Every finding on record at Hospicio La Guadalupe Inc

Based upon an Emergency Preparedness Program (EPP) survey performed on 10/25/2024 from 8:10 AM to 10:15 AM, to evaluate emergency preparedness requirements, it was determined that the facility failed to develop procedures to inform State and local emergency preparedness officials about patients in need of evacuation from their residences at any time due to an emergency situation based on the patients medical or psychiatric condition and home environment. --- Findings include: During the review of the facilities Emergency Preparedness Program with the Quality Manager (employee #1) on 10/25/2024 it was noted that the facility failed to have written procedures to notify State and local emergency preparedness officials about patients in need of evacuation from their residences at any time due to an emergency as required under §418.113(b)(2).

Based upon an Emergency Preparedness Program (EPP) survey performed on 10/25/2024 from 8:10 AM to 10:15 AM, 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 Quality Manager (employee #1) on 10/25/2024 it was noted that the facility failed to stablish 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 on 10/25/2024 from 8:10 AM to 10:15 AM, to evaluate emergency preparedness requirements, it was determined that the facility failed to develop procedures for sharing information and medical documentation for patients under the facility's care, as necessary, with other health care providers to maintain the continuity of care. --- Findings include: During the review of the facilities Emergency Preparedness Program with the Quality Manager (employee #1) on 10/25/2024 it was noted that the facility failed to provide a written method for sharing information and medical documentation for patients under the facility's care, as necessary, with other health care providers to maintain the continuity of care as required under §418.113(c)(4)-(6).

Based upon an Emergency Preparedness Program (EPP) survey performed on 10/25/2024 from 8:10 AM to 10:15 AM, to evaluate emergency preparedness requirements, it was determined that the facility failed to develop and maintain an emergency preparedness training and testing program. --- Findings include: During the review of the facilities Emergency Preparedness Program with the Quality Manager (employee #1) on 10/25/2024 it was noted that the facility failed to develop and maintain an emergency preparedness training and testing program based on the facilities risk assessment.

Based on four Home visit with record review and fifteen records reviewed (RR), it was determined that the facility failed to ensure that the patients were free to exercise their rights to complaint by providing them the phone numbers of the State Agency and local Medicare agency, for 10 out of 19 records reviewed (H.V-.R.R. #1, #2, #3, #4, R.R. #3, #4, #5, #6, #7, and #8). --- 6. HV. #3 is a 75 -years-old female, admitted to the facility on 07/08/2023 with a diagnosis of Alzheimer Disease with Late Onset, Diabetes Mellitus Type II, Chronic Ischemic Heart Disease, Bed confinement. During the record review performed on 10/24/2024 at 4:00 PM, it was found that in the certification period 20 of 60 days, from 08/31/2024 through 10/30/2024, the interdisciplinary group establish in the plan of care: Registered Nurse (RN) services 2 visit per week and as needed (PRN), Hospice Aid (HHA) 3 visit per week and as needed, Physician 1 visit per month and as needed, Social Worker 1 visit per month and as needed and Spiritual Advisor 1 visit per month and as needed. a) No evidence was found in record of the State Agency and Medicare local agency numbers. 7. HV. #4 is a 94 -years-old female, admitted to the facility on 02/22/2024 with a diagnosis of Chronic Ischemic Heart Disease, unspecified Dementia. During the record review performed on 10/25/2024 at 12:40 PM, it was found that in the certification period 2 of 60 days, from 10/19/2024 through 12/17/2024, the interdisciplinary group establish in the plan of care: Registered Nurse (RN) services 2 visit per week and as needed (PRN), Hospice Aid (HHA) 3 visit per week and as needed, Physician 1 visit per month and as needed, Social Worker 1 visit per month and as needed and Spiritual Advisor 1 visit per month and as needed. a) No evidence was found in record of the State Agency and Medicare local agency numbers. 8. RR. #3 is a 88 -years-old female, admitted to the facility on 08/09/2024 with a diagnosis of Chronic Ischemic Heart Disease, Anemia, Hypertensive Heart Disease. During the record review performed on 10/25/2024 at 1:30 PM, it was found that in the certification period 1 of 90 days, from 08/09/2024 through 11/06/2024, the interdisciplinary group establish in the plan of care: Registered Nurse (RN) services 2 visit per week and as needed (PRN), Hospice Aid (HHA) 2 visit per week and as needed, Physician 1 visit per month and as needed, Social Worker 1 visit per month and as needed and Spiritual Advisor 1 visit per month and as needed. a) No evidence was found in record of the State Agency and Medicare local agency numbers. 