Every finding on record at Hospicio San Francisco De Asis Inc

Based on an unannounced recertification Emergency Preparedness on 01/23/2024 from 9:30 AM. till 4:30 PM, it was determined that the facility failed to evidence the development, of the emergency preparedness program related to the absent of policies and procedures and evidence of the program which makes this Condition of Participation: 42 CFR §418.113 Emergency Preparedness requirements for Hospice, Not Met. --- Based on an unannounced recertification Emergency Preparedness survey and documents reviewed provide by Clinical Manager (employee #2) on 01/23/2024 from 9:30 AM. till 4:30 PM, it was determined that the facility failed to evidence the development, of the emergency preparedness program. The facility did not provide evidence of the compliance for tags E001, E004, E006, E007, E009, E013, E016, E019, E023, E024, E025, E026, E029, E030, E031, E032, E033, E036, E037, E039.

Based on an unannounced recertification Emergency Preparedness survey and documents reviewed on 01/23/2024 from 9:30 AM. till 4:30 PM, it was determined that the facility failed to develop and maintain and update at least every two years emergency preparedness plan with specific approach to the location of the facility and surroundings including emerging infectious disease. --- Findings Include: During the review of the Emergency Preparedness Program with the Clinical Manager (employee # 2) on 01/23/2024 from 9:00 AM. till 4:30 PM, it was determined that the facility failed to develop and maintain and update at least every two years. The facility could not evidence a structured Emergency Operation Plan.

Based on an unannounced recertification Emergency Preparedness survey and documents reviewed on 01/23/2024 from 9:00 AM till 4:30 PM, it was determined that the facility failed to develop and maintain an emergency preparedness plan that include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, pandemics, natural disasters, and other emergencies that would affect the facility ability to provide care. --- Findings include: During the review of the facilities Emergency Preparedness Program with the Clinical Manager (employee # 2) on 01/23/2024 from 9:00 AM till 4:30 PM, it was determined that the facility failed to include a documented facility and community based all hazard approach risk assessment.

Based on an unannounced recertification Emergency Preparedness survey and documents reviewed on 01/23/2024 from 9:30 AM till 4:30 PM, it was determined that the facility failed to develop and maintain an emergency preparedness plan that address patient population, types of services the facility has the ability to provide, continuity of operations and delegation of authority. --- Findings include: During the review of the facilities Emergency Preparedness Program with the Clinical Manager (employee #2) on 01/23/2024 from 9:00 AM till 4:30 PM, it was determined that the facility failed to address the ability of providing services to patients during emergencies, continuity of operations, delegation of authorities and succession plans.

Based on an unannounced recertification Emergency Preparedness survey and documents reviewed on 01/23/2024 from 9:00 AM till 4:30 PM, it was determined that the facility failed to develop and maintain an emergency preparedness plan that include a process for cooperation and collaboration to maintain a respond during a disaster or emergency situation. --- Findings include: During the review of the facilities Emergency Preparedness Program with the Clinical Manager (employee #2 ) on 01/23/2024 from 9:00 AM till 4:30 PM, it was determined that the facility failed to develop and maintain an emergency preparedness plan that include a process for cooperation and collaboration to maintain a respond during a disaster or emergency situation.

Based on an unannounced recertification Emergency Preparedness survey and documents on 01/23/2024 from 9:30 AM till 4:30 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to develop policies and procedures based on the emergency and communication plan. --- Findings include: During the review of the facilities Emergency Preparedness Program with the Clinical Manager (employee #2 ) on 01/23/2024 from 9:00 AM till 4:30 PM, it was noted that the facility failed to stablish policies and procedures based on the emergency plan, risk assessment and communication plan as required under §418.113(b) of the Emergency Preparedness

Based on an unannounced recertification Emergency Preparedness survey and documents on 01/23/2024 from 9:00 AM till 4:30 PM, it was determined that the facility failed to develop policies and procedures based on the emergency plan and communication plan that must follow up on with on duty staff and patients to determine services needed and to inform State and Local officials of staff and patients unable to contact when as needed. --- Findings include: During the review of the facilities Emergency Preparedness Program with the Clinical Manager (employee #2 ) on 01/23/2024 from 9:00 AM till 4:30 PM, it was noted that the facility 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 on an unannounced recertification Emergency Preparedness survey and documents reviewed on 01/23/2024 from 9:00 AM till 4:30 PM, 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 Clinical Manager (employee #2) on 01/23/2024 from 9:00 AM till 4:30 PM, 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 on an unannounced recertification Emergency Preparedness survey and documents reviewed on 01/23/2024 from 9:00 AM till 4:30 PM, it was determined that the facility failed to develop policies and procedures for medical documentation that preserves patient information, protects confidentiality of patient information and secures and maintains availability of records. --- Findings include: During the review of the facilities Emergency Preparedness Program with the Clinical Manager (employee #2 ) on 01/23/2024 from 9:00 AM till 4:30 PM, it was noted that the facility failed to have policies and procedures describing the system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains the availability of records.

