Hospicio La Montana

“Based on an interview with the agency’s Director of Services (Employee No. 1) on 10/ 15/ 2025, it was determined that the facility did not ensure it had occupational therapy, speech therapy, and nutrition professionals on staff to care for hospice patients if they needed services. This condition, according to 42 CFR 418.74, is “Not Met.” Findings include:During an interview conducted on 10/15/2025 at 10:00 a.m., the agency’s Director of Services (Employee No. 1) stated that they have contracts but do not have occupational therapy, speech therapy, and nutritionist staff. A credential review on 10/15/2025 at 11:47 a.m. revealed no evidence and confirmed that the required non-core service professionals are unavailable.”

“Based on the record review (RR) and interview with the manager (Employee #2) during the review process on October 16, 2025, which began at 8:30 a.m., it was determined that the facility did not ensure that established nursing services were provided, ensuring the scope and frequency of necessary services established to meet the specific needs of the patient and their family. Findings include:1. RR #1 It was found that the established visit frequency of one visit per week was not offered during the week of 09/28/2025 to 10/04/2025.2. RR #2 It was found that the established visit frequency of two visits per week was not offered during the week of 09/07/2025 to 09/13/2025, and during the week of 09/28/2025 to 10/04/2025, one of the two established visits was not offered.3. RR #3 It was evident that the established visit frequency of 1 visit per week was not met with the established visits during the following weeks: 08/31/2025 to 09/06/2025, 09/07/2025 to 09/13/2025 and 09/21/2025.4 4. RR #4 It was found that the established visit frequency of one visit per week was not offered during the week of 09/07/2025 to 09/13/2025.”

“Based on interviews with the facility administrator (employee # 1) and document review performed on October 16, 2025, from 10:00 AM to 11:00 AM, it was determined that the facility failed to ensure that an ongoing program for quality improvement and patient safety is defined, implemented, and maintained, and is evaluated annually. Findings include:1. A review of the Corporate Board of Directors’ regulations manual (October 2024 revision) was done on October 16, 2025, at 10:00 AM.a. The board of director’ s responsibilities section did not include the responsibility to ensure that an ongoing program for quality improvement and patient safety is defined, implemented, and maintained. 2. During an interview with the facility administrator (employee # 1) performed on October 16, 2025, at 11:00 AM, he stated that: a. The board of director’ s responsibilities section document was under revision and that the responsibility to ensure an ongoing program for quality improvement and patient safety was going to be added.b. The facility quality improvement committee has not held any meetings during 2025 because in March 2025 was pending the recruitment of administrative staff, the clinical manager and the clinical supervisor prior to reactivating meetings. Because the staff mentioned was already recruited, he stated that he was going to activate it as soon as possible. 3. The quality improvement committee records file shows no meetings during 2025.”

“Based on an interview and review of the volunteer manual with the Agency Services Manager (Employee No. 2) on 10/15/2025 at 12:00 PM, it was determined that the center failed to ensure the recruitment and retention of volunteer staff, even though they have strategies to implement as described in the manual. Findings include:During an interview conducted on 10/15/2025 at 12:00 AM, the Agency Services Manager (Employee No. 2) stated that they currently do not have volunteer services and that recruitment and retention strategies are in place, but they are finding it difficult to recruit due to the requirements imposed by the Human Resources department.”

“Based on interviews with the facility administrator (employee # 1) and document review performed on October 16, 2025, from 10:00 AM to 11:00 AM, it was determined that the Governing body and administrator failed to assume full authority and responsibility for the continuous quality assessment and performance improvement in the facility. Findings include:1. A review of the Corporate Board of Directors’ regulations manual (October 2024 revision) was done on October 16, 2025, at 10:00 AM.2.The board of director’ s responsibilities section did not include the responsibility for the continuous quality assessment and performance improvement in the facility.3. During an interview with the facility administrator (employee # 1) performed on October 16, 2025, at 11:00 AM, he stated that:a. The board of director’ s responsibilities section document was under revision and that the full authority and responsibility for the continuous quality assessment and performance improvement in the facility was going to be added.”

