Med Health Hospice Corp

“Based on observation made on three (3) home visits (H.V) performed on 01/29/2025 to evaluate emergency preparedness requirements, it was determined that the facility failed to ensure to meet the applicable provisions in accordance with the safety requirements for 1 out of 3 (H.V #3). Findings include: During three (3) home visits (HV) performed on 01/28/2025, the following was identified: 1. H.V #3 is an 87-year-old male admitted on 08/23/2024 with diagnosis of Alzheimer. During observations in the room, we identified a connected multiplug placed in a night table and towels placed on top of it which place risk of fire.”

“Based on observation, interview and police and procedure reviewed, three (3) home visits (H.V) performed on 01/29/2025, it was determined that the facility failed to ensure that the Licensed Practical Nurse (LPN) and Registered Nurse (RN) complies with the standard practice precaution to prevent the transmission of infectious agent 3 out of 3 (H.V #1, #2, #3) during the glove change procedure and a visit to the medication area. Findings include: During the home visits at 10:00 AM to 2:00 PM, the following was observed: 1. H.V #1 is an 82-year-old female admitted 09/05/2024 with diagnosis of Alzheimer Late Unset. The home visit was performed on 01/29/2025 at 2:09 PM with the Registered Nurse (RN) (employee #3). a. At 2:12 PM, the Registered Nurse (RN) (employee #3) had six opportunities to use hand sanitizer on glove changes. b. At 2:24 PM, the Registered Nurse (RN) (employee #3) after the right trunk ulcer healing procedure, she touched the scissors without using hand sanitizer and changing gloves. c. At 2:31 PM, the Registered Nurse (RN) (employee #3) after the ulcer healing procedure clean the scissors without using hand sanitizer or changing gloves. 2. H.V #2 is a 68-year-old female admitted 09/26/2024 with diagnosis of Chronic obstructive pulmonary disease (COPD). The home visit was performed on 01/29/2025 at 11: 45 AM with the Registered Nurse (RN) (employee #4). a. At 12:04 PM, the Registered Nurse (RN) (employee #4) after counting the medicines, she took off his gloves and did not wash his hands. 3. H.V #3 is an 87-year-old male admitted 08/23/2024 with diagnosis of Alzheimer. The home visit was performed on 01/29/2025 at 10:19 AM with the Licensed Practical Nurse (LPN) (employee #5). a. At 10:28 AM, the Licensed Practical Nurse (LPN) had three opportunities to use hand sanitizer on glove changes. b. At 10:41 AM, the Licensed Practical Nurse (LPN) during the bed bath procedure did not provide cleaning between the fingers and toes. c. At 10: 50 AM, the Licensed Practical Nurse (LPN) during bed bath procedure was observed with gel nails, administrative order #284. d. At 10:55 AM, the licensed practical nurse (LPN) during the bed bath procedure left the urine collection bag touching the floor. During the visit a medication area at 2:05 PM, the following was observed: 1. During the tour of the medication area in the company of the Service Director (employee #1) and the Coordinator Supervisor (employee #2), we observed five (5) Clotrimazole and Betamethasone Dipropionate 1% cream expired on 2/2024.”

“Based on observation made on three (3) home visits (H.V) performed on 01/29/2025, it was determined that the facility failed to ensure that the maintenance of equipment on 2 out of 3 (H.V #2, #3). Findings include: During the home visits at 10:00 AM to 2:00 PM, the following was observed: 1. 1. H.V #1 is an 82-year-old female admitted 09/05/2024 with diagnosis of Alzheimer Late Unset. a. The oxygen condenser was observed with maintenance date 04/02/2024 and 12/02/2024 expired. 2.2. H.V #2 is a 68-year-old female admitted 09/26/2024 with diagnosis of Chronic obstructive pulmonary disease (COPD). a. The oxygen condenser was observed with maintenance date 03/02/2024 and /09/02/2024 expired.”

“Based on a recertification survey, the review of documents related to the volunteer program and interview with the Service Director (employee #1)on 02/28/ 2024, it was determined that the facility failed to develop and implement policies and procedures for use of volunteers accordingly to the State Operations Manual Appendix M 418.78, Rev. 210 of 02-03-23, for hospice. Findings include: During the review of documents related to the volunteer program and interview with the Service Director (employee #1) on 02/28/ 2024 at 1:30 PM, It was noted that the facility program was drafted in 2007 and refers to CFR 42 418.70. The Condition of Participation that refers to Volunteers in the current revision (Rev. 210 02-03-23) is CFR 42 418.78, which is not included in the facility’s policies. Also, the presented Volunteer program evaluated referred to Med Care Hospice not to Med Health Hospice Inc. .”