9. RR. #6 is a 95 -years-old female, admitted to the facility on 09/12/2024 with a diagnosis of Heart Failure unspecified, Diabetes Mellitus Type II, Hypertensive Heart, Cardiac Arrhythmia. During the record review performed on 10/25/2024 at 2:15 PM, it was found that in the certification period 1 of 60 days, from 09/12/2024 through 11/10/2024, the interdisciplinary group establish in the plan of care: Registered Nurse (RN) services 2 visit per week and as needed (PRN), Physician 1 visit per month and as needed, Social Worker 1 visit per month and as needed and Spiritual Advisor 1 visit per month and as needed. a) No evidence was found in record of the State Agency and Medicare local agency numbers. 10. RR. #8 is a 85 -years-old female, admitted to the facility on 09/16/2024 with a diagnosis of Alzheimer Disease with late onset, Hypothyroidism, Diabetes Mellitus Type II, Hypertensive Heart Disease. During the record review performed on 10/25/2024 at 3:35 PM, it was found that in the certification period 1 of 90 days, from 09/16/2024 through 12/14/2024, the interdisciplinary group stablish in the plan of care: Registered Nurse (RN) services 2 visit per week and as needed (PRN), Physician 1 visit per month and as needed, Social Worker 1 visit per month and as needed and Spiritual Advisor 1 visit per month and as needed. a) No evidence was found in record of the State Agency and Medicare local agency numbers. 1. H.V. #1 is a 93 -years-old female, admitted to the facility on 08/15/2024 with a diagnosis of Alzheimer Disease. During the record review performed on 10/24/2024 at 3:00 PM, it was found that in the certification period 1 of 60 days, the interdisciplinary group establish in the plan of care: Registered Nurse (RN) services 2 visit per week and as needed (PRN), Hospice Aid (HHA) 3 visits per weeks and as needed (PRN), Physician 1 visit per Month (1 MO), Social Worker 1MO and Spiritual Advisor 1MO. a. No evidence was found in record of the State Agency and Medicare local agency numbers to file a complaint. 2. H.V. #2 is an 89 -years-old male, admitted to the facility on 08/28/2024 with a diagnosis of Heart Failure Disease. During the record review performed on 10/24/2024 at 3:50 PM, it was found that in the certification period 1 of 60 days, the interdisciplinary group establish in the plan of care: Registered Nurse (RN) services 2 visit per week and as needed (PRN), Hospice Aid (HHA) 3 visit per weeks and as needed (PRN), Physician 1 visit per Month (1 MO), Social Worker 1MO and Spiritual Advisor 1MO. a. No evidence was found in record of the State Agency and Medicare local agency numbers. 3. R.R. #4 is an 88 -years-old male, admitted to the facility on 08/16/2024 with a diagnosis of Chronic Ischemic Heart Disease. During the record review performed on 10/25/2024 at 12:44 PM, it was found that in the certification period 1 of 90 days, from 08/16/2024 through 11/13/2024, the interdisciplinary group establish in the plan of care: Registered Nurse (RN) services 2 visit per week (wk) and as needed (PRN), Physician 1 visit per Month (1 MO), Social Worker 1MO and Spiritual Advisor 1MO. a. No evidence was found in record of the State Agency and Medicare local agency numbers. 4. R.R. #5 is an 81 -years-old male, admitted to the facility on 09/05/2024 with a diagnosis of Alzheimer Disease with Late Onset. During the record review performed on 10/25/2024 at 1:42 PM, it was found that in the certification period 1 of 60 days, from 09/05/2024 through 11/03/2024, the interdisciplinary group establish in the plan of care: Registered Nurse (RN) services 2 visit per week (wk) and as needed (PRN), Hospice Aid (HHA) 4 visit per weeks (wks), Physician 1 visit per Month (1 MO), Social Worker 1MO and Spiritual Advisor 1MO. a. No evidence was found in record of the State Agency and Medicare local agency numbers. 5. R.R. #7 is a 96 -years-old female, admitted to the facility on 09/13/2024 with a diagnosis of Malignant Neoplasm of Breast Disease. During the record review performed on 10/25/2024 at 1:16 PM, it was found that in the certification period 1 of 90 days, from 09/13/2024 through 12/11/2024, the interdisciplinary group establish in the plan of care: Registered Nurse (RN) services 2 visit per week (wk) and as needed (PRN), Hospice Aid (HHA) 1 visit per weeks (wks) and as needed (PRN), Physician 1 visit per Month (1 MO), Social Worker 1MO and Spiritual Advisor 1MO. a. No evidence was found in record of the State Agency and Medicare local agency numbers.

