Every finding on record at Hospicio Divina Misericordia, Corp

Based upon an Emergency Preparedness Program (EPP) survey performed on 01/15/2025 from 8:00 AM through 3:30 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 a disaster or emergency situation. --- Findings include: During the review of the facilities Emergency Preparedness Program with the CEO (employee #1) and facility Supervisor (employee #2) on 01/15/2024, 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 01/15/2025 from 8:00 AM through 3:30 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to develop procedures to follow up with on- duty staff and patients to determine services that are needed, in event that there is an interruption in services during or due to an emergency. The hospice must inform State and local officials of any on-duty staff or patient that they are unable to contact. --- Findings include: During the review of the facilities Emergency Preparedness Program with the CEO (employee #1) and facility Supervisor (employee #2) on 01/15/2024,it was noted that the EP failed to have written procedures to follow up with on- duty staff and patients to determine services that are needed, in event that there is an interruption in services during or due to an emergency, also the hospice must inform State and local officials of any on-duty staff or patient that they are unable to contact as required under §418.113(b)(1).

Based upon an Emergency Preparedness Program (EPP) survey performed on 01/15/2025 from 8:00 AM through 3:30 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to develop procedures to inform State and local emergency preparedness officials about patients in need of evacuation from their residences at any time due to an emergency situation based on the patients medical or psychiatric condition and home environment. --- Findings include: During the review of the facilities Emergency Preparedness Program with the CEO (employee #1) and facility Supervisor (employee #2) on 01/15/2024, it was noted that the EP failed to have written procedures not notify State and local emergency preparedness officials about patients in need of evacuation from their residences at any time due to an emergency as required under §418.113(b)(2).

Based upon an Emergency Preparedness Program (EPP) survey performed on 01/15/2025 from 8:00 AM through 3:30 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to have policies and procedures describing the system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains the availability of records. --- Findings include: During the review of the facilities Emergency Preparedness Program with with the CEO (employee #1) and facility Supervisor (employee #2) on 01/15/2024, it was noted that the EP failed to have written process for preserving patient information as required under §418.113(b)(4).

Based upon an Emergency Preparedness Program (EPP) survey performed on 01/15/2025 from 8:00 AM through 3:30 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to develop arrangements with other facilities or other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services. --- Findings include: During the review of the facilities Emergency Preparedness Program with the CEO (employee #1) and facility Supervisor (employee #2) on 01/15/2024, it was noted that the EP failed to have written arrangements with other facilities or other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients.

Based upon an Emergency Preparedness Program (EPP) survey performed on 01/15/2025 from 8:00 AM through 3:30 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set and risk assessment. --- Findings include: During the review of the facilities Emergency Preparedness Program with the CEO (employee #1) and facility Supervisor (employee #2) on 01/15/2024, it was noted that the EP failed to develop and maintain an emergency preparedness training and testing program based on the facilities risk assessment. The facility did not have a testing program to validate acquired knowledge for trainings.

Based on observation, interview and police and procedure reviewed, three (3) home visits (H.V) performed on 01/15/2025 in company of Registered Nurse (employee #4), it was determined that the facility failed to ensure that the Licensed Practical Nurse (LPN) provide privacy to the patient for 1 out of 3 (H.V #3). --- Findings include: During the home visit #3 at 9:30 AM to 10:20 AM, the following was observed: 1.H.V #3 is an 86-year-old male admitted 01/11/2024 with diagnosis of Pulmonary Fibrosis. The home visit was performed on 01/15/2025 at 9:34 AM with the Licensed Practical Nurse (LPN) (employee #3). 2. During the bed bath procedure performed by LPN she did not provide privacy to the patient, open window and open door were observed. 3. During the bed bathing procedure LPN placed a small towel that only covered the genital area and left the rest of the body uncovered. 4.The facility failed to provide privacy to the patient during the bed bath procedure.

