Every finding on record at Hospicio La Monserrate Inc

Based upon an Emergency Preparedness Program (EPP) survey performed on 11/13/2024 from 10:30 AM to 1:30 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 QAPI Manager (employee #2) on 11/13/2024 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 on 11/13/2024 from 10:30 AM to 1:30 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 QAPI Manager (employee #2) on 11/13/2024 it was noted that the facility failed to stablished 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 11/13/2024 from 10:30 AM to 1:30 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to maintain an emergency preparedness communication plan that complies with Federal, State and local laws. --- Findings include: During the review of the facilities Emergency Preparedness Program with QAPI Manager (employee #2) on 11/13/2024 it was noted that the facility failed to have in place a written communication plan of how the facility coordinates patient care and how the facility interacts and coordinate with emergency management systems to protect health and safety of patients as required under §418.113(c).

Based upon an Emergency Preparedness Program (EPP) survey performed on 11/13/2024 from 10:30 AM to 1:30 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to develop primary / alternate means for communication with staff, Federal, State regional and local emergency management agencies in compliance with Federal, State and local laws. --- Findings include: During the review of the facilities Emergency Preparedness Program with the QAPI Manager (employee #2) on 11/13/2024 it was noted that the facility failed to 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 under §418.113(c)(3).

Based on a recertification survey, the review of documents related to the volunteer program and interview with the Human Resources Director (employee #5), it was determined that the facility failed to maintain volunteer staff to provide administrative or direct patient care equal to five percent of the total patient care hours of all paid hospice employees and contract staff. --- Findings include: 1. During the review of volunteer program on 11/14/2024 at 10:30 AM it was evidenced that the agency do not meet with the requirement to comply with a minimal of 5 percent of cost services from the total patient care hours of all paid hospice employees and contract staff. The facility did not provide evidence of the 5 percent (%) of saving with the volunteer program. 2. The facility failed to maintain volunteer staff to provide administrative or direct patient care equal to five percent of the total patient care hours of all paid hospice employees and contract staff.

Based on three Home Visit (HV) with records reviewed, sixteen records reviewed (RR), staff and caregiver interviews, it was determined that the facility failed to ensure that the clinical record contains current assessment and reassessments for each hospice patient related to Registered Nurses (RN) notes for 1 out of 19 records reviewed. (HV-RR#3) --- Findings include: . HV-RR # 3 is a 90-year-old female is a 90-year-old female who was admitted on 07/08/2024 with a diagnosis of Senile Degeneration of Brain and Alzheimer Disease. The interdisciplinary group determined two visits per week for the Registered Nurse (RN). According to the medical record review performed on 11/14/2024 at 1:00 PM, the following was found: a. No evidence was found of nurses notes reassessments from week started on 10/6/2024 through 11/14/24, when the record was reviewed. b. During interview with employee # 1 on 11/14/2024 stated that there was a visit log were the nurse registered every encounter with patient and relatives during home visits. c. Copy of the log was presented, showing the following dates of home visits performed by the RN signed by patient relatives: 10/3/2024, 10/7/2024, 10/10/2024, 10/14/2024, 10/17/2024, 10/21/2024, 10/24/2024, 10/29/2024. During and interview with RR # 3 and patients' caregiver interview performed on 11/14/2024 at 10:00AM, stated that the patient received RN visits three times per week. T The facility failed to ensure accessible and available nurses reassessments in the medical record.

Based on review of the contracted personnel credential files (CF) with the human resources (employee #5) and interview performed on 11/14/2024 at 2:00 PM, it was determined that the facility failed to ensure that 3 out of 4 contracted staff who provide services have updated credential files related to Speech Therapy, Occupational Therapist and Physician. (CF#1, #2, #3). --- Findings include: The facility failed to ensure that all personnel qualifications are kept updated. 1. CF# 1- Occupational therapist. · The contract document did not specify the beginning date and ending date. · The contract addendum was not signed by an employee. · No diploma as evidence of educational requirement. 2. CF # 2- Physician. · Criminal background check was issued on 04/25/2023. · State narcotics license was due since 07/31/2024. 3. CF # 3. Speech Language Therapist · Speech language therapist contract document did not specify the beginning date and ending date. · No evidence of Criminal background check. · No health certificate. · No diploma nor license as evidence of educational and state requirement. During interview with employee # 5 (Human Resources Officer) on 11/14/2024 at 2:00 PM, she stated that some of the personnel documents could be archived in the other agency were the personnel are contracted.

