Every finding on record at Servicios De Hospicio De Adjuntas

Based upon an Emergency Preparedness Program (EPP) survey performed on 11/07/2024 from 8:00 AM through 3:00 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to failed to include a documented facility and community based all hazard approach risk assessment. Last HVA was performed on 2018. --- Findings include: During the review of the facilities Emergency Preparedness Program with the Operation Manager (employee #1) and Social Worker (employee #6) on 11/07/2024 at 10:30 AM it was noted that the facility failed to include a documented facility and community based all hazard approach risk assessment. Last HVA was performed on 2018.

Based upon an Emergency Preparedness Program (EPP) survey performed on 11/07/2024 from 8:00 AM through 3:00 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 Operations Manager (employee #1) and Social Worker (employee #6) on 11/07/2024 at 10:30 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.

Based upon an Emergency Preparedness Program (EPP) survey performed on 11/07/2024 from 8:00 AM through 3:00 PM, to evaluate emergency preparedness requirements, 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 the Operations Manager (employee #1) and Social Worker (employee #6) on 11/07/2024 at 10:30 AM 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 upon an Emergency Preparedness Program (EPP) survey performed on 11/07/2024 from 8:00 AM through 3:00 PM, to evaluate emergency preparedness requirements, 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 Operations Manager (employee #1) and Social Worker (employee #6) on 11/07/2024 at 10:30 AM it was noted that the facility 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 11/07/2024 from 8:00 AM through 3:00 PM, to evaluate emergency preparedness requirements, it was determined 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. --- Findings include: During the review of the facilities Emergency Preparedness Program with the Operations Manager (employee #1) and Social Worker (employee #6) on 11/07/2024 at 10:30 AM it was noted that the facility failed to have written process for preserving patient information as required under §494.62(b)(4).

Based upon an Emergency Preparedness Program (EPP) survey performed on 11/07/2024 from 8:00 AM through 3:00 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 Operations Manager (employee #1) and Social Worker (employee #6) on 11/07/2024 at 10:30 AM 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 11/07/2024 from 8:00 AM through 3:00 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to develop and maintain an emergency preparedness training and testing program that is based on the emergency plan. --- Findings include: During the review of the facilities Emergency Preparedness Program with the Operations Manager (employee #1) and Social Worker (employee #6) on 11/07/2024 at 10:30 AM it was noted that the facility failed to develop and maintain an emergency preparedness training and testing program based on the facilities risk assessment.

Based upon an Emergency Preparedness Program (EPP) survey performed on 11/07/2024 from 8:00 AM through 3:00 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. --- Findings include: During the review of the facilities Emergency Preparedness Program with the Operations Manager (employee #1) and Social Worker (employee #6) on 11/07/2024 at 10:30 AM 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 three home visit (H.V) with seven records reviewed (R.R) interviews and observations on 11/07/2024 through 11/08/2024, it was determined that the facility failed to ensure that the patient rights' are promoted related to security, dignity and privacy for 1 out of 3 HV. (HV#1). --- Findings include: 1. HV#1 is an 85-year-old male with admitted 09/29/2024 with Alzheimer disease end stage. Was noted in the medical record that the certification was going for the four of sixty. He was under the services of physician visit 1 month and as needed (PRN), social work 1 month and PRN, spiritual counselor 1 month and PRN, Home maker 5 days a week and registered nurse 3 days a week and as needed. a. On 11/07/2024 at 1:42 PM, during the ulcer care procedure, it was observed that the registered nurse (employee #11) leaves the window curtains open without providing privacy to the patient.

Based on interview with the nursing supervisor (employee #9) on 11/08/2024, it was determined that the facility failed to ensure availability of medical supplies and devices to meet patient needs for 1 out of 3 home visits (HV). (HV#3) --- Findings include: 1. During home visit #3 on 11/08/2024 at 10:03 AM the patient was observed with continuous irrigation foley connected to an IV line. The nursing supervisor (employee #9) was interviewed on 10/08/2024 at 11:00 AM, she stated that the irrigation lines were in short supply.