Based on observation, four Home Visit (H.V.) review of policy and procedure, it was determined that the facility failed to ensure that nursing personnel provide care with accepted standards of practice of infection control during the ulcer care, Foley insertion and patient bath for 4 out of 4 Home Visit (H.V. #1, #2, #3 and #4). It was also observed that the bio-medical equipment storage room does not meet the temperature requirements. --- 3. HV #1 is a 93-year-old female admitted on 08/15/2024 with a diagnosis of Alzheimer disease, unspecified. The patient was visit on 10/24/2024 at 11:22 AM until 12:32 PM accompanied with a facility registered nurse (employee #7). During the visit it was observed that the patient was alert but not conscious, bedridden and totally dependent of activities of daily living. The patient has 2 sacral ulcers that is cleaning every 3-4 days. The patient was receiving a visit of the employee #7 to provide ulcer care. a) It was observed that the employee #7 put on the protective equipment including the surgical gown before entering the patient's home. The Facilitys failed to provide a policy where its employees can identify the appropriate time to put on protective equipment to provide patient care. Nursing standards state that if there is no respiratory illness within the home, the surgical gown should be put on as close as possible to the process to be performed, in this case, ulcer care. 4. HV #2 is an 89-year-old male admitted on 08/28/2024 with a diagnosis of Heart Failure disease, unspecified. The patient was visit on 10/25/2024 at 9:47 AM until 11:46 AM accompanied with a facility registered nurse (employee #8). During the visit it was observed that the patient was oriented in person but not in time and place. The patient has a Foley Catheter #20, for bladder incontinence need that is change every thirty days. The patient was receiving the visit of employee #8 to perform the Foley Catheter change and care of sacral ulcer. a) It was observed that the employee #8 washed her hands but the estimated hand washing time at each opportunity did not last more than 10 seconds. The Facilitys policy states that hand washing should last between 10 to 15 seconds. The CDC states that effective hand washing should last at least 20 seconds. 5.During the tour of the facility's storage rooms performed on 10/25/2024 at 4:22 PM it was observed that the air conditioning in the surgical equipment storage room was turned off, there was no daily temperature record, and the temperature was 78 degrees F. The facility failed to provide a policy specifying the proper storage temperature of surgical products according to the manufacturer's instructions. 1.HV #3 is a 75-year-old female admitted on 07/08/2023 with a diagnosis of Alzheimer disease with late onset, Diabetes Mellitus Type II, Chronic Ischemic Heart Disease, Bed confinement. The patient was visit on 10/24/2024 at 11:45 AM until 1:20PM accompanied with a register nurse of this facility, (employee #9). During the visit it was observed that the patient was lethargic, not conscious, bedridden and totally dependent of activities of daily living. The patient has one Sacral Ulcer Stage IV that is cleaning every 3-4 days. The patient was receiving visit of the employee #9 to provide ulcer care. a) It was observed that during the ulcer treatment procedure, employee #9, applied a clean dressing with dirty gloves, which increases the potential infection. The Facility Healing of ulcers and/or wounds policy was review on 03/02/2023, states that once the employee has cleaned the ulcer, she must remove her gloves, wash her hands with water and soap, and put on clean gloves to apply clean gauze with adhesive tape. 2.HV #4 is a 94-year-old female admitted on 02/22/2024 with a diagnosis of chronic ischemic heart disease, unspecified Dementia. The patient was visit on 10/25/2024 at 9:05 AM until 11:40 AM accompanied with a license practical nurse of this facility, (employee #10). During the visit it was observed that the patient was alert, oriented in person only, bedridden and totally dependent of activities of daily living. The patient was receiving visit of the employee #10 to provide her with bed bath. a) It was observed that the employee #10, put the protective equipment, face mask and surgical gown before entering the patients house. The Facilitys failed to provide a policy where its employees can identify the appropriate time to put on protective equipment to provide patient care. Findings Include: During the Home visit performed on 10/24/2024 and 10/25/2024 the following was observed:

Based on the review of the facility contracts and interview with the Administrator (employee #6) performed on 10/25/2024 at 1:00 PM, it was determined that the facility failed to ensure that occupational therapy services (OT) were available. --- Findings include: 1. During the survey process the administrator employee #6 was interview on 10/25/2024 at 1:00 PM and the surveyor asked if they have a contract services with OT, he state that the contract with the OT expired, I have tried to contact him by phone but he does not answer, I approached a facility near here that provides therapies but they refused because they provided services to children, not adults, which is why I do not have the services. 2. The facility failed to ensure that occupational therapy (OT) services were available.