Based on an unannounced recertification Emergency Preparedness survey and documents reviewed on 01/23/2024 from 9:30 AM till 4:30 PM, it was determined that the facility failed to ensure that the emergency plan policies and procedures are developed 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 Clinical Manager (employee #2 ) on 01/23/2024 from 9:00 AM till 4:30 PM, 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 on an unannounced recertification Emergency Preparedness survey and documents reviewed on 01/23/2024 from 9:00 AM till 4:30 PM, it was determined that the facility failed to develop policies and procedures to arrangements with other facilities and other providers to receive patients in event of limitations or cessation of operations to maintain the continuity of services. --- Findings include: During the review of the facilities Emergency Preparedness Program with the Clinical Manager (employee #2 ) on 01/23/2024 from 9:00 AM till 4:30 PM, it was noted that the facility failed to have written arrangements with other dialysis facilities or other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to hospice patients.

Based on an unannounced recertification Emergency Preparedness survey and documents reviewed on 01/23/2024 from 9:00 AM till 4:30 PM, it was determined that the facility 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. --- Findings include: During the review of the facilities Emergency Preparedness Program with the Clinical Manager (employee #2) on 01/23/2024 from 9:00 AM till 4:30 PM, it was noted that the facility 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 on an unannounced recertification Emergency Preparedness survey and documents reviewed on 01/23/2024 from 9:30 AM till 4:30 PM, 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 the Clinical Manager (employee # 2) on 01/23/2024 from 9:00 AM till 4:30 PM, 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 on an unannounced recertification Emergency Preparedness survey and documents reviewed on 01/23/2024 from 9:30 AM till 4:30 PM, it was determined that the facility failed to develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated the communication plan that include, Hospice employees, Entities providing services under arrangement, Patients' physicians, Other hospices. --- Findings include: During the review of the facilities Emergency Preparedness Program with the Clinical Manager (employee #2) on 01/23/2024 from 9:00 AM till 4:30 PM, it was noted that the facility failed to provide contact information for the Staff, Entities providing services under arrangements, patients physicians and other facilities as required under §484.102(c) of the Emergency Preparedness.

Based on an unannounced recertification Emergency Preparedness survey and documents reviewed on 01/23/2024 from 9:00 AM till 4:30 PM, it was determined that the facility failed to develop and maintain an emergency preparedness communication plan that include Federal emergency preparedness staff and other sources of assistance. --- Findings include: During the review of the facilities Emergency Preparedness Program with the Clinical Manager (employee #2 ) on 01/23/2024 from 9:00 AM till 4:30 PM, it was noted that the facility failed to provide evidence of the Emergency Preparedness Communication Plan that included updated contact information for Federal, State, tribal, regional or local emergency preparedness staff and other sources of assistance

Based on an unannounced recertification Emergency Preparedness survey and documents reviewed on 01/23/2024 from 9:00 AM till 4:30 PM, it was determined that the facility failed to develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and include primary and alternate for communicating with the, Federal, State, tribal, regional, and local emergency management agencies. --- Findings include: During the review of the facilities Emergency Preparedness Program with the Clinical Manager (employee #2) on 01/23/2024 from 9:00 AM till 4:30 PM, 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 an unannounced recertification Emergency Preparedness survey and documents reviewed on 01/23/2024 from 9:30 AM till 4:30 PM, it was determined that the facility failed to develop a method for sharing information and medical documentation for patients under the facility's care, as necessary, with other health care providers to maintain continuity of care that complies with Federal, State and local. --- Findings include: During the review of the facilities Emergency Preparedness Program with the Clinical Manager (employee #2) on 01/23/2024 from 9:00 AM till 4:30 PM, it was noted that the facility failed to 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 Emergency Preparedness survey and documents reviewed on 01/23/2024 from 9:30 AM till 4:30 PM, it was determined that the facility did not provide evidence of emergency preparedness training and testing. --- Findings include: During the review of the facilities Emergency Preparedness Program with the Clinical Manager (employee # 2) on 01/23/2024 from 9:00 AM till 4:30 PM, it was noted that the facility failed to develop and maintain a emergency preparedness training and testing program based on the facilities risk assessment.

Based on an unannounced recertification Emergency Preparedness survey and documents reviewed on 01/23/2024 from 9:00 AM till 4:30 PM, it was determined that the facility failed to develop and maintain an emergency preparedness training program. --- Findings include: During the review of the facilities Emergency Preparedness Program with the Clinical Manager (employee #2 ) on 01/23/2024 from 9:00 AM till 4:30 PM, it was noted that the facility failed to provide documentation of training on emergency preparedness policies and procedures to all new and existing staff.