“Based on a recertification survey, performed on 02/27/2024 to 02/28/2024 at 8:00 AM through 4:00 PM, three (3) Home Visit (H.V), with twelve (12) Record Review (R.R) with the Services Director (employee #1) and interview, it was determined that the facility failed to ensure that hospice organized, manage and administer resources to provide the hospice care and services to patients, caregivers and families necessary for the palliation and management of the terminal illness, failed to promote staffing pattern and each nurse caseload is performed in a manner to prevent the risk to have overworked nurses and poor patient care. Filed to ensure to have Physical Therapy and Dietary Counseling. Failed to revise and update the voluntary Manual. The facility failed to comply with Condition of Participation (COP) §418.72 Physical Therapy (PT), Occupational Therapy (OT), and Speech-Language Pathology (SLP), COP: §418.78 Voluntary that made this condition not met. (Cross Reference L597, L603, L676, L641, L651, l652). Finding Included: 1. Failed to ensure that hospice organized, manage and administer resources to provide the hospice care and services to patients, caregivers and families necessary for the palliation and management of the terminal illness. 2. Failed to promote staffing pattern and each nurse caseload is performed in a manner to prevent the risk to have overworked nurses and poor patient care. 3. Failed to ensure to have Physical Therapy and Dietary Counseling. 4. Failed to revise and update the voluntary Manual.”

“Based upon an Emergency Preparedness Program (EPP) survey performed on 02/27/2024 from 9:30 AM to 4:00 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 Service Director (employee #1) on 02/27/2024 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)(3).”

“Based upon an Emergency Preparedness Program (EPP) survey performed on 02/27/2024 from 9:30 AM to 4:00 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to develop arrangements with other facilities and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services. Findings include: During the review of the facilities Emergency Preparedness Program with the Service Director (employee #1) on 02/27/2024 it was noted that the facility failed to have written arrangements with other hospice facilities or other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to hospice facility patients.”

“Based upon an Emergency Preparedness Program (EPP) survey performed on 02/27/2024 at 9:00 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. Findings include: During the review of the facilities Emergency Preparedness Program with the Service Director (employee #1) on 02/27/2024 it was noted that the facility failed to 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 on a recertification survey and complaint investigation 104916 , review of policies and procedures and interview with the Service Director (employee #1), it was identified that facility failed to ensure that patient’s rights are promoted related to voice grievances regarding treatment preferences. Facility’s policy of Grievances last update in 2007 was reviewed with Service Director (employee #1), on 02/28/2024 at 1:00 PM. Policy clearly stated on the procedures that all grievance received at facility will be screened documented and investigated. The facilitys document with details of every grievance or desire to modify services received based on preferences was not promoted accordingly with the following findings identified during survey procedures on 02/27/2024 through 02/28/2024 from 8:30 AM till 4:30 PM: 1.R.R. #10 who is a 76-year-old male who was admitted on 01/03/2023 with a diagnosis of Coronary Artery Disease was reviewed on 02/27/2024 at 10:00 AM with the Service Director (employee #1) it was identified that this patient caregiver (wife) revoke hospice services on 09/28/2023. When discussing the case with Service Director (employee #1) on 02/27/2024 at 10:15 AM she stated that this patient caregiver revoked hospice services because she wants to receive services from a home care provider. Service Director (employee #1) stated on interview on 02/27/2024 at 10:45 AM that this patient caregiver disagrees with the management that patient was receiving and this this provokes the decision to revoke services to receive aggressive management of patient health condition. Service Director (employee #1) stated that she remembers that patients caregiver complaint regarding facility services and file a complaint in another organization. She stated that close to the days when patient caregiver voice her preference to revoke hospice services a person from an outside organization made a phone call to the facility to request information about the case. She stated that she does not remember the date when this phone call was received, however she remembers that a person spoke with her in relation to patient management. She stated that the day that she received this phone call she was visiting a patient from the agency, and she did not remember this persons name and details of her conversation with her. Service Director (employee #1) stated that she did not write or log this complaint according to facility procedures. Since the caregiver revoked hospice services of her husband on 09/28/2024 the situation went unnoticed, and nothing related to the compliant concerns were investigated. 2. The facility failed to document and investigate details related to patients caregivers that involve patients/caregivers related with their care, treatment, and services. 3. Facility failed to ensure that informal written or verbal complaint that is made is being screened and documented accordingly with facility polices.”