Based on four Home visits with record review and fifteen records reviewed, it was determined that the facility failed to ensure that the hospice aide has a written patient care instructions for each patient assigned prepared by a registered nurse, for 12 out of 19 record review (H.V. #1, #2, #3, #4, R.R. #2, #3, #7 #9, #10, close R.R bereavement (CRRB) CRRB #1, and #3, Close Record Review Discharge (CRRD) CRRRD #1). --- 10. HV. #3 is a 75 -years-old female, admitted to the facility on 07/08/2023 with a diagnosis of Alzheimer Disease with late onset, DM type II, Chronic ischemic heart disease, bed confinement. During the record review performed on 10/24/2024 at 4:00 PM, it was found that in the certification period 20 of 60 days, the interdisciplinary group establish in the plan of care: Registered Nurse (RN) services 2 visit per week and as needed (PRN), Hospice Aid (HHA) 3 visit per weeks and as needed (PRN). No evidence was found that the RN performed and write patient care instructions for patient assigned to the HHA. 11. HV. #4 is a 94 -years-old female, admitted to the facility on 02/22/2024 with a diagnosis of Chronic ischemic heart disease, unspecified dementia. During the record review performed on 10/25/2024 at 12:40 pm, it was found that in the certification period 2 of 60 days, the interdisciplinary group establish in the plan of care: Registered Nurse (RN) services 2 visit per week and as needed (PRN), Hospice Aid (HHA) 3 visit per weeks and as needed (PRN). No evidence was found that the RN performed and write patient care instructions for patient assigned to the HHA. 12. RR. #3 is a 88 -years-old female, admitted to the facility on 08/09/2024 with a diagnosis of Chronic ischemic heart disease, anemia, hypertensive heart disease. During the record review performed on 10/25/2024 at 1:30 PM, it was found that in the certification period 1 of 90 days, the interdisciplinary group establish in the plan of care: Registered Nurse (RN) services 2 visit per week and as needed (PRN), Hospice Aid (HHA) 2 visit per weeks and as needed (PRN). No evidence was found that the RN performed and write patient care instructions for patient assigned to the HHA. 7. R.R. #7 is a 96 -years-old female, admitted to the facility on 09/13/2024 with a diagnosis of Malignant Neoplasm of Breast Disease. During the record review performed on 10/25/2024 at 1:16 PM, it was found that in the certification period 1 of 90 days, the interdisciplinary group establish in the plan of care: Registered Nurse (RN) services 2 visit per week and as needed (PRN), Hospice Aid (HHA) 3 visit per weeks. No evidence was found that the RN performed and write patient care instructions for patient assigned to the HHA. 8. H.V. #1 is a 93 -years-old female, admitted to the facility on 08/15/2024 with a diagnosis of Alzheimer Disease. During the record review performed on 10/24/2024 at 3:00 PM, it was found that in the certification period 1 of 90 days, the interdisciplinary group establish in the plan of care: Registered Nurse (RN) services 2 visit per week and as needed (PRN), Hospice Aid (HHA) 3 visit per weeks. No evidence was found that the RN performed and write patient care instructions for patient assigned to the HHA. 9. H.V. #2 is an 89 -years-old male, admitted to the facility on 08/28/2024 with a diagnosis of Heart Failure Disease. During the record review performed on 10/24/2024 at 3:50 PM, it was found that in the certification period 1 of 90 days, the interdisciplinary group establish in the plan of care: Registered Nurse (RN) services 2 visit per week and as needed (PRN), Hospice Aid (HHA) 3 visit per weeks. No evidence was found that the RN performed and write patient care instructions for patient assigned to the HHA. Finding Include: 1. R.R. #2 is a 96 -years-old female, admitted to the facility on 08/08/2024 with a diagnosis of Heart Failure, Hypertensive Heart Disease, Chronic Ischemic Heart Disease and Chronic Kidney Disease. During the record review performed on 10/25/2024 9:40 AM, it was found that in the certification period 2 of 60 days, the interdisciplinary group establish in the plan of care: Registered Nurse (RN) services 2 visit per week and as needed (PRN), Hospice Aid (HA) 3 visit per weeks. No evidence was found that the RN performed and write patient care instructions for patient assigned to the HA. 2. R.R. #9 is a 91 years- old female, admitted to the facility on 09/26/2024 with a diagnosis of Malignant Neoplasm Hypopharynx, Diabetes Mellitus Type II (DM II) and Chronic Kidney Disease. During the record review performed on 10/25/2024 10:30 AM, it was found that in the certification period 1 of 90 days the interdisciplinary group establish in the plan of care: Registered Nurse (RN) services 2 visit per week and as needed (PRN), Hospice Aid (HA) 3 visit per weeks. No evidence was found that the RN performed and write patient care instructions for patient assigned to the HA. 3.R.R. #10 is a 73 years- old male, admitted to the facility on 10/06/2024 with a diagnosis of Malignant Neoplasm of Brain, DM II and Hypertensive Heart Failure. During the record review performed on 10/25/2024 10:00 AM, it was found that in the certification period 1 of 90 days the interdisciplinary group establish in the plan of care: Registered Nurse (RN) services 2 visit per week and as needed (PRN), Hospice Aid (HA) 3 visit per weeks. No evidence was found that the RN performed and write patient care instructions for patient assigned to the HA. 4. CRRB #1 is a 97 years- old female, admitted to the facility on 06/14/2024 with a diagnosis of Cerebral Infarction, and DM II and Chronic Kidney Disease (CKD). During the record review performed on 10/25/2024 11:00 AM, it was found that in the certification period 1 of 90 days the interdisciplinary group establish in the plan of care: Registered Nurse (RN) services 2 visit per week and as needed (PRN), Hospice Aid (HA) 3 visit per weeks. No evidence was found that the RN performed and write patient care instructions for patient assigned to the HA. 5. CRRB #3 is a 86years- old female, admitted to the facility on 07/12/2024 with a diagnosis of Chronic Obstructive Pulmonary Disease, Sepsis, Alzheimer and Pneumonia. During the record review performed on 10/25/2024 1:03 PM, it was found that in the certification period 1 of 90 days the interdisciplinary group establish in the plan of care: Registered Nurse (RN) services 2 visit per week and as needed (PRN), Hospice Aid (HA) 5 visit per weeks. No evidence was found that the RN performed and write patient care instructions for patient assigned to the HA. 6. CRRD #1 is a 91 years- old female, admitted to the facility on 07/18/2024 with a diagnosis of Chronic Ischemic Heart Disease and Alzheimer. During the record review performed on 10/25/2024 1:40 PM, it was found that in the certification period 1 of 90 days the interdisciplinary group establish in the plan of care: Registered Nurse (RN) services 2 visit per week and as needed (PRN), Hospice Aid (HA) 3 visit per weeks. No evidence was found that the RN performed and write patient care instructions for patient assigned to the HA.

Based on review of governing body meeting, interviews with the administrator (employee #6) and the medical director (employee #2), it was determined that the facility failed to ensure that the governing body designated a qualified administrator responsible for the day-to-day operation of the hospice and possess education and experience. --- Findings Include: 1.During the recertification survey process the administrator employee #6 was asked by the surveyor to fill out the CMS-417 form and to provide the governing body manual and meeting on 10/25/2024 at 9:00 AM. The employee #6 states that "facility had a reorganization due to issues with the pass administration. The facility had to reorganize the governing body and now the facilitys employee are administrating the facility since September 2023, they create a new governing body and the governing body appointed him as the administrator, previously he was the social worker of the facility when employees took the administration of the facility he was part of the governing body, then pass to be the administrator". Interview with the Medical Director employee #2 on 10/25/2024 at 4:30 PM he states that the "facility previous administration decrease the salary due to it was very high and due to this there was a restructuring in order not to close operations of the hospice and leave employees without work. They suggest transferring the facilitys to the employees. Now the employees, organized the governing board in which I am the president. Since there was no designated administrator, we chose employee #6 as administrator. Currently, the rent for the premises is $6,000, but we reached an agreement between the owner of the premises and the facility for 50% of the rent. We are in talks with the municipality to obtain a donated place to relocate. There was a reduction in staff, volunteer hours, and functions. We are waiting for some aid from FEMA, they say it will be coming soon, but the change that took place has been delayed to have a break. The employee #2 was asked by the surveyor if they filled a CMS-855 form with the Fiscal Intermediary due to the change in the administrative personnel, he state that he knows that the lawyer made all change with the state but did not know if he completed the 855with CMS. Facility failed to notified to the Medicare Fiscal Intermediary NGS and the State Agency of changes in the administrative personnel on charge of the facility.

