Divina Presencia Hospice Inc.

“Based on a recertification survey, interview, it was determined that the facility failed to ensure that core services, are provided directly by hospice employee related to spiritual counseling. Findings include: 1. During interview on 12/12/2023 at 8:45 AM the Administrator employee #1 state that the facility has 5 Registered Nurse (RN), that 1 were facility contract, they have 2 License Practice Nurse (LPN) by contract, 2 social workers that 1 was contract, and 1 spiritual counselor that was contract and have 2 physicians that 1 was contract. During interview with the administrator employee #1. On 12/14/2023 at 8:13 AM stated that the facility employee spiritual counselor resigns on 10/27/2023, I have interviewed several spiritual counselors, but they only want a professional service contract because they work in another Hospice. I have placed ads for the need to employ full-time spiritual advisors in online classifieds and on the hospice website. The patients have not been left uncovered because I have a part-time contract and a volunteer spiritual advisor who currently covers 22 of the 30 patients. I have offered him the position, but he does not want it, he just wants to volunteer. 2. The facility failed to provide core service Spiritual Counselor directly by hospice employees.”

“Based on the review of the facility’s services agreements and interview with the Administrator (employee #1), it was determined that the facility failed to ensure that the services described by regulation for Physical therapy (PT), Occupational therapy (OT), and Speech-language pathology (ST) are provided directly by the hospice or under arrangements which makes this this condition not met. Findings include: During interview on 12/14/2023 at 8:45 AM the Administrator employee #1 state that the facility lacks an agreement or contract with the services related to OT, PT, and ST long time ago. The Administrator stated during an interview that the hospice lacks services for because they are difficult to hire under contract. I have contacted home care or an independent therapist, but I have not been able to hire any of the therapists.”

“Based on the review of the facility’s services agreements and interview with the administrator employee #1, it was determined that the facility failed to provide Occupational Therapy (OT), Physical Therapy (PT) and Speech Language Pathology Therapy (ST) Service which makes this this condition not met. Finding include: 1. The facility administrator employee #1 stated on 12/14/2023 at 8:45 AM during an interview that the facility lacks an agreement or contract with the services related to Occupational therapy, Physical therapy, and Speech-language pathology therapy. The administrator stated during an interview that the hospice lacks services for a long time because are difficult to hire under contract.”

“Based upon an Emergency Preparedness Program (EPP) survey performed on 12/13/2022 at 8:30 AM through 4:00 AM, 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 ( employee #3) on 12/13/2022 at 9:30 AM it was noted that the facility failed to include a written 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 12/13/2023 at 8:30 AM through 4:00 PM, to evaluate emergency preparedness requirements for recertification, it was determined that the facility failed to develop and maintain policies and procedures related with the role of the facility under a waiver declared by the Secretary in accordance with section 1135 of the Act in the provision of care and treatment. Finding includes: During the review of the facilities Emergency Preparedness Program with the Quality Coordinator (employee #3) on 12/13/2023 it was noted that the EP failed to include policies and procedures which outline the facility’s role in the provision of care and treatment under section 1135 waivers during a declared public health emergency in alternate care sites as required under §418.113(b)(6)(C)(iv).”

“Based upon an Emergency Preparedness Program (EPP) survey performed on 12/13/2023 from 8:30 AM to 4:00 PM, to evaluate emergency preparedness requirements for recertification, it was determined that the facility failed to develop and maintain updated contact information for the following: Federal, State, tribal, regional or local emergency preparedness staff and other sources of assistance. Findings include: During the review of the facilities Emergency Preparedness Program with Quality Coordinator (employee #3) on 12/13/2023 it was noted that the facility failed provide evidence of the Emergency Preparedness Communication Plan that included updated contact information for Federal, State, tribal, regional or local emergency preparedness staff and other sources of assistance.”