“Based on a recertification survey, performed on 02/27/2024 through 02/28/2024 twelve (12) records reviewed (RR) and three (3) home visits (HV) with the Medical Record (employee #2), and with the Services Director (employee #1) and interview, it was determined that the facility failed to ensure that services are provide accordingly with patients needs and the plan of care established by the interdisciplinary group and failed to update and individualized the plan of care for 6 out of 15 (H.V. #2, #3 and R.R #1, #2, #3, and #5). 3. R.R #1 is an 87-year-old female admitted on 09/01/2021 with a diagnosis of Chronic Kidney Disease (CKD). During the review of the medical record performed on 02/27/2024 at 1:07 PM, it was found that the nurse identified and activate patient plan of care, however, no evidence was found that the nurse updates each plan of care accordance to patient needs for: a. Pressure Areas b. Hyperlipidemia c. Fall Risk d. Intestinal Elimination e. Affliction before death f. Health Assistant Need g. Health Assistant Need h. Housekeeper Need i. Dry skin j. Dysphagia k. Insomnia l. Restlessness m. Fecal incontinence n. Urinary Incontinence o. Cough episode p. Lack of knowledge of using therapy machine q. Insecurity Lack of Knowledge Use of Oxygen Tank and Oxygen Concentrator r. Weight loss activated 8/11/2023. s. Pressure injury activated on 11/14/2023. t. Hypoglycemia Activated on 08/11/2023Fluid management in the Diet activated on 8/11/2023. u. Accumulation of Secretions activated on 08/11/2023. v. Ignorance of Suction Machine Operation and Function activated on 08/11/2023. ​ 4. R.R #2 is a 103-year-old female admitted on 12/16/2021 with a diagnosis of Alzheimer. During the review of the medical record performed on 02/28/2024 at 10:30 am, it was found that the nurse identified and activate patient plan of care, however, no evidence was found that the nurse updated each plan of care accordance to patient needs for: a. Burning when urinating Activated on 11/03/2023. b. Difficulty offering Spiritual Therapy Through Conversation due to Disorientation activated on 07/21/2023. 5. R.R #3 is a 90-year-old female admitted on 12/07/2021 with a diagnosis of Coronary Artery Disease (CAD). During the review of the medical record performed on 02/28/2024 at 9:29 AM, it was found that the nurse identified and activate patient plan of care, however, no evidence was found that the nurse actualized each plan of care accordance to patient needs for: A. Urinary Catheter Management updated on 03/28/2022. b. Unknown Use of action and adverse reaction to medications activated on 03/21/2022. c. Infection activated on 03/17/2022. d. Pressure injury activated on 07/03/2022. e. Risk of deterioration of skin integrity activated on 10/02/2022. f. Dry Cough Episode activated on 01/18/2022. g. Pain activated on 01/18/2022. h. Intestinal elimination activated on 12/21/2021. i. Urinary tract infection updated on 12/16/2021. j. Fall Risk last updated on 07/14/2023. k. Fecal Incontinence activated on 07/12/2021. l. Urinary Incontinence activated on 07/12/2021. m. Dysphagia activated on 07/12/21. n. Hyperglycemia updated on 07/12/2021. o. Weight Loss updated on 07/12/2021. p. Deficit Knowledge about ulcer activated on 07/12/2021. q. Dry Skin activated on 07/12/2021. r. Pressure injury activated on 07/12/2021. s. Unawareness of the Terminal Condition activated on 07/12/2021. t. High blood pressure 07/12/2021. u. Altered intestinal elimination related to Constipation activated on 06/02/2024. v. Improper Medication Management activated on 11/28/2023. w. Skin rash activated on 05/10/23 and 11/28/2023. x. Risk of deterioration of skin integrity activated on 11/28/2023. y. Alteration in the visual system activated on 11/16/2023. z. Alteration in comfort related to Episode of Nausea and Vomiting activated on 06/10/2023. aa. Pain activated on 04/10/2023. 6. R.R #5 is a 73-year-old female admitted on 09/22/2023 with a diagnosis of CKD. During the review of the medical record performed on 09/22/2023 at 1:00 pm, it was found that the nurse identified and activate patient plan of care, however, no evidence was found that the nurse updates each plan of care accordance to patient needs for: a. Urinary Catheter Management activated on 09/22/2023. b. Fecal incontinence activated on 09/22/2023. c. Respiratory Difficulty activated on 09/22/2023. d. Liquid Management in the patient’s diet activated on 09/22/2023. e. Dehydration activated on 09/22/2023. f. Risk of falling activated on 09/22/2023. g. Dry Skin activated 09/22/2023. h. Lack of knowledge in the use and Adverse Action and Reaction to Medications activated on 09/22/2023. i. Weight loss activated on 09/22/2023. j. Poor appetite activated on 09/22/2023. k. Management of a bedridden patient on 09/22/2023. l. Diarrhea on 10/26/2023. m. Unrest on 11/11/2023 n. Risk of Falling on 06/11/2023. o. Pain on 03/11/2023. p. Urinary Infection on 03/11/2023. ​ During interview with the Service Director on 02/28/2024 at 10:40 AM state that the nurse identified patient problems and activate the plan of care and each discussion of the plan of care in the interdisciplinary group meeting updates the plan of care and if resolve close the plan of care problem resolved. Findings include: 1. HV #2 is a 90-year-old male admitted on 11/01/2023 with Parkinson disease. During the record review on 02/28/2024 at 8:43 AM, it was determined that after admission Interdisciplinary Group (IDG) establish the following frequency to the services Registered Nurse (RN) two (2) visit a week and as needed, Home Health Aide (HHA) (5) visit and as needed, Physician one (1) visit a month as needed, Social Worker one (1) visit a month as needed and Spiritual Counselor one (1) visit a month as needed. a. No evidence was found of the RN offering one (1) visit on the weekend 02/11/2024 to 02/17/2024 and two (2) visits on 02/18/2024 to 02/24/20224. 2. HV #3 is a 93-year-old female admitted on 04/13/2022 with Liver disease. During the record review on 02/28/2024 at 1:50 PM, it was determined that after admission Interdisciplinary Group (IDG) establish the following frequency to the services Registered Nurse (RN) two (2) visit a week and as needed, Home Health Aide (HHA) (5) visit and as needed, Physician one (1) visit a month as needed, Social Worker one (1) visit a month as needed and Spiritual Counselor one (1) visit a month as needed. a. No evidence was found of the RN offering one (1) visit on the weekend 01/28/2024 to 02/03/2024 and two (2) visits on 02/04/2024 to 02/10/2024. b. No evidence was found of the HHA offering five (5) visits on 02/04/2024 to 02/10/2024 and 02/11/2024 to 02/24/2024.”