Based on observation, interview and police and procedure reviewed, three (3) home visits (H.V) performed on 01/15/2025 in company of Registered Nurse (employee #4), it was determined that the facility failed to ensure that the Licensed Practical Nurse (LPN) complies with standard practice precautions to prevent the transmission of infectious agents 1 out of 3 (H.V #3) during the bed-bath procedure and a visit to the wear house surgical supplies. --- Findings include: During a home visit #3 at 9:30 AM to 10:20 AM, the following was observed: 1.H.V #3 is an 86-year-old male admitted 01/11/2024 with diagnosis of Pulmonary Fibrosis. The home visit was performed on 01/15/2025 at 9:34 AM with the Licensed Practical Nurse (LPN) (employee #3). During the home visit with the (employee #3) it was observed the following: a. At 9:34 AM, the Licensed Practical Nurse (LPN) (employee #3) placed the case without using a under pad. b. At 9:36 AM, the employee #3 do not disinfect non-critical equipment before and after patient use. c. At 9:38 AM, the employee #3 perform hand washing in approximately to five (5) to eight (8) seconds before bathing the patient. d. At 9:52 AM, during the patient's bed bathing, employee #3 failed on four (4) occasions to perform water changes in accordance with policy and four (4) glove changes. e. At 10:08 AM, after finishing the bed bath, employee #3 washes her hands for approximately to five (5) to (8) seconds. The facility failed to ensure the practice of standard precautions, prevention and transmission of infections. 3. On 01/15/2025 at 3:20 PM during the visit to the warehouse facilities the following was identified: a. The supply of medical-surgical material is observed four boxes directly on the floor. b. The observed boxes contain medical-surgical equipment, the first contains 18 boxes of urinary catheters, the second contains 1 box of serums-intravenous fluids, the third 10 boxes of Towel drapes and the fourth contains 10 boxes of syringes and 10 boxes of tongue depressors. c. The executive director stated that they were under construction and that usually the equipment was not placed directly on the floor. The facility did not provide the policy for the management of medical-surgical equipment in the warehouse facilities. 2. During the home visit conducted on 01/15/2024, the following was observed: a. On 01/15/2025 at 9:45 AM, it was observed at home visit # 3 that the humidifier tank connected to oxygen concentrator showed signs of mold in its inside. b. On 01/15/2025 at 9:45 AM, it was observed at home visit # 3 that the concentrator breathing vents were covered with dust indicating lack of maintenance and disinfection.

Based on the review of documents related to the volunteer program and interview with the CEO (employee #1), 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 01/15/2024 at 2:30 PM, the facility did not have did written evidence of the calculation of comparison of voluntary hours worked versus hours of direct care to patients that evidence compliance with the five (5) percent.

Based on a recertification survey, the review sixteen credential files (C. F.), it was determined that the facility failed to ensure that 7 out of 16 employees who provide services have updated credentials related to Nurses (NCF), Home Health Aide (HHACF), Speech Language (STCF), Occupational Therapist (OTCF), Counseling Spiritual (CSCF), Storage Medical Supplies and Durable Medical Equipment (SMS&DMECF) and Secretary (SCF), as required by State and Local laws. --- Findings include: 1. On 01/15/2025 at 11:30 AM during review of the credential file it was identify the following: a. Six out of sixteen credential files did not contain updates Health Certificate in the credential file expired on 09/13/2024(SMS&DMECF#1), 09/13/2024(SCF#2), 06/22/2024(OTCF#3), 04/21/2024(CSCF#8), 09/12/2024(NCF#9) and 11/15/2024(NCF#11). b. One out of sixteen credential files did not contain evidence of Hepatitis B Vaccines (SMS&DMECF#1). c. Three out of sixteen credential files did not contain evidence of influenza Vaccines or Exoneration, (OTCF#3, STCF#5 and CSCF#8). d. One out of sixteen credential files did not contain updates CPR in the credential filed expired on 04192024, (HHA#13).

