Hospicio La Paz Inc.

“Based on review of 21 medical records, policies procedures and interviews with Administrator (employee #3) during survey process perform from 10/21/25 through 10/22/25 from 8:00 AM thru 4:00 PM, it was determined that facility failed to have available, physical therapy services. Which makes this Condition of Participation out of compliance. Findings include:1.Accordingly with information provided by the Administrator (employee #3) on 19/21/25 at 10:00 AM facility did not had physical therapy personnel services since April 15, 2025 when facility did not renew physical therapy employee contract.2. It was asked to the Administrator (employee #3) on 10/21/25 at 10:00 AM to explain and evidence activities performed after April 15, 2025 to recruit physical therapy services. 3. Administrator (employee #3) evidence and explain on 10/21/25 at 11:51 AM that the facility announces the vacancy for this position on the hospice web page on 10/21/25. 4. Administrator (employee #3) was asked on 10/21/25 at 11:55 AM if before 10/21/25 facility carries out another negotiation or agreement with other hospice to make available physical therapy services. She stated that facility did not carry out another negotiation or agreement with other hospice to make available physical therapy services.”

“Based on twenty-seven records reviewed with director service (employee #2) on 10/22/2025, it was determined that the facility failed to ensure that the nutritionist performed the initial assessment no later than 5 days after the patient’s admission in 1 0ut of 27 RR. (RR #9) Findings include:R.R #9 is a 76 year- old female admitted to the facility on 04/16/2025with Malignant Pelvis Neoplasm. The care plan was observed according to the patient’s needs: nursing: 2 visits per week plus as needed, social work: 1 per month plus as needed, doctor: 1 per month plus as needed, religious counselor: 2 per month as needed, nutrition: 1 initial visit as needed, and practical nurse: 3 times per week plus as needed. Observations made during record reviews on 10/22/2025 at 11:45 AM, the following was found:It was observed that the nutrition staff made the initial visit eight days after admission.”

“Based on twenty-seven records reviewed (RR) with service director (employee #2) on 10/22/2025, it was determined that the facility failed to ensure scheduled visits by the interdisciplinary group in 1 out of 27 RR. (RR #9) Findings include:During the evacuation of medical records, the following was found: a. R.R #9 is a 76 year- old female admitted to the facility on 04/16/2025with Malignant Pelvis Neoplasm. The care plan was observed according to the patient’s needs: nursing: 2 visits per week plus as needed, social work: 1 per month plus as needed, doctor: 1 per month plus as needed, religious counselor: 2 per month as needed, nutrition: 1 initial visit as needed, and practical nurse: 3 times per week plus as needed. Observations made during record reviews on 10/22/2025 at 11:45 AM, the following was found:The absence of clinical notes from the physician in the months of July and August, 2025 was observed.”

“Based on observation made regarding the care provided during one out of six home visits (H.V) on 10/21/2025, it was determined that the facility failed to comply with infection control standards during the hand washing, Foley catheter and ulcer care for 1 out of 6 HV. (HV #4) Findings include:H.V #4 is a 99 year- old male admitted to the facility on 07/02/2025 with Metabolic Encephalopathy. The care plan was observed according to the patient’s needs: nursing: 2 visits per week plus as needed, social work: 2 per months plus as needed, doctor: 1 per month plus as needed, religious counselor: 2 per month as needed, and nutrition: 1 initial visit as needed. Observations made during the catheter insertion and ulcer care procedure on October 21, 2025, at 11:18 AM, revealed the following:It was observed that the registered nurse (employee #4) used 70% alcohol to wash her hands instead of hand sanitizer during urinary catheter insertion and ulcer care procedures.It was observed that the registered nurse (employee #4) wore gel nails. It was observed that the registered nurse (employee #4) after preparing the sterile field for ulcer care, placed a trash bag over it.It was observed that the registered nurse (employee #4) touched the curtain with her gloves while caring for the ulcer and then took the hydrogel and placed it on the patient’s ulcer. She did not change gloves or wash her hands with soap and water or hand sanitizer.It was observed that the registered nurse (employee #4) wrote initials on the catheter with a marker pen.”

“Based on the interview conducted with Social Work (employee #8) on 10/22/2025 at 11:18 AM, it was determined that the facility failed to ensure ongoing efforts to recruit and retain volunteers. Findings include:During the interview with Social Worker (employee #8), she mentioned that she collaborated verbally and physically with the Abelardo Martinez Otero School and National University College. She did not provide evidence of the collaborations carried out with both institutions.Social work (employee #8) provided evidence that volunteer recruitment activities are carried out annually on the facility’s Facebook page. The last recruitment activity took place on March 1, 2024.”