Based on an unannounced recertification Emergency Preparedness survey and documents reviewed on 01/23/2024 from 9:30 AM till 4:30 PM, it was determined that the facility failed to conduct exercises to test the emergency plan. --- Findings include: During the review of the facilities Emergency Preparedness Program with the Clinical Manager (employee #2) on 01/23/2024 from 9:00 AM till 4:30 PM, it was noted that the facility failed to conduct exercises to test facilities emergency plan.

Based on a recertification survey, fourteen records reviewed (R.R) with the nurse supervisor employee #2, it was determined that the facility failed to ensure that the registered nurse complete the initial assessment within 48 hours after the election of hospice care for 1 out of 14 records reviewed (R.R- H.V #3). --- Findings include: 1. R.R.-H.V. #3 is a 91-year-old female admitted on 01/16/2024 with a diagnosis of Alzheimer. During the review of the medical record performed on 01/25/2024 at 11:21 AM, it was revealed that patient was referred to the hospice on 01/16/2024. No evidence was found in the electronic record or in the hard copy record that the Registered Nurse, the Physician, the Social Worker (SW) and the Spiritual Assessor (SA) performed the Initial Comprehensive Assessment.

Based on a recertification survey, fourteen records reviewed (R.R) with the nurse supervisor employee #2, it was determined that the facility failed to ensure that the interdisciplinary Group (IDG) complete the comprehensive assessment no later than 5 calendar days after the election of hospice care for 1 out of 14 record review. (R.R. #5). --- Findings include: 1. R.R. #5 is an 86-year-old male admitted on 08/17/2023 with a diagnosis of Heart Failure. During the review of the medical record performed on 01/25/2024 at 2:12 PM reveal that patient was refer to the hospice on 08/17/2023, the Social Worker (SW) and the physician performed the Comprehensive Assessment on 08/17/2023, however the Registered Nurse (RN) enters to perform the initial comprehensive assessment on 09/14/2023, twenty-nine (29) days later and no evidence was found that the Spiritual Assessor (SA) documented the initial comprehensive and be completed no later than 5 calendar days.

Based on a recertification survey, fourteen records reviewed (R.R) with the nurse supervisor employee #2, it was determined that the facility failed to develop an individualized written plan of care for each patient that reflect patient and family goals and interventions based on the problems identified in the initial comprehensive include all services necessary for the palliation and management of the terminal illness for 1 out of 14 record review. (R.R-H.V #3). --- Findings include: 1. R.R.- H.V #3 is a 91-year-old female admitted on 01/16/2024 with a diagnosis of Alzheimer. During the review of the medical record performed on 01/25/2024 at 11:21 AM, it was revealed that patient was referred to the hospice on 01/16/2024. No evidence was found in the electronic record or in the hard copy record that the Interdisciplinary Group (IDG) develop an individualized written plan of care that reflect patient and family goals and interventions based on the problems identified in the initial comprehensive include all services necessary for the palliation and management of the terminal illness. The initial Plan of care was performed on 01/24/2024 at 3:10 PM when discuss the patient admission. The nurse supervisor employee #2 stated on 01/25/2024 that the initial IDG of patient admitted was performed at 14 days or 2 weeks of admission.

Based on a recertification survey, fourteen records reviewed (R.R) with the nurse supervisor employee #2, it was determined that the facility failed to ensure that the plan of care detailed a statement of the scope and frequency of services to meet the patient and family need of the Home Health Aids (HHA) and Homemaker (HM) for 3 out of 14 record review. (R.R. #2, #3, #4, #6 and #7). --- Findings include: 3. R.R #2 is a 101-year-old male admitted on 11/02/2022 with a diagnosis of Chronic Ischemic Heart Disease. During the review of the medical record performed on 01/25/2024 at 3:25 PM, the plan of care did not detail the frequency of visits for the HHA in the visit calendar. The HHA was visiting the patient from 4-5 days a week. 4. R.R #3 is an 89-year-old male admitted on 11/02/2022 with a diagnosis of Chronic Ischemic Heart Disease. During the review of the medical record performed on 01/25/2024 at 11:00 AM, the plan of care did not detail the frequency of visits for the HHA in the visit calendar. The HHA was visiting the patient from 4-5 days a week. 5. R.R #4 is an 88-year-old female admitted on 07/08/2022 with a diagnosis of End Stage Renal Disease (ESRD). During the review of the medical record performed on 01/25/2024 at 1:00 PM, the plan of care did not detail the frequency of visits for the HHA in the visit calendar. The HHA was visiting the patient from 4-5 days a week. Findings include: 1. R.R #6 is an 80-year-old female admitted on 12/16/2023 with Alzheimers disease with late onset. During the record review on 1/24/2024 at 2:10 PM, it was noted that after admission Interdisciplinary Group (IDG) establish the following frequency to the services Registered Nurse (RN) two (2) visit a week and as needed, Physician one (1) visit a month as needed, Social Worker one (1) visit a month as needed and Spiritual Counselor one (1) visit a month as needed. During the record review, it was found one visit of the Registered nurse was missing on the 1/14/2024 to 1/20/2024 and interview with the Nurse Supervisor (employee #3) on 01/24/2024 at 2:45 PM stated that she did not have access to all the nursing notes archived in the electronic medical record. 2. R.R #7 is an 82-year-old male admitted on 09/26/2023 with Chronic Obstructive Pulmonary disease with (acute) exacerbation. During the record review on 01/24/2024 at 11:10 AM, it was noted that after admission Interdisciplinary Group (IDG) establish the following frequency to the services Registered Nurse (RN) two (2) visit a week and as needed, Physician one (1) visit a month as needed, Social Worker one (1) visit a month as needed, Spiritual Counselor one (1) visit a month as needed and Home Health Aide (HHA) four (4) visit a month as needed. During the record review, it was found one visit of the Home Health Aide are missing on the 12/24/2023 to 12/30/2023 and one visit of the Home Health Aide missing the on 12/31/2023 to 01/06/2024, interview with the Nurse Supervisor (employee #3) on 01/24/2024 at 2:45 PM stated that she did not have access to all the nursing notes archived in the electronic medical record.

