Every finding on record at Hospicio Plena Serenidad

Based on observation, three Home Visit (H.V.), and review of policy and procedure manual, it was determined that the facility failed to ensure that nursing personnel provide adequate patient privacy during the ulcer care for 1 out of 3 home visits (H.V. #1) --- Findings include: 1.      HV #1 is an 84-years-old female admitted on 09/27/2024 with a diagnosis of Alzheimer disease, unspecified. The patient was visit on 10/14/2025 at 10:25 AM until 11:13 AM accompanied with a facility registered nurse (employee #3). 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 one sacral ulcer that is cleaning every 2 times a week by the RN. The patient was receiving a visit of the employee #3 to provide ulcer care. a)      It was observed that the employee #3 did not close the windows curtains before started to provide care to the patient sacral ulcer.

Based on the review of documents related to the volunteer program and interview with the Administrator (employee #1), it was determined that the facility failed to maintain a documented record of the volunteer staff who provide administrative or direct patient care with the description of duties and worked hours. --- Findings include:1. During the interview and review of volunteer program with the Administrator (employee #1) on 10/15/2025 at 3:30PM it was evidenced that the agency did not have documented evidence to prove that the volunteer personnel have been working providing administrative or direct patient care.

Based on the review of documents related to the volunteer program and interview with the Administrator (employee #1), it was determined that the facility failed to maintain a documented record of the volunteer staff who 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:During the interview and review of volunteer program with the Administrator (employee #1) on 10/15/2025 at 3:30PM it was evidenced that the agency did not have documented evidence to prove that they 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.

Based on the review of credential file (C.F.), government body minutes and interview with the Administrator (employee #1) on 10/15/2025 at 1:45 PM it was determined that the facility failed to have a qualified hospice administrator appropriately designated. --- Findings include: 1.      During the administrator credential file (C.F.) review on 10/15/2025 at 1:45 PM no administrative management education was found to qualify for the position nor an appropriate appointment by the governing body.2.      In an interview with the administrator (employee #1) on 10/15/2025 at 1:55 PM she stated that the government body did verbally appointment her to have the position during a conference, but she does not have an administrator management education.

Based on the review of credential file (C.F.) and interview with the Administrator (employee #1) on 10/15/2025 at 4:15 PM, it was determined that the facility failed to have a physician designee in the medical director absence. --- Findings include: 1.      During an interview with the administrator (employee #1) on 10/15/2025 at 4:15pm, she stated that they do not have a physician designee to the medical director position in the absence of the medical director.

Based upon an Emergency Preparedness Program (EPP) survey performed on 11/08/2022 at 9:00 AM through 4:00 PM , to evaluate emergency preparedness requirements, it was determined that the facility failed to develop and maintain an emergency preparedness plan that must be reviewed and updated at least every two years. --- Findings include: During the review of the facilities Emergency Preparedness Program with Service Supervisor employee #1 and Executive Director employee #3 on 11/08/2022 at 10:20 AM it was noted that the facility failed to develop and maintain an Emergency Preparedness Plan that must be reviewed, and updated at least every 2 years as required under §418.113(a). The last update of the Emergency Preparedness Plan was performed on January 2020.

Based upon an Emergency Preparedness Program (EPP) survey performed on 11/08/2022 at 9:00 AM through 4:00 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to develop and implement emergency preparedness policies and procedures, based on the emergency plan, risk assessment and the communication plan. The policies and procedures must be reviewed and updated at least every 2 years. --- Findings include: During the review of the facilities Emergency Preparedness Program with Service Supervisor employee #1 and Executive Director employee #2 on 11/08/2022 at 9:00 AM through 4:00 PM it was noted that the facility failed to stablished policies and procedures based on the emergency plan, risk assessment and communication plan as required under §418.113(b) of the Emergency Preparedness.

Based upon an Emergency Preparedness Program (EPP) survey performed on 11/08/2022 at 9:00 AM through 4:00 AM, to evaluate emergency preparedness requirements for recertification, 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 Service Supervisor employee #1 and Executive Director employee #2 on 11/08/2022 at 10:30 AM it was noted that the EP 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 on 11/08/2022 at 9:00 AM through 4:00 AM, to evaluate emergency preparedness requirements for recertification, 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 Service Supervisor employee #1 and Executive Director employee #2 on 11/08/2022 at 11:00 AM it was noted that the EP failed to have written procedures not 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 10/13/2022 at 9:00 AM to 11:30 AM, to evaluate emergency preparedness requirements for recertification, 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 Service Supervisor employee #1 and Executive Director employee #2 on 11/08/2022 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 11/08/2022 at 9:00 AM through 4:00 AM, to evaluate emergency preparedness requirements for recertification, it was determined that the facility failed to develop and maintain policies and procedures related with the role of the facility under a waiver declared by the Secretary in accordance with section 1135 of the Act in the provision of care and treatment. --- Finding includes: During the review of the facilities Emergency Preparedness Program with Service Supervisor employee #1 and Executive Director employee #2 on 11/08/2022 it was noted that the EP failed to include policies and procedures which outline the facility's role in the provision of care and treatment under section 1135 waivers during a declared public health emergency in alternate care sites as required under §418.113(b)(6)(C)(iv).

Based upon an Emergency Preparedness Program (EPP) survey performed on 11/08/2022 at 9:00 AM through 4:00 AM, to evaluate emergency preparedness requirements for recertification, 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: During the review of the facilities Emergency Preparedness Program with Service Supervisor employee #1 and Executive Director employee #2 on 11/08/2022 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 11/08/2022 at 9:00 AM through 4:00 AM, to evaluate emergency preparedness requirements for recertification, it was determined that the facility failed to develop primary / alternate means for communication with HHAs 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 Service Supervisor employee #1 and Executive Director employee #2 on 11/08/2022 it was noted that the facility failed 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 upon an Emergency Preparedness Program (EPP) survey performed on 11/08/2022 at 9:00 AM through 4:00 AM, to evaluate emergency preparedness requirements for recertification, it was determined that the facility failed to provide a method for sharing information and medical documentation for patients under the hospice'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 Service Supervisor employee #1 and Executive Director employee #2 on 11/08/2022 it was noted that the facility failed provide a written method for sharing information and medical documentation for patients under the hospice's care, as necessary, with other health care providers to maintain the continuity of care as required under §418.113(c)(4)-(6).

