Every finding on record at Americare Health LLC

An unannounced Emergency Preparedness Program (EPP) and recertification inspection was conducted by the Puerto Rico State Agency surveyors at the Cuidado Casero Guaynabo on November 1, 2022 from 8:15 AM through 12:00 PM (Event ID: 5E251-H). As a result of findings the facility was found in compliance with 42 CFR § 484.102 Conditions of Participation for Emergency Preparedness for Home Health Care. However, three (3) standard level deficiencies were cited as listed below: Survey Date: 11/01/2022

Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This STANDARD is not met as evidenced by: Based on an Emergency Preparedness Program (EPP) survey and review of the Emergency Preparedness Plan (EPP) for recertification, performed on 11/01/2022 from 8:15 AM through 12:00 PM, to evaluate the Emergency Preparedness requirements, it was determined that the facility failed to ensure Policies and Procedures concerning the use of volunteers in an emergency. Findings include: During the review of the facilities Emergency Preparedness Program on 11/01/2022 from 8:15 AM through 12:00 PM 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 §484.102(b)(5)

Development of Communication Plan CFR(s): 484.102(c) §403.748(c), §416.54(c), §418.113(c), §441.184(c), §460.84(c), §482.15(c), §483.73(c), §483.475(c), §484.102(c), §485.68(c), §485.625(c), §485.727(c), §485.920(c), §486.360(c), §491.12(c), §494.62(c). (c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. This STANDARD is not met as evidenced by: Based on an Emergency Preparedness (EP) survey and review of the Emergency Preparedness Plan (EPP) for recertification, performed on 11/01/2022 from 8:15 AM to 12:00 PM, to evaluate the emergency preparedness requirements, it was determined that the facility failed to develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws. Findings include: 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 under §484.102(c).

Primary/Alternate Means for Communication CFR(s): 484.102(c)(3) §403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (3) Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. *[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID's staff, Federal, State, tribal, regional, and local emergency management agencies. This STANDARD is not met as evidenced by: Based on an Emergency Preparedness (EP) survey and review of the Emergency Preparedness Plan (EPP) for recertification, performed on 11/01/2022 from 8:15 AM to 12:00 PM, to evaluate the emergency preparedness requirements, it was determined that the facility failed to develop primary / alternate means for communication with HHA’s staff, Federal, State regional and local emergency management agencies in compliance with Federal, State and local laws. Findings include: The facility did not 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 §484.102(c)(3).

An unannounced Recertification survey was conducted by the Puerto Rico State Agency surveyor at Cuidado Casero Guaynabo, Inc Home Health Agency on November 01, 2022 through November 02, 2022 (Event ID: 5E251-H1). The facility is in compliance with the requirements of 42 CFR Part 484 Conditions of Participation for Home Health Agencies. Survey Dates: 11/01/2022-11/02/22 Survey Census: 56 patients Sample Size: 7 Home Visit: 3 Record Review:7 Covid-19: COVID 19 Vaccination evaluated during the survey. Patient Covid-19 positive: 0 Staff Covid-19 positive: 0 Staff Vaccinated %: 100% (fully vaccine)