Every finding on record at Emmanuel Hospice Care Inc

Based on an unannonced Emergency Preparedness (EP) survey and documents requested on 11/16/2021 and 11/17/2021 at 8:15 AM till 3:00 PM at to the administrative assistance of the facility (employee #1) it was determined that the facility failed to evidence the development, of the emergency preparedness program related to the absent of policies and procedures and evidence of the plan which makes this Condition of Participation : 42 CFR 418.113 Emergency Preparedness requirements for Hospice. Not Met. The facility did not provide evidence at the time of the inspection of the conpliance for tags: E001, E004, E006, E007, E009, E013, E016, E023, E024, E025, E026, E029, E030, E031, E032, E033, E036, E037, E039 and E042.

Based on an unannounced recertification survey, observations made during three home visit (HV) and review of policies and procedures, it was determined that the facility failed to ensure that patient's rights are promoted related to a ulcers care procedure and the lack of environmental privacy for 1 out of 3 home visit (H.V #1). Findings include: H.V. #1 is a 65 years old male admitted on 11/04/2021 with a diagnosis of Cerebral Infarction Unspecified and secondary diagnosis Diabetes Mellitus, Pressure Ulcer of Right HIP Stage III, Dysphagia, Oropharyngeal Phase, Complete Traumatic Amputation at Knee Level Right Lower Leg and Bed Confinement. The HV was performed on 11/16/2021 at 10:35 AM for ulcer's care with the registered nurse (employee #5). Alert, not oriented, does not verbalize, stagnant with limitation of movement. Resting in bed, urinary incontinent with use of disposable diapers. The patient has three ulcers number one Stage II ulcer in right trochanter measuring Long 3.0 cms x Wide 3.0 cms x Depth 0.0 cms, 10.0-centimeter pocket, exposure of muscle, bone soft tissue, necrotic tissue and irregular borders, surrounding skin, pink and reddish edema and stench. Ulcer number two Stage III left heel with Long 12.0 cms x Wide 12.0 cms x Depth 1.0 cms and third ulcer localized on left ankle with measure with Long 4.0 cms x Wide 4.0 cms x Depth 0.2 cms. was sensitive to the touch and totally dependent on activities of daily living. On 11/16/2021 from 10:35 AM through 11:30 AM, during the three ulcers local care the registered nurse (employee #5) did not close the two windows and the room door. During observations made of the procedure on 11/16/2021 at 10:35 AM, registered nurse #5 did not provide privacy to promote patient's rights related with dignity, respect and privacy.

Based on an unannounced recertification survey, eleven clinical records reviewed, three home visits (HV) with record review (RR), review of policies and procedures (P&P's), performed on 11/16/2021 and 11/17/2021 at 8:00 AM. till 6:15 PM in company of Nursing Supervisor (employee #4), it was determined that the facility failed to ensure and document an effective infection control program that protects patients, families, visitors and hospice personnel by preventing and controlling infectious and communicable diseases for 2 out of 3 home visits. (HV#1 and #2). Findings include: 1. H.V. #1 is a 65 years old male admitted on 11/04/2021 with a diagnosis of Cerebral Infarction Unspecified and secondary diagnosis Diabetes Mellitus, Pressure Ulcer of Right HIP Stage III, Dysphagia, Oropharyngeal Phase, Complete Traumatic Amputation at Knee Level Right Lower Leg and Bed Confinement. The Home Visit was performed on 11/16/2021 at 10:35 AM for ulcer's care with the registered nurse (employee #5). During the ulcer's care with the employee #5 it was observed the following: a. As observed the Register Nurse (RN) employee #5, placed the blue pad on a freezer which is kept in the room area and then placed the briefcase of materials on the top of the blue pad. He did not wash his hands with soap and water or use a hand sanitizer, he gloves his hands and took materials to be used during care of the ulcers from the briefcase. He placed a blue pad on the patient's bed and then placed a sphygmomanometer and thermometer on a blue pad and then disinfected equipment, took vital signs, placed the equipment on the blue pad again and disinfected. He did not remove gloves and then placed gauzes, gloves, saline solution, hydrogel, silver alginate, scissors and adhesive tape on the same blue pad. b. The register nurse (employee #5) removed the gauzes of the right hip ulcer, abundant fetid exudate was observed. Necrotic tissue at edges and surrounding area red. After performing the local care of the hip ulcer remove the gloves put on other gloves but did not wash hands with soap and water or use hand sanitizer. Then dry the ulcer, applied