Every finding on record at Hospicio La Milagrosa

Based upon an Emergency Preparedness Program (EPP) survey performed on 12/20/2024 from 9:00 AM through 12:00 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 Administrative Assistant (employee #4) on 12/20/2024 at 9:30 AM 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 12/20/2024 from 9:00 AM through 12:00 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 the Administrative Assistant (employee #4) on 12/20/2024 at 9:30 AM, 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 12/20/2024 from 9:00 AM through 12:00 PM, to evaluate emergency preparedness requirements for recertification, 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 the Administrative Assistant (employee #4) on 12/20/2024 at 9:30 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 §418.113(c) of the Emergency Preparedness.

Based upon an Emergency Preparedness Program (EPP) survey performed on 12/20/2024 from 9:00 AM through 12:00 PM, to evaluate emergency preparedness requirements for recertification, it was determined that the facility failed to develop and maintain updated contact information for the following: Federal, State, tribal, regional or local emergency preparedness staff and other sources of assistance. --- Findings include: During the review of the facilities Emergency Preparedness Program with the Administrative Assistant (employee #4) on 12/20/2024 at 9:30 AM, it was noted that the facility failed to provide evidence of the Emergency Preparedness Communication Plan that included updated contact information for Federal, State, tribal, regional or local emergency preparedness staff and other sources of assistance.

Based upon an Emergency Preparedness Program (EPP) survey performed on 12/20/2024 from 9:00 AM through 12:00 PM, it was determined that the facility failed to develop primary / alternate means for communication with staff, Federal, State regional and local emergency management agencies in compliance with Federal, State and local laws. --- Findings include: During the review of the facilities Emergency Preparedness Program with the Administrative Assistant (employee #4) on 12/20/2024 at 9:30 AM, it was noted that the facility failed 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 §418.113(c)(3).

Based on observations to review policies and procedures, during a tour of the medical-surgical equipment storage, it was determined that the facility failed with the use of practice standards for prevention and the requirements for temperature recording and storage cleaning. --- Findings includes: 1. The standard and policy on control and management of medical supplies in the hospice storage was reviewed on 12/19/2024 at 9:00 AM and states in section #2 that supplies must be stored in a clean, dry and well-ventilated area. Temperature and humidity must be controlled according to the manufacturer's specifications. a) During the tour of the facility's storage performed on 12/19/2024 at 9:47 AM, in an interview with storage guard (employee # 6), it was observed that the medical-surgical material storage had a damaged temperature and humidity thermometer and did not have a daily temperature record. b) During the tour of the facility's storage performed on 12/19/2024 at 9:50 AM, in an interview with storage guard (employee # 6), it was observed that in several compartments for storing medical-surgical equipment there was dust.

Based on interview with Executive Director (employee # 5) on 12/20/2024 at 12:30 PM, it was determined that the facility failed to ensure core service are provide directly by hospice employee with counseling services which makes this Condition Not Met. --- Findings include: During the interview with the Executive Director (employee #5) on 12/20/2024 at 12:30 PM she stated that the spiritual counseling staff was under contracted services. However she stated that she offered her to be part of the team of permanent personnel not hired but refers that she prefers to be under contract if not she will resign. The facility did not ensure that the spiritual counselor was part as an employee of the facility.

Based on the review policies and procedures manuals on 12/19/2024 at 10:45 AM accompanied by the facility Service Director (employee #3) the following were identified: --- Findings include: 1. Occupational Manual was reviewed on 07/2023, and the next revision accordance of the hospice agency was to be on 07/2025, however no signature of the person who reviewed the manual on July 2023. The manual lack of index. 2. 2. Physical Therapy Manual was last reviewed in July /2023 and lacks the signature of the person who review the manual in July 2023. The manual lacks index. 3. 3. Pathology Therapy Manual lacks index. The manual has no legible name of the person who prepared it nor who reviewed it in 2023. The next revision was on August 2025. 4. 4. Nutritional Manual was prepared in May/2024 however the name is not legible of the person who prepare the manual. 5. 5. The Administrative Manual was reviewed on 12/2022 and the next revision was on 12/2024 however lacks of secretary's name and signature.