Based on an unannounced recertification survey, the review of the admission packet given to the patients with documents, three home visits (H.V) with records reviewed and eight records reviewed (R.R), it was determined that the facility failed to ensure that patient's is treat with respect, privacy and dignity related to nursing personal did not close the living room windows and door and did not provide privacy around the patient bed during remove Foley catheter, during provide clean genital area, insertion the foley catheter and during providing sacral ulcer care. The patient was maintained uncovered and expose all the time for 1 out of 3 Home Visits (H.V. #2). --- Findings include: 1. During the review of documents that are given to the patient upon admission and the admission packet as reviewed on 11/08/22 at 8:45 AM it was found that it did not include updated information related to the agency to call along with telephone numbers to file a grievance at the State agency and failed to have the hot line for Medicare. 2.The document provide that indicates the telephone numbers to call in case of emergencies indicates 24 hours service but does not establish seven days a week and only indicates the first option '' tele-answer and the second option only shows a telephone number but does not specify which agency it belongs to. 3. H.V #2 is an 85-year-old female admitted on 06/15/2022 with a diagnosis of Cerebral Infarction Unspecified and secondary diagnosis of Hypertension, Bed Confinement Status (Bedridden), Urinary and Fecal Incontinence and Sacral Ulcer. The HV was performed on 11/08/2022 at 12:00 midday (md), with the Social Worker (employee #6) to observe foley catheter change and sacral ulcer care performed by the register nurse (RN) (employee #4). a. On 11/08/2022 at 12:00 md a patient bed is observed in the living room of the patient's home. The patient daughter reports that her mother moved to the living room because her room has problems with the ceiling and has filtration problems, which is why she was relocated to the living room for the moment. b. The facility failed to ensure that procedures are performed in an acceptable manner according with nursing care and patient's rights and does not ensure that the patients' Dignity and Privacy are promoted. c. The patient living room windows was maintain open during all of the two procedures ''Foley Catheter and Sacral Ulcer Care '' and patient was uncovered all the time. The nurse failed to provide patient privacy.

Based on an unannounced recertification survey, observations made during a home visit (HV) and records reviewed (RR) it was determined that the facility failed to ensure that the patient receive effective pain management and symptom control from the hospice for conditions related to the terminal illness for 1 out of 3 home visits with records reviewed (H.V. #3). --- Findings include: 1. H.V #3 is a 67-year-old male admitted on 09/02/2022 with a diagnosis of Chronic Obstructive Pulmonary Disease and secondary diagnosis of Alzheimer Disease with Late Onset, Cerebral Infarction Unspecified and Bed Confined Status (Bedridden). The H.V was performed on 11/10/2022 at 9:00 A.M with the Register Nurse (RN) (employee #5) to observe gastrostomy local care, respiratory and skin assessment. a. This patient lives in a nursing home, during the visit the patient was observed bedridden totally dependent on activities of daily living, fecal and urinary incontinence, was maintain with foley catheter. He has problem to swallow foods, drink liquids and chew, was maintain with gastrostomy (PEG #24) and receiving Jevity 1.2 calories at 60 ml per hour with Kangarro machine. Was maintain with oxygen concentrates by nasal cannula at 2 liters/minute. The nurse performed the patient assessment and the patient refer chest and leg pain. The nursing home nurse administered Mobic 7.5 mgs. by gastrostomy tube according with the physician order. The hospice nurse continues with the assessment and was identified pressure area in left heel and sacral area. The hospice nurse oriented the nursing home nurse to change the patient position every two hours. During the visit it was observed that the patient has long toenails, and the nurse was oriented to notify the physician. b. During the home visit performed on 11/10/2022 at 9:00 AM at the '' Nursing Home'' the surveyor requests the medications used by the patient, according with the hospice nurse employee #5 stated : '' I do not have the control of the medications of the patient, I cannot perform the drug check when I make the visits to the nursing home because they are locked and the person who has control of the drugs when I come to offer the patient care is not present. I supply the drugs that the hospice provides according to the doctor's order.'' Related to Pain Management Drugs '' Movic 7.5 mgs. tablet to administer 1 tablet by gastrostomy twice a day. The medication was delivered on 11/08/2022 they are received by the nursing home staff. c. During interview conducted on 11/10/2022 at 9:25 AM with the nursing home nurse related to the patient medications, she stated "The medication G Tusicof 10 ml. every six hours by Gastrostomy it was discontinued on November 3, 2022, by verbal order of the patient's physician. However, the hospice nurse employee #5 stated that she did not know that the patient is not receiving the medication ''G Tusicof.'' According of the home nurse this medication was discontinue by the nursing home physician on 11/03/2022 by verbal order, however, the plan of care provide evidence that the patient received this medication until 10/21/2022. The nursing home nurse stated "will notify the patient physician to send the written order. The nursing home nurse reported not knowing that she had to request a medical order and send it to the hospice. The nurse employee #5 failed to perform the drug check on each visit to ensure that the patient receives the medications according to the medical orders and to avoid errors in administration. The hospice nurse failure to ensure that the nursing home reports any changes related to the patient's treatment. d. The hospice nurse failed to assure that the patient pain and symptoms management in a timely fashion. The hospice lacks to have methods in place to ensure that the patient's pain and all other distressing symptoms are controlled effectively 24 hours a day 7 days a week in all settings and wherever the patient resides. e. The hospice nurse (employee #5) fails to make sure that the person receiving the medications in the nursing home is a health care professional which place at risk the safety of the medications and the life of the patient in care. f. The hospice nurse (employee #5) failed to perform the weekly drug review in accordance with the hospice policy.. g. During the home visit performed on 11/10/2022 at 9:00 AM at the '' Nursing Home'' it was observed in the area of the head of the patient's bed a large '' Oxygen tank '' directly on the floor without a safety base. The oxygen tank does not have an inspection seal. The patient was maintain with oxygen concentrates by nasal cannula at 2 liters/minute with oxygen concentrator localized at the left side of his bed. This situation puts the safety of the patient's in this nursing home at risk.

