Every finding on record at Hospicio Krystal Inc

Observed in Record Review. In 4 of 10 patient records reviewed, The surveyor observed in 1/10 records that the chaplain failed to complete initial assessment within 5 days and in 4/10 records the social worker failed to complete their initial assessments within five days after the election of hospice benefit . This was discussed and confirmed with organization leadership

Observed in Record Review. In 4 of 10 patient records reviewed, The surveyor observed that MSW had not provided care according to POC. The surveyor observed that the POC ordered for 1Xmonth X 3 months however no MSW visits had been made during that time period specified on POC . In discussion with organization leadership it was verbalized that organization had been without a MSW except by phone and no phone visits had been documented . The surveyor also observed in 1/10 records with CHHA that the order on POC had been 2X week and the CHHA had seen the patient 3 x week for 3 weeks in one certification period. This issue was discussed and confirmed with organization leadership.

Observed in Tracer Activities. The surveyor observed that although the organization had made efforts through advertisement in multiple venues that volunteers had not provided at least 5% of the total patient care hours of all paid hospice employees and contract staff. At the time of survey the organization had zero volunteers, but had one in process of orientation. The surveyor noted that in 2024 and in 2025 the organization had zero volunteers. The issue was discussed and confirmed with organization leadership.

Observed in Tracer Activities. The surveyor observed that the organization had not met in 2024 , 2025 or as yet in 2026 a minimum of 5% total patient care hours . The surveyor was informed that although the organization had made efforts with proof of advertisement in 2024 and 2025 they had not retained any volunteers, but did at the time of survey have one in orientation. This issue was discussed and confirmed with organization leadership.

Observed in Document Review. In 2 of 2 patient records reviewed, The surveyor observed that the hospice had not provided a summary of care to receiving facility when patient revoked and went to hospital. Organization leadership stated this was not part of their process at this time. The issue was discussed and confirmed with organization leadership.

Observed in HR File Review. In 4 of 4 HR files reviewed, for nurses that ongoing primary source verification had not been done. The organization had been doing primary source verification for nursing only at the time of hire and documenting. This issue was discussed and confirmed with organization leadership.

Observed in Record Review. In 11 of 11 patient records reviewed, The surveyor observed that the goals had not been measurable. For example when pain had been listed as care plan issue the goal was generic and not measurable. The issue had been noted in case of social worker goals and spiritual goals. Organization stated part of problem was related to EMR, but had not fixed the problem to date. The issue was discussed and confirmed with leadership.

Observed in Record Review. In 8 of 11 patient records reviewed, The surveyor observed that care had not been provided according to hospice plan of care. The chaplain, according to plan of care was to visit patient 1 time a month and surveyor noted on some records it had been greater than 6 months since chaplain visit without change to POC. This issue was discussed and confirmed with organization leaders.

Observed in Data Session. The surveyor observed in review of data and discussion with organization leaders that performance improvement projects had not been conducted in 2020, 2021 or as yet in 2022.

Observed in Data Session. The surveyor observed that in 2020, 2021 or as yet in 2022 that the organization had not documented what performance improvement projects were being conducted, the reasons for conducting these projects, and the measurable progress achieved on them. The organization leadership stated that they had not completed projects at the time of survey.

Observed in Individual Tracer. The surveyor noted during home visit one that nurse failed to complete hand hygiene after removing her gloves while completing wound care six times. The surveyor observed on six glove changes during the wound care process that the nurse failed to clean hands as required by CDC and organization policy. The issue was discussed and confirmed with organization leadership.

Observed in Record Review. The surveyor observed in case that patient was transferred to hospital and revoked that no discharge summary had been sent to hospital that was treating patient. This issue was discussed and confirmed with organization.