Based on a recertification survey, fourteen records reviewed (R.R) with the nurse supervisor employee #2, it was determined that the facility failed to ensure that the Interdisciplinary Group (IDG) review, revise and document the individualized plan as frequently as the patients condition requires, but no less frequently than every 15 calendar days for 7 out of 14 record review. (R.R-H.V. #1, #2, R.R. #1, #2, #3, #4 and #5). --- Findings include: 1. R.R-H.V. #1 is a 78-year-old male admitted on 12/29/2023 with a diagnosis of Carcinoma In situ of Larynx. During the review of the medical record performed on 01/25/2024 at 9:30 AM, no evidence was found of the IDG review and updated the patient plan of care every 15 days. 2. R.R.- H.V. #2 is an 87-year-old female admitted on 10/05/2023 with a diagnosis of Alzheimer. During the review of the medical record performed on 01/25/2024 at 10:00 AM, no evidence was found of the IDG review and updated the patient plan of care every 15 days until 01/10/2024. 3. R.R #1 is a 96-year-old female admitted on 04/27/2023 with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD). During the review of the medical record performed on 01/23/2024 at 1:43 PM, no evidence was found of the IDG review and updated the patient plan of care every 15 days since 10/04/2023. 4. R.R #2 is a 101-year-old male admitted on 11/02/2022 with a diagnosis of Chronic Ischemic Heart Disease. During the review of the medical record performed on 01/25/2024 at 3:25 PM, no evidence was found of the IDG review and updated the patient plan of care every 15 days since 10/04/2023 for the recertification. 5. R.R #3 is an 89-year-old male admitted on 11/02/2022 with a diagnosis of Chronic Ischemic Heart Disease. During the review of the medical record performed on 01/25/2024 at 11:00 AM, no evidence was found of the IDG review and updated the patient plan of care every 15 days since 10/04/2023 for the recertification. 6. R.R #4 is an 88-year-old female admitted on 07/08/2022 with a diagnosis of End Stage Renal Disease (ESRD). During the review of the medical record performed on 01/25/2024 at 1:00 PM, no evidence was found of the IDG review and updated the patient plan of care every 15 days until 11/21/2023. 7. R.R #5 is an 86-year-old female admitted on 08/17/2023 with a diagnosis of Heart Failure. During the review of the medical record performed on 01/25/2024 at 2:00 PM, no evidence was found of the IDG review and updated the patient plan of care every 15 days until 11/21/2023.

Based on a recertification survey, documents reviewed on 01/23/2024 to 01/25/2023 from 8:30 AM to 4:00 PM, it was determined that the facility failed to evidence the development, implement, and maintain an effective, ongoing, hospices wide data-driven quality assessment and performance improvement program that reflects the complexity of its organization and services which makes this condition §418.58 Quality assessment and performance improvement-(QAPI) Not Met. --- Findings include: The facility fails to provide written evidence of policies & procedures, manual, protocols, structure and all elements necessary for a QAPI program.

Based on a recertification survey and administrative documents review with the Nurse Supervisor (employee # 2) on 01/25/2024 at 10:00 AM, it was determined that the facility failed to demonstrate measurable improvement indicators related to improved palliative outcome and hospice services. --- Findings include: 1. During survey procedures on 01/25/2024 at 10:10 AM documentation related with the facility Quality Assessment Performance Improvement program were review however evidence provided annual Quality Assessment and Improvement and indicators reports of year 2023 do not demonstrate to comply with this requirement. It was found that the information related to Quality Assessment and Improvement activities was collected and documented in an unorganized and unsystematic way on patients palliative outcome and hospice service.