“Based on a recertification survey, nineteen (19) records reviewed (R.R), and interview with the administrator (employee #1), it was determined that the facility failed to ensure that the interdisciplinary group (IDG) complete the comprehensive assessment no later than 5 calendar days of election of hospice care for 2 out of 19 records reviewed (R.R #3 and #4). Findings include: During the review of 19 record review with the administrator employee #1, it was found the following: 1. R.R. #3 is a 79-year-old male admitted on 08/29/2023 with a diagnosis of Chronic Obstructive Pulmonary Disease. During the review of the medical record performed on 12/12/2023 at 2:12 PM reveal that patient was refer to the hospice on 08/28/2023, the Registered Nurse (RN) enters to perform the initial comprehensive assessment on 11/09/2023, the Social Worker (SW) and the Spiritual Assessor (SA) performed the respective Comprehensive Assessment on 11/08/2023, however no evidence was found that the physician documented the physician initial comprehensive and be completed no later than 5 calendar days. 2. R.R. #4 is a 75-year-old female admitted on 11/07/2023 with a diagnosis of Alzheimer End Stage. During the review of the medical record performed on 12/12/2023 at 2:48 pm reveal that patient was refer to the hospice on 11/07/2023, the Registered Nurse (RN) entrance to perform the initial comprehensive assessment on 11/07/2023, the Spiritual Assessor (SA) performed the initial Comprehensive Assessment on 11/08/2023, and the Social Worker (SW) performed the initial comprehensive assessment on 11/09/2023, however no evidence was found that the physician documented the physician initial comprehensive and be completed no later than 5 calendar days. 3. During interview with the Medical Director employee #2 on 12/12/2023 at 11:00 AM State that physician note was delayed due to have many patients and I first offer care and attend to the patients, I leave writing for later. If I start writing during my intervention with the patient, I cannot see the patient’s needs. That is the reason that the documentation of the physician was delayed.”

“Based on a recertification survey, observations made during four home visits (H.V), it was determined that the facility failed to follow acceptable standards of infection control during the procedure of Foley change in 1 out of 4 home visits. Failed to comply with Department of Health Administrative Order #284 establishes the use of artificial nails. (H.V #3) Findings include: 1. HV# 3 is an 87-year-old female admitted on 05/11/2023 with diagnosis Basal cell Carcinoma of Skin, Unspecified. The patient was visited on 12/12/2023 at 9:36 AM accompanied by facility nursing personnel (employee #4). During the visit the patient was observed bedridden and totally dependent on activities of daily living, fecal and urinary incontinence. The patient has a gastrostomy #26 with Jeivity feeding 1.5 calories lowering by machine at 45 milliliters per hour and foley catheter with continuous irrigation dropping to 30 milliliters per hour with changes twice a month. a. The registered nurse -RN (employee #5) did not put on gloves before cleaning critical equipment. b. A lit pedestal fan was observed spreading particles from the environment. c. The registered nurse opened the Foley kit and removed all the equipment from the sterile field and placed it in the fenestration with clean gloves. d. The RN was wearing clean gloves and put the sterile gloves on top of the clean gloves. e. During the Foley insertion it was observed that the RN (employee #5) wiped the patient with Betadine from bottom to top. f. After inserting the Foley, the registered nurse connected the saline irrigation without flushing the line. g. The bed rail was touching the fenestration of the sterile field where the foley equipment was located. h. During the foley insertion it was observed that the RN (employee #5) failed to follow the agencys policies and procedure related to appropriate standards of infection control Foley change. 12. During the observation area on 12/12/2023 to 07/14/2023 at 8:30 AM to 2:00 PM the following was found: a. On 07/18/2023 to 07/19/2023 during the tour of the patient’s treatment area, it was observed the nurses (employees #3 and #4,) with long and artificial nails. Facility failed to comply with Department of Health Administrative Order #284 which establishes the use of artificial nails, and length to avoid risk of contamination.”

“Based on a recertification survey, the review of the registered nurse (RN), physicians (Ph), social workers (SW), spiritual advisor, nutritionist and voluntary credential files, it was determined that the facility failed to ensure that all credential file are in compliance with applicable local law for hospice related to update personnel credential file: annual evaluation, hepatitis B vaccine, , law 300, criminal record and influenza vaccine for 12 out 17 personnel credential file (RN #2, RN #6, RN #7, RN #8, RN #9, PhD #1, PhD #2, SW #2, Nut #1, Volunteer #1, Volunteer #2 and Volunteer #3). Findings include: 1.During the review of the nursing credential file on 12/13/2023 at 1:15 PM, it was determined: a. RN #2 on the credential file did not contain evidence of annual evaluation. b. RN #6 on the credential file did not contain evidence of annual evaluation. c. RN #7 on the credential file did not contain evidence of annual evaluation. d. RN #8 on the credential file did not contain evidence of annual evaluation. e. RN #9 on the credential file did not contain evidence of annual evaluation. The facility failed to ensure that annual evaluations of nursing staff credentials file were continued. 2.During the review of the physician credential file on 12/13/2023 at 1:15 PM, it was determined: a. PhD #1 on the credential file did not contain evidence of Influenza vaccine or evidence of exoneration, Law 300, and Criminal record. b. PhD #2 on the credential file did not contain evidence of Law 300. The facility failed to ensure that Influenza vaccine, Law 30, and Criminal record of Physician staff credentials file were continued. 3. During the review of the social worker credential file on 12/13/2023 at 1:15 PM, it was determined: a. SW #2 on the credential file did not contain evidence of annual evaluation. The facility failed to ensure that annual evaluations of social worker staff credentials file were continued. 4.During the review of the nutritionist credential file on 12/13/2023 at 1:15 PM, it was found: a. Nutritionist #1 on the credential file did not contain evidence of annual evaluation. The facility failed to ensure that annual evaluations of Nutritionist staff credentials file were continued. 5.During the review of the Volunteer credential file on 12/13/2023 at 1:15 PM, it was determined: a. Volunteer #1 on the credential file did not contain evidence of annual evaluation. b. Volunteer #2 on the credential file did not contain evidence of annual evaluation. c. Volunteer #3 on the credential file did not contain evidence of annual evaluation, Law 300, and criminal record. The facility failed to ensure that annual evaluations, Law 300, and criminal record of Volunteer staff credentials file were continued.”