Based on an unannounced recertification surver, observation, policies and procedure review and inteview in 3 home visit (HV) with records reviewed, and eight (8) records reviewed (R.R.) performed on 03/23/2022 through 03/24/2022 in with the Supervisor (employee #1), it was determined that the facility failed to include in the patient plan of care a detailed statement of the physician , Home Health Aide (HHA) and the Homemaker (HM) frequency of visit to meet the patient and caregivers needs. For 3 out of 3 home visits with record review and 4 records review (HV#1, #2 and #3 and RR #4, #5, #7 and #8). Findings include: 1. H.V. #1 is an 89-year-old male admitted on 11/30/2021 with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and Congestive Heart Failure (CHF). Record Review performed on 03/23/2022 at 3:30 PM provide evidence that the patient last recertification was performed on 02/16/2022 to the second period of 90 days. During the record review it was found the following: a. During the interdisciplinary group (IDG) meeting performed on 03/02/2022 and on 03/23/2022 to review the plan of care, the facility failed to include the physician frequency of visit, they only write as needed (PRN) and did not include the HHA frequency. 2. H.V. #2 is an 81-year-old female admitted on 08/10/2020 with a diagnosis of Alzheimer and High Blood Pressure (HBP). Record Review performed on 03/23/2022 at 3:00 PM provides evidence that the patient last recertification was performed on 01/19/2022 to the six unlimited period of 60 days. During the record review it was found the following: a. During the recertification performed on 01/19/2022 and interdisciplinary group (IDG) meeting performed on 02/02/2022, on 02/16/2022 and on 03/23/2022 to review the plan of care, the facility failed to include the physician frequency of visit and only document as needed (PRN) and did not include the HHA frequency. 3. H.V. #3 is an 81-year-old female admitted on 02/18/2020 with a diagnosis of Alzheimer. Record Review performed on 03/24/2022 at 8:15 AM provide evidence that the patient last recertification was performed on 01/26/2022 to the eighteen unlimited period of 60 days. During the record review it was found the following: a. During the recertification performed on 01/26/2022 and interdisciplinary group (IDG) meeting performed on 01/19/2022, on 02/09/2022, on 02/23/2022, on 03/09/2022 and on 03/23/2022 to review the plan of care, the facility failed to include the physician frequency of visit and only document as needed (PRN) and did not include the HHA frequency. 4. R.R. #5 is a 72-year-old male admitted on 07/31/2018 with a diagnosis of Cerebrovascular Accident (CVA), High Blood Pressure (HBP) and Diabetes Mellitus (DM). Record Review performed on 03/24/2022 at 11:00 AM provide evidence that the patient last recertification was performed on 03/02/2022 to the twenty unlimited period of 60 days. During the record review it was found the following: a. During the recertification performed on 03/02/2022 and interdisciplinary group (IDG) meeting performed on 03/19/2022 and on 03/23/2022 to review the plan of care, the facility failed to include the physician frequency of visit and only document as needed (PRN). 5. R.R. #8 is an 83-year-old female admitted on 07/19/2019 with a diagnosis of Alzheimer end stage, Asthma and Dementia. Record Review performed on 03/24/2022 at 11:24 AM provide evidence that the patient last recertification was performed on 02/23/2022 to the fourteen unlimited period of 60 days. During the record review it was found the following: a. During the recertification performed on 02/23/2022 and interdisciplinary group (IDG) meeting performed on 03/02/2022 and on 03/16/2022 to review the plan of care, the facility failed to include the physician frequency of visit and only document as needed (PRN). During the record review it was found the following: 6. R.R. #4 is an 82 years old male admitted on 07/17/2019 with a diagnosis of Alzheimer, CKD End Stage Renal Disease (ESRD), Diabetes Mellitus (DM) and Coronary Heart. Failure (CHF). Record Review performed on 03/24/2022 at 8:15 AM provide evidence that the patient last recertification number #14 was performed on 03/03/2022 to 05/02/2022 the fourteen unlimited period of 60 days. During the record review it was found the following: a. During the recertification performed on 02/23/2022 and interdisciplinary group (IDG) meeting performed on 03/02/2022 and on 03/16/2022 to review the plan of care, the facility failed to include the physician frequency of visit, only write as needed (PRN). b. According with the patient record review on 03/24/2022 at 8:15 AM the patient received Home Health Aide services. The recertification #14 performed on 02/16/2022 for period 03/03/2022 to 05/16/2022 and interdisciplinary group (IDG) meeting performed on 02/16/2022 to establish the professional services and the frequency of visits that the patient received during this period did not included Home Health Aide services. The nurse supervisor (employee # 1) was interview on 03/24/2022 at 8:30 AM and she stated: '' The patient has a home health aide service since admission on August 11/2019 with frequency three times a week and that it is undefined and is not included in the recertification for this reason." During the record review it was found that there is no order until 08/04/2021 and the last order was reviewed on 08/04/2021. The notification to the patient about the care plan where it establishes the services that they will receive during this period does not include the Home Health Aide services. c. According with the patient record review on 03/24/2022 at 8:15 AM the patient received Home Health Aide services since admission on August 11/2019 with frequency three times a week and that it is undefined. The form for the weekly report of the hospice assistant and the record of visits to patients where the date of the visit is written, time of entry and exit, signature of the professional and signature of the family member was evaluated and reviewed from November 28, 2021 to March 19/2022 and revealed that the Home Health Aide only offered services two (2) days a week. 7. R.R. #7 is a 103 years old male admitted on 06/28/2019 with a diagnosis of COPD and secondary diagnosis of COD. Record Review performed on 03/24/2022 at 10:00 AM provide evidence that the patient last recertification was performed on 02/12/2022 to the twenty unlimited period of 60 days. During the record review it was found the following: a. During the recertification performed on 02/02/2022 and interdisciplinary group (IDG) meeting performed on 02/02/2022 and established the professional services and the frequency of visits that the patient received during this period from 02/12/2022 to 04/13/2022. On this period included Housekeeper with frequency of 3 visits per week and Home Health Aide 2 visits per week. b. On 02/12/2022 the patient notification plan of care, the facility failed to include the physician frequency of visit, only writes as needed (PRN) and failed to include the Home Health Aide services.