Based upon an Recertification and Emergency Preparedness Program (EPP) survey performed on 11/13/2024 from 10:30 AM to 1:30 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to meet the applicable provisions in accordance with the Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4.) for 2 out of 3 home visits (HV).(HV#1 and #3). --- Findings include: Based on three (3) home visits (HV) performed between November 13 and 14, 2024 the following was identified: On two (2) out of three (3) home visits performed by the surveyors, no signs were observed notifying the use of oxygen. No signage was observed at the entrance to the residence nor was any signage observed in the room where the oxygen was being used. On three (3) out of three (3) home visits performed by the surveyors, electrical safety was not observed in the patients' residences. According to the institution's internal policies, residence hall receptacles must be checked before connecting electrical equipment such as oxygen concentrators. When requesting evidence of the validations, the institution could not provide evidence. The use of multipliers was also observed that could overload the electrical circuits, putting the risk of fire. Three (3) out of three (3) exit signs on the facility were observed un energized by emergency power or by battery power source.

Based on an unannounced recertification survey and abbreviated COVID-19 Focused Infection Control Survey (FICS): Acute and Continuing Care, observation, interview and policies and procedure review in 3 home visit (HV), performed on 01/19/2022 in company of the Quality and Infection Control Coordinator (employee #2), it was determined that the facility failed to properly prevent effective infection control program that protects patients, families, visitors and hospice personnel by preventing and controlling infectious and communicable diseases of COVID-19 for 3 out of 3 home visits. (HV#1, #2 and #3). Findings include: 1. H.V. #2 is an 82-year-old female admitted on 01/30/2019 with a diagnosis of Senile degenerative of brain, Parkinson, Diabetes Mellitus Type II. The Home Visit was performed on 01/19/2022 at 12:00 PM for ulcer care Registered Nurse (employee #4). During the home visit with the employee #4 it was observed the following: a. Not observed perform COVID-19 screening question related to exposure to COVID-19 cases. b. The employee #4 did not clean and disinfected the non-critical equipment, sphygmomanometer, stethoscope, oximeter, and thermometer. 2. H.V. #3 is a 94-year-old female admitted on 07/24/2018 with a diagnosis of Senile Degenerative, Cachexia. The Home Visit was performed on 01/19/2022 at 2:45 PM for bed bath with the Home Health Aid (LPN) (employee #5). During the Bed bath with the employee #5 it was observed the following: a. Not observed perform COVID-19 screening question related to exposure to COVID-19 cases. b. As observed the LPN employee #5, before initiate patient care washes her hand with soap and water, then initiate to provide bed bath care to the patient and from 6 opportunity to perform hand wash failed to hand wash 5 out of 6 opportunities to performed hand wash after glove change with hand sanitizer or soap and water. 3. When the surveyor arrives to the facility no evidence was observed that the facility performance a screening process for those that enter to the facility to mitigate the risk of COVID-19 exposure, they only take temperature, provide hand sanitizer, and demand the use of mask. After the initial the survey on 01/19/2022 at 1:30 PM the facility performed a Questioner COVID 19 table with the screening question to personnel and visitor. 4. During the 3 Home Visit Performed on 01/19/2022, the facility personnel employee #4, employee #5 and employee #6 were not observed perform COVID-19 screening question related to exposure to COVID-19 cases. 5. No evidence was provided that the Screening was performance since the initial of the COVID-19 pandemic.