Based on a recertification survey, the review of quality assessment activities and interview with the Nurse Supervisor (employee # 2), it was determined that the facility failed to evidence that quality assessment and performance improvement- (QAPI) program measure, analyze, and track quality indicators, including adverse patient events, and other aspects that allow the hospice to evaluate care processes, hospice services, and operations. --- Findings include: The facility failed to provide evidence on 01/25/2024 at 10:35 AM of assessing quality in all areas of operations that might adversely affect patient care or core hospice services. The center did not show evidence of data that could improve quality, indicators, or measures. The facility did not provide evidence of written policies, procedures, manuals, protocols, structure, and all elements necessary for a QAPI program. However, there was no documentary evidence of the program's activities related to the measurement, analysis, and monitoring of quality indicators.

Based on a recertification survey, documents reviewed with the Nurse Supervisor (employee #2) on 01/25/2024 at 10:30 AM, it was determined that the facility failed to include as part of the Quality Assessment and performance improvement –(QAPI) indicators and other relevant data related with the service and activities that may impact patient and family care. --- Findings include: 1. During survey procedures on 01/25/2024 at 10:30 AM there was no evidence that the hospice collect data related to volunteers as part of QAPI program activities to use the data collected to identify opportunities for improvement. During the interview the Nurse Supervisor (employee #2) she explains that he did not know that volunteers could be included in the QAPI program.

Based on a recertification survey, the review of quality assessment activities and interview with the Nurse Supervisor (employee #2), it was determined that the facility failed evidence performance improvement activities that focus on high risk, high volume, or problem-prone areas. --- Findings include: 1.The facility failed to provide evidence on 01/25/2024 at 10:40AM of performance improvement activities that focus on high risk, high volume, or problem-prone areas for year 2023. 2. The facility did not provide evidence of written policies, procedures, manuals, protocols, structure, and all elements necessary for a quality assessment and performance improvement program. They had no documentary evidence of the program's activities related to the measurement, analysis, and monitoring of quality indicators.

Based on a recertification survey, the review of quality assessment activities and interview with the Nurse Supervisor (employee #2), it was determined that the facility failed to evidence performance improvement activities who consider incidence, prevalence, and severity of problems in those areas. --- Findings include: The facility failed to provide evidence on 01/25/2024 at 10:10 AM of improvement activities who consider incidence, prevalence, and severity of problems in those areas. Performance improvement activities that focus on high risk, high volume, or problem-prone areas for the year 2023. The facility did not provide evidence of written policies, procedures, manuals, protocols, structure, and all elements necessary for a quality assessment and performance improvement program. They had no documentary evidence of the program's activities related to the measurement, analysis, and monitoring of quality indicators.

Based on a recertification survey, the review of quality assessment activities and interview with the Nurse Supervisor (employee #2), it was determined that the facility failed to evidence performance improvement activities related with affect palliative outcomes, patient safety, and quality of care. --- Finding include: The facility failed to provide evidence on 01/25/2024 at 10:50 AM of performance improvement activities related with palliative outcomes, patient safety, and quality of care. The facility did not provide written evidence of updated policies, procedures, manuals, protocols and structure and all elements necessary for a quality assessment and performance improvement program. They had no documentary evidence of program activities related to palliative outcomes, patient safety, and quality of care provided.

Based on a recertification survey, the review of quality assessment activities and interview with the Nurse Supervisor (employee #2), it was determined that the facility failed to evidence performance improvement activities that track adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning. --- Findings include: The facility failed to provide evidence on 01/24/2024 at 10:53 AM of performance improvement activities that track adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning for year 2023. The facility did not provide written evidence of the policies, procedures, manuals, protocols and update structure and all elements necessary for a quality assessment and performance improvement program. They had no documentary evidence of performance improvement activities that tracked patient adverse events, analyzed their causes, and implemented preventive actions and mechanisms that included feedback and learning throughout the hospice.

Based on a recertification survey, the review of quality assessment activities and interview with the Nurse supervisor (employee #2), it was determined that the facility failed to evidence actions aimed at performance improvement and, after implementing those actions, the measure of its success and tracking performance to ensure that improvements are sustained. --- Findings include: The facility failed to provide evidence on 01/25/2024 at 10:55 AM am of actions aimed at performance improvement and, after implementing those actions, the measure of its success and tracking performance to ensure that improvements are sustained for year 2023. The facility did not provide written evidence of the policies, procedures, manuals, protocols and update structure and all elements necessary for a quality assessment and performance improvement program. They had no documentary evidence of performance improvement activities that tracked patient adverse events, analyzed their causes, and implemented preventive actions and mechanisms that included feedback and learning throughout the hospice.