Based on an unannounced recertification survey, observations during a home visit and records reviewed, it was determined that the facility failed to ensure that the patient's caregiver is involved in the developing of the patient's plan of care for 3 out of 3 home visits with records reviewed (H.V. #1, #2 and #3) and 6 of 8 close records review (R.R. #1, #2, #3, #4, #5 and #6) --- Findings include: 1. H.V #1 is a 91-year-old female admitted on 10/27/2021 with a diagnosis of Alzheimer, Parkinson, Hight Blood Pressure, Bed Confinement Status (Bedridden), Urinary and Fecal Incontinence and Gastrostomy. The HV was performed on 11/08/2022 at 3:15 PM with the Social Worker (employee #6) to observe bed bath performed by the Home Health Aide (HHA) (employee #8). According of the established patient plan of care discussed by the interdisciplinary group and according of the patient needs written on 10/28/2022 revealed that the facility hospice provide evidence of the '' form related to orientation and delivered of the Plan of Care established by the IDG", it revealed that the designated person who received the orientation of the plan of care for this re-certification did not sign the plan of care. The plan of care lacks the patient resource signature and lacks the hospice representative signature. 2. H.V #2 is an 85-year-old female admitted on 06/15/2022 with a diagnosis of Cerebral Infarction Unspecified and secondary diagnosis of Hypertension, Bed Confinement Status (Bedridden), Urinary and Fecal Incontinence, Hyperlipidemia, Hight Blood Pressure, Diabetes Mellitus Type II, Alzheimer, Chronic Renal Failure and Sacral Pressure Ulcer Stage III. The HV was performed on 11/08/2022 at 12:00 midday (md). with the Social Worker (employee #6) to observe foley catheter change and sacral ulcer care performed by the register nurse (RN) (employee #4). According of the established patient plan of care discussed by the interdisciplinary group and according of the patient needs written on 11/04/2022 revealed that the facility hospice provide evidence of the '' form related to orientation and delivered of the Plan of Care established by the IDG", it revealed that the designated person who received the orientation of the plan of care for this re-certification did not sign the plan of care. The plan of care lacks the patient resource signature and lacks the hospice representative signature. 3. H.V #3 is a 67-year-old male admitted on 09/02/2022 with a diagnosis of Chronic Obstructive Pulmonary Disease and secondary diagnosis of Alzheimer Disease with Late Onset, Cerebral Infarction Unspecified and Bed Confined Status (Bedridden). The H.V was performed on 11/10/2022 at 9:00 A.M with the Register Nurse (RN) (employee #5) to observe gastrostomy local care, respiratory and skin assessment. According of the established patient plan of care discussed by the interdisciplinary group and according of the patient needs written on 10/28/2022 revealed that the facility hospice provide evidence of the '' form related to orientation and delivered of the Plan of Care established by the IDG", it revealed that the designated person who received the orientation of the plan of care for this re-certification did not sign the plan of care. The plan of care lacks the patient resource signature and lacks the hospice representative signature. 4. RR #1 is a 94-year-old female admitted on 03/11/2021 with a diagnosis of Alzheimer Disease with Late onset, Bed Confinement Status (Bedridden), Urinary and Fecal Incontinence, Hyperlipidemia and Sacral Pressure Ulcer Stage III. The record review was performed on 11/10/2022 at 12:45 PM. with the Service Director and provide evidence that the patient has 21 one ulcers. During reviewed the nurses notes the ulcer #3, #4, #7, #8, #9 and #10 they do not appear in the nurses notes, the Service Director nurse (employee #1) says: '' that if they not appear in the nurse documentation, it means that have healed and that there is no way to be sure.'' However, that all the nurses notes reflect the same information. She refers to the fact that the electronic program they have does not accept changes in the documentation and is repetitive. According of the established patient plan of care discussed by the interdisciplinary group and according of the patient needs written on 11/04/2022 revealed that the facility hospice provide evidence of the '' form related to orientation and delivered of the Plan of Care established by the IDG", it revealed that the designated person who received the orientation of the plan of care for this re-certification did not sign the plan of care. The plan of care lacks the patient resource signature and lacks the hospice representative signature. 5. RR #2 is a 91-year-old female admitted on 06/03/2022 with a diagnosis of COPD, Diabetes Mellitus Type II, Hight Blood Pressure and Renal Failure. The plan of care performed in 11/04/2022 establish frequency of visit: R.N 2 visits per week and (PRN) when needed, HHA 3 visits per week and PRN, MD 1 visit per month and PRN, Spiritual Advisor 2 visits per month and PRN, Social Worker 2 visits per month and PRN, Home Maker 2 visits per week and PRN and Nutritionist 1 visit and PRN. According of the established patient plan of care discussed by the interdisciplinary group and according of the patient needs written on 11/04/2022 revealed that the facility hospice provide evidence of the '' form related to orientation and delivered of the Plan of Care established by the IDG", it revealed that the designated person who received the orientation of the plan of care for this re-certification did not sign the plan of care. The plan of care lacks the patient resource signature and lacks the hospice representative signature. 6. RR #3 is a 99-year-old male admitted on 10/28/2022 with a diagnosis of Cerebro Vascular Accident, Dementia, Hight Blood Pressure and Bed Confinent. The plan of care establish frequency of visit: R.N 2 visits per week and (PRN) was needed, HHA 3 visits per week and PRN, MD 1 visit per month and PRN, Spiritual Advisor 2 visits per month and PRN , Social Worker 2 visits per month and PRN and Nutritionist 1 visit and PRN. According of the established patient plan of care discussed by the interdisciplinary group and according of the patient needs written on 11/01/2022 revealed that the facility hospice provide evidence of the '' form related to orientation and delivered of the Plan of Care established by the IDG", it revealed that the designated person who received the orientation of the plan of care for this re-certification did not sign the plan of care. The plan of care lacks the patient resource signature and lacks the hospice representative signature. 7. RR #4 is a 70-year-old female admitted on 09/12/2022 with a diagnosis of Malignant Neoplasm and Localized Edema. The plan of care establishes frequency of visit: R.N 3 visits per week and (PRN) was needed, HHA 5 visits per week and PRN, MD 1 visit per month and PRN, Spiritual Advisor 2 visits per month and PRN, Social Worker 2 visits per month and PRN and Nutritionist 1 visit and PRN and Home Maker 5 visits per week and PRN. According of the established patient plan of care discussed by the interdisciplinary group and according of the patient needs written on 10/28/2022 revealed that the facility hospice provide evidence of the '' form related to orientation and delivered of the Plan of Care established by the IDG", it revealed that the designated person who received the orientation of the plan of care for this re-certification did not sign the plan of care. The plan of care lacks the patient resource signature and lacks the hospice representative signature. 8. RR #5 is a 92-year-old male admitted on 04/13/2022 with a diagnosis of End Stage Renal Disease, Hight Blood Pressure, Dementia and Coronary Heart Accident. The plan of care establishes frequency of visit: R.N 2 visits per week and (PRN) was needed, MD 1 visit per month and PRN, Spiritual Advisor 2 visits per month and PRN, Social Worker 2 visits per month and PRN and Nutritionist 1 visit and PRN. According of the established patient plan of care discussed by the interdisciplinary group and according of the patient needs written on 10/28/2022 revealed that the facility hospice provide evidence of the '' form related to orientation and delivered of the Plan of Care established by the IDG", it revealed that the designated person who received the orientation of the plan of care for this re-certification did not sign the plan of care. The plan of care lacks the patient resource signature and lacks the hospice representative signature. 9. RR #6 is a 96-year-old male admitted on 12/25/2020 with a diagnosis of Alzheimer End Stage and Bedridden. The plan of care establishes frequency of visit: R.N 2 visits per week and (PRN) was needed, HHA 5 visits per week and PRN, MD 1 visit per month and PRN, Spiritual Advisor 2 visits per month and PRN, Social Worker 2 visits per month and PRN and Nutritionist 1 visit and PRN. According of the established patient plan of care discussed by the interdisciplinary group and according of the patient needs written on 10/28/2022 revealed that the facility hospice provide evidence of the '' form related to orientation and delivered of the Plan of Care established by the IDG", it revealed that the designated person who received the orientation of the plan of care for this re-certification did not sign the plan of care. The plan of care lacks the patient resource signature and lacks of the hospice representative signature.