Based on a recertification survey, four records reviewed (R.R.) for bereavement counseling, it was determined that the facility failed to ensure that bereavement services is available to the family and other individuals in the bereavement plan of care up to one year following the patient death for 4 out of 4 records reviewed (R.R. #7, #8, #9 and #10). Findings include: 1. R.R. #7 is a 90 years old male who was admitted on 07/16/2020 with a diagnosis of Senile Degeneration of Brain and Cerebral Ischemia. During the record review on 01/22/2022 at 2:00 PM it was found that the Interdisciplinary group plan of care performed on 07/16/2020 establish the following frequency to the core services Registered Nurse Services (RN): 2 visit per week and as necessary (PRN), Physician Services: 1 initial visit and PRN, Social Worker Services 1 visit per month and PRN, and the Counseling Services 1 initial visit and PRN. The following was found: a. On 02/12/2021 the RN (employee #6) documented that daughter call the facility and notified daddy just passed away at 12:05 PM. The RN makes a visit with physician (employee #8) who evaluates the patient and is absent from vital sings B/P 0/0 R/R 0/0 and physician certifies the death of the patient at 12:05 PM on 02/12/2021. b. The postmortem care was provided by the nurse. The funeral company was notified. The nurse provide support to patient caregiver. The nurse notified the patient's death to the hospice staff for post-mortem protocol. c. No evidence was found that the Social worker initiate the counselor process. No evidence of documentation related to the social worker intervention before, during and after the patient death. d. The Spiritual advisor (employee #7) initiate the counselor process on 02/11/2021 by means of a call made by a nurse since the patient was in the process of death. e. The spiritual advisor performed the initial counseling and bereavement assessment to evaluate caregiver and families needed during the dying process and up to one years following the patient death on 2/15/2021 three days later. The next intervention was performed on 3/25/2021 however, no evidence of bereavement intervention on April, June, July, August, September, October, November and December /2021. f. No evidence was found that the Inter Disciplinary Group- IDG perform and initiate the plan of care for bereavement. 2. R.R. #8 is a 70 years old male who was admitted on 8/4/2021 with a Diagnosis of Secondary Malignant Neoplasm of Liver and Intrahepatic bile duct, Muscle Weakness generalized. According to the medical record review performed on 01/21/2022 at 2:00 PM the patient received nursing services with a frequency of two (2) visits per week and P.R.N. (when as needed), physician services, social services and counseling services one (1) visit per month and P.R.N. The patient died on 08/06/2021 and the following was found: a. On 08/06/2021 at 9:03 AM the nurse received a phone call at 9:03 AM notifying the patient's daughter that my father died. The last visit performed by the visiting nurse and the physician was on 08/06/2021 at 10:30 AM. The nurse and the physician visit the patient house and on the assessment the patient did not respond and no vital sings and declared death by the doctor at 10:35 AM. Post death care offered. The physician orders consolation program notified spiritual advisor. b. The patient record revealed that the agency failed to perform an IDG meeting to establish the plan of care for bereavement counseling. Lacks a social worker note only wrote on 08/06/2021 '' patient passed away.'' Three days later 08/09/2021 the spiritual adviser makes a call to family. On 09/13/2021 thirty days later the spiritual advisor notes reveled that the family accepted the counseling service. No evidence of counseling notes o October, November and December of 2021. 3. R.R. #9 is an 88 years old female who was admitted on 02/07/2020 with a Diagnosis of Chronic combined systolic congestive and Diastolic congestive heart failure. According to the medical record review performed on 01/21/2022 at 3:00 PM the patient receiving nurse services with a frequency of two (2) visits per week and P.R.N (when as needed), physician services, social services and counseling services one (1) visit per month and P.R.N The patient died on 07/23/2021 and the following was found: a. The patient record revealed that the agency performs an IDG meeting to establish the plan of care for bereavement counseling. Lacks a social worker note only wrote on 07/23/2021 '' patient passed away.'' Four days later on 07/27/2021 was the first spiritual adviser intervention. On 08/27/2021 thirty days later the spiritual advisor notes reveled that the relative did not answer phone call. No evidence of counseling notes on September, October, November and December of 2021. 4. R.R. #10 is a 79 years old female who was admitted on 12/17/2021 with a Diagnosis of Hodgkin Disease Lymphoma. According to the medical record review performed on 01/21/2022 at 3:30 PM the patient receiving nurse services with a frequency of two (2) visits per week and P.R.N (when as needed), physician services, social services and counseling services one (1) visit per month and P.R.N. The patient died on 12/22/2021 and the following was found: a. The patient record revealed that the agency did not perform an IDG meeting to establish the plan of care for bereavement counseling. Lacks a social worker note. Nine days later 12/31/2021 was the first spiritual adviser intervention. No evidence of counseling notes on January of 2022.