Based on three home visits (HV) with records reviewed, fourteen records reviewed (RR), administrative documents review, policies and procedures (P&P's) reviewed, interview with the Quality assurance officer ( employee # 2) (employee #1), during a survey process performed from 11/07/2024 thru 11/08/2024, from 8:30 AM thru 2:00 PM, it was determined that the facility failed to promote that information from performance being achieved published on the Medicare.gov Hospice Compare is used to identify gaps in execution. --- a. Quality assurance officer (employee #2) provided evidence on 11/08/2024 at 9:15 AM of activities performed by the facility to measure, analyze and track quality indicators. b. Facility Medicare.gov public report of quality measures last update August 28, 2024, was discussed with Quality assurance officer (employee #2) on 11/09/2024 at 9:38 AM. c. The surveyor requests the facilitys quality assurance officer (employee #2) evidence of the Medicare.gov Hospice Compare data analysis, discussion and establishment of activities to improve in areas where the achievement does not compare favorably with the same industry. d. The surveyor requests to the quality officer (employee #2) if the facility discusses, analyzes and track quality indicators related to quality of patient care that appear in Medicare.gov Hospice Compare. e. The Quality assurance officer (employee #2) stated in interview on 11/08/2024 at 9:35 AM that facility did not discuss, analyze or track quality process measures related with Checking if patients are short of breath, beginning treatment for patients with shortness of breath and Offering care for constipation for patients taking opioids. He also stated that the facility did not include indicators related to these type of process measures in their Quality assurance annual plan.

Based on the review of quality assurance activities and interview with the quality assurance officer (employee #2), it was determined that the facility failed to ensure that one or more specific quality improvement projects are undertaken each year. --- 1. The facility failed to provide evidence on 11/08/2024 at 9:55 AM of performance improvements projects completed in the prior years. 2. During interview on 11/08/2024 at 9:50 AM quality assurance officer (employee #2), stated that facility did not perform any performance improvements projects on year 2024 and year 2024 respectively. 3. 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 the home visits (HV) conducted on 11/07/2024 through 11/08/2024, it was determined that the facility failed it to ensure follows accepted standards of practice to prevent the transmission of infections and communicable disease for 2 out of 3 (HV #1 and HV #3). --- Findings include: 1.During the home visits conducted on 10/08/2024 to 10/09/2024, the following was observed: a. On 11/07/2024 at 1:19 PM, it was observed at home visit #1 that the (employee #11) with acrylic nails. The facility failed to follow Administrative Order #284. b. On 11/07/2024 at 1:32 PM, it was observed at home visit #1 that the (employee #11) did not change gloves on 3 occasions during ulcer healing. c.On 11/08/2024 at 9:21 AM, it was observed at home visit #3 that the (employee #10) did not use hand sanitizer during glove changes when bathing in bed. d. On 11/08/2024 at 9:40 AM, it was observed at home visit #3 that the (employee #10) clean the genital area three times with the same cloth without changing it or cleaning it with soap and water. e. On 11/08/2024 at 9:57 AM, it was observed at home visit #3 that the (employee #10) did not clean the critical equipment before placing it in the case. f. On 11/08/2024 at 10:03 AM, t was observed during the visit to home # 3 that the patient had an irrigation in the foley with a regular IV line. Nursing supervisor employee #9 was interviewed on 10/09/2024 at 11:00 AM about what was found during home visit #3, she stated that there was a shortage of equipment and to be able to use the regulator so that family members would not open the irrigation line by mistake.

Based on the employee file reviewed on 11/08/2024, it was determined that the facility failed to meet the specific qualifications required for medical social services practice in Hospice. --- Findings include: 1. During the evaluation of employee files on 11/08/2024 at 1:22 PM, it was noted that the social worker (employee #6) membership was expired 09/30/2024.

Based on the review of the employees contracts and interview with the facility Administrator (employee # 3), performed on 11/07/2024 at 8:50 AM, it was determined that the facility failed to ensure that Occupational Therapy Services (OT) were available. --- Findings include: 1. When performing the facilitys contract review the surveyor did not find evidence of a contract or arrangement with OT (Occupational Therapy Services). 2. On interview with the Administrator on 11/07/2024 at 8:50 AM he refer that the facility did not have OT employee by contract. Only have Physical Therapy (PT) and Speech Language Pathology by contract. 3. The facility failed to ensure that Occupational Therapy Services (OT) services were available.