Based on an unannounced recertification survey, three home visits (HV) with records reviewed (RR) and eight sample records reviewed performed on November 08 through 10, 2022, it was determined that the facility failed to ensure that a drug regimen review is performed by the professional staff on every home visit, for 1 out of 11 records review. (HV#3) --- Findings include: 1. H.V #3 is a 67-year-old male admitted on 09/02/2022 with a diagnosis of Chronic Obstructive Pulmonary Disease, and secondary diagnosis of Alzheimer Disease with Late Onset, Cerebral Infarction and Bed Confinement Status, Gastrostomy. Patient lives in a Nursing Home he is bedridden. The frequency of visits are as follow: RN 2 visits per week and as needed (PRN), Physician 1 visit per month and PRN, Social Worker 2 visits per month and PRN, Counselor 2 visits per month and LDN PRN. a. During the H.V. performed on 11/10/2022 at 9:00 AM drug regimen review was not performed by the Register Nurse employee #5. The surveyor requested the patient's medications and the nursing home nurse refused to bring them. After several minutes, evidence of all medications in use was brought by the nursing home nurse and they were reviewed. It was found that the patient has one medication not included on the facility list '' G Tusicof '' provide by the nursing home nurse. b. The patient plan of care of 10/28/2022 provide evidence that the patient received the following medications: 1.Silvadene 1% one application topical daily2. G Tusicof 10 ml. every 6 hours by PEG 3. Ipratropium 0.02 % ml 1 ampulla FFT every 6 hours4. Mobic 7.5 mgs 1 tab. two times daily by PEG 5. Spiriva Respimat 1.25 mcg 1 cap. inhaled PM 6. Lipitor 10 mgs 1 tab. by PEG PM.7. Flomax 0.4 mg. 1 cap. by PEG daily8. Keppra 100 mgs 5 ml. by PEG 2 times daily9. Baclofen 20 mgs 1 tab. by PEG daily10. Folic Acid 1 mg. 1 tab. by PEG daily11. Synthroid 100 mcgs 1 tab by PEG daily12. Losartan /Hydroc 50/12,5 mgs 1 tab by PEG daily13. Nausea Relief 15 ml by PEG every 8 hours/PRN c. According of the facility plan of care establishes that it will be reviewed every two weeks or when necessary and all changes will be notified to the patient and family resource. However, the RN employee #5 hospice nurse, according of the plan of care establishes a frequency of visits twice a week. The record was review on 11/10/2022 at 11:30 AM and provide evidence that the nurse visits the patient at the nursing home two times a week according of plan of care, however, no evidence of medication review. d. The plan of care of 10/28/2022 is not marked if the patient or caregiver was oriented on the established plan and if they understand it. Is not signed by either patient / or resource and hospice representative.

Based on an unannounced recertification survey, observations and review of eleven loose pages and interview with the agency's Service Director (employee #1) on 11/09/2022 at 2:50 PM it was determined that hospice failed to have a method in place to develop, implemented and maintain an effective, ongoing, hospice - wide data driven quality assessment and performance improvement program. The facility did not have all patient care disciplines, actually lacks Speech Therapist. Did not provide evidence of Program objectives, self-assessment which includes criteria and/or measures generated by the medical and professional staff which reflects hospice best practice patterns, staff performance and patient outcomes, all of which makes this condition "Not Met". --- Did not provide evidence of Program objectives, self-assessment which includes criteria and/or measures generated by the medical and professional staff which reflects hospice best practice patterns, staff performance and patient outcomes, all of which makes this condition "Not Met".

Based on an unannounced recertification survey, observations, review of documents and interview with the agency's Service Director (employee #1) on 11/10/2022 at 3:300 PM, it was determined that facility failed to maintain and document an effective infection control program that protects patients, families, visitors, and hospice personnel by preventing and controlling infections and communicable diseases. This condition "Not Met". (Cross reference Tags G578, G579, G687). --- This condition "Not Met". (Cross reference Tags G578, G579, G687).

Based on an unannounced recertification survey, observations during 3 home visits (HV) with records reviewed (RR), 8 sample records review (RR), interview with the Service Director (Employee #1), performed on 11/08/2022 and 11/10/2022 from 8:00 AM thru 4:30 PM it was determined that the facility failed to ensure and organize and effective Infection Control Program that protects patients, family members and facility personnel using measures for prevention of cross contamination and controlling diseases. --- Findings include: 1.The facility failed to ensure and have in place an effective Infection Control Program, with a system in place to communicate with all facility personnel, patients, and families about infection control prevention during daily activities. a. The facility did not provide evidence of Quality Assessment Performance Improvement- QAPI activities. On interview with Service Director (Employee #1), on 11/09/2022 and 11/10/2022 from 8:00 AM through 4:00 PM it was identified that facility failed to maintain Infection Control Program that identifies and prevent risk of cross contamination and transmission of infectious agents where the patients reside. b. The facility failed to provide evidence of the Infection Control Committee meetings performed during years 2021 and 2022. No evidence was provided of meetings minutes to determine the topics discussed and the final resolutions. c. It was found that the infection control monitoring activities are performed under the Quality Program as an indicator, however the facility did not provide evidence of the Quality Program. d. The facility did not provide evidence of the Infection Control Manual on 11/08/2022 through 11/10/2022. e. During interview with the Service Director (Employee #1) on 11/09/2022 at 3:30 PM she stated that she is the person in charge of Infection Control, Quality, Nursing Supervisor and Director of Service. ''Related to how many times the infection control committee meetings were performed, she stated: '' 'The Infection Control Program does not have individualized committee meetings. However, she did not provide evidence of the Infection Control Committee and did not provide evidence of the Quality Program (QAPI) meetings.'' f. The hospice Service Director did not provide evidence of the Infection Control Program, also has not been established as an individualized program that respond to the Administration. However, the facility did not provide evidence of the administrator credential file.