“Based on a recertification survey, performed on 02/27/2024 to 02/28/2024 at 8:00 AM through 4:00 PM, three (3) Home Visit (H.V), with twelfth (12) Record Review (R.R) with the Services Director (employee #1) and interview, it was determined that the facility failed to ensure that the plan of care include a detailed statement of the scope and frequency Home Health Aide (HHA), Registered Nurse (RN) necessary to meet the specific patient and family needs, X out of 3. (HV #2 and HV #3) Findings include: 1. R.R-HV #2 is a 90-year-old male admitted on 11/01/2023 with Parkinson disease. During the record review on 02/28/2024 at 8:43 AM, it was found that after admission Interdisciplinary Group (IDG) establish the following frequency to the services Registered Nurse (RN) two (2) visit a week and as needed, Home Health Aide (HHA) (5) visit and as needed, Physician one (1) visit a month as needed, Social Worker one (1) visit a month as needed and Spiritual Counselor one (1) visit a month as needed. a. During record review, one RN visit from 02/11/2024 to 02/17/2024 and 02/18/2024 to 02/24/2024 (2) RN visits were found to be missing, During an interview with the Medical Registrar (employee #6) on 02/28/2024 at 1:43 PM stated that he could not find the nursing notes. 2. R.R.-HV #3 is a 93-year-old female admitted on 04/13/2022 with Liver disease. During the record review on 02/28/2024 at 1:50 PM, it was determined that after admission Interdisciplinary Group (IDG) establish the following frequency to the services Registered Nurse (RN) two (2) visit a week and as needed, Home Health Aide (HHA) (5) visit and as needed, Physician one (1) visit a month as needed, Social Worker one (1) visit a month as needed and Spiritual Counselor one (1) visit a month as needed. a. One RN visit from 01/28/2024 to 02/03/2024 and from 02/04/2024 to 02/10/2024 (2) RN visits were found to be missing, b. Five HHA visits from 02/04/2024 to 02/10/2024 and from 02/11/2024 to 02/17/2024 were found to be missing, During an interview with the Medical Registrar (employee #6) on 02/28/2024 at 1:50 PM stated that he could not find the HHA and the nurses notes.”

“Based on a recertification survey, observations made during three home visits (H.V), it was determined that the facility failed to follow an acceptable standard of infection control during the procedure of hand wash performed in 2 out of 3 home visits. Failed to comply with Department of health Administrative Order #284 established the use of artificial nails. (H.V#2 and HV #3). Findings include: 1.H.V #2 is a 90-year-old male admitted on 11/01/2023 with diagnosis Parkinson disease with Dyskinesia. The patient was visited on 02/27/2024 at 11:32 AM accompanied by facility nursing personnel (employee # 3). During the visit the patient was observed bedridden and totally dependent on activities of daily living. The Register Nurse (RN) (employee #3) proceeded to wash hands after drying the hands, then took the hands of the care giver to lift her from the seat. He put on the gloves without using hand sanitizer before putting on the gloves. The RN had 7 opportunities to use hand sanitizer or hand wash before putting on gloves while he was intervening with the patient. 2.H.V #3 is a 93-year-old female admitted on 04/13/2022 with diagnosis Liver disease. The patient was visited on 02/27/2024 at 12:44 PM accompanied by facility Home Health Aide- HHA (employee #4). During the visit the patient was observed bedridden and totally dependent on activities of daily living. The HHA #4 was observed wearing gel nails while offering the bath to the patient. 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, twelve (12) records reviewed (RR) and three (3) home visits (HV), review of policies and procedures, interview with the Service Director (employee #1), it was determined that facility failed to ensure that the Dietary counseling, when identified in the plan of care, must be performed by a qualified dietitians to assure that the dietary needs of the patient 15 out of 15. Findings include: The facility did not ensure that a standardized way of identifying nutritional status and body dimensions was implemented. During the survey procedures, from 02/27/2024 to 02/28/2024 from 8:00 AM to 4:00 PM, the following was found. a. During the evaluation on 02/27/2024 to 02/28/2024 from 8:00 AM to 4:00 PM in the 12 sample clinical records, the evaluation by the dietary Counseling staff was not found. b. The service director (employee #1) was interviewed on 02/28/2024 at 2:54 PM stating that since the beginning of Covid -19 they do not have dietician services. Currently, those who were doing the nutritional evaluations of the patients are the physicians personnel.”