“Based on a recertification survey, interview, nineteen (19) records reviewed (R.R), it was determined that the agency failed to ensure Home Health Aide (HHA) are assigned by a Registered Nurse (RN) or other appropriate skilled professional, with written patient care instructions for 2 out of 19 records reviewed (R.R #2 an #4). Findings include:1. RR #2 is an 83-year-old female patient admitted on 09/23/2023 with a diagnosis Cerebrovascular Accident (CVA) and according to the record review performed 12/12/2023 at 11:20 AM, patient had order for HHA services with a frequency of 3 visits per week beginning on 09/23/23.During the review of the medical record on 12/12/2023 at 11:20 AM, it was found lack of the written patient care instructions for the home health aide. Facility provides only the home health aide supervision documentation.2. RR #4 is a 75-year-old female patient admitted on 11/07/2023 with a diagnosis Alzheimer End Stage and according to the record reviewed performed 12/12/2023 at 2:48 PM, patient had order for HHA services with a frequency of 3 visits per week beginning on 09/23/23.During the review of the medical record on 12/12/2023 at 2:48 PM, it was found lack of the written patient care instructions for the home health aide. The facility provides only the home health aide supervision documentation.”

“2. R.R. #2 is an 83-year-old female who was admitted on 09/23/2023 with a Diagnosis of Cerebrovascular Accident. According to the medical record review performed on 12/12/2023 at 11:20 am provides evidence that the patient was totally dependent on ADL, alert, disoriented, bedridden, with tracheostomy. The plan of care performed by the physician and the IDG on 09/23/2023 of the certification establish that nursing service provide 2 visit per week an PRN, the Physician 2 visit per month and PRN, the Social Worker 2 visit per month and PRN, the Spiritual counselor 2 visit per month and PRN and the Home Health Aid (HHA) 3 visit per week. The following was found during the record reviewed: a. The facility electronic medical record does not provide to evaluate the Registered Nurse supervision of the HHA. The nurse progress note appears that HHA was supervised but not appears the supervision evaluation question. 3. R.R. #4 is a 75-year-old female who was admitted on 11/07/2023 with a Diagnosis of Alzheimer. According to the medical record review performed on 12/12/2023 at 2:48 pm provides evidence that the patient was totally dependent on ADL, alert, disoriented, bedridden, stagnant. The plan of care performed by the physician and the IDG on 11/07/2023 of the certification establish that nursing service provide 2 visit per week an PRN, the Physician 2 visit per month and PRN, the Social Worker 2 visit per month and PRN, the Spiritual counselor 2 visit per month and PRN and the Home Health Aid (HHA) 5 visit per week. The following was found during the record reviewed: a. The facility electronic medical record does not provide to evaluate if the Registered Nurse supervision of the HHA. The nurse progress note appears that HHA was supervised but not appears the supervision evaluation question.”

“Based on a recertification survey, four home visit (H.V) with records reviewed (R.R), it was determined that the facility failed to ensure that the medical director (employee #3) review the clinical information for each hospice patient and provide written certification that it is anticipate that the patients life expectancy is 6 month or less if the illness runs its normal course for 2 out of 19 records reviewed (R.R #8 and R.R #9). Findings include: 1.R.R #8 is a 100-year-old male who was admitted on 10/11/2023 with diagnosis End Stage Hear Failure. According to the medical record review performed 12/13/2023 at 8:28 AM provide evidence that the physician did not provide the patient’s initial visit after being admitted to the hospice service. The facility failed to show in the medical record the physicians initial information documented about the patient’s life expectancy. 2.R.R #9 is a 102-year-old female who was admitted on 11/22/2003 with diagnosis Acute Systolic Heart Failure. According to the medical record review performed 11/22/2023 at 1:45 PM provide evidence that the physician did not provide the patient’s initial visit after being admitted to the hospice service. The facility failed to show in the medical record the physicians initial information documented about the patient’s life expectancy.”