Based on a the review of documents related to the volunteer program and interview with the Operations Manager (employee #1), it was determined that the facility failed to document and demonstrate viable and ongoing efforts to recruit and retain volunteers. --- Findings include: The facility did not present evidence of efforts in favor of hiring volunteer personnel on any platform.

Based on the review of documents related to the volunteer program and interview with the Operations Manager (employee #1), it was determined that the facility failed to provide the saving cost achieve by using the volunteers in different roles at the facility. --- Findings include: 1. On 11/07/2024 at 2:30 PM during the review of the volunteer program no evidence of the monthly cost saving through the use of volunteer were found. The facility did not provide evidence of volunteers working in any position. 2. The facility failed to provide the saving cost achieve by using the volunteers in different roles at the facility.

Based on the review of documents related to the volunteer program and interview with the Operations Manager (employee #1), it was determined that the facility failed to maintain volunteer staff to provide administrative or direct patient care equal to five percent of the total patient care hours of all paid hospice employees and contract staff. --- Findings include: 1. During the review of volunteer program on 11/07/2024 at 2:30 PM it was evidence that the agency do not meet with the requirement to comply with a minimal of 5 percent of cost services from the total patient care hours of all paid hospice employees and contract staff. The facility did not provide evidence of the 5 percent of saving with the volunteer program. 2. The facility failed to maintain volunteer staff to provide administrative or direct patient care equal to five percent of the total patient care hours of all paid hospice employees and contract staff.

Based on the review of the procedures manual on 11/8/2024 at 11:10 AM, it was determined that the facility failed to ensure that employees possess the education and experience in accordance with hospice policies and procedures. --- Findings include: 1. During the review of the nursing procedures manual, no policies and procedures on airway suctioning were found. The nursing supervisor (employee #9) was interviewed on 11/08/2024 at 11:00 AM and stated that she did not have them available. Based on the review policies and procedures manuals on 11/07/2024 at 11:25 AM accompanied by the facility Operational Manager (employee #1) the following were identified: Findings include: 1. Manual de Medicamentos was reviewed on 10/2023 and the next revision accordance of the hospice agency was to be on 10/2024, however no evidence of revision according to the facility policies and procedures the manual lack of revision. 2. Manual de Occupational Therapy was last reviewed on 04/ 2023 and the next revision was to be 04/2023 according with the facility policies and procedures. However, the last revision performed on 04/2023 was not sign with the physician and the Occupational therapist. 3. Manual de Terapia Fisica was last reviewed on Abril /2022 however, the next revision should has been 04/2023 according to the facility policies and procedures the manual lacks of revision. 4. The Hospice Governing Body failed to assure ensuring that the hospice manuals related to policies and procedures were reviewed according to the facility policy every year.

Based on the review of the facility education program and interview with the Nursing Supervisor (employee #9) it was determined that the facility failed to provide Annual Education Plan related to orientation about the hospice philosophy, mission, vision and thanatology in service educations to all employees and contracted staff who have patient and family contact. --- 1.Facility employee in service education plan for year 2023 and 2024 was review on 11/08/2024 at 10:00 AM with Nursing Supervisor (employee #9). 2. During the review of employee in service education plan for year 2023 and 2024 it was identified that in-service training plan for those years did not include educational activities related with hospice philosophy, mission, vision and essentials of thanatology, death, dying and bereavement. 3. Nursing Supervisor (employee #9) stated on interview on 11/08/2024 at 10:30 AM that during year 2023 and what is offering in the year 2024 no in-service training related with hospice philosophy, mission, vision and thanatology was provided to facility employees. 4. The facility failed to promote educational activities that could help to increase employees level of efficiency, knowledge and skills in hospice philosophy that emphasizes in compassionate care, respect for patient wishes and family support through an interdisciplinary team. 5. The facility failed to promote educational activities that could help to increase employees level of efficiency, knowledge and skills in aspects of death as well as psychological and social aspects related with death.