“Based on a recertification survey, and complaint investigation,104920 and interview with Service Director (employee #1) and Social worker (employee # 10) it was identified that facility failed to develop and implement policies and procedures who guide the home maker services. This deficient practice had the potential to affect 34 out of 34 patients receiving services. Findings include: Social worker While reviewing policies that structure facility homemaker duties and services provided at the facility on 02/28/2024 at 2:00 PM the following was identified: 1. Social worker (employee # 10) was interview on 02/28/2024 at 11:30 AM in relation with home maker criteria in which facility based their home maker services provision. During interview employee #10 stated that to provide this service every patient needs are carefully assessed in order to determine the need of assistance in maintaining a safe and healthy environment and carry out the treatment plan. He stated that if is identified the need of this service inclusion of this is recommended and approved after discussion by the interdisciplinary members on the Interdisciplinary Group (IDG) meeting. 2. It was requested to the Service Director (employee #1) on 02/28/2024 at2:30 PM the policies and procedures who guide the home maker services. She stated that not policies and procedures who govern home maker services were developed or implemented at the facility.”

“Based on a recertification survey, performed on 02/27/2024 to 02/28/2024 at 8:00 AM through 4:00 PM, three (3) Home Visit (H.V), with twelve (12) Record Review (R.R) with the Services Director (employee #1) and interview, it was determined that the facility failed to ensure that the governing body assumes full legal authority and responsibility for the management of the hospice, is responsible for the day-to-day operation of the hospice. Related to review and update facilitys policy and procedure and manuals. Finding include: 1. During the review of Policy and Procedure of Care Plan on 02/28/2024 at 1:00 PM, it was found that the policy was created in 2007. This policy was on review however, the governing body did not approve and implemented this revision. 2. During the review of documents related to the volunteer program with the Service Director (employee #1) on 02/28/ 2024 at 1:30 PM, it was noted that the facility program was drafted in 2007 and refers to CFR 42: §418.70. The Condition of Participation that refers to Volunteers in the current revision (Rev. 210 02-03-23) is CFR 42 §418.78, which is not included in the facility’s policies. Also, the presented Volunteer program evaluated referred to Med Care Hospice not to Med Health Hospice Inc. It was found that the governing body failed to develop and implement policies and procedures for the use of volunteers.”

“Based on a recertification survey, and complaint investigation, and interview with the nursing personnel (employee #3, employee #5, employee #11, and employee #13) and interview with Service Director (employee #1) it was identified that facility failed to promote staffing pattern and each nurse caseload was performed in a manner that prevent the risk of had overworked nurses and poor patient care. Failed to provide Dietary Counseling and Physical Therapy Services. This deficient practice had the potential to affect 34 out of 34 patients receiving services. 3. The following was identified during survey procedures, 02/27/2024 through 02/28/2024 from 8:30 AM through 4:00 PM: During the review of each case, it was identified that the facility did not use a Nutritional evaluation tool for the patients. According to the information provided by the Service Director (employee #1) during the interview on 02/27/2021 at 10:00 AM, mentioned that during the beginning of the Covid-19 pandemic they did not have a nutritionist available, that the Nutritional assessments are performed by the physicians. 2. During interview with the Service Director employee #1 on 02/27/2024 at 10:00 AM, the surveyor asks if facility have and arrangement with physical therapy services and Dietitian Service. The Service Director state that the Physical therapy is difficult to recruit and does not have the service and does not have the nutritionist for the dietary counseling, they had an excellent nutritionist but she died and currently it has become difficult to recruit again, at the moment the physician performed the nutritional risks and orders the diet. 1.While reviewing nursing staffing schedule for home visit based on current level of care provided to active patients and information of how the hospice provides 24-hours services receiving services the following was identified on 02/27/2024 at 9:00 AM: a. Accordingly with information provided by Service Director (employee #1) on interview on 02/27/2024 at 9:30 AM facility had a census of active cases of 34 patients. There are 3 register nurses assigned to those patients. She explain that until February 9, 2024 there were 4 register nurses but one of the nurses renounce on February 9, 2024. Accordingly to the number of active patients to each one of those 3 nurses were assigned 11 patients to visit with a frequency of two visits per week. In addition to those 11 patients that each nurse had assigned them were assigned to perform new admissions to the hospice program in case that an admission enter to the program. In addition to this to make available 24- hours services each one of those 3 nurses were assigned on a weekly rotating basis for coverage on call nursing services. The nurse in charge of on call services will coverage the 34 patients needs if required when assigned. She explain that during natural year 2022 and 2023 facility had only being able to recruit young graduate nurses. She also explain that due to the fact that facility had only being able to recruit young graduate nurses, facility faces the challenges that entails to recruit young graduate nurses. She stated that young graduate nurses faces challenges as they integrate into the culture of a work environment and one of the significant challenges that facility faces is that those young graduates nurses had a significant challenge to organizing their workflow and manage their time. She stated that since during natural year 2022 and 2023 facility had experienced a health care employees movement characterized by the resignation of them in the hire orientation process and that none of those personnel specially the nurses last a period of more that three to six months at the agency. b. Nursing personnel (employee #3) stated on interview on 02/27/2024 at 11:54 AM that he works as register nurse at the facility since May, 2023. He stated that he graduate from nursing school on year 2022 and since then he is in the process of approve the nursing board exam because he is exercising the practice of nursing with a provisional license in PR. He stated that he was assigned with 11 patients to visit with a frequency of two visits per week if thew census is 34 patients but that he had assigned to perform new admissions to the hospice program in case that an admission enter to the program and he was assigned to provide on call services on a rotating weekly basis for coverage on call nursing services. He said that he is in charge of on call services will coverage the 34 patients needs if required when assigned. He said he likes to works on this facility however thinks that if there is less workload it must much easier to perform duties assigned. He also stated that pertinence documentation required to nursing personnel when intervene with patients its one of the elements that takes a lot of effort by each nurse to comply and based on workload there is a probability that sometimes the nurse become not in compliance with facility policies and procedures pertaining to documentation. c. Nursing personnel (employee #5) stated on interview on 02/28/2024 at 9:54 AM that she works as register nurse at the facility since November, 2023. She stated that she graduate from nursing school on August ,2023. She stated that she had a permanent license to exercise nursing practice in PR. She stated that she was assigned with 11 patients to visit with a frequency of two visits per week if the census is 34 patients but that she had assigned to perform new admissions to the hospice program in case that an admission enter to the program and she was assigned to provide on call services on a rotating weekly basis for coverage on call nursing services. She said that she is in charge of on call services will coverage the 34 patients needs if required when assigned. She stated that this is modified based on patient census change or modifications of patients frequency of visits identified in the discussions of the interdisciplinary team discussions, She said that the documentation required to be performed by each nurse in one of the aspects that based on her experience takes much of the time and could influence home visit schedule. d. Nursing personnel (employee #11) stated on interview on 02/28/2024 at 11:00 AM that she works as register nurse at the facility since November 30, 2023. She stated that she graduate from nursing school on year 2021. She stated that she had a permanent license to exercise nursing practice in PR. She stated that she was assigned with 11 patients to visit with a frequency of two visits per week if the census is 34 patients but that she had assigned to perform new admissions to the hospice program in case that an admission enter to the program and she was assigned to provide on call services on a rotating weekly basis for coverage on call nursing services. She said that she is in charge of on call services will coverage the 34 patients needs if required when assigned. She stated that to comply with documentation required to be performed by each nurse at the facility takes notes home and prepare the documentation at home in order to be more easily to perform other duties assigned. e. Nursing personnel (employee #13) stated on interview on 02/28/2024 at 1:30 PM that she works as Home Health Aide ( HHA) at the facility since May, 2023. She stated that she had license of Licensed practical Nurse since year 2016 She stated that with the current active census of 34 patients she had 8 patients assigned to provide home health aide services and that sometimes the town were patients home is located influence the time she spent traveling in the car to get from one residence to the other. She stated that no matter what happen she need to provide services to every patient assigned. She stated that since year 2023 she is the only HHA working at the facility and that if them recruit other HHA personnel workload is much easier to complete.”

