Every finding on record at Vida De Paz LLC

Observed in Record Review. In 1 of 10 patient records reviewed, it was noted that the organization did not ensure that the comprehensive assessment was updated at least every 15 days. For example, during a review of the medical record for RRHV#2, it was noted that the first update to the comprehensive assessment was completed 64 days after the initial plan of care was established. This observation was reviewed with the Administrator.

Observed in Record Review. In 7 of 10 patient records reviewed, The written plan of care failed to be based on the patient’s centered specific goals as identified in RRNHV#1: patient /CG will verbalize that depression is absent or reduced to an acceptable level. RRNHV#2: Pt/CG will verbalize demonstrate feeling supported by hospice team, family and/or friend and will adapt to changes, challenges and crisis's throughout the hospice admission. RRNHV#3: Patient will exhibit a decrease in pain related behaviors RRNHV#4: - patient/caregiver will verbalize that anxiety is absent or reduced to an acceptable level. RRNHV#5: Patient will exhibit a decrease in pain related behaviors. RRNHV#6: MSW goal -Patient/CG will express acceptance of health status and will find meaning in personal and health care treatment choices. RRNHV#7: patient/caregiver will verbalize that anxiety is absent or reduced to an acceptable level, this was observed and validated by the Administrator

Observed in Record Review. In 5 of 10 patient records reviewed, The organization plan of care failed to include all services needed for the palliation and management of the terminal illness and related conditions as evidenced in the following records no orders obtained: RRNHV#2: Patient is a type 2 diabetic and no parameter for care identified . RRNHV#3: The HHA care plan stated may apply Vitamin D with Zinc ointment to sacrum to prevent skin breakdown, instructions were not clear when to apply them. RRNHV#5: No glucose monitoring in the care plan, Facility currently monitoring blood sugar TID and diabetes managed with Humulin R 5 units TID and Metformin 500 mgs TID. RRNHV#6: Patient has an AICD and no goals and type 2 diabetic and no parameters identified. RRNHV#7: Patient has dialysis 3 times a week and not in the care plan, this was observed and validated by the Administrator

Observed in Record Review. In 7 of 10 patient records reviewed, The organization prior to providing care, the organization failed to obtains or renew PRN orders based on patients identified needs as evidenced in RRNHV#1:RRNHV#2, RRNHV#3, RRNHV#4, RRNHV#5, RRNHV#6 and RRNHV#7: MSW Freq: 1m3, PRN for psychosocial needs, end of life planning, family dynamics per patient/CG request and Chaplain: 1m3 PRN, for symptom management, immence, fall/injury, RN 1w14 PRN: for symptom management, immence, fall/injury, this was observed and validated by the Administrator

Observed in Record Review. In 1 of 10 patient records reviewed, The organization failed to ensure ongoing sharing of information between all disciplines as evidenced in RRNHV#3: HHA had a missed visit and documentation stated that physician and RN were not notified, this was observed and validated by the DON

Observed in Data Session. The organization failed to select performance improvement activities that affect palliative outcomes that are based on severity of problems as evidenced by there was no palliative performance improvement project, this was observed and validated by the DON

Observed in Infection Control Tracer. The organization failed to implement a hand hygiene program, set goals for improving compliance with hand hygiene guidelines and improve compliance with hand hygiene guidelines based on established goals, as evidenced by the organization was collecting data during supervising visits, however, did not have a written goal to compare the data to, and there was no analysis of the data being collected, this was observed and validated by Administrator

Observed in HR File Review. In 1 of 1 HR files reviewed, The organization completed the required aide competencies but the documentation failed to confirm competencies completed with an actual patient or a qualified pseudo patient, this was observed in the HHA personnel file HR#7, this was validated by the Administrator

Observed in Record Review. The organization did not ensure patient care plan goals were individualized, measurable and realistic. For example, the surveyor noted on HV #1/RR #1, HV #2/RR #2, HV #3/RR #3, RR #4, RR #5, RR #6, and RR #7, the patient’s care plan goals stated: “Patient will have acute confusion/delirium/agitation reduced to a manageable level to return to Routine Home Care level of care. Goal Length: Ongoing, Patient will verbalize having adequate rest at night. Goal Length: Ongoing, Patient will have dyspnea reduced to a manageable level to return to Routine Home Care level of care. Patient/caregiver will turn and reposition every two hours to prevent skin breakdown. Goal Length: Ongoing, oxygen satuations will remain above 92% Goal Length: Ongoing, Patient will have soft, formed stool every 1 to 3 days without straining. Goal Length: Ongoing. caregiver will be able to manage wound care at Routine Home Care level of care. Caregiver will demonstrate effective wound care. Patient/caregiver will maintain compliance with prescribed pain medication regimen, including adhering to prescription instructions, administering medications, monitoring for efficacy, and avoiding medication errors. Patient will have comprehensive assessment completed by end of 5th day after admission. Goal Length: Ongoing.” These goals are unrealistic, based on the patient’s diagnoses and do not contain information that can be accurately measured to assist staff in determining whether the patient is progressing towards achieving their goals. These findings were reviewed, discussed, and validated with the Administrator.

Observed in Tracer Activities. The organization did not ensure their infection control program included a complete Covid-19, Hand Hygiene and Influenza Program. For example, the surveyor noted there was no documentation of program data for these programs. Standards require organizations to develop and maintain a hand hygiene, influenza and Covid-19 program, within there infection control Program. These findings were reviewed, discussed and verified with the Administrator.

Observed in Tracer Activities. The organization did not ensure the bereavement coordinator possess the necessary credentials. For example, the surveyor noted bereavement services were supervised by the volunteer coordinator who did not have the required credentials. Standards require The individual(s) supervising the provision of bereavement services is a qualified professional with experience or education in grief or loss counseling. The findings were reviewed, discussed and validated with the Bereavement Coordinator and Administrator. Observed in Tracer Activities. The organization’s bereavement program was lacking key components. For example, on review of the hospice bereavement program, the surveyor noted there was no established support group offerings or structured support for the staff. Standards require hospices to provide an organized program for the provision of bereavement services. These findings were reviewed, discussed and validated with the Bereavement Coordinator and Administrator.

Observed in Record Review. In 5 of 7 patient records reviewed, The organization failed to obtain physician orders for services prior to providing care. For example, the surveyor noted on HV #1/RR #1, HV #3/RR #3, RR #5, RR #6 and RR #7, there were no physician orders to evaluate/admit the patient to hospice services. Additionally, on RR #7, the patient’s initial care plan did not contain an order for hospice aide services, although there was an aide care plan, along with documented visits. Standards require prior to providing care, the organization obtains or renews orders (verbal or written) from a physician or allowed practitioner in accordance with professional standards of practice and law and regulation. Theses findings were reviewed, discussed and verified with the Administrator.

Observed in Tracer Activities. The organization failed to produce evidence of volunteer recruitment and retain efforts. On review of the hospice volunteer program there was no documentation of recruitment and retention efforts, although the organization stated activities had taken place. Standards require hospice programs to document its efforts to recruit and retain volunteers. These findings were reviewed, discussed and validated with the Administrator.