Based on four Home visit with record review and fifteen records reviewed (RR), it was determined that the facility failed to ensure that patient's record included the nursing and Hospice aids clinical note, for 17 out of 19 record review (H.V. #1, #2, #3, #4, R.R. #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, close R.R bereavement (CRRB) CRRB #1, and #3, Close Record Review Discharge (CRRD) CRRRD #1). --- 7. R.R. #4 is an 88 -years-old male, admitted to the facility on 08/16/2024 with a diagnosis of Chronic Ischemic Heart Disease. During the record review performed on 10/25/2024 at 12:44 PM, it was found that in the certification period 1 of 90 days, from 08/16/2024 through 11/13/2024, the interdisciplinary group establish in the plan of care: Registered Nurse (RN) services 2 visit per week and as needed (PRN), Physician 1 visit per Month (1 MO), Social Worker 1MO and Spiritual Advisor 1MO. a. During the week of 08/30/2024 thought 09/05/2024, no evidence was found of one visit note of the RN, the RN visit on 08/04/2024. 8. R.R. #5 is an 81 -years-old male, admitted to the facility on 09/05/2024 with a diagnosis of Alzheimer Disease with Late Onset. During the record review performed on 10/25/2024 at 1:42 PM, it was found that in the certification period 1 of 60 days, from 09/05/2024 through 11/03/2024, the interdisciplinary group establish in the plan of care: Registered Nurse (RN) services 2 visit per week and as needed (PRN), Hospice Aid (HHA) 4 visit per weeks, Physician 1 visit per Month (1 MO), Social Worker 1MO and Spiritual Advisor 1MO. a. During the week of 09/05/2024 thought 09/11/2024, no evidence was found of two visits note of the HHA, the HHA visit on 09/06/2024 and 09/09/2024. b. During the week of 09/19/2024 thought 09/25/2024, no evidence was found of two visits note of the HHA, the HHA visit on 09/19/2024 and 09/24/2024. c. During the week of 10/17/2024 thought 10/23/2024, no evidence was found of two visits note of the HHA, the HHA visit on 10/17/2024 and 10/21/2024. d. During the week of 10/17/2024 thought 10/23/2024, no evidence was found of one visit note of the RN, the RN visit on 10/18/2024. 9. R.R. #7 is a 96 -years-old female, admitted to the facility on 09/13/2024 with a diagnosis of Malignant Neoplasm of Breast Disease. During the record review performed on 10/25/2024 at 1:16 PM, it was found that in the certification period 1 of 90 days, from 09/13/2024 through 12/11/2024, the interdisciplinary group establish in the plan of care: Registered Nurse (RN) services 2 visit per week and as needed (PRN), Hospice Aid (HHA) 1 visit per week and as needed (PRN), Physician 1 visit per Month (1 MO), Social Worker 1MO and Spiritual Advisor 1MO. a. During the week of 09/27/2024 thought 10/03/2024, no evidence was found of one visit note of the of the RN, the RN visit on 10/02/2024. 10. H.V. #1 is a 93 -years-old female, admitted to the facility on 08/15/2024 with a diagnosis of Alzheimer Disease. During the record review performed on 10/24/2024 at 3:00 PM, it was found that in the certification period 1 of 60 days, the interdisciplinary group establish in the plan of care: Registered Nurse (RN) services 2 visit per week and as needed (PRN), Hospice Aid (HHA) 3 visits per weeks and as needed (PRN), Physician 1 visit per Month (1 MO), Social Worker 1MO and Spiritual Advisor 1MO. a. During the week of 10/10/2024 thought 10/16/2024, no evidence was found of the two visits notes of the of the RN. b. During the week of 10/17/2024 thought 10/22/2024, no evidence was found of the two visits notes of the of the RN. c. During the week of 08/15/2024 thought 08/21/2024, no evidence was found of one visit note of the HHA, the HHA visit on 08/20/2024 and 08/21/2024. d. During the week of 08/22/2024 thought 08/28/2024, no evidence was found of one visit note of the HHA, the HHA visit on 08/22/2024 and 08/26/2024. 11. H.V. #2 is an 89 -years-old male, admitted to the facility on 08/28/2024 with a diagnosis of Heart Failure Disease. During the record review performed on 10/24/2024 at 3:50 PM, it was found that in the certification period 1 of 60 days, the interdisciplinary group establish in the plan of care: Registered Nurse (RN) services 2 visit per week and as needed (PRN), Hospice Aid (HHA) 3 visit per weeks and as needed (PRN), Physician 1 visit per Month (1 MO), Social Worker 1MO and Spiritual Advisor 1MO. a. During the week of 10/09/2024 thought 10/15/2024, no evidence was found of one visit note of the of the RN, the RN visit on 10/11/2024. b. During the week of 10/16/2024 thought 10/22/2024, no evidence was found of one visit note of the of the RN, the RN visit on 10/17/2024. c. During the week of 08/28/2024 thought 09/03/2024, no evidence was found of one visit note of the HHA, the HHA visit on 08/29/2024 and 08/30/2024. d. During the week of 09/11/2024 thought 09/17/2024, no evidence was found of one visit note of the HHA, the HHA visit on 09/12/2024 and 09/17/2024. e. During the week of 10/09/2024 thought 10/15/2024, no evidence was found of one visit note of the of the HHA, the HHA visit on10/11/2024. 