“Based on a recertification survey, nineteen (19) Records Reviewed (R.R), 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, Home Health Aid (HHA) visits, Physician Visit for 8 out of 19 records reviewed (R.R #1, #2, #3, #4, #7, #8, #9 and HV#1). Findings include: 1. R.R. #1 is a 63-year-old female who was admitted on 06/24/2023 with a Diagnosis of Amyotrophic Multiple Sclerosis. According to the medical record review performed on 12/12/2023 at 10:30 AM provides evidence that patient was total dependent of activity daily living (ADL), alert, oriented, bedridden, extremity contracture, with a colostomy, tracheostomy. The plan of care performed by the physician and the Interdisciplinary Group (IDG) on 09/07/2023 of the recertification establish that nursing service provide 2 visit per week an as necessary (PRN), the Physician 2 visit per month and PRN, the Social Worker and the Spiritual counselor exempt the services. The following was found during the record reviewed: a. No evidence has been found of the physician progress note since 09/11/2023 to present. b. The medical Director employee #2 notified that she meets with the patient visit and evaluation, but the progress note was delayed. 2. R.R. #2 is an 83-year-old female who was admitted on 09/23/2023 with a Diagnosis of Cerebrovascular Accident. According to the medical record review performed on 12/12/2023 at 11:20 AM provides evidence that the patient was totally dependent on ADL, alert, disoriented, bedridden, with tracheostomy. The plan of care performed by the physician and the Interdisciplinary Group (IDG) on 09/23/2023 of the certification establish that nursing service provide 2 visit per week an PRN, the Physician 2 visit per month and PRN, the Social Worker 2 visit per month and PRN, the Spiritual counselor 2 visit per month and PRN and the Home Health Aid (HHA) 3 visit per week. The following was found during the record reviewed: a. No evidence was found related to the Registered Nurse performing the HHA task assignment. b. No evidence was found of the physician progress note since 10/20/2023. 3. R.R. #3 is a 79-year-old male who was admitted on 08/29/2023 with a Diagnosis of Chronic Obstructive Pulmonary Disease. According to the medical record review performed on 12/12/2023 at 2:12 PM provides evidence that the patient was total dependent of ADL, alert, disoriented, bedridden. The plan of care performed by the physician and the IDG on 11/09/2023 of the recertification establish that nursing service provide 2 visit per week an PRN, the Social Worker 2 visit per month and PRN, the Spiritual counselor 2 visit per month. The following was found during the record reviewed: a. No evidence was found that the IDG established Physician frequency of visit. b. No evidence was found related to the physicians progress note since admission. 4. R.R. #4 is a 75-year-old female who was admitted on 11/07/2023 with a Diagnosis of Alzheimer. According to the medical record review performed on 12/12/2023 at 2:48 PM provides evidence that the patient was totally dependent on ADL, alert, disoriented, bedridden, stagnant. The plan of care performed by the physician and the IDG on 11/07/2023 of the certification establish that nursing service provide 2 visit per week an PRN, the Physician 2 visit per month and PRN, the Social Worker 2 visit per month and PRN, the Spiritual counselor 2 visit per month and PRN and the Home Health Aid (HHA) 5 visit per week. The following was found during the record reviewed: a. Patient was visited by the registered Nurse (RN) on 11/13/2023 and 11/17/2023, however no evidence was found that the RN measure the patient ulcers in the sacral area and Right Hips. b. No evidence was found related to the Registered Nurse performing the HHA task assignment. c. No evidence was found of the physicians progress note since admission. d. No evidence was found related to 2 out of 5 visits per week of the HHA during the week of 11/07/2023 through 11/11/2023 and 11/19/2023 through 11/25/2023 and 5 out of 5 visits of the weeks from 12/3/2023 through 12/09/2023. 5. R.R. #7 is an 89-year-old female who was admitted on 12/08/2023 with a Diagnosis of Parkinson Disease. According to the medical record review performed on 12/12/2023 at 2:48 PM provides evidence that the patient was totally dependent on ADL, alert, disoriented, bedridden, stagnant. The plan of care performed by the physician and the IDG on 12/08/2023 of the certification establish that nursing service provide 2 visit per week an PRN, the Physician 2 visit per month and PRN, the Social Worker 2 visit per month and PRN, the Spiritual counselor 2 visit per month and PRN. The following was found during the record reviewed: a. Patient was visited by the registered Nurse (RN) on 12/08/2023 to perform the initial assessment and 12/12/2023, however no evidence was found that the RN measures the patient ulcers in the sacral area, the Left Buttock, the Right foot and Left foot. Finding include: 6. HV #1 is a 77-year-old female who was admitted on 09/12/2023 with diagnosis of Malignant Neoplasm Unspecified part of unspecified Bronchus or Lung. According to the medical record reviewed performed on 12/12/2023 at 2:12 PM provides evidence that patient plan of care includes physician service two visits per month and HHA five visits per week. However, no evidence was found of the physician personnel visit and progress note in the month of October and November in the medical clinical record. No evidence was found of two HHA personnel visit and progress note from 09/17/2023 to 09/23/2023. No evidence was found of two visits in the month of October and two visits in the month of November by the physician. 7. R.R #8 is 100-year-old male who was admitted on 10/11/2023 with diagnosis End Stage Hear Failure. According to the medical record review performed 12/13/2023 at 8:28 AM provide evidence that patient plan of care includes physician service two visits per month. However, no evidence was found of the physician personnel visit and progress note in the month of October and November in the medical clinical record. No evidence was found of the physician personnel visit and progress note from 10/08/2023 through 10/31/2023 and 11/01/2023 through 11/30/2023. 8. R.R #9 is 102-year-old female who was admitted on 11/22/2023 with diagnosis Acute Systolic Heart Failure. According to the medical record review performed on 12/13/2023 at 1:45 PM provides evidence that patient plan of care includes physician services two visits per month and social worker two visits per month and social worker two visits per month. However, no evidence was found of the physician personnel and progress note in the month of November in the medical clinical record. No evidence was found of the physician personnel visit and progress note from 11/19/2023 through 11/25/2023 and 11/26/2023 through 12/2/2023. No evidence was found of the social worker personnel visit and progress note from 11/19/2023 through 11/25/2023 and 11/26/2023 through 12/2/2023.”