“Based on twenty-seven records reviewed (RR) with the Service Director (employee #2) on 10/22/2025, it was determined that the facility failed to ensure that the physician’s clinical notes were available in the clinical record for 1 out of 27 RR. (R.R # 9) Findings include:R.R #9 is a 76 year- old female admitted to the facility on 04/16/2025with Malignant Pelvis Neoplasm. The care plan was observed according to the patient’s needs: nursing: 2 visits per week plus as needed, social work: 1 per month plus as needed, doctor: 1 per month plus as needed, religious counselor: 2 per month as needed, nutrition: 1 initial visit as needed, and practical nurse: 3 times per week plus as needed. Observations made during record reviews on 10/22/2025 at 11:45 AM, the following was found:The absence of clinical notes from the physician in the months of July and August, 2025 was observed.”

“Based on the review of sixty personnel credential files (C.F) performed on 10/22/2025 from 12:00 pm till 2:00 pm with the facility Service Director employee #2, it was determined that the facility failed to ensure that employees who provide services as Nursing Credential File (NCF), Social Worker Credential File (SWCF), Spiritual Advisor credential File (SACF), Homemaker credential File (HMCF), Speech Therapy Credential File (STCF), Occupational Therapist Credential File (OTCF), Respiratory Therapist Credential File (RTCF) have updated credential files accordance to state and local law related to updated Cardiopulmonary Resuscitation (CPR), lack of Influenza, Hepatitis B and Covid 19 Vaccines, updated Criminal Record, Duties and functions and Annual Evaluation in 21 out of 60 (NCF #1, #4, #7, #13, #15, #18, #19, #20, #21, #22, #23, #24 and #25, SACF #6, #8 and #12, HMCF #1,#2, #4 and #6, OTCF #2). Findings include: 1. Review of sixty (60) credential files (C.F) of the hospice personnel on 10/22/2025 from 12:00 pm till 2:00 pm provided evidence of the following: a. Three out of twenty-five nursing credential files (NCF), did not contain evidence of updated CPR. (NCF #4, #20, and #23). b. One out of twenty-five NCF, did not contain evidence of Hepatitis B vaccine or title. (NCF #1). c. Two out of twenty-five NCF, did not contain evidence of updated Influenza vaccine. (NCF #21 and #25). d. Two out of twenty-five NCF, did not contain evidence of Covid 19 vaccine. (NCF #24 and #25). e. Two out of twenty-five NCF, did not contain evidence of updated Criminal Record. (NCF #7, and #13). f. Six out of twenty-five NCF, did not contain evidence of updated Annual Evaluation. (NCF #4, #13, #15, #18, #19 and #22). g. Two out of Seven SACF, did not contain evidence of updated Influenza vaccine. (SACF #6, and #8). h. One out of Seven SACF, did not contain evidence of updated Annual Evaluation. (SACF #12). i. Three out of Six HMCF, did not contain evidence of updated Influenza vaccine. (HMCF #2, #4 and #6).j. Three out of Six HMCF, did not contain evidence of updated Influenza vaccine. (HMCF #2, #4 and #6). k. Two out of Six HMCF, did not contain evidence of updated Annual Evaluation. (HMCF #1 and #2). l. One out of Six HMCF, did not contain evidence of Duties and functions. (HMCF #2). m. One out of One OTCF, did not contain evidence of updated Influenza vaccine. (OTCF #2).”

“Based on the review of sixty personnel credential files (C.F) performed on 10/22/2025 from 12:00 pm till 2:00 pm with the facility Service Director (employee #2), it was determined that the facility failed to ensure that all employees who have direct contact or access to patient records, as Nursing Credential File (NCF). Physician Credential File (PCF), Social Worker Credential File (SWCF), Spiritual Advisor credential File (SACF), Homemaker credential File (HMCF), Speech Therapy Credential File (STCF), Occupational Therapist Credential File (OTCF), Respiratory Therapist Credential File (RTCF) have the criminal background check in 15 out of 60 (NCF #2, #12, #13, #19, #20, #24 and #25, PCF #4 and #6, SWCF #5, SACF #2 and #14, HMCF #3 and #6, RTCF #4). Findings include: 1. On 10/22/2025 from 12:00 pm till 2:00 pm during the review of the credential files it was identified the following:a. NCF #2, #12, #13, #19, #20, #24 and #25, no evidence provided or updated the certified negative criminal background check (Ley 300).b. PCF #4, and #6, no evidence provided or updated the certified negative criminal background check (Ley 300).c. SWCF #4, no evidence provided or updated the certified negative criminal background check (Ley 300).d. SACF #2, and #14, no evidence provided or updated the certified negative criminal background check (Ley 300).e. HMCF #3, and #6, no evidence provided or updated the certified negative criminal background check (Ley 300).f. PTCF #4, no evidence provided or updated the certified negative criminal background check (Ley 300).”