12. HV. #3 is a 75 -years-old female, admitted to the facility on 07/08/2023 with a diagnosis of Alzheimer Disease with Late Onset, Diabetes Mellitus Type II, Chronic Ischemic Heart Disease, Bed confinement. During the record review performed on 10/24/2024 at 4:00 PM, it was found that in the certification period 20 of 60 days, from 08/31/2024 through 10/30/2024, the interdisciplinary group establish in the plan of care: Registered Nurse (RN) services 2 visit per week and as needed (PRN), Hospice Aid (HHA) 3 visit per week and as needed, Physician 1 visit per month and as needed, Social Worker 1 visit per month and as needed and Spiritual Advisor 1 visit per month and as needed. a) The RN performed visits from weeks this period (08/17/2024 through 10/26/2024), however no evidence was found related to patient glucose level (Dxt) during the visit. b) During the period of 09/20/2024 through 10/18/2024, no evidence was found of a supervision visit by the registered nurse. 13. RR. #3 is a 88 -years-old female, admitted to the facility on 08/09/2024 with a diagnosis of Chronic Ischemic Heart Disease, Anemia, Hypertensive Heart Disease. During the record review performed on 10/25/2024 at 1:30 PM, it was found that in the certification period 1 of 90 days, from 08/09/2024 through 11/06/2024, the interdisciplinary group establish in the plan of care: Registered Nurse (RN) services 2 visit per week and as needed (PRN), Hospice Aid (HHA) 2 visit per week and as needed, Physician 1 visit per month and as needed, Social Worker 1 visit per month and as needed and Spiritual Advisor 1 visit per month and as needed. a) During the week of 08/18/2024 thought 08/24/2024, no evidence was found of two visits note of the HHA. b) During the period of 09/19/2024 through 10/19/2024, no evidence was found of a supervision visit by the registered nurse. 14. RR. #6 is a 95 -years-old female, admitted to the facility on 09/12/2024 with a diagnosis of Heart Failure unspecified, Diabetes Mellitus Type II, Hypertensive Heart, Cardiac Arrhythmia. During the record review performed on 10/25/2024 at 2:15 PM, it was found that in the certification period 1 of 60 days, from 09/12/2024 through 11/10/2024, the interdisciplinary group establish in the plan of care: Registered Nurse (RN) services 2 visit per week and as needed (PRN), Physician 1 visit per month and as needed, Social Worker 1 visit per month and as needed and Spiritual Advisor 1 visit per month and as needed. a) The RN performed visit on 09/12/2024, on 09/13/2024, on 09/27/2024, on 09/30/2024, on 10/04/2024, on 10/09/2024, on 10/11/2024, and on 10/18/2024, however no evidence was found related to patient glucose level (Dxt) during the visit. 15. RR. #8 is a 85 -years-old female, admitted to the facility on 09/16/2024 with a diagnosis of Alzheimer Disease with late onset, Hypothyroidism, Diabetes Mellitus Type II, Hypertensive Heart Disease. During the record review performed on 10/25/2024 at 3:35 PM, it was found that in the certification period 1 of 90 days, from 09/16/2024 through 12/14/2024, the interdisciplinary group establish in the plan of care: Registered Nurse (RN) services 2 visit per week and as needed (PRN), Physician 1 visit per month and as needed, Social Worker 1 visit per month and as needed and Spiritual Advisor 1 visit per month and as needed. a) The RN performed visit on 09/17/2024, on 09/20/2024, on 09/23/2024, on 09/26/2024, on 10/03/2024, on 10/10/2024, on 10/16/2024, 10/18/2024, and on 10/22/2024, however no evidence was found related to patient glucose level (Dxt) during the visit. Finding Include: 1. R.R. #1 is a 89 -years-old female, admitted to the facility on 07/17/2024 with a diagnosis of Alzheimer, Hypothyroidism, Diabetes Mellitus Type II (DM II), Hypertensive Heart Disease. During the record review performed on 10/24/2024 1:00 PM, it was found that in the certification period 2 of 90 days, from 07/17/2024 through 10/14/2024, the interdisciplinary group establish in the plan of care: Registered Nurse (RN) services 2 visit per week (wk) and as needed (PRN), Hospice Aid (HA) 3 visit per weeks (wks), Physician 1 visit per Month (1 MO), Social Worker 1MO and Spiritual Advisor 1MO. a. During the week of 07/21/2024 thought 07/27/2024, no evidence was found of three visit note of the HA. b. During the week of 07/28/2024 thought 08/03/2024, no evidence was found of one visit note of the HA, the HA visit on 07/31/2024 and 08/01/2024. c. The RN performed visit on 08/13/2024, on 09/13/2024, on 09/18/2024, on 09/20/2024, on 09/23/2024, on 09/27/2024, on 10/01/2024, on 10/04/2024, and on 10/16/2024,however no evidence was found related to patient glucose level (Dxt) during the visit. d. During the week of 08/11/2024 thought 08/11/2024, 09/08/2024 though 09/14/2024 and 10/13/2024 thought 10/19/2024, no evidence was found of one visit note of the RN. 2. R.R. #2 is a 96 -years-old female, admitted to the facility on 08/08/2024 with a