Based on an unannounced recertification survey, observations od delivery of care made during three home visits (H.V), it was determined that the facility failed to follow acceptable standards of Infection Control during change the Foley catheter and ulcer care for hand washing for 1 out of 3 home visits (H.V #2). --- Findings include: 1. H.V #2 is an 85-year-old female admitted on 06/15/2022 with a diagnosis of Cerebral Infarction Unspecified and secondary diagnosis of Hypertension, Bed Confinement Status (Bedridden), Urinary and Fecal Incontinence, Hyperlipidemia, Hight Blood Pressure, Diabetes Mellitus Type II, Alzheimer, Chronic Renal Failure and Sacral Pressure Ulcer Stage III. The HV was performed on 11/08/2022 at 12:00 midday (md.) with the Social Worker (employee #6) to observe Foley catheter change and sacral ulcer care performed by the register nurse (RN) (employee #4). 2. During the visit at the patient home, the patient was observed bedridden and totally dependent on activities of daily living, fecal and urinary incontinence. The patient has a Foley catheter #16 that needs to be changed every thirty days according of the physician order. The following was observed during the nurse removed and change the Foley catheter: a. On 11/08/2022 at 12:00 md a patient bed is observed in the living room of the patient's home. The patient daughter reports that her mother moved to the living room because her room has problems with the ceiling and has filtration problems, which is why she was relocated to the living room for the moment. b. As observed the Register Nurse (RN) employee #4, performed the hand washing, before start did not dry hands, she took out gloves from the Ziploc bag located in the pocket on the right side of her uniform and put them on, then removed the sheet that covered patient leaving her exposed. c. Then did not take the vital signs to the patient. Removed the urine collection bag and discarded it. She removed gloves and went to her materials bag placed on the floor, put her hands in and took out a 10 ml. syringe, then took a pair of gloves out of her right pocket and put them on, she did not wash her hands or use hand sanitizer. The nurse did not turn off the fans, she did not close the windows or the door of the living room and removed the foley catheter, then removed her gloves and discard but did not wash her hands. d. She took out gloves from the Ziploc bag located in the pocket on the right side of her uniform and put them on, then clean the patient genital area per two times with water, she removed her gloves and discard, then put a pair of gloves and dry, then removed her gloves and discard. The nurse went to the bathroom and wash her hands but did not dry, she took a pair of gloves out of her right pocket and put them on. The RN employee #4 did not place a linen saver pad (under pad) on the patient bed, she put the sterile tray on the left side of the bed, open the sterile tray inflate the balloon with a sterile water, then put a portion of gel in the tray. She cleans the genital area with soap and water, then removed her gloves and put sterile gloves but did not wash her hands with soap and water before putting the sterile gloves. The nurse opens the packet of Betadine applicators and cleaning per three times but did not maintain her left hand to separate the labia majora and labia minora before inserting the catheter, release the labia's and took the foley catheter, applied the gel, then with her left hand separate the patient labia's and with her right hand insert the foley catheter. Then she inflates the balloon without first establishing urine flow, then urine was observed. The nurse removed her gloves did not wash her hands took out a pair of her pocket and put them on. She discards the material removed her gloves did not wash her hands took out a pair of her pocket and put them on then positioned the patient and placed pamper, then she placed collection bag on top of left side bed rail. The following was observed during the nurse performed the Sacral ulcer local care: a. At 12:10 PM the Register Nurse (employee #4) when finished the foley insertion initiated the sacral ulcer care. With the same gloves the nurse placed the patient on the left side with the assistance of the patient's daughter. The nurse prepared a treatment tray did not wash her hands and placed gloves, then removed bandage from the sacral area and discarded then removed gloves did not wash hands took out a pair of gloves of her pocket and put them on. The RN (employee #4) performed the sacral ulcer local care per three times with wound cleanser then did not dry the ulcer, take out of the tray Calcium Alginate open the package and then with your fingers cut a piece of Alginate and place it inside the sacral ulcer then takes a cotton swap and insert it inside the ulcer, then used the swap and introduce it into the Silvadene container took a portion and applied it around the borders of the sacral ulcer, then placed a regular gauze at the ulcer and then placed adhesive gauze to cover and fixed. At the end, the nurse removed the gloves but did not wash her hands, she took a pair of gloves from her right pocket of her uniform and put them on. The patient presented a small portion of stool, and the nurse cleaned the anal area and discarded it. Using the same gloves, she placed the diaper and blue pad. Then she placed the materials in a plastic box owned by the patient and placed it under the bed directly on the floor. Then removed gloves and discarded. She washed her hands, did not dry her hands due to the absence of hand paper. She left the bathroom and went to her briefcase of materials, before opening it, she dried her hands on both ends of her pants. Then she took a pair of gloves from her right pocket of her uniform one of the gloves fell on the floor, the RN picked it up discarded it in the trash can did not wash her hands took a pair of gloves from her right pocket of her uniform and put them on, then she performed the patient medication review, when finished the nurse took out the sphygmomanometer and thermometer from the briefcase and disinfected, then removed gloved and discarded by touching the lid of the trash can, then took a pair of gloves from her right pocket of her uniform and put them on. b. The R.N. (employee #4) did not take vital sings before performing procedures, however, only took blood pressure and temperature at the end of procedures. She did not take pulse and respiration and did not measure sacral ulcer. She disinfected the non-critical equipment sphygmomanometer and the thermometer. Then removed her gloves and discard. The register nurse did not performed hand washing with soap and water only applied hand sanitizer. c. The R.N. did not wash her hands with soap and water during all the procedures. The R. N. (employee #4) did not perform the hand washing techniques according to the hand washing protocol established by the CDC (Centers for Disease Control and Prevention). d. The R.N. (employee #4) did not prepare a sterile campus to put the materials. She put the materials directly to the patient bed. 3. The record was review on 11/09/2022 at 11:00 AM according of the plan of care written on 11/04/2022 at 9:15 PM per the Service Director Nurse (employee #1) refer that the patient has infection process on 11/03/2022. She writes in Condition Summary: '' Patient with foul - smelling urine. "Then she wrote: Medical orders: '' Physician (employee #7) ordered to administer Rocephine 1-gram intramuscular stat and Levaquin 250 mgs. one tablet daily for 5 days.'' a.The patient record did not provide evidence of urine sample and urine culture before and after treatment ordered by the physician. No evidence of written order of antibiotics performs by the hospice physician. During interview with the Service Director Nurse (employee #1) she stated the following: '' This Hospice never order or perform laboratory samples to the patients, if the nurse identifies any situation, the hospice physician is notified and orders treatment.'' However, the facility failed to ensure to perform laboratory samples before and after treatment. b. On 11/09/2022 at 12:05 PM during review the facility contracts, this Hospice has a contract with a Laboratory for two years from July 1, 2021, to January 2023. 4. The Agency failed to ensure that their personnel follow the infection control standard of practice during performed the Foley Catheter insertion and Ulcer local care. 5. The nurse techniques is prone to '' Cross Contaminating '' during perform the Foley catheter change and sacral ulcer local care not according with Infection Control Standard of practice and place risk at patient to acquire infections. 6. The R.N. employee #4 did not turn off the fan during initiated and ended the Foley catheter change procedure and sacral ulcer local care. 7. The R.N. employee #4 did not perform a correct management of '' regular and sterile gloves.''

