Every finding on record at Programa De Servicios De Salud En El Hogar Geminis, Inc.

Observed in Emergency Management Session. During the EOP document review, the organization had not documented in committee meeting minutes the review of all exercises and after-action reports. This is was discussed with the organization’s leadership team.

Observed in Record Review. The organization failed to plan the patient's care. During IDG attendance, the Hospice Nurse Surveyor observed no attendance of the Social Worker or Spiritual Care Provider. During conversation with the Director of Hospice and the Hospice Team, they noted that those employees are contracted employees and only attend if there is an issue with the patients. Both disciplines have orders to see the reviewed patients monthly, but were not attending IDG for collaboration with the team. This was discussed and reviewed with the Hospice Director and the Hospice Team.

Observed in Tracer Activities. The organization failed to provide for its planned scope and level of care, treatment, or services. During tracer activities for Leadership, the Hospice Nurse Surveyor observed the organization employed only contract employees for Spiritual Care and Medical Social Work. Therefore CORE services were not routinely provided directly by hospice employees. This was discussed and reviewed with the Hospice Director and the Hospice Team.

Observed in Record Review. ,records with aide services, the organization failed to supervise staff effectively. During record review for RRNHV#1, the Hospice Nurse Surveyor observed the patient was receiving Home Health Aide Services from the Health Assistant, who was following the Home Health Aide Plan of Care and did not perform any job duties within the organization besides the Home Health Aide duties. Supervision was being done monthly, but not at least every 14 days. This was discussed and reviewed with the Hospice Director.

Observed in HR File Review. In 8 of 8 HR files reviewed, who were due for a competency, the organization failed to assess staff competence. During HR file review for HR#1, HR#2, HR#3, HR#8, HR#9, HR#10, HR#11, and HR#12 there was no documentation of competency since 2021. The organization policy stated they would do competency annually. This was discussed and reviewed with the Hospice Team.

Observed in Tracer Activities. the organization failed to document review of clinical information for the hospice patient at initial certification. During record review for RRNHV#7, the Hospice Nurse Surveyor observed the CTI was not completed per organizational policy of within 24 hours of admission. As of the survey date, the patient was admitted 10 days prior and there was no documentation of a clinical review. This was discussed and reviewed with the Hospice Director and Hospice Team.

Observed in Record Review. In 2 of 4 patient records reviewed, the organization failed to assess and reassess its patients. During record review for RRHV#2, and RRHV#3, there was no documentation of the Medical Director's review of the clinical information with signature prior to the recertification. For example in RRHV#2, the new benefit period began 2 days prior to survey but there was no clinical documentation from the Physician. For RRHV#3, the new benefit period began 09/02, almost a month prior to survey, but there was no clinical documentation from the Physician. This was discussed and reviewed with the Hospice Director and Hospice Team.

Observed in HR File Review. In 1 of 12 HR files reviewed, the organization failed to verify staff qualifications. During HR file review for HR#6, the Hospice Nurse Surveyor observed lack of documentation for a background check at hire. the Health Assistant (LPN) was hired 8 months prior to survey and no background check had been completed. This was discussed and reviewed with the Hospice Team.

Observed in HR File Review. In 1 of 7 HR files reviewed, for the hospice program there was no documentation of initial training in emergency preparedness. In HR#3 for the hospice medical director there was no documented evidence of initial training in the agency's emergency management plan. This was validated with the HR manager.

Observed in Infection Control Tracer. In 3 of 3 home visits conducted, or hospice patients with the same RN, the nurse failed to follow agency policy on the use of her nursing bag. Agency policy titled Uso y Manejo del Malletin requires that the nurse remove all equipment and supplies from the bag and that he/she clean the equipment and wash hands before re-entering the bag. In HOHV#1, HOHV#2, and HOHV#3 the nurse entered the bag several times with gloved hands after making patient contact. She also returned at least one piece of equipment to her bag without cleaning the equipment in all three visits.

Observed in HR File Review. In 2 of 7 HR files reviewed, for the hospice program, the agency failed to document initial orientation to the employee's specific job duties. In HR#6 for the medical director there was no documentation of orientation to job duties. In HR#10 a nurse moved from the home health program to the hospice program and there was no documentation of orientation to the job duties of the hospice nursing position. This was validated with the HR manager.

Observed in HR File Review. In 1 of 7 HR files reviewed, for the hospice program, the agency failed to document initial competency In HR#3 for the medical director there was no documentation of initial competency. Observed in HR File Review. In 1 of 3 HR files reviewed, for the home health program, the agency failed to document initial competency. In HR#6 for the nursing supervisor, there was no documentation of initial competency. This was validated with the HR manager.

Observed in Record Review. In 1 of 2 contracts reviewed, for hospice the contract did not stipulate that the contractor would do criminal background checks on all staff who have access to patients or patient records. In Contract #2 for a pharmacy there was no stipulation that the pharmacy would conduct criminal background checks.