Based on four home visits with record reviewed and fifteen records reviewed (RR), it was determined that the facility failed to ensure that patient's records include the registered nurse, hospice aid and home makers clinical notes, for 1 out of 19 record review ( R.R. #3). --- Findings include: 1. R.R. #3 is an 87-years-old female, admitted to the facility on 07/13/2023 with a diagnosis of CKD. During the record review performed on 12/19/2024 at 12:45 P.M., it was found that in the certification period 16 of 60 days, the interdisciplinary group stablish in the plan of care: Registered Nurse (RN) services 2 visit per week (wk) and as needed (PRN). a. During the week of 11/24/2024 thought 11/30/2024, no evidence was found of one visit notes of the RN, the RN visit on 11/26/2024.

Based on the review of eight (8) credential files (C.F) with the Hospice Service Director (employee #3 ) performed on 12/20/2024 at 9:47 AM till 11:30 AM, it was determined that he facility failed to ensure that eight (8) of 21 employees who provide services have updated credential files related to Speech Language Pathology (SLP), Physical Therapist (PT), Occupational Therapist, Nutritionist, Social Worker, Spiritual Advisor and Physicians related to lack of Health Certificate, Annual Evaluation, Hepatitis B Vaccine, Influenza Vaccine, Covid 19 Vaccine, Ley 300 Criminal Record, Duties and Functions, Annual Nurse membership and Register. Speech Language Pathology (C.F. 2), Physical Therapist (C.F #1), Occupational Therapist (C.F #3), Nutritionist (C.F. 4), Spiritual Advisor (C.F. 5), Social Worker (C.F #6) and Physicians (C.F #7 and #8) . --- Findings include: 1. Review of eight (8) credential files (C.F.) of the Hospice on 12/20/2024 from 9:47 AM till 11:30 AM provide evidence of the following: a. Four (4) of eight (8) credential files (C.F.) did not contain evidence of updated Hepatitis B Vaccine. Physical Therapist (C.F #1), Speech Language Pathology (C.F. 2), Occupational Therapist (C.F #3 ) and Nutritionist (C.F #4). b. Five (5) of eight (8) credential files did not contain evidence of Influenza Vaccine. Physical Therapist (C.F #1), Speech Language Pathology (C.F.2), Occupational Therapist (C.F#3), Nutritionist (C.F #4) and Physician (C.F#8). c. Four (4) of eight (8) credential files (C.F) did not contain evidence of Covid 19 Vaccine. Speech Language Pathology (C.F #2), Occupational Therapist (C.F. 3), Nutritionist (C.F. 4) and Physician (C.F #8). d. Three (3) of eight credential files (C.F) did not contain evidence of Annual Evaluation. Physical Therapist (C.F #1), Speech Therapist (C.F #2) and Occupational Therapist (C.F #3). e. Three (3) of eight (8) credential files (C.F) did not contain evidence of Duties and Functions. Physical Therapist (C.F#1), Speech Therapist (C.F. #2) and Occupational (C.F #3). f. One (1) of eight (8) credential files (C.F) did not contain evidence of annual college payment. Physical Therapist (C.F #1). g. One (1) of eight (8) credential files (C. F) did not contain evidence of the Health Certificate. The health certificate expired on 12/12/2024. Physician (C.F #7).

Based on the review of twelve personnel credential files (C.F.) on 12/20/2024 at 10:40 A.M. with the nurse services director (employee #3), it was determined that the facility failed to ensure that 12 out of 21 employees record reviewed providing services have the criminal background check. --- Findings include: On 12/20/2024 at 10:30 A.M during review of the credential files the following was identified: a. 1. Physical therapist (employee #1), Language Pathology (employee #2), Nutritionist (employee #4), Spiritual Advisor (employee #5), Social Worker (employee #6), Physicians (employees #7 and #8). No evidence was provided of the certified negative criminal background check (Ley 300). 2. One (2) of four (8) credential files did not contain evidence of updated Criminal record. Occupational therapy (C.F. 3 expired on 12/13/2024) and Physician (C.F #8 expired on 10/31/2014). 3. On 12/20/2024 at 10:40 A.M. during review of the credential files it was identified the following: a. Registered Nurse (RN) #1, no evidence was provided of the certified negative criminal background check (Ley 300). b. Licensed practical nurse (LPN) #3, no evidence was provided of the certified negative criminal background check (Ley 300). c. Licensed practical nurse (LPN) #5, no evidence was provided of the certified negative criminal background check (Ley 300).