Based on an unannounced recertification survey, administrative documents review accompanied by the Service Director (employee # 1) performed on 11/09/2022 at 2:25 PM, it was determined that the facility failed to provide orientation on skilled nursing procedures to ensure staff competencies while providing direct care. --- Findings include: 1. The facility has developed an annual calendar of activities however, the annual plan for 2021 only presents education related to Hurricane before and after. 2. The facility did not provide evidence of annual calendar of activities plan for 2022. 3. The facility failed to develop an annual plan to reinforce skilled procedures that are offered at home. It was found that the agency offers treatments to patients however, no evidence of activities calendar for professional staff orientation.

Based on an unannounced recertification survey, review of Register Nurse (RN), License practical nurse (LPN), Physicians (MD), Physical therapy (PT), Occupational therapy (OT), Social Worker (SW), Spiritual Counselor, Home Maker, Housekeeper, Volunteers and Nutritionist credential files (C.Fs), it was determined that the agency failed to ensure that all C.Fs are in compliance with applicable local law for hospice agencies related to updated personnel C.F: Annual Membership, Influenza vaccine, Hepatitis B vaccine, Varicela y/o Titles, Health certificated, Cardiopulmonary Resuscitation (CPR) Certification approved by the American Heart Association (AHA), Annual evaluation, Competence, Abuse and Neglect Education, Hospice Philosophy Education and Expired Contract for 14 out of 15 personnel C.Fs (Nursing C.Fs #1, #2, #3 and #4, Physician C.Fs #5 and #6, Quality Coordinator C. F #7, Occupational Therapist C. Fs #8, Physical Therapist C.Fs #9, Spiritual Counselor C.Fs #10, Social Worker C.Fs #11, Home Maker C. F# 12 and #13, Volunteers C.F #14 ). --- Findings include: 1. During the review of Nursing, Physician, Social Worker, Spiritual Counselor, Home Makers, Physical Therapist, Occupational Therapist, Housekeepers and Volunteers C.Fs on 11/09/2022 from 12:40 PM till 2:30 PM, it was determined: a. Four out of four Nursing credentials files did not contain evidence of their updated Health Certificate (Nursing C.Fs. #1 expired on 02/03/2022, C.Fs #2 expired on 09/07/2022, C.Fs #3 expired on 09/07/2022 and C.Fs #4 expired on 09/07/2022). b. Three out of four nursing credentials files did not contain evidence of their updated Influenza vaccine according to the Health Department Administrative Order # 244 of October 10, 2008 (Nursing C.F. #1, #2 and #4). c. One out of four nursing credentials files did not contain evidence of their Hepatitis vaccine (Nursing C.F. #4). d. One out of four nursing credentials files did not contain evidence of their Varicella vaccine (Nursing C.F. #4). e. One out of four Nursing credentials files did not contain evidence of their updated CPR (C.Fs. #4 expired on 05/2021). f. One out of four Nursing credentials files did not contain evidence of their annual evaluation (C.Fs. #4). g. One out of two Physician credentials files did not contain evidence of the CPR (Physician C.Fs. #5). h. One out of two Physician credentials files did not contain evidence of their updated Influenza vaccine according to the Health Department Administrative Order # 244 of October 10, 2008 (Physician C.F. #6). The last evidence of influenza vaccine was administered on 12/10/2019). i. Two out of two Physician credentials files did not contain evidence of their updated Education related to Abuse and Neglect (Physician C.F. #5 04/14/2013 and (Physician C.F. #6 10/26/2016). j. One out of one Physical Therapist credentials files did not contain evidence of their updated Health Certificate (Physical Therapist C. F #9 expired on 12/10/2020). k. One out of one Physical Therapist credentials files did not contain evidence of their Influenza Vaccine, Annual Evaluation, Duties and functions and Competencies (Physical Therapist C. F #9). l. One out of one Physical Therapist credentials files did not contain evidence of their updated Education related to Abuse and Neglect and Hospice Philosophy ( (P.T C.F. #9 the last education was on 09/05/2006). m. One out of one Occupational Therapist credentials files did not contain evidence of their updated Health Certificate (Occupational Therapist C. F #8 expired on 08/10/2021). n. One out of one Occupational Therapist credentials files did not contain evidence of their Hepatitis B vaccine, Influenza Vaccine, Annual Evaluation, Duties and functions, Competencies, Education related to Abuse and Neglect and Hospice Philosophy (Occupational Therapist C. F #8). o. One out of one Social Worker credentials files (C.F. #11) did not contain evidence of their updated Health Certificate (Expired on 05/29/2022), the last Influenza Vaccine was administered in 10/21/2020. p. One out of one Spiritual Adviser credentials files (C.F. #10) did not contain evidence of updated Influenza Vaccine, was administer in 10/21/2020. q. One out of two Housekeeper credentials files (C.F. #12) did not contain evidence of Health Certificate (Expired on 08/09/2022), did not contain evidence of updated Influenza Vaccine was administer in 03/09/2019 and the last Education related to Hospice Philosophy was in 05/06/2019. r. One out of two Housekeeper credentials files (C.F. #13) did not have evidence of Hepatitis Vaccine. s. One out of one Volunteer credentials files (C.F. #14) according with the Executive Director this employee the functions he performs is an administrative volunteer however, the contract effective on 07/20/2021 per two years indicates Assistant Administrator and works five days a week 40 hours. The credential file did not contain evidence of Health Certificate, Hepatitis Vaccine, Influenza Vaccine, Annual Evaluation, Functions and Duties, Criminal Record, Law 300 and lack Education related to Hospice Philosophy, Abuse and Neglect, Covid 19, Emergency Management and others education related to the hospice. t. On 11/09/2022 at 11:00 AM the facility did not provide evidence of credential file of the Hospice Executive Director (employee #16) and Administrative Assistance (employee #17). According of the facility Service Director Nurse (employee #1) the Executive Director and the Administrator exercises both functions. 2. On 11/09/2022 at 12:05 PM during review the facility personnel contracts the following was found: a. Physician C.F. #5 was hired in 06/01/2018 contract expired 1//26/2020 b. Physician C.F. #6 was hired in 10/26/2018 contract expired 10/2020 c. Quality Coordinator C. F #7 was hired in 01/26/2018 contract expired 01/2020 d. Occupational Therapist C. F #8 was hired in 01/11/2019 contract expired 01/11/2021. e. Physical Therapist C. F #9 was hired in 08/09/2019 contract expired 08/09/2021.