diagnosis of Heart Failure, Hypertensive Heart Disease, Chronic Ischemic Heart Disease and Chronic Kidney Disease. During the record review performed on 10/25/2024 9:40 AM, it was found that in the certification period 2 of 60 days, from 08/08/2024 through 10/06/2024, and from 10/07/2024 through 12/05/2024, the interdisciplinary group establish in the plan of care: Registered Nurse (RN) services 2 visit per wk and PRN, Hospice Aid (HA) 3 visit per wks, Physician 1 MO, Social Worker 1MO and Spiritual Advisor 1MO. a. No evidence was found that the RN performed and write patient care instructions for patient assigned to the HA. b. During the week of 08/11/2024 thought 08/7/2024, no evidence was found of three visit note of the HA. c. During the week of 08/18/2024 thought 08/24/2024, no evidence was found of three visit note of the HA. d. During the week of 08/25/2024 thought 08/31/2024, no evidence was found of one visit note of the HA, the HA visit on 08/27/2024 and 08/31/2024. e. During the week of 09/15/2024 thought 09/21/2024, no evidence was found of one visit note of the HA, the HA visit on 09/16/2024 and 09/17/2024. f. During the week of 09/29/2024 thought 10/05/2024, no evidence was found of three visit note of the HA. g. During the week of 010/06/2024 thought 10/12/2024, no evidence was found of one visit note of the RN, the RN visit on 10/08/2024. g. No evidence was found that the RN performed and write patient care instructions for patient assigned to the HA. 3. R.R. #9 is a 91 years- old female, admitted to the facility on 09/26/2024 with a diagnosis of Malignant Neoplasm Hypopharynx, Diabetes Mellitus Type II (DM II) and Chronic Kidney Disease. During the record review performed on 10/25/2024 10:30 AM, it was found that in the certification period 1 of 90 days, from 09/26/2024 through 12/25/2024, the interdisciplinary group stablish in the plan of care: Registered Nurse (RN) services 2 visit per wk and PRN, Hospice Aid (HA) 3 visit per wks, Physician 1 MO, Social Worker 1MO and Spiritual Advisor 1MO. a. The RN performed visit on 09/27/2024, on 10/01/2024, on 10/03/2024, 10/07/2024, and on 10/10/2024, however no evidence was found related to patient glucose level (Dxt) during the visit. b. No evidence was found that the RN performed and write patient care instructions for patient assigned to the HA. 4. R.R. #10 is a 73 years- old male, admitted to the facility on 10/06/2024 with a diagnosis of Malignant Neoplasm of Brain, DM II and Hypertensive Heart Failure. During the record review performed on 10/25/2024 10:00 am, it was found that in the certification period 1 of 90 days, from 09/26/2024 through 12/25/2024, the interdisciplinary group establish in the plan of care: Registered Nurse (RN) services 2 visit per wk and PRN, Hospice Aid (HA) 3 visit per wks, Physician 1 MO, Social Worker 1MO and Spiritual Advisor 1MO. a. No evidence was found that the RN performed and write patient care instructions for patient assigned to the HA. b. During the week of 10/13/2024 thought 10/19/2024, no evidence was found of one visit note of the HA, the HA visit on 10/16/2024 and 10/17/2024. 5. CRRB #1 is a 97 years- old female, admitted to the facility on 06/14/2024 with a diagnosis of Cerebral Infarction, and DM II and Chronic Kidney Disease (CKD). During the record review performed on 10/25/2024 11:00 AM, it was found that in the certification period 1 of 90 days, from 09/26/2024 through 12/25/2024, the interdisciplinary group establish in the plan of care: Registered Nurse (RN) services 2 visit per wk and PRN, Hospice Aid (HA) 3 visit per wks, Physician 1 MO, Social Worker 1MO and Spiritual Advisor 1MO. a. No evidence was found that the RN performed and write patient care instructions for patient assigned to the HA. 6. CRRB #3 is a 86years- old female, admitted to the facility on 07/12/2024 with a diagnosis of Chronic Obstructive Pulmonary Disease, Sepsis, Alzheimer and Pneumonia. During the record review performed on 10/25/2024 1:03 PM, it was found that in the certification period 1 of 90 days, from 09/26/2024 through 12/25/2024, the interdisciplinary group establish in the plan of care: Registered Nurse (RN) services 2 visit per wk and PRN, Hospice Aid (HA) 5 visit per wks, Physician 1 MO, Social Worker 1MO and Spiritual Advisor 1MO. a. No evidence was found that the RN performed and write patient care instructions for patient assigned to the HA. 7. CRRD #1 is a 91 years- old female, admitted to the facility on 07/18/2024 with a diagnosis of Chronic Ischemic Heart Disease and Alzheimer. During the record review performed on 10/25/2024 1:40 PM, it was found that in the certification period 1 of 90 days, from 09/26/2024 through 12/25/2024, the interdisciplinary group stablish in the plan of care: Registered Nurse (RN) services 2 visit per wk and PRN, Hospice Aid (HA) 3 visit per wks, Physician 1 MO, Social Worker 1MO and Spiritual Advisor 1MO. a. No evidence was found that the RN performed and write patient care instructions for patient assigned to the HA.