alginate, removed his gloves puts another glove but did not washing his hands or used hand sanitizer. He disinfects the scissors cut gauzes and then placed the clean gauze and fixed. c. He performed the local care procedure at the two ulcers located on the left foot. During the local care procedure, the nurse removed his gloves put on other pair of gloves but did not wash hands with soap and water or use a hand sanitizer. d. The nurse (employee #5) changes per twelve times his gloves during ulcers care procedure, however, did not perform hand washing before, during or after performing healing procedures. e. During the ulcer care procedure, the nurse was assisted by the patient's caregiver, did not wash hands with soap and water, nor used hand sanitizer and she put on gloves. When moving the patient's bed, the garbage disposal turned over on the floor, the caregiver lifted it with the same gloves she continued assisting the nurse. The caregiver removed and discarded the gloves when the nurse finished providing care but did not performed hand washing with water and soap or used hand sanitizer. f. On 11/16/2021 at 10:46 AM during the ulcer care procedure the fan in the patient's room was kept on all the time. The bedroom door and the two windows were kept open. In the window where the air conditioning is located, a piece of deteriorate wood was observed with the presence of dust. g. The nurse (employee #5) do not use protective gowns or face shields during the procedure for taking vital signs, assessment of the patient and during the ulcers local care. h. The record was review on 11/16/2021 at 3:10 PM and no evidence of ulcer measure of the right hip ulcer and the two ulcers located on the left foot during the weeks 11/07/2021 and 11/14/2021. During the ulcer's care with the employee #5 on 11/16/2021 it was observed that the employee performed the ulcers care however, did not take the ulcer measures on this visit, but during the record review performed on 11/16/2021 at 3:10 PM the nurse documented the two ulcers measures of the left foot. 2. H.V. #2 is a 94-year-old male admitted on 08/12/2021 with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD, Congestive Heart Failure (CHF). The Home Visit was performed on 11/16/2021 at 11:45 am for ulcer care with the Quality and Infection Control Coordinator employee #3 and registered nurse (employee #6). During the ulcer care Stage II in process of cicatrization with the employee #6, it was observed the following: a.At arrive to patients' home the RN put on a gown wrong with the back part to the front. b. Did not wash his hand previously to started providing care to the patient. c. Takes vital sign without cleaning and disinfected the non-critical equipment (Sphygmomanometer, Stethoscope, thermometer) before and after use with the patient. d. The RN place a pair of non-sterile glove to provide care to the sacral ulcer Stage II, when remove the glove, puts on other pair of gloves without washing his hand or use hand sanitizer. e. During the ulcer care the RN cleans the ulcer with wound cleanser but did not dry the ulcer before applying Curafil and cover with gauze. f. The RN did not put all material needed to perform the procedure near to patient and must go to the living room to get more glove and return the bedroom where performed the procedure. g. When finish the procedure the RN goes to patient bathroom to wash his hand and takes Johnson and Johnson baby shampoo wash his hands then request to patient care giver to dry his hand, the patient caregiver brought a towel and dry his hands. 3. Quality and Infection Control Coordinator Employee #3 was asked on 11/16/2021 at 12:45 PM if the facility provide to the employees soap and paper towel, and she respond that the facility provides to all employees Liquid Soap, paper towel and hand sanitizer to perform the hand washing as many times as necessary. 4. When the surveyor arrives to the facility no evidence was observed that the facility performance a screening process for those that enter to the facility to mitigate the risk of COVID 19 exposure, they only provide hand sanitizer and demand the use of mask. 5. During the 3 Home Visit Performed on 11/16/2021, the facility personnel employee #5 and employee #6 was not observed perform COVID- 19 screening question related to exposure to COVID 19 cases. 6. No evidence was provided that the Screening was performance since the initial of the COVID 19 pandemic. 7. During interview with the Nurse Supervisor employee #4, and the Quality and Infection Control Coordinator employee #3, state on 11/17/2021 at 3:00 PM that the screening process was not performance since the PR Governance removed in June 2021.