“Based upon an Emergency Preparedness Program (EPP) survey performed on 11/28/2023 at 8:30 AM through 6:45 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 Administrator (employee #8) on 11/28/2023 at 8:30 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 11/28/2023 at 8:30 AM to 6:45 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 Administrator (employee #8) on 11/28/2023 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 upon an Emergency Preparedness Program (EPP) survey performed on 11/28/2023 at 8:30 AM through 6:45 PM, to evaluate emergency preparedness requirements for recertification, it was determined that the facility failed to provide a method for sharing information and medical documentation for patients under the hospice’s care, as necessary, with other health care providers to maintain the continuity of care. Findings include: During the review of the facilities Emergency Preparedness Program with the Administrator (employee #8) on 11/28/2023 it was noted that the facility failed to provide a written method for sharing information and medical documentation for patients under the hospice’s care, as necessary, with other health care providers to maintain the continuity of care as required under §418.113(c)(4)-(6).”

“Based on a recertification survey, six Home Visit (H.V.) to performed observation of nursing care with nursing personnel (employee #5) and (employee #2), and interview with facility services director (employee #1), it was determined that the agency failed to ensure that nursing personnel follow agency infection control policies and procedures and follow acceptable standard of practice for infection control during the ulcer care, bed bath and Foley insertion. This deficient practice was identified in 5 out of 6 home visits (H.V. #1, #3, #4, #5 and #6). The facility Infection Control Manual Program was reviewed on 11/28/2023 at 9:30 AM and on page 161 to 165 established Policies and Procedure Patient Bed Bath.’ On page 162 item #7 established the following: ’ Used three small towels to bathe the patient, one for face, one for body and other one for genital area.’ On item #13 established the following: ’ Rinse the towel and maintain at side. ’’ On item #14 established the following: ’’ Used the towel to wash the rest of the body. ’’ 5. Home visit #1 is an 87-year-old female admitted on 12/13/2022 with a diagnosis of Chronic Respiratory Failure Unspecified with Hypoxia or Hypercapnia and secondary diagnosis of Hypertensive Heart Disease with Heart Failure, Dysphagia, Full Incontinence of Feces, Feeding Difficulties, Bedridden, Dependence or Supplemental Oxygen and Dependence with urinary catheter. According to the patient’s plan of care performed on 11/17/2023 at 9:00 AM, the Register Nurse (RN) service 2 visits per week and PRN, HHA 2 visits per week and PRN, Physician Services 1 and according with the patient needs, Social Worker Services 1 visit per month and PRN, Spiritual Counselor 1 visit per month and PRN, Respiratory Services 1 visit and PRN, Nutrition 1 and PRN and Hospice Aide 3 visits per week. a. The patient was selected to home visit to evaluate the bed bath performed by the HHA on 11/28/2023 at 12:30 PM. The HHA (employee #6) performed the bed bath however, HHA#6 only used two small towels to provide the bed bath one to wash and one to dry. The HHA (employee #6) failed to provide the bed bath according with policies and procedures of the facility. 6. Home visit #4 is an 88-year-old male admitted on 10/02/2023 with diagnosis of Alzheimer Disease with Late Onset. and secondary diagnosis of Hypertensive Heart Failure without of Heart Failure, Urinary Incontinence, Full Incontinence of Feces, Edema Unspecified, Bedridden, Dependence on Supplemental Oxygen and Pressure Ulcer of other site Stage II. According to the patient’s plan of care performed on 11/17/2023 at 9:30 AM, the Register Nurse (RN) service 2 visits per week and PRN, Physician Services 1 and PRN, Social Worker Services 2 visits per month and PRN, Spiritual Counselor 2 visits per month and PRN and Nutrition 1 visit and PRN. a. The home visit was performed on 11/28/2023 at 4:30 PM to evaluate the folly catheter insertion and ulcer care performed per the Register Nurse (employee #7). During the home visit the patient was observed bed ridden, totally dependent on activities of daily living, fecal and urinary incontinence, and two pressure ulcers located on left lower extremity and pressure source localized on left heel. RN #7 provides local care for the two ulcers according to policies and procedures of the facility, however the nurse failed to perform the left heel assessment, did not remove the adhesive gauze to observed if the heel area improvement or deteriorated. b. The RN #7 stated the folly catheter change on 11/28/2023 at 5:15 PM, then she removed the saline solution with a syringe and then removed the folly catheter and discard and performed the perineal local care. However, before inserting the catheter the nurse failed to inflate the balloon with sterile water or normal saline solution to inspect it for leaks and continue with the folly catheter insertion. 7. Home visit #6 is a 77-year-old male admitted on 7/26/2023 with diagnosis of Alzheimer Disease with Late Onset. According with the patient’s plan of care performed on 11/7/2023 at 10:00 AM, the Register Nurse (RN) service 2 visits per week and PRN, Home Health Aide (HHA) service 3 visits per week and PRN, Physician service 1 visit per month and PRN, Social Worker service 2 visits per month and PRN, Spiritual Counseling 1 visit per month and PRN and Nutrition PRN. a. The home visit was performed on 11/28/2023 at 2:55 PM to evaluate the Foley catheter insertion per the Register Nurse (employee #4). The nurse performed the procedure without problems however, all of the time when goes to wash her hands she removed her gloves and discard them take a hand paper then put on her right pocket uniform goes to the bathroom washing her hands and them introduce her right hand on the interior of her right pocket and drys her hands, when finished goes to the patient room and continue with the procedures. She performed the same procedure all the time when performed the hand washing. Findings include: Review of facility policy Employees Personnel Appearance and Dress Code last review on 11/29/2023 at 1:25 PM with facility services director (employee #1) evidence that this policy establishes that personnel providing direct care and services must maintain nails with clear light colors in case that they use nail polish. 1.During home visit to HV#5 with nursing personnel (employee # 5) on 11/28/2023 where the nurse provide ulcer care it was observed that she had a yellow shiny nail polish. 2.During home visit to HV#3 with nursing personnel (employee #2) on 11/28/2023 where the nurse provide ulcer care it was observed that she had a green shiny nail polish. 3. Facility services director (employee #1) stated on interview on 11/29/2023 at 1:25 PM that nursing personnel assigned to provide patient direct care must use neutral and subdued nail polish and that this nail polish must not be chip off in order to avoid harboring germs beneath. She also stated that nursing personnel are not authorized to wear dark color nail polish. Ulcer care policy and procedures last update on year 2018 was review with facility services director (employee #1) on 11/30/2023 at 10:20 AM during the review the facility services director (employee #1) stated on interview that if is feasible clean field with items and supplies to be used during wound care must be prepared in a separate area and not directly on patients bed in order to prevent cross contamination with patients belongings and bed sheets. 4. H.V. #3 is a 67-year-old male who was admitted on 10/19/2023 with a Diagnosis of Chronic Respiratory Failure with Hypoxia. This patient had a stage 2 ulcer on the sacral area. According to the Plan of care reviewed on 1/24/20/16 at 9:00 AM the patient has Nursing services with a frequency of 2 visits per week and as necessary to assess patient and provide ulcer care. During the H.V performed on 11/28/2023 at 2:35 PM with nursing personnel (employee #2) the following was observed: a.Nursing personnel (employee #2) prepare clean field with ulcer care items and supplies directly on the bottom side of patient bed. This practice promotes contamination of materials, items and supplies.”

