Hospicio La Monserrate

“Based upon an Emergency Preparedness Program (EPP) survey performed on 11/13/2024 from 10:30 AM to 1:30 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 QAPI Manager (employee #2) on 11/13/2024 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 11/13/2024 from 10:30 AM to 1:30 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 QAPI Manager (employee #2) on 11/13/2024 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)(4).”

“Based upon an Emergency Preparedness Program (EPP) survey performed on 11/13/2024 from 10:30 AM to 1:30 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to maintain an emergency preparedness communication plan that complies with Federal, State and local laws. Findings include: During the review of the facilities Emergency Preparedness Program with QAPI Manager (employee #2) on 11/13/2024 it was noted that the facility failed to have in place a written communication plan of how the facility coordinates patient care and how the facility interacts and coordinate with emergency management systems to protect health and safety of patients as required under §418.113(c).”

“Based upon an Emergency Preparedness Program (EPP) survey performed on 11/13/2024 from 10:30 AM to 1:30 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to develop primary / alternate means for communication with staff, Federal, State regional and local emergency management agencies in compliance with Federal, State and local laws. Findings include: During the review of the facilities Emergency Preparedness Program with the QAPI Manager (employee #2) on 11/13/2024 it was noted that the facility failed to provide evidence of the Emergency Preparedness Communication Plan that included primary and alternate means for communicating with the facility staff, Federal, State, regional and local emergency management agencies under §418.113(c)(3).”

“Based on a recertification survey, the review of documents related to the volunteer program and interview with the Human Resources Director (employee #5), it was determined that the facility failed to maintain volunteer staff to provide administrative or direct patient care equal to five percent of the total patient care hours of all paid hospice employees and contract staff. Findings include: 1. During the review of volunteer program on 11/14/2024 at 10:30 AM it was evidenced that the agency do not meet with the requirement to comply with a minimal of 5 percent of cost services from the total patient care hours of all paid hospice employees and contract staff. The facility did not provide evidence of the 5 percent (%) of saving with the volunteer program. 2. The facility failed to maintain volunteer staff to provide administrative or direct patient care equal to five percent of the total patient care hours of all paid hospice employees and contract staff.”

“Based on three Home Visit (HV) with records reviewed, sixteen records reviewed (RR), staff and caregiver interviews, it was determined that the facility failed to ensure that the clinical record contains current assessment and reassessments for each hospice patient related to Registered Nurses (RN) notes for 1 out of 19 records reviewed. (HV-RR#3) Findings include: . HV-RR # 3 is a 90-year-old female is a 90-year-old female who was admitted on 07/08/2024 with a diagnosis of Senile Degeneration of Brain and Alzheimer Disease. The interdisciplinary group determined two visits per week for the Registered Nurse (RN). According to the medical record review performed on 11/14/2024 at 1:00 PM, the following was found: a. No evidence was found of nurses notes reassessments from week started on 10/6/2024 through 11/14/24, when the record was reviewed. b. During interview with employee # 1 on 11/14/2024 stated that there was a visit log were the nurse registered every encounter with patient and relatives during home visits. c. Copy of the log was presented, showing the following dates of home visits performed by the RN signed by patient relatives: 10/3/2024, 10/7/2024, 10/10/2024, 10/14/2024, 10/17/2024, 10/21/2024, 10/24/2024, 10/29/2024. During and interview with RR # 3 and patients’ caregiver interview performed on 11/14/2024 at 10:00AM, stated that the patient received RN visits three times per week. T The facility failed to ensure accessible and available nurses reassessments in the medical record.”

“Based on review of the contracted personnel credential files (CF) with the human resources (employee #5) and interview performed on 11/14/2024 at 2:00 PM, it was determined that the facility failed to ensure that 3 out of 4 contracted staff who provide services have updated credential files related to Speech Therapy, Occupational Therapist and Physician. (CF#1, #2, #3). Findings include: The facility failed to ensure that all personnel qualifications are kept updated. 1. CF# 1- Occupational therapist. · The contract document did not specify the beginning date and ending date. · The contract addendum was not signed by an employee. · No diploma as evidence of educational requirement. 2. CF # 2- Physician. · Criminal background check was issued on 04/25/2023. · State narcotics license was due since 07/31/2024. 3. CF # 3. Speech Language Therapist · Speech language therapist contract document did not specify the beginning date and ending date. · No evidence of Criminal background check. · No health certificate. · No diploma nor license as evidence of educational and state requirement. During interview with employee # 5 (Human Resources Officer) on 11/14/2024 at 2:00 PM, she stated that some of the personnel documents could be archived in the other agency were the personnel are contracted.”

“Based upon an Recertification and Emergency Preparedness Program (EPP) survey performed on 11/13/2024 from 10:30 AM to 1:30 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to meet the applicable provisions in accordance with the Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4.) for 2 out of 3 home visits (HV).(HV#1 and #3). Findings include: Based on three (3) home visits (HV) performed between November 13 and 14, 2024 the following was identified: On two (2) out of three (3) home visits performed by the surveyors, no signs were observed notifying the use of oxygen. No signage was observed at the entrance to the residence nor was any signage observed in the room where the oxygen was being used. On three (3) out of three (3) home visits performed by the surveyors, electrical safety was not observed in the patients’ residences. According to the institution’s internal policies, residence hall receptacles must be checked before connecting electrical equipment such as oxygen concentrators. When requesting evidence of the validations, the institution could not provide evidence. The use of multipliers was also observed that could overload the electrical circuits, putting the risk of fire. Three (3) out of three (3) exit signs on the facility were observed un energized by emergency power or by battery power source.”