Based on unannounced recertification survey, review of fifteen (18) credential files (C.F) and administrative documents with the nurse supervisor (employee #4) performed on 11/16-17/2021, it was determined that the facility failed to ensure that employees who have direct contact or access to patient records obtain and maintain criminal background check required under federal law and accordance with State requirements, Law 300 for 5 out of 18 files evaluated. (CF #3, #6, #8, #9 and #16). Findings include: A. Credential files review: 1. Five out of 18 CF reviewed on 11/17/2021 at 3:00 PM, no evidence was found criminal background check (CF #3, #6, #8, #9 and #16).

Based on unannounced recertification survey,records reviwed (RR), three home vistis (HV) and review of eighteen credential files (C.F) and administrative documents with the nurse supervisor (employee #4) performed on 11/16-17/2021, it was determined that the facility failed to ensure that employees who provide services have updated credentials, Cardio Pulmonary Resuscitation CPR, Health certificate, Hepatitis B vaccine, Influenza vaccine, Mal Practice, Education Abuse and Neglect and Law 300 for 6 out of 18 files evaluated. (CF #6, #7, #9, #16, #17 and #18). Also the facility faild to conply with State Nursing regulation under Law Number 254 of December 31, 2015 that regulated nursing services in Puerto Rico by using a Homemaker (HM) to provide license practical nurse (LPN) that conducts Home Health Aides ( HHA) funtions when they are not available for patient care (H.V.#3 and RR #6 and #10). Findings include: A. Credential files review: 1. Two out of 18 CF reviewed on 11/17/2021 at 3:00 PM, no evidence was found for the Hepatitis vaccine administration physician (CF #9 and #16 ). 2. Three out of 18 CF reviewed on 11/17/2021 at 3:00 PM, no evidence was found for the Influenza vaccine administration (CF #16, #17 and #18 ). 3. One out of 18 CF failed to show evidence related to Negative Criminal Record (Certificado de Antecedentes Penales) as observed on CF #9. 4. Three out of 18 CF failed to show evidence of the Health Certificate, CF #6 the health certificate expired on 10/21/2021, CF #7 the health certificate expired on 10/06/2021 and CF #9 the health certificate expired on 09/25/2020. 5. One out of 18 CF failed to show evidence of the CPR, as observed on CF #9. 6. One out of 18 CF failed to show evidence of the Malpractice Insurance, CF #9. B. The facility failed to ensure that the home a health aide (HHA) that performance total hygiene to the patient comply with the Law 254 from December 31, 2015 that Regulate Nursing Practice in Puerto Rico and do not recognize the homemaker to perform the patient bath when (HHA) is not available. Accordance to the Law that Regulate Nursing Practice in Puerto Rico Law 254 from December 31, 2015 the License practice Nurse (LPN) Performs basic nursing procedures and techniques, related to hygiene, comfort, feeding, elimination, ambulation, rest and other needs of the patient/client. (H.V.#3 and RR #6 and #10). During the patient's records review on 11/16/2021 and 11/17/2021 at 1:15 PM till 4:00 PM the following was found: 1.The facility in the absence of the license practical nurse (LPN) during the months of May, July, August, September, October and November of 2021 appointed the homemaker to perform functions of practice nurse (LPN). The homemaker job description include only assistance in the daily patient needs. However, the facility failed to ensure that the HHA perform total hygiene to the patient. The law 254 from December 31, 2015 that Regulate Nursing Practice in Puerto Rico do not recognize the homemaker to perform the patient bath when HHAs are not available. Accordance to the Law that Regulate Nursing Practice in Puerto Rico Law 254 from December 31, 2015 the License practice Nurse (LPN) performs basic nursing procedures and techniques, related to hygiene, comfort, feeding, elimination, ambulation, rest and other needs of the patient/client. a. R.R. #6 is an 89 years old female admitted on 09/01/2021 with a diagnosis of Degenerative Disease of Nervous System and secondary diagnosis Muscle Weakness Generalized, Cachexia and Bed Confinement (Bed