storage room was visited with Nursing supervisor (employee #3). The entrance of the storage room had a wooden door that was observed in need of repair. The area on the middle of the door was observed with chipped wooden pieces. This wooden chipped area does not permit proper cleaning and disinfection of the door. The storage room was observed in need of cleaning and in need of paint. At the left side near the entrance door it was observed ceiling tiles with black humidity stains.

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 spiritual counseling. --- 1. During interview on 11/08/2022 from 08:45 am the Services Director employee #4 state that the facility has 4 Registered Nurse (RN), that only 1 were facility employee, they have 4 License Practice Nurse (LPN), 1 social worker, 1 spiritual counselor that was contract and have 3 physician that was contract. 2. The facility failed to provide core service Spiritual Counselor directly by hospice employees.

Based on a recertification survey performed on 11/08/2022 through 11/10/2022, four (4) Focus Record Review Nurse Supervisor (employee #3), it was determined that the facility failed to ensure that the clinical records contain current findings for each hospice patient related to pertinent information who provide the basis to evidence that patient is dealing with uncomfortable physical symptoms and psychological distress common at the end-of-life for 4 out of 4 Focus Record Review (F.R.R # 1, #2, #3 and #4) --- 1. F.R.R # 1 a 93-year-old female who was admitted on 04/25/2019 with a diagnosis of Heart Failure record review was performed on 11/09/2022 1:30 PM with the Nurse supervisor (employee #3). Case was reviewed for the last three Interdisciplinary group (IDG) discussions (on 09/28/2022, on 10/12/2022 and on 10/26/2022). Frequency for visit for this patient was established by the IDG on 1 visit per week and PRN as needed for the Register Nurse (RN), 1 visit per month and PRN as needed for the Social Worker and 1 visit per month and PRN as needed for the Spiritual Counselor. As stated on the last three IDG group discussions and establishment for the plan of care on 09/28/2022, on 10/12/2022 and on10/26/2022, No change was documented related to Pain Management, Sleep, Skin condition, level of care, no changed was performed to the plan of care. The nurses note and the plan of care did not include pertinent information who provide the basis to evidence that patient is dealing with uncomfortable physical symptoms and need the interventions planned and delineated on the IDG group discussions. Nurse documentation did not evidence severity of symptoms an intensity of treatment that show patient deterioration and ease end of life suffering. Findings were discussed with nurse supervisor (employee #3) on 11/10/2021 at 09:30 am. Review of the on-call logbook form 2019 to the present days performed on 11/08/2022 at 9:30 am no evidence was found related to patient or relative performed a crisis on call during the last recertification. 2. F.R.R # 2 a 78-year-old male who was admitted on 01/17/2020 with a diagnosis of Heart Failure record review was performed on 11/09/2022 2:00 PM with the Nurse supervisor (employee #3). Case was reviewed for the last three Interdisciplinary group (IDG) discussions (on 10/05/2022, on 10/19/2022 and on 11/02/2022). Frequency for visit for this patient was established by the IDG on 1 visit per week and PRN as needed for the Register Nurse (RN), 1 visit per month and PRN as needed for the Social Worker and 2 visit per month and PRN as needed for the Spiritual Counselor. As stated on the last three IDG group discussions and establishment for the plan of care on 10/05/2022, on 10/19/2022 and on 11/02/2022, no change was documented related to Pain Management, Sleep, Skin condition, level of care, no changed was performed to the plan of care. The nurses note and the plan of care did not include pertinent information who provide the basis to evidence that patient is dealing with uncomfortable physical symptoms and need the interventions planned and delineated on the IDG group discussions. Nurse documentation did not evidence severity of symptoms an intensity of treatment that show patient deterioration and ease end of life suffering. Findings were discussed with nurse supervisor (employee #3) on 11/10/2021 at 09:30 am. Review of the on-call logbook form 2020 to the present days performed on 11/08/2022 at 9:30 am no evidence was found related to patient or relative performed a crisis on call during the last recertification. 3. F.R.R # 3 a 91-year-old female who was admitted on 04/19/2021 with a diagnosis of Alzheimer record review was performed on 11/09/2022 2:30 PM with the Nurse supervisor (employee #3). Case was reviewed for the last three Interdisciplinary group (IDG) discussions (on 10/05/2022, on 10/19/2022 and on 11/02/2022). Frequency for visit for this patient was established by the IDG on 1 visit per week and PRN as needed for the Register Nurse (RN), 1 visit per month and PRN as needed for the Social Worker and 1 visit per month and PRN as needed for the Spiritual Counselor. As stated on the last three IDG group discussions and establishment for the plan of care on 10/05/2022, on 10/19/2022 and on 11/02/2022, no change was documented related to Pain Management, Sleep, Skin condition, level of care, no changed was performed to the plan of care. The nurses note and the plan of care did not include pertinent information who provide the basis to evidence that patient is dealing with uncomfortable physical symptoms and need the interventions planned and delineated on the IDG group discussions. Nurse documentation did not evidence severity of symptoms an intensity of treatment that show patient deterioration and ease end of life suffering. Findings were discussed with nurse supervisor (employee #3) on 11/10/2021 at 09:30 am. Review of the on-call logbook form 2021 to the present days performed on 11/08/2022 at 9:30 am no evidence was found related to patient or relative performed a crisis on call during the last recertification. 4. F.R.R #4 an 83-year-old female who was admitted on 05/19/2021 with a diagnosis of Alzheimer record review was performed on 11/09/2022 2:50 PM with the Nurse supervisor (employee #3). Case was reviewed for the last three Interdisciplinary group (IDG) discussions (on 09/28/2022, on 10/12/2022 and on 10/26/2022). Frequency for visit for this patient was established by the IDG on 1 visit per week and PRN as needed for the Register Nurse (RN), 1 visit per month and PRN as needed for the Social Worker and 1 visit per month and PRN as needed for the Spiritual Counselor. As stated on the last three IDG group discussions and establishment for the plan of care on 09/28/2022, on 10/12/2022 and on 10/26/2022, no change was documented related to Pain Management, Sleep, Skin condition, level of care, no changed was performed to the plan of care. The nurses note and the plan of care did not include pertinent information who provide the basis to evidence that patient is dealing with uncomfortable physical symptoms and need the interventions planned and delineated on the IDG group discussions. Nurse documentation did not evidence severity of symptoms an intensity of treatment that show patient deterioration and ease end of life suffering. Findings were discussed with nurse supervisor (employee #3) on 11/10/2021 at 09:30 am. Review of the on-call logbook form 2019 to the present days performed on 11/08/2022 at 9:30 am no evidence was found related to patient or relative performed a crisis on call during the last recertification.