“Based on re-certification survey, the review of thirty three (33) credential files (C.F) with the Hospice Nurse Director (employee #1) performed on 11/29/2023 from 2:30 PM thru 4:00 PM and 11/30/2023 from 8:00 AM thru 11:00 AM, it was determined that the facility failed to ensure that 9 out of 38 employees who provide services have updated credential files related to Register Nurses (RN), Physicians (MD), Social Workers (SW), Spiritual Advisor (SA), Biomedico and Speech Pathologist as required in accordance with State and Local Laws related to the lack of Annual Evaluations, Health Certificate, Hepatitis and Influenza Vaccine. Annual Evaluations (RN, C.F’s #3, #9, #10 and #19, SW CF’s #23, #25 and #26 and Housekeepers #31), Health Certificate (C.F #22) Hepatitis Vaccine CF’s #37 and #38 and Influenza Vaccine CF # 38. Findings include: Review of thirty - three (33) credential files (C.F) of the hospice on 11/29/2023 and 11/30/2023 provided evidence of the following: Eight (8) of thirty eight (33) credential files did not contain evidence of updated Annual Evaluation (RN’s CF #3, #9, #10 and #19), ( SW #23, #25 and #26), SA #25) and HK #31). Two (2) of thirty three (33) credential files did not contain evidence of Hepatitis Vaccine or the serology test ( Biomedicine CF #37 and SP CF#38). (1) of thirty three (33) credential files did not contain evidence of Influenza Vaccine (RN CF#4, #5, #8, #9, #13, #17, #19), ( MD CF#4), (SW CF #23), (SP CF #38).”

“Based on the review of the facility’s volunteers level of activity and interview with the Administrator (employee #8) on 11/28/2023, it was determined that the facility failed to comply with core services concerning the use volunteers. Findings Include: After review of documentation on 11/28/2023 at 2:15 PM it was noted that the facility did not comply with the minimum of 5 percent of day to day administrative and/ or direct patient care services. The Administrator stated during interview that the hospice encounters problems in recruiting outside volunteer personnel and utilizes in hospice personnel to do some volunteer work.”