Based on the employee file reviewed , it was determined that the facility failed to evaluate the skill and competence of all personnel in written form of the training and education services provided during the 12 months. --- Findings include: 1.During the evaluation of employee records in the company of the nursing supervisor (employee #9) on 11/08/2024 at 11:23 AM, it was found that the records of the License Practical Nurse (LPN) from 2023 to 2024 did not have competencies performed. The nursing supervisor (employee #9) was interviewed on 11/08/2024n at 11:00 AM stated that she had not performed the competencies for the 2023 LPNs and had only performed to the LPNs (employees #10 and #12) and was gradually performing the 2024 competencies.

Based on tree home visit with records reviewed and ten records reviewed (RR), it was determined that the facility failed to ensure that patient's record included the nursing and Hospice aids clinical note, for 1 out of 14 records reviewed (H.V. #3). --- Findings include: 1. H.V. #3 is a female, admitted to the facility on 04/09/2024 with a diagnosis of Chronic obstructive pulmonary disease (COPD). During the record review performed on 11/07/2024 at 10:41 AM, it was found that in the certification period 9 of 60 days, the interdisciplinary group establish in the plan of care: Registered Nurse (RN) services 2 visit per week (wk)and as needed (PRN). a. During the week of 10/06/2024 thought 10/12/2024, no evidence was found of one visit note of the RN, the RN visit on 10/08/2024. b. During the week of 10/13/2024 thought 10/19/2024, no evidence was found of two visits notes of the RN.

Based on observations on the supplies warehouse and pharmacy department accompanied by the facility Administrator (employee #3) on 11/08/2024 at 10:05 A.M, it was determined that the facility fail to comply with medication label and expiration date. --- Findings include: 1. During observation perform on 11/08/2024 at 10:15 A.M. accompanied with the Administrator it was identified the medication refrigerator two (2) vials of Tuberculin Purified Protein Darivative, Diluted Aplisol 5 TU/0.1 ml. (1 ml – 10 tests) Lot. 61619 with expiration date of September / 2024. a One of the vials was observed open with minimal drug content, lacks labeled with date, hour and the name of the professional who opening the vial. The second vial was closed with the cap, however, the two vials expired two months ago. b The hospice failed to have a system to ensure that the drugs and biologicals must be labeled in accordance with currently accepted professional practice and must include appropriate usage and instructions, as well as an expiration date.

Based on the review of four (4) credential files (C.F) with the Hospice Nurse Supervisory (employee # 9) performed on 11/07/2024 at 8:50 AM till 10:30 AM, it was determined that he facility failed to ensure that 4 of 18 employees who provide services have updated credential files related to Speech Language Pathology (SLP), Physical Therapist (PT), Nutritionist and Pharmacist related to lack of Health Certificate, Annual Evaluation, Hepatitis B Vaccine, Influenza Vaccine and Criminal Record. Speech Language Pathology (C.F. #1), Physical Therapist (C.F #2), Nutritionist ( C.F. #3) and Pharmacist (C.F. #4). --- Findings include: 1. Review of four (4) credential files (C.F.) of the Hospice on 11/07/2024 from 8:50 AM till 10:30 AM provide evidence of the following: a. One (1) of four (4) credential files (C.F.) did not contain evidence of updated Hepatitis B Vaccine. Speech Language Pathology (C.F. #1). b. One (1) of four (4) credential files did not contain evidence of Influenza Vaccine. Speech Language Pathology (C.F.#1). c. Four (4) of four (4) credential files did not contain evidence of Annual Evaluation (C.F. #1, C. F. #2, C.F #3 and C.F.#4).

Based on the review of four personnel credential files (C.F.) on 11/07/2024 at 8:50 AM with the facility nurse supervisor (employee #9) it was determined that the facility failed to ensure that 2 out of 18 employees providing services have the criminal background check ( SLP #1 and CF#1). --- Findings include: On 11/07/2024 at 8:50 A.M during review of the credential files it was identified the following: a. Speech Language Pathology (SLP) #1, no evidence was provided of the certified negative criminal background check (Ley 300). b. One (1) of four (4) credential files did not contain evidence of updated Criminal record. Speech Language Pathology (C.F. #1).