Based on a recertification survey, three Home Visit (H.V) with Record Reviewed, ten Record Review (RR), review of policy and procedure, it was determined that the facility failed to ensure that the clinical record contain correct clinical past and current findings for each hospice patient related to Registered Nurse (RN) visits for 5 out of 13 records review (H.V. #1, #2, R.R #2, #5 and #6) Findings include: 1. H.V. #2 is an 82-year-old female admitted on 01/30/2019 with a diagnosis of Senile degenerative of brain, Parkinson, Diabetes Mellitus Type II. According to the medical record review performed on 01/19/2022 at 09:51 am provides evidence that: patient was total dependent of activity daily living (ADL), bedridden, alert, have a trochanter ulcer stage III. The plan of care performed by the physician and the Interdisciplinary group on 01/07/2022 of the recertification establish that nursing service provide 2 visit per week an as necessary (PRN), the Physician 1 visit per month and PRN, the Social Worker 1 visit per month and PRN and the Spiritual counselor 1 visit per month. The following was found during the record reviewed: a. No progress notes of the Registered Nurse since 12/14/2021 until 01/17/2022. 2. R.R. #2 is an 86-year-old male admitted on 06/15/2021 with a diagnosis of Malignant Neoplasm of extrahepatic bile duct. According to the medical record review performed on 01/19/2022 at 10:44 AM provides evidence that: patient was leaving in a substitute home, was alert, Disoriented, difficult to talk, total dependent of activity daily living (ADL), bedridden, have a foley catheter #18 3 ways, change monthly. The plan of care performed by the physician and the Interdisciplinary group on 01/07/2022 of the recertification establish that nursing service provide 2 visit per week an as necessary (PRN), the Physician 1 visit per month and PRN, the Social Worker 1 visit per month and PRN and the Spiritual counselor 1 visit per month. The following was found during the record reviewed: a. No progress notes of the Registered Nurse since 12/12/2021 until 01/03/2022. b. The facility performs a meeting with the Registered Nurses (R.N.) on 02/10/2021 and establish that due to the administrative order were stablish the restriction of visit to the substitute homes (Centros de Cuido de Envejecientes) per COVID 19, the nursing personnel performed the visit, 1 visit per week for patients' evaluation, delivery of supply and medication and the other visit was performed by phone. However, no evidence was found related to physician order decrease the frequency of the R.N. visit. 3. R.R. #5 is a 76-year-old female admitted on 06/10/2021 with a diagnosis of Senile degenerative of brain and cerebral Ischemia. According to the medical record review performed on 01/20/2022 at 11:48 AM provides evidence that: patient was disoriented, difficult to talk, total dependent of activity daily living (ADL), bedridden. The plan of care performed by the physician and the Interdisciplinary group on 01/14/2022 of the recertification establish that nursing service provide 2 visit per week an as necessary (PRN), the Physician 1 visit per month and PRN, the Social Worker 1 visit per month and PRN and the Spiritual counselor 1 visit per month. The following was found during the record reviewed: a. During the week of 12/12/2021 till 12/18/021 the record lack of one progress notes of the Registered Nurse. 01/03/2022. 4. R.R. #6 is a 93-year-old female admitted on 05/21/2020 with a diagnosis of Alzheimer. According to the medical record review performed on 01/20/2022 at 1:00 PM provides evidence that: patient was alert, disoriented, difficult to talk, total dependent of activity daily living (ADL), bedridden. The plan of care performed by the physician and the Interdisciplinary group on 01/07/2022 of the recertification establish that nursing service provide 2 visit per week an as necessary (PRN), the Physician 1 visit per month and PRN, the Social Worker 1 visit per month and PRN and the Spiritual counselor 1 visit per month. The following was found during the record reviewed: a. No progress notes of the Registered Nurse since 12/20/2021 until 01/20/2022. 5. H.V. #1 is an 82-year-old female admitted on 12/27/2021 with a diagnosis of Senile Degeneration of Brain, Diabetes Mellitus, Arteriosclerotic Heart Disease and Angina Pectoris. According to the medical record review performed on 01/20/2022 at 9:00 AM provides evidence that: patient was total dependent of activity daily living (ADL), bedridden, alert, have multiples ulcers stage II, foley catheter #16 two way change on 01/03/2022 and continue oxygen at three liters by nasal canula. The plan of care performed by the physician and the Interdisciplinary group on 01/12/2022 of the recertification establish that nursing service provide 2 visit per week an as necessary (PRN), the Physician 1 visit per month and PRN, the Social Worker 1 visit per month and PRN and the Spiritual counselor 1 initial visit and when as needed. The following was found during the record reviewed: a. The progress notes of the Registered Nurse since 01/09/2022 until 01/15/2022 lacks the ulcers measures of the sacral and gluteal ulcer. b. No evidence of progress notes of the Registered Nurse since 01/16/2022 until 01/22/2022.