“Based on a recertification survey, performed on 02/27/2024 to 02/28/2024 at 9:00 AM through 4:00 PM, three (3) Home Visit (H.V), with twelfth (12) Record Review (R.R) with the Services Director (employee #1) and interview, it was determined that the facility failed to ensure that the plan of care include a detailed statement of the scope and frequency Home Health Aide (HHA), Registered Nurse (RN) necessary to meet the specific patient and family needs and failed to ensure that patient medical record include patient plan of care, updated plan of care, clinical note of all discipline Registered Nurse (RN), Home Health Aide (HHA), Home Maker (HM), Social Worker (SW), Physician (P) and Spiritual Assessor (SA) for 8 out of 15 records reviewed (R.R.-H.V #1, #2, #3, RR #1, #2, #3, #5 and #11). 7. Home Visit #1 is an 88 years old, female patient admitted on 03/16/2022 with diagnosis of Alzheimer, Bed Confinent Status, Diabetes Mellitus Type II, Hight Blood Pressure, Full Incontinence of Feces, Urinary Incontinence, Dysphagia, Pressure Ulcer of Left heel Stage II and Disnea. The patient was visit on 02/27/2024 at 1:50 PM. The patient was observed bedridden, alert, total depended on daily ADL’S, difficulty verbal expression, postrate on bed and blanderized diet. Accompany with family care giver, her daughter. a. During the home visit performed on 02/27/2024 at 1:50 PM a medication review was performed. Based on the information provided by patient daughter and the last patient plan of care reviewed on 02/14/2024 was identified that the patient is only taking Panadol 500 mgs p.o. 2 tablets every 4 hours and Sylvadine 1 % apply to the afected area two times daily. b. On 08/10/2023 at 9:04 AM the physician (employee #18) ordered hold medications (Glimepizide 2 mgs. tab. 1 tab. bid, Omeprazole 20 mgs. 1 cap. in AM, , Vitamin D-3 10,000 units cap. in AM, Lisinopril 5 mgs. 1 tab. daily in AM and Plavix 75 mgs.1 tab. in AM) per one week because the patient caregiver notify that did not administered the medications according of the physician prescription because cause nauseas and the physician ordered maintain the patient on observation and notify changes. c. On 08/18/2023 the physician (employee #18) evaluated the ’’ hold medications ’’ and ordered to continue to administered the medications ordered by the physician ’’ however the facility continue with the hold medications order of 8/10/2023. During the home visit performed on 02/27/2024 at 1:50 PM the patient care giver refer that her mother only received “ Panadol 2 tablets by mouth when as needed. d. On 07/02/2023 at 11:00 AM the physician (employee #18) ordered a urinary catheter #16 and change every 30 days. per vaginal itching until two weeks and ordered a urine sample. During the record review performed on 02/28/2024 at 9:00 AM the nurses notes did not provide evidence when the nurse catheterized the patient and no evidence when the nurse realized the urine sample, however no evidence on the nurses notes when the nurse change the folly catheter every 30 days according of the physician order. The patient record lacks of physician order to discontinue the folly catheter. During the record review no evidence of the urine sample result. The Clinical Service Director was interview on 02/28/2024 at 11:30 AM related to the urine sample and she call to the laboratory and she stated that the laboratory never received the urine sample and she refer that the nurse never took the urine sample. The facility failed to assure that the patient received the services according of her needs. 3. R.R #1 is an 87-year-old female admitted on 09/01/2021 with a diagnosis of Chronic Kidney Disease (CKD). During the review of the medical record performed on 02/27/2024 at 1:07 PM, the plan of care stablishes the following frequency of visits for Registered Nurse (RN)N 2 visit per week and as needed (PRN), Social Worker 1 visit per month and PRN, Home Health Aids (HHA) 5 visits per week, Home Maker (HM) 3 visit per week, Spiritual Assessor 1 visit per month and PRN and Physician 1 visit per month and PRN. It was found the following: a. During the week from 01/21/2024 through 01/27/2024, no evidence was found of one visit of the HHA. b. During the week from 01/28/2024 through 02/03/2024, no evidence was found of one visit of the RN. c. During the week from 02/11/2024 through 02/17/2024, no evidence was found of one visit of the RN, 5 visit of the HHA and 3 visit of the Home Maker (HM). d. During the week from 02/18/2024 through 02/24/2024, no evidence was found of two visits of the RN, five visit of the HHA and 3 visit of the HM. 4. R.R #2 is a 103-year-old female admitted on 12/16/2021 with a diagnosis of Alzheimer. During the review of the medical record performed on 02/28/2024 at 10:30 AM, the plan of care stablishes the following frequency of visits for Registered Nurse (RN) 2 visit per week and as needed (PRN), Social Worker 1 visit per month and PRN, Spiritual Assessor 1 visit per month and PRN and Physician 1 visit per month and PRN. It was found the following: a. During the week from 02/04/2024 through 02/10/2024, no evidence was found of one visit of the RN. b. During the week from 02/11/2024 through 02/17/2024, no evidence was found of one visits of the RN, one visit of the physician. c. During the week from 02/18/2024 through 02/24/2024, no evidence was found of two visits of the RN. 5. R.R #3 is a 90-year-old female admitted on 12/07/2021 with a diagnosis of Coronary Artery Disease (CAD). During the review of the medical record performed on 02/28/2024 at 9:29 AM, the plan of care stablishes the following frequency of visits for Registered Nurse (RN)N 2 visit per week and as needed (PRN), Social Worker 1 visit per month and PRN, Spiritual Assessor 1 visit per month and PRN and Physician 1 visit per month and PRN. It was found the following: a. During the month of January 2024, no evidence was found of the physician visit of the month of January, last visit on 12/27/2023 and the next visit was on 02/08/2024. b. During the week from 02/04/2024 through 02/10/2024, no evidence was found of two visits of the RN. c. During the week from 02/11/2024 through 02/17/2024, no evidence was found of two visits of the RN. d. During the week from 02/18/2024 through 02/24/2024, no evidence was found of two visits of the RN. 6. R.R #5 is a 73-year-old female admitted on 09/22/2023 with a diagnosis of CKD. During the review of the medical record performed on 09/22/2023 at 1:00 PM, the plan of care stablishes the following frequency of visits for Registered Nurse (RN) 2 visit per week and as needed (PRN), Social Worker 1 visit per month and PRN, Spiritual Assessor 1 visit per month and PRN and Physician 1 visit per month and PRN. It was found the following: a. During the week from 12/31/2023 through 01/06/2024, no evidence was found of tone visit of the RN. b. During the week from 02/11/2024 through 02/17/2024, no evidence was found of one visit of the RN. c. During the week from 02/18/2024 through 02/24/2024, no evidence was found of two visits of the RN. d. During the month of February 2024, no evidence was found of the physician visit of the month, Last visit on 01/22/2024. Facility’s policy of Medical Record Documentation last update in March 2021 was reviewed with Service Director (employee #1), on 02/28/2024 at 2:30 PM. Policy clearly stated on the procedures that to documentation related with healthcare professionals must be available on the medical record in a period of 24-48 hours after service was provided. 1. The availability, completeness and accuracy of medical health patient record information was not promoted or performed. The following was identified during survey procedures, 02/27/2024 through 02/28/2024 from 8:30 AM through 4:00 PM when facility was requested to provide evidence of initial assessment and nurses progress notes of records of cases on the sample selection: 2.The following was identified while reviewing RR #11 on 02/28/2024 at 10:30 AM with Service Director (employee #1): a.R.R. #11 is an 89 years old female who was admitted on 09/26/2023 with a diagnosis of Cerebro Vascular Accident. Alzheimer Early Onset was reviewed on 02/28/2024 at 9:00 AM with the Service Director (employee #1). While reviewing the case it was identified that the documentation of the initial assessment and history performed by the nurse who visit the patient on 09/26/2024 was not found on the medical record. Nursing progress notes pertaining to home visits performed by the register nurse on 10/06/2023,10/20/2024 and 10/26/2024 were not found either on the medical record. Service Director (employee #1) stated in an interview on 02/28/2024 at 1:50 PM that this medical record documentation was requested to be completed by the register nurse who performed those home visits and the initial assessment. She also explained that the register nurse resigns from the agency on 10/16/2024 and before leaving he/she did not complete and deliver the documentation that she owed. The facility begins a legal process on 01/25/2024 to get her to comply, however at this moment this has not been possible. Findings include: 1. R.R-HV #2 is a 90-year-old male admitted on 11/01/2023 with Parkinson disease. During the record review on 02/28/2024 at 8:43 AM, it was found that after admission Interdisciplinary Group (IDG) establish the following frequency to the services Registered Nurse (RN) two (2) visit a week and as needed, Home Health Aide (HHA) (5) visit and as needed, Physician one (1) visit a month as needed, Social Worker one (1) visit a month as needed and Spiritual Counselor one (1) visit a month as needed. a.During record review, one RN visit from 02/11/2024 to 02/17/2024 and 02/18/2024 to 02/24/2024 (2) RN visits were found to be missing, During an interview with the Medical Registrar (employee #6) on 02/28/2024 at 1:43 PM stated that he could not find the nursing notes. 2. R.R.-HV #3 is a 93-year-old female admitted on 04/13/2022 with Liver disease. During the record review on 02/28/2024 at 1:50 PM, it was determined that after admission Interdisciplinary Group (IDG) establish the following frequency to the services Registered Nurse (RN) two (2) visit a week and as needed, Home Health Aide (HHA) (5) visit and as needed, Physician one (1) visit a month as needed, Social Worker one (1) visit a month as needed and Spiritual Counselor one (1) visit a month as needed. a. One RN visit from 01/28/2024 to 02/03/2024 and from 02/04/2024 to 02/10/2024 (2) RN visits were found to be missing, b. Five HHA visits from 02/04/2024 to 02/10/2024 and from 02/11/2024 to 02/17/2024 were found to be missing, During an interview with the Medical Registrar (employee #6) on 02/28/2024 at 1:50 PM stated that he could not find the HHA and the nurses notes.”