Based on a recertification survey, the review of quality assessment activities and interview with the Nurse Supervisor (employee #2), it was determined that the facility failed to ensure that one or more specific quality improvement projects are undertaken each year. --- Findings include: The facility failed to provide evidence on 01/25/2024 at 11:00 AM of performance improvements projects currently underway, as well as those completed in the prior year. The agency failed to comply with the requirement established on February 2, 2009, for all hospices on 418.58 (d) where they must develop, implement, and evaluate performance improvement projects every year.

Based on a recertification survey, the review of quality assurance activities and interview with the Nurse Supervisor (employee #2), it was determined that the facility failed to conduct performance improvement projects annually, based on the needs of the hospice's population and internal organizational needs that reflects the scope, complexity, and past performance of the hospice's services and operations. --- Findings include: The facility failed to provide evidence on 01/25/2024 at 11:10 AM of performance improvements projects currently underway, as well as those completed in the prior year. The facility failed to determine hospice's population and internal organizational needs, must reflect the scope, complexity, and past performance of the hospice's services and operations to use this information to develop, implement and evaluate performance improvement projects.

Based on a recertification survey, the review of quality assurance activities and interview with the Nurse Supervisor (employee #2), it was determined that the facility failed through its Governing Body to establish and to organize a Quality Assessment and Performance Improvement program-QAPI. --- Findings include: 1. The Facility provided no evidence on 01/25/2024 at 11:20 AM., of the organization of the continuous quality program and developed quality activities under the supervision of the quality coordinator, the medical director and other members of the interdisciplinary team that are part of the quality committee.

Based on observations and review of Quality Assessment and Performance Improvement- (QAPI) policies and procedures with the Nurse Supervisor (employee #2), it was determined that the agency failed to evidence that an ongoing program for quality improvement and patient safety is defined, implemented, and maintained and is evaluated annually. --- Findings include: 1. Agency policies and procedures related to QAPI program activities were reviewed on 01/25/2024 from 11:25 AM with the Nurse supervisor (employee #2). The QAPI program policies and procedures include provisions which state that the agency must maintain an ongoing program for quality improvement and patient safety which is evaluated annually. However, no evidence was found that performance improvement activities were executed during the natural year of 2023.

Based on a recertification survey, review of the infection prevention and control program activities and interview with the Nurse Supervisor (employee #2), it was determined that the facility failed to provide infection control education to employees, and contracted personnel. --- Findings include: 1. During the facility's infection prevention control review, efforts to educate health care staff and facility employees about the requirements it was found: a. Evidence of the in services education plan related to infection control of year 2023 was not provided. The facility failed to provide evidence in the year 2023 of the annual education program direct employees and contracted staff.

Based on a recertification survey and interview, it was determined that the facility failed to ensure that core services are provided directly by hospice employees related to spiritual counseling. --- Findings include: 1. During interview on 01/23/2024 at 9:15 AM the Human Resources employee #3 state that the facility has 5 Registered Nurse (RN), that 1 was facility employee, they have 2 License Practice Nurse (LPN) that were contract, 1 social worker that was contract, and 1 spiritual counselor that was contract and have 5 physicians that 3 were contract. 2. The facility failed to provide core service Social Worker and Spiritual Counselor directly by hospice employees.

Based on a recertification survey, interview with the Human Resources employee #3, it was determined that the facility failed to ensure that the services described in §418.72 Physical therapy, occupational therapy, and speech-language pathology are provided directly by the hospice or under arrangements. --- Findings include: During interview on 01/23/2024 at 9:15 AM the Human Resources employee #3 state that the facility has a contract with an Occupational Therapist and with a Speech-language pathology Therapist but not have Physical Therapist contract, has been unsuccessful and was difficult to hire under contract.

Based on a recertification survey, interview with the Human Resources employee #3, it was determined that the facility failed to provide Physical Therapy (PT) Service which makes this this condition not met. --- Findings include: 1. The facility Human Resources employee #3 stated on 01/23/2024 at 9:15 AM during an interview that the facility lacks an agreement or contract with the services related to Physical therapy, has been unsuccessful and was difficult to hire under contract.

Based on a recertification survey, fourteen records reviewed (R.R) with the nurse supervisor employee #2, it was determined that the facility failed to ensure that the Registered Nurse (RN) assigned writes patient care instruction to the Home Health Aide (HHA) for 3 out of 14 records reviewed (R.R.- H.V #3, R.R #2, and #3). --- Findings include: 1. H.V #3 is a 91-year-old female admitted on 01/16/2024 with a diagnosis of Alzheimer. During the review of the medical record performed on 01/25/2024 at 11:21 AM, it was revealed that patient was referred to the hospice on 01/16/2024. No evidence was found in the electronic record or in the hard copy record that the Interdisciplinary Group (IDG) develop an individualized written plan of care that reflect patient and family goals and interventions based on the problems identified in the initial comprehensive include all services necessary for the palliation and management of the terminal illness. No evidence was found that the RN assigned written patient care instructions to the HHA. Evidence was found that the HHA performs patient visit to provide bed bath from 2 to 4 visits per week. 2. R.R #2 is a 101-year-old male admitted on 11/02/2022 with a diagnosis of Chronic Ischemic Heart Disease. During the review of the medical record performed on 01/25/2024 at 3:25 PM, no evidence was found that the RN assigned written patient care instructions to the HHA. Evidence was found that the HHA performs patient visit to provide bed bath from 3 to 5 visits per week. 3. R.R #3 is an 89-year-old male admitted on 11/02/2022 with a diagnosis of Chronic Ischemic Heart Disease. During the review of the medical record performed on 01/25/2024 at 11:00 AM, no evidence was found that the RN assigned written patient care instructions to the HHA. Evidence was found that the HHA performs patient visit to provide bed bath from 3 to 5 visits per week.