Based on an unannounced recertification survey and abbreviated COVID-19 Focused Infection Control Survey (FICS): Acute and Continuing Care, observation, interview and policies and procedure review in 3 home visit (HV), performed on 03/23/2022 in company of the Supervisor (employee #1), it was determined that the facility failed to properly prevent effective infection control program that protects patients, families, visitors and hospice personnel by preventing and controlling infectious and communicable diseases of COVID-19 for 3 out of 3 home visits. (HV#1, #2 and #3). Findings include: A. During the COVID- 19 Focused Infection Control Survey: Acute and continuing Care performed on March 23 through 24, 2022, it was found that: 1. In the entrance the facility does not have a screening process, the Nurse supervisor state on 03/23/2022 at 9:00 AM, that they were screening personnel and visitor and patient at home until June 2021. Then after June 2021 they oriented patient and care giver to notified to the agency personnel if patient or caregiver have any COVID-19 symptom or receive any visitor from outside of Puerto Rico (P.R) and have symptom. 2. The facility have visitor restriction, but after the local government release the restriction, no facility limitation, but they educate the patient, their caregiver personnel continue with hand washing and use of mask. 3. The facility failed to ask to the personnel or visitor related to exposure to COVID-19, screening question and assess symptom. 4. During the bed bath procedure the Home Health Aide (License Practical Nurse -LPN) wash the hands with soap and water in the entrance, however, did not change her gloves and performed hand wash between the different step of the bath procedure. 5. The facility failed to document in the patient record the assessment of question related to exposure to COVID-19, screening and assessment symptom during the home visit. 6. During the three-home visit performed on 03/23/2022 the facility personnel failed to ask to the patient, or their relative question related to exposure to COVID 19, screening question and assessment symptom during the home visit. B. During the home visit it was observed the following: 1. H.V. #1 is an 89-year-old male admitted on 11/30/2021 with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and Congestive Heart Failure (CHF). The Home Visit was performed on 03/23/2022 at 12:20 PM for Bed Bath Procedure with the license practice Nurse (LPN) (employee #3). During the home visit with the employee #3 it was observed the following: a. Not observed perform COVID-19 screening question related to exposure to COVID-19 cases. b. The employee #4 failed to change her glove and wash her hands during all step of the bath procedure, with the same glove that started finish the procedure. c. The employee #4 failed to change the water during all step of the bath procedure, with the same water in the basin that started, finish the bath procedure. d. The employee #4 failed to change the gloves after inserting hands with the same glove that provide care to the perianal area in the Oxide the zinc cream container and the new petroleum Jelly container, contaminating the two container and expose risk of patient to cross contamination. 2. H.V. #2 is an 81-year-old female admitted on 08/10/2020 with a diagnosis of Alzheimer and High Blood Pressure (HBP). The Home Visit was performed on 03/23/2022 at 10:00 AM for Ulcer Care with the Registered Nurse (RN) (employee #2). During the home visit with the employee #2 it was observed the following: a. Not observed perform COVID-19 screening question related to exposure to COVID-19 cases. b. The employee #2 failed to clean and disinfected the non-critical equipment, sphygmomanometer, stethoscope, oximeter, and thermometer before use with the patient and after used. When the RN #2 perform the clean and disinfection, she disinfected the saturometer and with the same glove introduce her gloved hand into the briefcase to store the saturometer, this procedure the RN #2 repeats with the sphygmomanometer, stethoscope and thermometer and with the same used disinfected wipe clean the interior of the briefcase. c. The employee #2 failed to use and protective paper towel between the sphygmomanometer and patient skin. d. The employee #2 during the ulcer care use the non-sterile gauze to provide ulcer care directly from the gauze package and with the same glove that provide ulcer care, contaminating the non-used nonsterile gauze and exposure the patient risk to cross contamination. e. The employee #2 failed to change her glove and wash her hands during the different step of ulcer care. 3. H.V. #3 is an 81-year-old female admitted on 02/18/2020 with a diagnosis of Alzheimer. The Home Visit was performed on 03/23/2022 at 11:20 AM for Ulcer Care with the RN (employee #4). During the home visit with the employee #4 it was observed the following: a. Not observed perform COVID-19 screening question related to exposure to COVID-19 cases. b. The employee #4 was observed using the technique of multiples glove to provide patient care and discarded and continue providing care without hand washing during glove change. c. The employee #4 performed the non-critical equipment disinfection over the briefcase and only use one spray of alcohol over the noncritical equipment and did not wipe to complete the disinfection. d. The employee #4 was observed using the multiple glove technique to provide the sacral ulcer care, she put on more than three non-sterile glove and after remove the ulcer bandage, remove one glove then clean, remove other glove, apply the calcium alginate and the A+D foam, apply Silvadene in the ulcer border remove other gloves put gauze on the ulcer to cover the sacral ulcer, remove other glove, and continue collecting the used material. The RN failed to wash her hands between glove change and the multiple gloves use not is and accepted technique by the Centers for Disease Control and Prevention (CDC). e. The employee #4, failed to provide care to the right hip ulcer due to that the LPN provide care when provide bath care. Accordance to the Puerto Rico State Law #254 of December 31, 2015, ulcer care is provided by the Registered Nurse not the License Practical Nurse.

