Every finding on record at Luz De Esperanza Home Care

A Standard Recertification survey was conducted on November 20 through November 21, 2025, from 8:00 AM through 5:00 PM at Luz de Esperanza Home Care in Manati (Event ID: 1DBC87-H1). As results of the findings, the facility was found not in compliance with 42 CFR §484 Requirements for Home Health Agency with the following Standard level deficiencies listed below: Survey Date: 11/21/2025 Survey Census: 96 patients Sample Size: 10 Home Visits: 4 Record Review: 3 Closed Record Review Discharge: 3

Medical social services supervised by MSW CFR(s): 484.75(c)(3) Medical social services are provided under the supervision of a social worker that meets the requirements of §484.115(m). This ELEMENT is not met as evidenced by: Base on staff interview and credential file reviewed performed on 11/21/2025 at 1:25PM to 1:30PM, it was found that the facility failed to supervise the social worker assistant by a social worker with a master or doctoral degree. Findings include: 1. During an interview with the nursing supervisor (employee #2) performed on 11/21/2025 at 1:25PM, she stated that the social worker of the facility has a bachelor’s degree and is supervised by her. 2. The credential file of the social worker assistant was verified accompanied by employee #2 on 11/21/2025 at 1:30PM and it was confirmed that the education degree is a bachelor.

An unannounced Recertification and Emergency Preparedness survey was conducted by the Puerto Rico State Agency surveyors at Luz de Esperanza Home Care on October 13, 2022 (Event ID: 5DF2B-H1) from 8:30 AM till 1:30 PM. As results of finding the facility was found to be in compliance with 42 CFR Part 484.102 Emergency Preparedness Requirements for Home Health Agency. However, two (2) standard level deficiencies were cited as listed below: Survey date: 10/13/2022

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 upon an Emergency Preparedness Program (EPP) survey performed on 10/13/2022 at 9:00 AM to 11:30 AM, 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 Service Director employee #2 on 10/13/2022 at 10:30 AM 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).

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(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:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: Based upon an Emergency Preparedness Program (EPP) survey performed on 10/13/2022 from 9:00 AM to 11:30 AM, to evaluate 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: During the review of the facilities Emergency Preparedness Program with Service Director, employee #2, on 10/13/2022 at 11:00 AM it was noted that the Communication Plan failed to provide contact information for the Staff, Entities providing services under arrangements, patients physicians and other facilities as required under §484.102(c) of the Emergency Preparedness.

A Recertification, and Emergency Preparedness survey was conducted by the Puerto Rico State Agency surveyor at Luz de Esperanza Home Care, Inc. on October 12, 2022, through October 13, 2022 (Event ID 5DF2B-H1). As results of finding during the Recertification survey the facility is in compliance with 42 CFR §484 requirements for Home Health Agency (HHA): Survey Date: 10/12/2022 through 10/13/2022 Patient Census: 103 Home Visits: 4 Records Reviewed: 3 Close Record Review: 3 PUI-0 COVID-19 Positive Cases -0 Staff PUI- 0 Staff Positive COVID-19- 0 Staff Vaccine 100%