“Based on three Home Visit (HV) with records reviewed (RR), fourteen records reviewed (RR) , it was determined that the facility failed to ensure that the clinical record contains current clinical notes for each hospice patient related to physician service and based on the review of active patient records (RR) and deceased patient records (CRRD) on 10/15/2025 and 10/16/2025, it was determined that the facility did not ensure the nursing professional’s clinical notes were included in the patient’s record as part of the required content demonstrating the care provided, changes, among others for 6 out of 14 RR (RR-HV 1, #2 , #3, RR #1,# 2, and #3). 4. RR No. 2 does not show clinical notes for visits made on the following days: 08/12, 08/15, 08/19, 08/22, 08/26, 08/28, 09/02, 09/05, 09/16, 09/18, 09/22, 09/24, 09/30, 10/08 (2 notes: regular visit and PRN visit) and 10/10 of 2025.5. RR No. 3 does not show clinical notes for visits made on the following days: 08/11, 08/15, 08/18, 08/26, 08/28 and 08/29 of 2025.6. RR No. 4 has clearly not been recertified for the period in which review was from 8/7 to 10/5 2025. Findings include:1. HV # 1 is a 62-year-old female who was admitted on 03/31/2025 with a diagnosis of Alzheimer Disease. The interdisciplinary group determined one visit per month for the Physician (MD). According to the medical record review performed on 10/16/2025 at 9:00 AM, the following was found:a. No evidence of physician’s notes reassessments for the month of September. 2. HV # 2 is a 94-year-old female who was admitted on 06/27/2025 with a diagnosis of Alzheimer Disease with Late Onset. The interdisciplinary group determined one visit per month for the Physician (MD). According to the medical record reviewperformed on 10/16/2025 at 9:00 AM, the following was found: a. No evidence of physician’s notes reassessments for the month of September. 3. HV # 3 is a 67-year-old male who was admitted on 05/16/2025 with a diagnosis of Bening Neoplasm of Cerebral Meninges. The interdisciplinary group determined one visit per month for the Physician (MD). According to the medical record review performed on 10/16/2025 at 9:00 AM, the following was found:a. No evidence of physician’s notes reassessments for the month of September. The facility failed to ensure accessible and available physician’s updated comprehensive assessments and clinical notes in the medical record.”

“Based on the review of active patient records (RR) and deceased patient records (CRRD) on 10/15/2025 and 10/16/2025, it was determined that the facility did not ensure that the physician documented the patient recertification required in 418.22 and 418.25 and described in 418.102(b) and 418.102(c). Findings include:During the record review, the following were identified:1. CRRD #1 is evidently not recertified for the period under review (12/06 to 07/08, 2025).2. CRRD #2 is evidently not recertified for the period under review of 10/03, 2025.3. RR #2 is evidently not recertified for the period under review from 03/08 to 04/12, 2025.4. RR #3 is evidently not recertified for the period under review from 06/10 to 10/11, 2025.5. RR #4 is evidently not recertified for the period under review from 07/08 to 05/10, 2025.6. In an interview with the medical director (employee #5) conducted on 10/15/2025 at 3:30 pm, she acknowledged She has visual impairments and is adjusting since purchasing a larger iPad and using dictation to allow for quick and secure documentation. It’s evident that she makes the appropriate visits, which she also confirms.”

“Based on the review of credential files (C. F.) social worker, it was determined that the facility failed to ensure that those who provide services have updated credentials related social worker, as required by State and Local laws. Findings include:1. On 10/15/2025 at 10:00 AM during review of the credential file it was identify the following:a. There are no hospice program duties and functions listed in Social Worker file.b. In an interview with the administrator (Employee #1) and the manager (Employee #2), they explain that the social worker is on maternity leave and a social worker from the system has been assigned as a replacement.”