Based on the review of forty three credential files (C.F) with the Human Resources Assistant (employee #9), performed on 01/22/2022 from 1:15 PM thru 2:30 PM, it was determined that the facility failed to ensure an update credential related to Influenza Vaccine Exoneration, Hepatitis B Vaccine, updated Health certification, updated Cardiac Respiratory Resuscitation certification (CPR), Law 300 and Professional Registry for 13 out of 43 credential files (C.F #8, #9, #11, #14, #16, #17,#19, #20, #21, #25, #26, #27, and #29). Findings include: Review of forty-three (43) credential files of the personnel of the hospice on 01/22/2022 from 1:15 PM thru 2:30 PM provided evidence of the following: 1. In the Registered Nurse (RN) Credentials File (C.F), it was found the following: a. Two out of ten RNs C.F, did not contain evidence of updated exoneration for the Influenza Vaccine (C.F #8 and #9). 2. The License Practice Nurse (LPN) Credential File (C.F), it was found the following: a. Four out of eleven LPNs C.F, did not contain evidence of updated exoneration for the Influenza Vaccine (C.F #11, #14, #16 and #17). b. One out of eleven LPNs C.F, did not contain evidence of Registration of Professionals (C.F #17). c. One out of eleven LPNs C.F, did not contain evidence of updated Health certification (C.F. #17) the last health certification was on 09/18/2020. d. One out of eleven C.F did not contain evidence of updated CPR certification (C.F#11) the last CPR certification expired on 09/09/2021. e. One out of eleven C.F did not contain evidence of annual evaluation (C.F#11). 3. The Physician C.F, it was found the following: a. One out of four physicians C.F, did not contain evidence of updated Health certification (C.F. #19). The last health certificate expired on 12/01/2018. b. One out of four physicians C.F did not contain evidence of updated CPR certification (C.F#19). c. One out of four physicians C.F, did not contain evidence of Hepatitis B vaccine (C.F #19). d. One out of four physicians C.F, did not contain evidence of Influenza Vaccine Exoneration (C.F.#19). e. Three out of four physicians C.F, did not contain evidence of ' ' Ley 300 de 1999 Ley de Verificación de Historial Delictivo'' Criminal Background Check (C.F #19, #20 and #21). 4. The Housekeepers C.F, it was found the following: a. One out of nine housekeepers C.F did not contain evidence of updated Influenza Vaccine exoneration (C.F #27). b. Three out of nine housekeepers C.F, did not contain evidence of updated Health Certificate (C.F #25, #27 and #29). c. Three out of three housekeeper's C.F did not contain evidence of updated Hepatitis Vaccine exoneration (C.F #25, #26 and #27).