Based on a recertification survey performed on 11/08/2022 through 11/10/2022, three (3) Home Visit (H.V.) with records reviewed, eight Record Reviewed (R.R.) and four focus R.R with Nursing supervisor (employee #3) and interview, it was determined that the facility failed to ensure each patient's record include Physician certification of terminal illness as required in §418.22 and §418.25 once is referred and admitted to receive services by the facility for 4 out of 15 records reviewed ( R.R.#1, R.R.#2, R.R.#3, and R.R. #5 ). --- 2. R.R. #1, an 85-year-old male who was admitted on 11/01/2022 with a diagnosis of Parkinson was reviewed on 11/09/2022 at 9:40 AM with Nursing supervisor (employee # 3) During the review, it was identified that a medical prescription format was used to refer patient from hospital to receive hospice services. However, this document did not include relevant information related with patient expectancy of life-or-death imminence. 3. R.R. #2, an 82-year-old female who was admitted on 11/04/2022 with a diagnosis of Breast Cancer was reviewed on 11/09/2022 at 9:51 AM with Nursing supervisor (employee # 3) During the review, it was identified that a medical prescription format was used to refer patient from hospital to receive hospice services. However, this document did not include relevant information related with patient expectancy of life-or-death imminence. 4. R.R. #3 an 86-year-old female who was admitted on 11/04/2022 with a diagnosis of End Stage Renal Disease (ESRD) was reviewed on 11/08/2022 at 3:00 PM with Nursing supervisor (employee # 3) During the review, it was identified that a medical prescription format was used to refer patient from hospital to receive hospice services. However, this document did not include relevant information related with patient expectancy of life-or-death imminence. 5. During interview on 11/08/2022 at 2:55 PM the Nursing supervisor (employee # 3) stated that facility had a format for this procedure and that facility always request that the referral physician complete the document that include relevant information related with patient expectancy of life-or-death imminence. Findings include: 1.R.R. # 5, a 76 years old female who was admitted on 06/08/2022 with a diagnosis of Alzheimer was reviewed on 11/08/2022 at 9:45 AM with Nursing supervisor ( employee # 3) During the review it was identified that a medical prescription format was used to refer patient from hospital to receive hospice services. However, this document did not include relevant information related with patient expectancy of life or death imminence. During interview on 11/08/2022 at 2:55 PM the Nursing supervisor ( employee # 3) stated that facility had a format for this procedure and that facility always request that the referral physician complete the document that include relevant information related with patient expectancy of life or death imminence.