Based on a recertification survey, Home Visit (HV), medical records reviewed (RR), review of information and interview with nursing supervisor ( employee #3), it was identified that facility failed to ensure that the interdisciplinary group meeting documentation include pertinent information related with an holistic approach and treatment delivery of services provided to patients. This deficient practice was identified on 2 out of 11 records reviewed ( H.V #2 and H.V. # 3). Findings include: A mechanism to ensure facility promote a comprehensive evaluation of disciplines who take part in the interdisciplinary group meeting discussion to provide feedback to be used to evaluate the patient care plan was not followed, not performed. These findings were identified during the review of medical records on 11/17/21 at 10:00 AM with the nursing supervisor (employee# 3): 1.H.V # 2 is a 95 years old female patient admitted on 07/13/21 with a diagnosis of Alzheimer Disease. The documentation of the interdisciplinary group meeting performed on 11/03/21 did not include enough information to justify that the interdisciplinary group plan of care and services provided include provisions take in to account mental factors and symptoms management of the patient terminal illness. Information found documented during the interdisciplinary group meetings was found to be repetitive, did not include details and appears to be unfinished. 2.H.V # 3 is a 86 years old male patient admitted on 09/28/21 with a diagnosis of Prostate Cancer. This patient had a sacral ulcer stage 2 since admission. The documentation of the interdisciplinary group meeting performed on 11/03/21 did not include information related with integumentary status or sacral ulcer evolution. This patient also had a urinary catheter due to urinary retention since admission to receive services by the facility, the documentation of the interdisciplinary group meeting performed on 11/03/21 did not include information related with the frequency in which the urinary catheter is going to be changed. 3. During interview on 11/17/21 at 10:30 AM the nursing supervisor (employee #3) stated that when facility perform the interdisciplinary group meeting personnel in charge of patients discussed pertinent information related with patient status and response to interventions provided. This discussion is documented on a format named " Reunión del grupo interdisciplinario actualización del plan de cuidado", Meeting of the Interdisciplinary Group Plan of Care Update ". She stated that if during the discussion the interdisciplinary group members identified the need to modify the plan of care, the plan of care is revised and modified, and the documentation is included in a format named " Plan de Cuidado Interdisciplinario ", Interdisciplinary Plan of Care. Nursing supervisor stated that she understands that sometimes there are many details of the interdisciplinary group meeting discussion that are not documented on the " Reunion del grupo interdisciplinario ctualizacion del plan de cuidado" Meeting of the Interdisciplinary Group Plan of Care Update ".