Based on an recertification survey, review of documents related to the volunteer program and interview, it was determined that the facility failed to document and demonstrate viable and ongoing efforts to recruit and retain volunteers. --- Findings include: On 01/23/2024 at 10:30 AM documents to evaluate the volunteer program were requested to the Human Resources Supervisor (employee #3). Human Resources Supervisor (employee #3), stated on interview that facility did not perform activities to promote the recruitment and retention of volunteers during year 2023.

Based on a recertification survey, the review of the facility education program and interview, it was determined that the facility failed to provide orientation about the hospice philosophy to all employees and contracted staff who have patient and family contact. --- Findings include: 1. During the review of the year 2023 education program on 01/24/2024 at 3:00 PM to 4:00 PM, no evidence was found that the facility provides to their employee and contracted personnel a reinforce orientation related to mission, vision, and philosophy of the agency. During the interview with the Nurse supervisor (employee #3) person in charge to perform the education program on 01/24/2024 at 3:00 PM, she stated that they orient the patient and family, but the staff is not oriented about the philosophy, vision, and mission.

Based on a recertification survey, the review of the facility education program and interview, it was determined that the facility failed to provide an initial orientation for each employee that addresses the employees specific job duties related to hospice philosophy. --- Findings include: 1. During the review of the year 2023 education program on 01/24/2024 at 3:00 PM to 4:00 PM, no evidence was found that the facility provides an initial orientation to their employee and contracted personnel related to mission, vision, and philosophy of the agency. During the interview with the Nurse supervision (employee #3) person in charge to perform the education program on 01/24/2024 at 3:00 PM, she stated they do not provide an initial orientation to their employee and contracted personnel related mission, vision, and philosophy of the agency.