“Based on the recertification survey performed on 02/27/2024 and 02/28/2024, three home visits (H.V) with records reviewed (R.R.), twelve records reviewed, interviews and observations, it was determined that the facility failed to ensure that all entries must be legible, clear, complete, and appropriately authenticated and dated in accordance with hospice policy and currently accepted standards of practice for 1 out of 3 home visits (HV) (R.R.-HV#1) Findings include: R.R.-HV#1 is and 88 years old, female patient admitted on 03/16/2022 with diagnosis of Alzheimer, Bed Confinent Status, Diabetes Mellitus Type II, High Blood Pressure, Full Incontinence of Feces, Urinary Incontinence, Dysphagia, Pressure Ulcer of Left heel Stage II and Dyspnea. The patient was visit on 02/27/2024 at 1:50 PM. The patient was observed bedridden, alert, total depended on daily ADL’s, difficulty verbal expression, prostrated on bed. Accompany with family care giver her daughter. a. The record was review on 02/28/2024 at 9:00 AM and provide evidence that all progress notes, plan of care, physician orders and others document written per the physician (employee #19) not legible. The record provide evidence that all of progress notes, plans of care and others documents written per the physician is not legible and lacks of information related to vitals sings and oxygen therapy. b. The facility Clinic Service Director (employee #1) was interview on 02/28/2024 at 11:00 AM related to this situation and she refer that the physician always has written the same. The facility did not have electronically clinical records.”