“Based on a recertification survey, nineteen (19) Records Reviewed (R.R), it was determined that the facility failed to ensure that the Physician performed the certification and recertification progress note of terminal illness as required by regulation. Findings include: 1. R.R. #1 is a 63-year-old female who was admitted on 06/24/2023 with a Diagnosis of Amyotrophic Multiple Sclerosis. According to the medical record review performed on 12/12/2023 at 10:30AM provides evidence that the patient was total dependent of activity daily living (ADL), alert, oriented, bedridden, extremity contracture, with a colostomy, tracheostomy. The plan of care performed by the physician and the Interdisciplinary Group (IDG) on 09/07/2023 of the recertification establish that nursing service provide 2visit per week an as necessary (PRN), the Physician 2 visit per month and PRN, the Social Worker and the Spiritual counselor exempt the services. The following was found during the record reviewed: a. On 12/07/2023 the IDG performed the Plan of care for the Recertification; however, no evidence was found that the physician documented the physician progress note of the recertification. 2. R.R. #4 is a 75-year-old female who was admitted on 11/07/2023 with a Diagnosis of Alzheimer. According to the medical record reviewed performed on 12/12/2023 at 2:48 PM provides evidence that the patient was totally dependent on ADL, alert, disoriented, bedridden, stagnant. The plan of care performed by the physician and the IDG on 11/07/2023 of the certification establish that nursing service provide 2 visit per week an PRN, the Physician 2 visit per month and PRN, the Social Worker 2 visit per month and PRN, the Spiritual counselor 2 visit per month and PRN and the Home Health Aid (HHA) 5 visit per week. The following was found during the record reviewed: a. On 11/07/2023 the IDG performed the Plan of care for the Certification; however, no evidence was found that the physician documented the physician progress note of the certification.”

“Based on a recertification survey, review of 16 employees credential files and interview with the Administrator (employee #1) performed from 12/13/2023 at 2:00 PM, it was determined that the facility failed to ensure that de criminal background check is performed to all hospice employees who have direct patient contact or access to patient records. This deficient practice was identified in 3 out of 16 credential files reviewed of facility employees (PhD #1, PhD #2, Volunteer #3). Finding include: 1.During review of employees and contracted credential files with the Administrator (employee #1) on 12/13/2023 at 2:00 PM, it was identified that 3 employees credential files had no evidence of a criminal background check (PhD #1, PhD #2, Volunteer #3).”