Every finding on record at Sendero De Luz Hospice Inc

Based on observations, review of policies and procedures, during a tour of the medical-surgical equipment warehouse, performed on 01/22/2025 at 8:30 AM, it was determinate that the facility failed to follow standards of practice for evaluation of the expiration date of the medical-surgical supply. --- Findings Include: a) During the tour of the facility's storage performed on 01/22/2025 at 8:30 AM accompanied and in an interview with employee #1 (nursing supervisor), it was observed that several Lemon-Glycerin swabs ticks had an expiration date of 11/04/2023 and 03/2024. On 01/22/2025 at 12:40 PM the coordinator of the infection control program (employee #2), that provided the facility's policy and procedure for maintaining the facility's warehouse, was reviewed in 01/2020 and states in section #1 that the warehouse manager will be responsible for monitoring and supervising the arrangement of the goods, counting the stock and rotation considering their expiration. It also establishes in section #3 that at the end of each month, supplies and/or supplements that have expired will be discarded.

Based on the review of fifteen (15) credential files (C.F) with the Hospice Executive Director (employee #3) performed on 01/22/2025 at 12:50 PM till 2:30 PM, it was determined that he facility failed to ensure that 4 of 15 employees who provide services have updated credential files related to Speech Language Pathology (C.F #12), Physical Therapist (C.F #11), Occupational Therapist (C.F #13) and Spiritual Counselor (C.F #10) related to lack of Hepatitis B Vaccine, Influenza Vaccine and COVID 19 Vaccine. --- Findings include: 1. Two (2) of fifteen (15) credential files did not contain evidence of updated Hepatitis B Vaccine. C.F #10 and C.F #11. 2. Three (3) of fifteen (15) credential files did not contain evidence of Influenza Vaccine. C.F #11, C.F #12 and C.F #13. 3. Three (3) of fifteen (15) credential files did not contain evidence of COVID 19 Vaccine. C.F #11, C.F #12 and C.F #13.

Based on the review of fifteen (15) personnel credential files (C.F.) with the Hospice Executive Director (employee #3) performed on 01/22/2025 at 12:50 PM till 2:30 PM, it was determined that the facility failed to ensure that 2 out of 15 employees record reviewed providing services have the criminal background check. --- Findings include: 1. Physical Therapist (PT), no evidence was provided of the certified negative criminal background check (Ley 300). 2. Speech Language Pathology (SLP), no evidence was provided of the certified negative criminal background check (Ley 300).

Based upon an Recertification and Emergency Preparedness Program (EPP) survey performed on 01/22/2025 from 8:30 AM to 2:30 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to meet the applicable provisions in accordance with the Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4.) for 1 out of 3 home visits (HV).(HV#2). --- Findings include: Based on home visit (HV) performed on January 22, 2025, the following was identified: 1. During HV #2, no signage was observed at the entrance to the residence stating, ";No Smoking" or ";Oxygen in Use". 2. During HV #2, electrical safety was not observed in the patients' residences. When requesting electrical safety policy from the facility, the institution could not provide any. The use of multipliers (multiplugs) was also observed that could overload the electrical circuits, putting the risk of fire.

Based on an Emergency Preparedness Program (EPP) survey performed on 12/20/2022 at 8:30 AM through 4:30 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to include a process for cooperation and collaboration with local, tribal, regional, State and Federal emergency preparedness officials effort to maintain an integrated response during s disaster or emergency situation. --- Findings include: During the review of the facilities Emergency Preparedness Program with the Quality Coordinator and Executive Director on 12/20/2022 at 9:30 AM it was noted that the facility failed to include a process for cooperation and collaboration with local, tribal, regional, State and Federal emergency preparedness officials as required under §418.113(a)(4) of the Emergency Preparedness. No communication has been established with Regional Health Care Coalition (HCC).

Based on an Emergency Preparedness Program (EPP) survey performed on 12/20/2022 at 8:30 AM to 4:30 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to ensure policies and procedures to facilitate the support of volunteers and other healthcare professionals in an emergency. --- Findings include: During the review of the facilities Emergency Preparedness Program with the Quality Coordinator and Executive Director on 12/20/2022 it was noted that the facility failed to stablished policies and procedures to ensure and facilitate the support of volunteers and other healthcare professionals in an emergency as required under §418.113(b)(4).

Based on an unannounced recertification survey, review of Register Nurse (RN), License practical nurse (LPN), Physicians (MD), Physical therapy (PT), Occupational therapy (OT), Speech Therapist (ST), 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 C.Fs are in compliance with applicable local law for hospice agencies related to updated personnel C.F: Influenza vaccine and Hepatitis B vaccine. --- 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 12/20/2022 from 10:00 PM till 11:45 AM, it was determined: a. Three out of three credentials' files did not contain evidence of their updated Influenza vaccine according to the Health Department Administrative Order # 244 of October 10, 2008 (Speech Therapy C.F. #5, Physical Therapist C. F. #6, and Occupational Therapist C. F. #7). b. Five out of five credentials' files did not contain evidence of their Hepatitis Vaccine (Speech Therapy C.F. #5, Physical Therapist C. F. #6, Occupational Therapist C. F. #7, Housekeepers C.F. #8 and C.F.#9 and Volunteer C.F. #10).

Based on an unannounced recertification survey, three home visits with record review and eight records reviewed without home visits with the nursing staff and nursing service director, it was determined that the facility failed to ensure that the bereavement counseling services reflects family needs and timely communication between the hospice staff and patient / family for 1 out of 11 records reviewed (R.R # 11). --- Findings include: 1.RR #11 is an 86-year-old male patient admitted on 08/05/2022 with a diagnosis of Alzheimer Disease and secondary diagnosis of Hight Blood Pressure. The record was selected to record review on 12/20/2022 at 11:47 A.M. for bereavement and counseling services. The patient has poor prognosis, debility, dependent for all the activities of daily living, multiple ulcers, sacral, left leg and right leg, foley catheter in place, receiving enteral alimentation with PEG #24, fecal incontinence, poor saturation, poor sleep, and continued deterioration expected according with the physician initial history. The initial evaluation of spiritual adviser was carried out on 08/05/2022. The patient died on 08/14/2022 nine days after being admitted. The record was reviewed on 12/21/2022 at 4:45 P.M. and did not provide the following evidence: '' The day when the patient died, no evidence of the facility spiritual advisor call or visit the patient house. Did not visit the patient house or the funeral home. According of the general notes the first call was performed on 08/29/2022 at 9:32 A.M twenty-four days later (24) and according of the note did not contact the patient son. The second call was performed on 08/30/2022 at 10:00 A.M and according of the note did not contact the patient son. The third call was performed on 08/31/2022 at 3:01 P.M and according of the note did not contact the patient son and administrative discharge s determined by consolation therapy. However, according of the record the facility spiritual advisor failure to make the first call to start consolation therapy and it was not until 24 days after the call was made. The spiritual advisor never visits the patient house postmortem to provide support on death process. However, the agency failure to ensure that all the services are performed according to the patient needs and when the patient died. No evidence was found that the counselor visits the patient at home the day when the patient died, or at the funeral home or cemetery. No evidence was found in the clinical record of the coordination of all staff (core services) to ensure the continuity of care. No evidence was found in the clinical record related to the patient and family being prepared spiritually on the moment that the patient dies. No evidence was found that the interdisciplinary group discussed, developed or implemented a plan of care for the patient's family emotional needs.