Every finding on record at Visiting Nurse Association Gregoria Auffant, Inc

An unannounced Recertification and Emergency Preparedness survey was conducted by the Puerto Rico State Agency surveyors at Home Care Gregoria Auffant on November 21, 2024 (Event ID: 64BD7-H1) from 8:00 AM till 10:00 AM. As results of finding the facility was found to be in compliance with 42 CFR Part 484.102 Emergency Preparedness Requirements for Home Care.

A Standard Unannounced Recertification survey was conducted on November 20 through November 21, 2024, from 8:80 AM through 4:00 PM by the Puerto Rico State Agency surveyors at the Home Health Visiting Nurse Association Gregoria Auffant at Hato Rey (Event ID: 64BD7-H1) with ten (10) records reviewed and seven (7) home visits. 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 deficiency listed below: Survey Date: 11/21/2024 Survey Census: 232 patients Sample Size: 17

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on the review of Policies and Procedures Manual and three (3) closed patient clinical records reviewed (RR) on 11/20/2024 from 11:00 AM till 3:00 PM accompanied by the facility Director of Compliance Corporative and Quality of Care (employee #5) , it was determined that the facility failed to ensure that all the records maintain the actualized plans of care according with the facility policies and procedures for 3 out of 3 close records that did not identify action and meets, date, evaluation of problem and the date when the problem resolved. (RR# 3, #4 and #5) Findings include: 1. R.R # 3 is a 74-year-old male patient admitted on 04/18/2024 with diagnosis of Functional Quadriplegia, Alzheimer, Psychosis, Dementia and Convulsions. The plan of care was initiated on admission by the physical therapist, however, did not identify the action and meets, date of re-evaluation, evaluation of problem during the patient received physical therapy and date when the problem resolved. The patient was discharged on 08/06/2024 and the plan of care was maintained in blank. 2. R.R # 4 is an 81-year-old female patient admitted on 05/17/2024 with diagnosis of Muscle Wasting and other diagnosis of Pain in left Shoulder, Difficulty of Walking, Parkinsonism Unspecify Functional Limitations. The plan of care was initiated on admission by a physical therapist (employee #12) on 05/17/2024, however did not identify action and meets, date of re-evaluation, evaluation of problem during the patient received physical therapy and date when the problem was resolved. The patient was discharged on 07/15/2024 and the plan of care was maintained in blank. 3. R.R #5 is an 81-year-old male patient admitted on 07/25/2024 with diagnosis of Muscle Weakness, Difficulty Walking and other diagnosis of Convulsions, Alzheimer and Diabetes Mellitus. The plans of care were initiated on admission by physical therapist (employee #12) on 07/25/2024, however did not identify action and meets, date of re-evaluation, evaluation of problem during the patient received physical therapy and date when the problem was resolved. The patient completes the treatment evaluated by the physical therapist (employee #12) and was discharged on 09/09/2024. However, the care plans were maintained in blank. 4. The agency failed to maintain a mechanism to ensure that the plan of care was reviewed according to the patient needs, when the problem resolved and at the moment when the patient was discharge.