Based on a recertification survey, fourteen records reviewed (R.R) with the nurse supervision employee #2, it was determined that the facility failed to ensure that patient medical record include patient plan of care, updated plan of care, initial comprehensive assessment, clinical note of all discipline Registered Nurse (RN), Home Health Aide (HHA), Home Maker (HM), Social Worker (SW), Physician (P) and Spiritual Assessor (SA) for 8 out of 14 records reviewed (RR-HV #1, #2, #3, R.R.#1, #2, #3, #4 and #5). --- Findings include: 1. R.R.- H.V #1 is a 78-year-old male admitted on 12/29/2023 with a diagnosis of Carcinoma In situ of Larynx. During the review of the medical record performed on 01/25/2024 at 9:30 AM, the calendar visits stablish the following frequency of visits for RN 2 visit per week and as needed (PRN), SW 1-3 visit per month and PRN, HHA 5 visits per week, SA 1-3 visit per month and PRN and Physician 1 visit per month. It was found the following: a. No evidence was found of the Interdisciplinary Group (IDG) developing, reviewing, and updating the patient plan of care every 15 days. b. During the week from 12/31/2023 through 01/06/2024, no evidence was found of two visits of the HHA, and 5 visits of the HM. c. During the week from 01/07/2024 through 01/13/2024, no evidence was found of one visit of the HM. d. During the week from 01/14/2024 through 01/20/2024, no evidence was found of one visit of the HHA. 2. R.R.-H.V. #2 is an 87-year-old female admitted on 10/05/2023 with a diagnosis of Alzheimer. During the review of the medical record performed on 01/25/2024 at 10:00 AM, the calendar visits stablish the following frequency of visits for RN 2 visit per week and as needed (PRN), SW 1 visit per month and PRN, SA 1 visit per month and PRN and Physician 1 visit per month and PRN. The HHA instruction assigned establishes 5 visits per week. It was found the following: a. No evidence was found of the Interdisciplinary Group (IDG) developing, reviewing, and updating the patient plan of care every 15 days until 01/10/2024. b. During the week from 12/24/2023 through 12/30/2023, no evidence was found of one visit of the HHA. c. During the week from 12/31/2023 through 01/06/2024, no evidence was found of two visits of the HHA. d. During the week from 01/14/2024 through 01/20/2024, no evidence was found of one visit of the HHA. e. No evidence was found of the physician progress note and patient evaluation since 11/15/2023. 3. R.R.- H.V #3 is a 91-year-old female admitted on 01/16/2024 with a diagnosis of Alzheimer. During the review of the medical record performed on 01/25/2024 at 11:21 AM, was found the following: a. No evidence was found related to the Initial comprehensive Assessment from the RN, Physician, Social Worker, Spiritual Assessor. b. No evidence was found of the Interdisciplinary Group (IDG) developing, reviewing, and updating the patient plan of care until 01/24/2024. c. No evidence was found related to RN progress note and Home Maker note. 4. R.R #1 is a 96-year-old female admitted on 04/27/2023 with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD). During the review of the medical record performed on 01/23/2024 at 1:43 PM, on 06/28/2023 the nurse documented the following frequency of visits for RN 2 visit per week and as needed (PRN), SW 1 visit per month and PRN, SA 1 visit per month and PRN and Physician 1 visit per month and PRN. It was found the following: a. No evidence was found of the Interdisciplinary Group (IDG) reviewing and updating the patient plan of care every 15 days until 10/04/2023 a recertification. 5. R.R #2 is a 101-year-old male admitted on 11/02/2022 with a diagnosis of Chronic Ischemic Heart Disease. During the review of the medical record performed on 01/25/2024 at 3:25 PM, the calendar visits stablish the following frequency of visits for RN 2 visit per week and as needed (PRN), SW 1 visit per month and PRN, SA 1 visit per month and PRN and Physician 1 visit per month and PRN. It was found the following: a. No evidence was found of the Interdisciplinary Group (IDG) reviewing and updating the patient plan of care every 15 days until 10/04/2023 a recertification. b. The HHA visited patients to provide bed bath from 3-5 days a week, however no evidence was found related to HHA assigned instruction and the RN supervision. c. No evidence was found related to the SA note since 12/24/2023. 6. R.R #3 is an 89-year-old male admitted on 11/02/2022 with a diagnosis of Chronic Ischemic Heart Disease. During the review of the medical record performed on 01/25/2024 at 11:00 AM, the calendar visits stablish the following frequency of visits for RN 2 visit per week and as needed (PRN), SW 1 visit per month and PRN, SA 1 visit per month and PRN and Physician 1 visit per month and PRN. It was found the following: a. No evidence was found of the Interdisciplinary Group (IDG) reviewing and updating the patient plan of care every 15 days until 10/04/2023. b. During the week from 12/24/2023 through 12/30/2023, no evidence was found of two visits of the RN. c. During the week from 01/07/2024 through 01/13/2024, no evidence was found of one visit of the RN. d. Evidence was found that the HHA performed patient visit for bed bath from 3-5 visits per week, however no evidence was found that the RN performed the HHA assigned instruction for this case. 7. R.R #4 is an 88-year-old female admitted on 07/08/2022 with a diagnosis of End Stage Renal Disease (ESRD). During the review of the medical record performed on 01/25/2024 at 1:00 PM, the calendar visits stablish on 08/02/2023 the following frequency of visits for RN 2 visit per week and as needed (PRN), SW 1 visit per month and PRN, SA 1 visit per month and PRN and Physician 1 visit per month and PRN, HHA 5 visits per week and HM 5 visit per week. It was found the following: a. No evidence was found of the Interdisciplinary Group (IDG) reviewing and updating the patient plan of care every 15 days since 11/21/2023. b. During the week from 12/24/2023 through 12/30/2023, no evidence was found of two visits of the RN and one visit of the HHA. c. During the week from 12/31/2023 through 01/06/2024, no evidence was found of one visit of the RN and two visits of the HHA. d. During the week from 01/14/2024 through 01/20/2024, no evidence was found of one visit of the HHA. e. No evidence was found of the RN supervising the HHA every 15 days. f. No evidence was found of the HM assignment instruction, visit and supervision. Since 122/4/2023. 8. R.R #5 is an 86-year-old female admitted on 08/17/2023 with a diagnosis of Heart Failure. During the review of the medical record performed on 01/25/2024 at 2:00 PM, the calendar visits stablish the following frequency of visits for RN 2 visit per week and as needed (PRN), SW 1 visit per month and PRN, SA 1 visit per month and PRN and Physician 1 visit per month and PRN and HHA 5 visits per week. It was found the following: a. No evidence was found of the Interdisciplinary Group (IDG) reviewing and updating the patient plan of care every 15 days since 11/21/2023. b. During the week from 12/24/2023 through 12/30/2023, no evidence was found of one visit of the HHA. c. During the weeks from 12/17/2023 through 01/13/2024, no evidence was found of two visits of per week of the RN. d. During the week from 01/14/2024 through 01/20/2024, no evidence was found of one visit of the RN and 5 visit of the HHA and the HM. e. No evidence was found of the physician progress note and patient evaluation since 11/15/2023.