Based on an unannounced recertification survey, three Home Visit (H.V) with Records Reviewed (R.R), eight Records Reviewed with the Director Service (Employee #1) on 11/08/2022 through 11/10/2022 from 8:00 AM till 4:30 PM and interviews , it was determined that the facility failed to ensure that the clinical record contain current and correct clinical information for each hospice patient related to Register Nurse (R.N), visits and ulcer measures and classification by the staff that performed the visit for 9 out of 11 records reviewed, (H.V. #1, #2, #3 and R.R #1, #2, #3 , #4, #5, #6). --- Findings include: During the review of three H.V with RR and eight RR on 11/08/2022 through 11/10/2022 from 8:00 AM till 4:30 PM it was found the following: 1.H.V #1 is a 91-year-old female admitted on 10/27/2021 with a diagnosis of Alzheimer, Parkinson, Hight Blood Pressure, Bed Confinement Status (Bedridden), Urinary and Fecal Incontinence and Gastrostomy. The HV was performed on 11/08/2022 at 3:15 PM with the Social Worker (employee #6) to observe bed bath performed by the Home Health Aide (HHA) (employee #8). During the interview with the patient's daughter reported that she flushed the expired or discontinued medications down the toilet. No evidence in the patient record documentation related to disposition of medications when expired or discontinued. 2. H.V #2 is an 85-year-old female admitted on 06/15/2022 with a diagnosis of Cerebral Infarction Unspecified and secondary diagnosis of Hypertension, Bed Confinement Status (Bedridden), Urinary and Fecal Incontinence, Hyperlipidemia, Hight Blood Pressure, Diabetes Mellitus Type II, Alzheimer, Chronic Renal Failure and Sacral Pressure Ulcer Stage III. The HV was performed on 11/08/2022 at 12:00 midday (md). with the Social Worker (employee #6) to observe Foley catheter change and sacral ulcer care performed by the register nurse (RN) (employee #4). a. According to the RN initial assessment performed on 06/15/2022 at 2:45 PM during the visit the RN assess a pressure ulcer located on the Sacral area, Stage III measure Length 2.0 centimeters (cms) x Width 2.0 cms x Depth 0.5 cms. b. On RN visit performed on 10/04/22 and 10/06/22 the nurse did not classified the Stage and documented in the same week the same measure. On 10/11/22, 10/13/22, 10/18/22, 10/20/22 ulcer with measure 2.0 centimeter (cm) per 2.0 cm per 1.0 depth. On the week 10/24/22 ulcer with measure 2.0 centimeter (cm) per 2.0 cm per 1.0 depth. and 10/27/22 ulcer with measure 2.0 centimeter (cm) per 2.0 cm per 0.8 depth. On the week 11/01/22 ulcer with measure 2.0 centimeter (cm) per 2.0 cm per 1.0 depth. On 11/08/2022 at 12:00 md. with the Social Worker (employee #6) the surveyor visits the patient home to observe sacral ulcer care performed by the register nurse (RN) (employee #4). During the nurse ended the local care procedure never performed ulcer measurement, however the nurse documented on the note ulcer with measure 2.0 centimeter (cm) per 2.0 cm per 0.8 depth. c. During the record review with the hospice Director Service on 11/10/2022 at 1:00 PM it was identified that all the nurses' notes reflect the same information. She refers to the fact that the electronic program they have does not accept changes on the documentation and is repetitive. d. The record was review on 11/10/2022 at 1:00 PM according of the plan of care written on 11/04/2022 at 9:15 PM per the Service Director Nurse (employee #1) refer that the patient has infection process on 11/03/2022. She writes in Condition Summary: '' Patient with foul - smelling urine. "Then she wrote: Medical orders: '' Physician (employee #7) ordered to administer Rocephine 1-gram intramuscular stat and Levaquin 250 mgs. one tablet daily for 5 days.'' The patient record did not provide evidence of urine sample and urine culture before and after treatment ordered by the physician. No evidence of written order of antibiotics performs by the hospice physician. During interview with the Service Director Nurse (employee #1) she stated the following: '' This Hospice never order or perform laboratory samples to the patients, if the nurse identifies any situation, the hospice physician is notified and orders treatment.'' However, the facility failed to ensure to perform laboratory samples before and after treatment. 3. H.V #3 is a 67-year-old male admitted on 09/02/2022 with a diagnosis of Chronic Obstructive Pulmonary Disease and secondary diagnosis of Alzheimer Disease with Late Onset, Cerebral Infarction Unspecified and Bed Confined Status (Bedridden). The H.V was performed on 11/10/2022 at 9:00 A.M with the Register Nurse (RN) (employee #5) to observe gastrostomy local care, respiratory and skin assessment. a. This patient lives in a nursing home, during the visit the patient was observed bedridden totally dependent on activities of daily living, fecal and urinary incontinence, was maintain with foley catheter. He has problem to swallow foods, drink liquids and chew, was maintain with gastrostomy (PEG #24) and receiving Jevity 1.2 calories at 60 ml per hour with Kangarro machine. Was maintain with oxygen concentrates by nasal cannula at 2 liters/minute. The nurse performed the patient assessment and the patient refer chest and leg pain. The nursing home nurse administered Mobic 7.5 mgs. by gastrostomy tube according with the physician order. The hospice nurse continues with the assessment and was identified pressure area in left heel and sacral area. The hospice nurse oriented the nursing home nurse to change the patient position every two hours. During the visit it was observed that the patient has long toenails, and the nurse was oriented to notify the physician. b. During the home visit performed on 11/10/2022 at 9:00 AM at the '' Nursing Home'' the surveyor requests the medications used by the patient, according with the hospice nurse employee #5 stated : '' I do not have the control of the medications of the patient, I cannot perform the drug check when I make the visits to the nursing home because they are locked and the person who has control of the drugs when I come to offer the patient care is not present. I supply the drugs that the hospice provides according to the doctor's order.'' Related to Pain Management Drugs '' Movic 7.5 mgs. tablet to administer 1 tablet by gastrostomy twice a day. The medication was delivered on 11/08/2022 they are received by the nursing home staff. c. During interview conducted on 11/10/2022 at 9:25 AM with the nursing home nurse related to the patient medications, she stated "The medication G Tusicof 10 ml. every six hours by Gastrostomy it was discontinued on November 3, 2022, by verbal order of the patient's physician. However, the hospice nurse employee #5 stated that she did not know that the patient is not receiving the medication ''G Tusicof.'' According of the home nurse this medication was discontinue by the nursing home physician on 11/03/2022 by verbal order, however, the plan of care provide evidence that the patient received this medication until 10/21/2022. The nursing home nurse stated "will notify the patient physician to send the written order. The nursing home nurse reported not knowing that she had to request a medical order and send it to the hospice. d. The nurse employee #5 failed to perform the drug check on each visit to ensure that the patient receives the medications according to the medical orders and to avoid errors in administration. The hospice nurse failure to ensure that the nursing home reports any changes related to the patient's treatment. e. The hospice nurse failed to assure that the patient pain and symptoms management in a timely fashion. The hospice lacks to have methods in place to ensure that the patient's pain and all other distressing symptoms are controlled effectively 24 hours a day 7 days a week in all settings and wherever the patient resides. f. The hospice nurse (employee #5) fails to make sure that the person receiving the medications in the nursing home is a health care professional which puts at risk the safety of the medications and the life of the patient in your care. g. The hospice nurse (employee #5) failed to perform the weekly drug review in accordance with the hospice policy. 4. RR #1 is a 94-year-old female admitted on 03/11/2021 with a diagnosis of Alzheimer Disease with Late onset, Bed Confinement Status (Bedridden), Urinary and Fecal Incontinence, Hyperlipidemia and Sacral Pressure Ulcer Stage III. The record review was performed on 11/10/2022 at 12:45 PM. with the Service Director and provide evidence that the patient has 21 one ulcers. During reviewed nurses notes the ulcer #3, #4, #7, #8, #9 and #10 they do not appear in the nurses' notes, the Service Director nurse (employee #1) says: '' that if they do not appear in the nurse documentation, it means that it has healed and that there is no way to be sure.'' However, that all the nurses' notes reflect the same information. She refers to the fact that the electronic program they have does not accept changes in the documentation and is repetitive. 5. RR #2 is a 91-year-old female admitted on 06/03/2022 with a diagnosis of COPD, Diabetes Mellitus Type II, Hight Blood Pressure and Renal Failure. The plan of care performed in 11/04/2022 establish frequency of visit: R.N 2 visits per week and (PRN) was needed, HHA 3 visits per week and PRN, MD 1 visit per month and PRN, Spiritual Advisor 2 visits per month and PRN, Social Worker 2 visits per month and PRN, Home Maker 2 visits per week and PRN and Nutritionist 1 visit and PRN. The patient plan of care was not sign by the patient/ caregiver and hospice representative. The area designated to mark if the patient was consulted and changes in the treatment plan were explained to them appear in blank. The facility did not provide evidence of nurses notes because has problem with the electronic system 6. RR #3 is a 99-year-old male admitted on 10/28/2022 with a diagnosis of Cerebro Vascular Accident, Dementia, Hight Blood Pressure and Bed Confinent. The plan of care establishes frequency of visit: R.N 2 visits per week and (PRN) was needed, HHA 3 visits per week and PRN, MD 1 visit per month and PRN, Spiritual Advisor 2 visits per month and PRN, Social Worker 2 visits per month and PRN and Nutritionist 1 visit and PRN. The patient plan of care was performed in 11/01/2022 did not signed by the patient/ caregiver and hospice representative. The area designated to mark it the patient was consulted and changes in the treatment plan were explained to them appear in blank. The facility did not provide evidence of nurses notes because has problem with the electronic system. 7. RR #4 is a 70-year-old female admitted on 09/12/2022 with a diagnosis of Malignant Neoplasm and Localized Edema. The plan of care establishes frequency of visit: R.N 3 visits per week and (PRN) was needed, HHA 5 visits per week and PRN, MD 1 visit per month and PRN, Spiritual Advisor 2 visits per month and PRN, Social Worker 2 visits per month and PRN and Nutritionist 1 visit and PRN and Home Maker 5 visits per week and PRN. The patient plan of care was performed in 10/28/2022 was not signed by the patient/ caregiver and hospice representative. The area designated to mark it the patient was consulted and changes in the treatment plan were explained to them appear in blank. 8. RR #5 is a 92-year-old male admitted on 04/13/2022 with a diagnosis of End Stage Renal Disease, Hight Blood Pressure, Dementia and Coronary Heart Accident. The plan of care establishes frequency of visit: R.N 2 visits per week and (PRN) was needed, MD 1 visit per month and PRN, Spiritual Advisor 2 visits per month and PRN, Social Worker 2 visits per month and PRN and Nutritionist 1 visit and PRN. The patient plan of care was performed in 10/28/2022 was not signed by the patient/caregiver and hospice representative. The area designated to mark if the patient was consulted and changes in the treatment plan were explained to them appear in blank. The facility did not provide evidence of nurses notes because has problem with the electronic system 9. RR #6 is a 96-year-old male admitted on 12/25/2020 with a diagnosis of Alzheimer End Stage and Bedridden. The plan of care establishes frequency of visit: R.N 2 visits per week and (PRN) was needed, HHA 5 visits per week and PRN, MD 1 visit per month and PRN, Spiritual Advisor 2 visits per month and PRN, Social Worker 2 visits per month and PRN and Nutritionist 1 visit and PRN. The patient plan of care was performed in 10/28/2022 was not signed by the patient/caregiver and hospice representative. The area designated to mark it the patient was consulted and changes in the treatment plan were explained to them appear in blank.