Based on a recertification survey, three home visits (HV) with records reviewed (RR), eight records reviewed, and documents reviewed, it was determined that the facility failed to provide infection control education to employees and contracted providers. Findings include: 1. The facility failed to provide evidence on 03/23/2022 at 10:00 AM of annual educational program for year 2022 related with education to direct employees and contacted staff. 2. Did not include vision and mission of the hospice program.

Based on a recertification survey, three Home Visit (H.V) and eight Records Reviewed (R.R), it was determined that the facility failed to ensure that the all medical record contain past and current findings, no evidence of the ulcer measure accordance to facility policy and procedure for 1 out of 11 records reviewed (R.R #7). Findings include: 1. R.R #7 is a 103 years old male patient admitted on 06/28/2019 with a diagnosis of COPD and CAD. The medical record review on 03/24/2022 at 10:00 AM. During the record review it was identified that patient have stage II ulcer on both gluteal area that measure at admission 1.0 centimeter (cm) Long and .08 cm Wide. However, in the recertification period from 02/12/2022 to 04/13/2022, the sacral ulcer measure on 01/18/2022 was 1.0 cm x 0.8cm, then the registered nurse (RN) measure on 01/21/2022 with measure 1.0 cm x 1.0 cm x 0.0, on 01/25/2022, 01/28/2022, 02/01/2022 and 02/04/2022 , the RN measure the sacral ulcer, however no evidence of measure from this date to the present. The nurse note did not provide evidence if the ulcer completes the healing process. According to the facility policy and procedure tittle Estimate of Ulcers and Wound: according to the procedure the nurse measures the ulcers one day a week and evaluated in case the ulcers present changes and the physician changes in the treatment are necessary. 2. The facility failed to measure the sacral ulcer every week accordance to facility policy and procedure.

Based on a recertification survey, the review of twelve credential files (C.F), it was determined that the facility failed to ensure that 4 out of 12 employees who provide services have updated credentials related to Nurses (NCF), Physical Therapist (PTCF), Occupational Therapist (OTCF) and Secretary (SCF), as required by State and Local laws. Findings include: 1. On 03/24/2022 at 2:30 PM during review of the credential file it was identify the following: a. One out of twelve credential files did not contain updated Health Certificate in the credential file expired on 02/25/2021. (PTCF#12). b. One out of twelve credential files did not contain evidence of Hepatitis B Vaccines (SCF#2) c. Three out of twelve credential files did not contain evidence of Influenza Vaccines or the Exoneration, (RNCF#4, OTCF#10 and PTCF#12) d. One out of twelve credential files did not contain evidence annual evaluation and competencies (SCF#2).