Ridden). The record was reviewed on 11/16/2021 at 2:55 PM and reveled that the facility in the absence of the license practical nurse (LPN) during the months of May, July, August, September, October and November of 2021 appointed the homemaker to perform functions of practical nurse. The patient record provide evidence that the homemaker visit the patient on September 6, 10, 13, 17, 20, 24 and 27 of 2021, October 1, 4, 8, 11, 15, 18, 22, 25 and 29/2021 and November 1, 5, 8 and 12, 2021. b. The record reveled that the patient received services during the months of May, July, August, September, October and November of 2021 by the homemaker to perform functions as license practice nurse. The patient record provide evidence that the homemaker visits the patient on September 7, 10, 13, 15, 17, 20, 22, 24, 27 and 29 of 2021. On October 1, 4, 8, 11, 15, 18, 20, 22, 25, 27 and 29/2021. On November 1, 3, 5, 8, 10 and 12, 2021. According to the weekly services report of the homemaker, the patient receives services three days a week for a period of two hours. This report does not indicate at what hours the employee visited the patient. According to the weekly services report the patient did not receive services on September 6 and October 13/2021 due to the absence of the homemaker. c. R.R. #10 is a 93 years old female admitted on 01/21/2021 with a diagnosis of Alzheimer Disease, Bedridden. The record was reviewed on 11/16/2021 at 2:00 PM and reveled that the facility in the absence of the license practical nurse during the months of May, July, August, September and October of 2021 appointed the homemaker to perform functions of license practical nurse. The patient record provide evidence that the homemaker (employee #8) visit the patient on May 14, 2021. On July 12, 14, 16, 19, 21 and 23 of 2021. On August 3, 4, 6 and 12 of 2021. On September 10, 2021 and October 6, 2021. The patient record reveled that all the notes of the visits made were documented by the homemaker and the type of visit is as HHA (license practical nurse) and signed by the homemaker (employee #8). The information documented in these notes reveals taking vital signs, general aspects of the patient, intervention carried out, complete bath in bed, change of position, general grooming, exercises, steps and extended functions. All notes are signed by the homemaker (employee #8). The license number does not appear in the notes because the person making the note is the homemaker who performed the duties of the license practical nurse. d. Interview with the nursing supervisor (employee #4) on 11/17/2021 at 3:00 PM she stated that when the license practical nurse is absent the facility hospice uses the homemaker to perform license practical nurse duties. These activities involve direct patient care however, the homemaker does not have the skills or training to perform these tasks. No evidence was found of an authorized agency which governs this discipline related to homemaker when they provide direct patient care, nor are they included under the law 254 for nusing sevices. c. H.V. #3 is a 87 years old female admitted on 07/22/2021 with a diagnosis of Malignant Neoplasm of Endometrio and Chronic Kidney Disease End Stage. The record was reviewed on 11/17/2021 at 10:15 am and reveled that the facility in the absence of the license practical nurse (HHA) during the months of August of 2021 appointed the homemaker to perform functions of license practical nurse. The patient record provide evidence that the homemaker (employee #8) visit the patient on August 3, 4, and 6 of 2021. The patient record reveled that all the notes of the visits made were documented by the homemaker and the type of visit is as HHA (license practical nurse) and signed by the homemaker (employee #8). The information documented in these notes reveals taking vital signs, general aspects of the patient, intervention carried out, complete bath in bed, change of position, general grooming, exercises, steps and extended functions. All notes are signed by the homemaker (employee #8). The license number does not appear in the notes because the person making the note is the homemaker who performed the duties of the license practical nurse.