Based on an unannounced recertification survey performed on 11/08/2022 through 11/10/2022, observations in the medical surgical storage area and interview with person in charge (employee #1), it was determined that the facility failed to promote the maintenance of appropriate conditions on the medical surgical storage, medical equipment, and medications area. --- Findings include: 1. Medical surgical supply storage area was visited with the Service Director (employee #1), on 11/10/2022 at 8:40 AM and it was identified: a. In the entrance at the right side of the corridor a bathroom was observed, in the interior the trash can lacks plastic bag, near the trash can man's clothes directly on the floor (pants, shirt and shoes). Brush to clean the toilet directly on the floor. No dispenser and no hand paper. b. medical equipment was observed on the right side of the corridor and at the end of the left side of corridor in front of the '' Exit door '' six medium oxygen tanks were observed directly on the floor and without a safety base. c. At the left side of this corridor near the oxygen tanks the medical surgical supply storage was observed, the interior of this medical surgical materials with dust accumulation was observed and detected on shelves and walls. d. In the area located at the main entrance a dirty plastic sink with dark spots was observed. At the top near the water faucet two cups for personal use and a bottle of water was observed. Bucket with used water and direct mop on the floor was observed near the plastic sink. Box with biohazard material uncovered was observed at the right side, water was observed on the floor. Dividing wall with loose tiles, dirty, dark stains due to moisture. Six medium deteriorate oxygen tanks with dust were observed directly on the floor and without a safety base near this dividing wall. 2. Area designated for medications an unlocked metal shelf was observed. Inside, medicines for patient's use were observed. The following was detected: a. Four Anti-diarrheal expired on 09/2022 Lot. P117060b. Ketorolac 30 mgs /ml expired on 09/2022 Lot. 201033 c. Triple Antibiotic open and lacks identification label d. Silvadene open and lacks identification labele. Vitamin K open and lacks identification labelf. Two bottles of Kaopectate expired date on 10/2022 Lot. 19K229 g. Milk of Magnesia expired date on 10/2022 h. Nystatin oral expired date on 05/2022 with name of deceased patient. 3. Emergency briefcase was found without a lock, is not identified and lacks list of medications. 4. The hospice Service Director (employee #1) during interview related to the facility storage conditions and related to medication area she was maintain quiet.