Based on an unannounced recertification survey, three Home Visit (H.V) with records reviewed , eight Record Review (RR), review of policy and procedure, it was determined that the facility failed to ensure that the clinical record contain correct clinical past and current findings for each hospice patient related to Registered Nurse (RN) visits and Physician (MD) visits, for 5 out of 11 records and home visits review (H.V #1, R.R #1, R.R #3, R.R #4 and R.R #5) Findings include: 1. H.V. #1 is a 92-year-old male who was admitted on 10/25/2021 with a Diagnosis of Pulmonary Fibrosis. According to the medical record review performed on 11/16/2021 at 11:11 AM. The visit frequency is nursing service (RN) 2 visit per week an as necessary (PRN), Home Health Aid (HHA) 3 visit per week, Physician (MD) 1 visit per month and PRN, Social Worker (SW) 1 visit per month and PRN and Spiritual counselor (SC)1 visit per month. The following was found during the record reviewed: a. No evidence was found related to MD initial evaluation during the week of 10/24/2021 to 10/30/2021. 2. R.R. #8 is a 98-year-old female who was admitted on 10/30/2020 with a Diagnosis of Congestive Heart Failure (CHF). According to the medical record review performed on 11/16/2021 at 1:58 PM. The visit frequency is nursing service (RN) 2 visit per week an as necessary (PRN), Physician (MD) 1 visit per month and PRN, Social Worker (SW) 1 visit per month and PRN and Spiritual counselor (SC)1 visit per month. The following was found during the record reviewed: a. No evidence was found related to MD notes from 09/19/2021 through 11/16/2021. One RN Notes missing for the week of 10/17/2021 to 10/23/2021 and one RN Notes missing for the week 10/31/2021 to 11/06/2021. R.R # 3 is a 96-year-old female who was admitted on 10/06/2021 with a Diagnosis Respiratory system disease. According to the medical record review performed on 11/17/2021 at 8:45 AM. The visit frequency is nursing service (RN) 2 visit per week an as necessary (PRN), Home Health Aid (HHA) 3 visit per week, Physician (MD) 1 visit per month and PRN, Social Worker (SW) 1 visit per month and PRN and Spiritual counselor (SC)1 visit per month. The following was found during the record reviewed: a. No evidence was found related to MD notes from 10/03/2021 through 11/16/2021. R.R # 4 is a 70-year-old male who was admitted on 10/06/2021 with a Diagnosis of CHF. According to the medical record review performed on 11/17/2021 at 9:12 AM. The visit frequency is nursing service (RN) 2 visit per week an as necessary (PRN), Home Health Aid (HHA) 3 visit per week, Physician (MD) 1 visit per month and PRN, Social Worker (SW) 1 visit per month and PRN and Spiritual counselor (SC)1 visit per month. The following was found during the record reviewed: a. No evidence was found related to MD initial evaluation during the week of 10/03/2021 to 10/09/2021. R.R # 5 is a 57-year-old female who was admitted on 10/26/2021 with a Diagnosis of Cerebrovascular Accident (CVA). According to the medical record review performed on 11/17/2021 at 9:12 AM. The visit frequency is nursing service (RN) 2 visit per week an as necessary (PRN), Home Health Aid (HHA) 3 visit per week, Physician (MD) 1 visit per month and PRN, Social Worker (SW) 1 visit per month and PRN and Spiritual counselor (SC)1 visit per month. The following was found during the record reviewed: a. No evidence was found related to MD initial evaluation during the week of 10/24/2021 to 10/30/2021.

Based on a recertification survey, observations of the inactive medical record storage and interview with nursing supervisor (employee #3) it was identified that facility failed to ensure inactive clinical record is safeguard against damage or mutilation before inactivation or destruction. Findings include: 1.Second floor of the facility office is being used to storage inactive medical records as observed on 11/17/21 at 11:10 AM. 2. All cardboard boxes containing medical records are observed located directly on the floor one on the top of the others. Storage of the boxes containing medical records ones on the top of the others and directly on the floor could cause damage or mutilation of the medical records. 3.Nursing supervisor (employee #3) stated on interview on 11/17/21 at 11:12 AM that this storage contains inactive medical records since year 2010.

Based on an unannounced re-certification survey, the review of eighteen(18) credential files (C.F) performed on 11/17/2021 from 11:00 AM till 1:30 PM, it was determined that the facility failed to ensure that 6 out of 18 employees who provide services have updated credential files related to Register Nurses (RN), Physicians (MD), Social Worker (SW), Physical Therapist (PT), Speech therapist (ST) and Occupational therapist (OT) as required in accordance with State and local laws related to the lack of Health Certificate, Influenza Vaccines, Cardio Pulmonary Resuscitation (CPR), College of Nursing Professionals, State narcotic license and Law 300 ((RN) C.F's #1, Physician (MD) C.F #1, (SW) C.F #1, (OT, PT, ST) C.F #1, C.F #2 C.F #3 and (SW) C.F #1). Findings include: 1. Review of eighteen (18) credential files (C.F) of the hospice on 11:00 AM till 1:30 PM provided evidence of the following: a. Four out of eighteen credential files did not contain evidence of updated Health Certificate (PT, OT, ST) C.F #1, C.F #2, C.F #3 and (SW) C.F #1). b. One out of eighteen credential files did not contain evidence of Influenza Vaccine administration or Exoneration (MD) (C.F #1). c. One out of eighteen credential files did not contain evidence of state narcotic license (MD) (C.F #1). d. One out of eighteen credential files did not contain evidence of updated CPR (MD C. F's #1). e. One out of eighteen credential files did not contain evidence of updated Law 300 (MD C. F's #1). f. One out of eighteen credential files did not contain evidence of updated College of Nursing Professionals (RN) (C.F # 4).