“Based on a recertification survey and complaint investigation,1049920 and interview with the Outside contractor medical durable equipment employee (employee #9) it was identified that facility failed to demonstrate that routine and preventive maintenance of durable equipment provided to patients is performed. This deficient practice had the potential to affect 34 out of 34 patients receiving services. Findings include: While review outside medical durable equipment contractor documentation on 02/28/2024 at 10:32 AM it was requested to the outside contractor medical durable equipment employee (employee #9) evidence of the review or certification with information that the medical or biomedical equipment function. 2. Evidence provided during survey procedures on 02/28/2024 at 10:00 AM of medical durable and biomedical equipment maintenance only include repairs of any equipment breakdowns and restoring to full functionality or replacement of equipment that does not function properly to patients who request revision of those equipments. 3. The outside contractor medical durable equipment employee (employee #9) stated on interview on 02/28/2024 at 10:45 AM that he does not have an inventory of equipment in use and did not have any evidence that include review or certification that the medical or biomedical equipment provided to patients function accordingly with manufactures specifications. 4. The outside contractor medical durable equipment employee (employee #9) stated on interview on 02/28/2024 at 10:45 AM that on an ongoing basis he monitors equipment performance if necessary conduct regular servicing who include testing batteries if apply, clean and inspect function, however he did not document those revisions.”