During observation of the building it was noticed that the facility failed to meet the applicable provisions and must proceed in accordance with the Health Care Facilities Code (NFPA 99 and Tentative Interim Amendments TIA 12-2, TIA 12-3, TIA 12-4, TIA 12-5 and TIA 12-6). --- Findings include: No exit sign observed in conference room door marked as emergency exit on evacuation map. No emergency lights through out facility and on exit routes. Fire extinguisher certification expired since November.

Based on recertification survey, observations, review of credential files and interview with infection control officer (employee#4), it was determined that the facility failed to maintain and document an effective infection control program to properly prevent and protect patients, families, visitors, and hospice personnel of the spread of infections and communicable diseases. Findings include: 1. A mechanism to ensure that facility identify and act upon risks for the acquisition and transmission of infectious agents in all facility settings and related environment, was not performed accordingly with these findings identified during survey procedures performed from 02/08/2022 thru 02/10/2022, from 8:00 AM thru 3:00 PM: a. It was identified that facility had working an employee in charge of medical supplies and equipment storage area. This employee notify facility on 01/08/2021 that he refuses to receive COVID-19 vaccination due to medical contraindication reasons. Facility then proceed to request a negative COVID-19 test results and evidence of the medical contraindication or certification of reason for no vaccination since 01/08/2021, accordingly with dispositions of the established by Puerto Rico Department of Health Administrative Order (OE-2021-075). b. During the review of this case on 02/10/2022 at 10:25 AM and interview with infection control officer (employee#4), she explains that only four negative COVID-19 test results dated 12/24/2021, 01/11/2022, 01/27/2022, 02/03/2022 and 02/07/2022 was provided. c. During the review of this case on 02/10/2022 at 10:40 AM and interview with infection control officer (employee#4), she stated that there is no evidence of medical contraindication or certification of reason for no vaccination since 01/08/2021.

Based on recertification survey, observations, review of credential files and interview with infection control officer (employee #4),and facility services director ( employee#3) it was determined that the facility failed to assure policies and procedures to properly prevent transmission of infections and communicable diseases, are developed and implemented in order to protects patients, families, visitors, and hospice personnel. Findings include: 1. A mechanism to ensure that facility promote the use of maintain infection prevention practices that apply to all patients, regardless of suspected or confirmed infection status, in any setting in which healthcare is delivered, was not performed accordingly with these findings identified during survey procedures performed from 02/08/2022 thru 02/10/2022, from 8:00 AM thru 3:00 PM: a. During the review of nasopharyngeal and orotracheal suction procedures on 02/08/2022 at 9:25 AM and interview with infection control officer (employee#4), and facility services director ( employee #3) it was identified that facility policies did not include specific procedures to guide personnel to promote an appropriate use of mouth, nose, clothing and eye protection) is worn for performing Aerosol Generating Procedures and/or any procedure that are likely to generate splashes or sprays of body fluids. During the review of this policy both employees infection control officer (employee#4), and facility services director ( employee #3) explain step by step the procedure followed when personnel need to perform nasopharyngeal, orotracheal suction or any other Aerosol Generating Procedures and/or any procedure that are likely to generate splashes or sprays of body fluids, however information provided during interview is not found included as part of facility policy. 2. A mechanism to ensure that facility had in place structure (policies, procedures, mechanisms) to follow instructions established by Puerto Rico Department of Health related with COVID-19 home test management and report was not performed accordingly with these findings identified during survey procedures performed from 02/08/2022 thru 02/10/2022, from 8:00 AM thru 3:00 PM: a. It was identified that on 12/24/2021 facility had a patient admitted receiving services record review #11 from who relatives perform a COVID-19 home test due to an apparently exposition to a COVID-19 positive person. b. Surveyor ask services director ( employee #3) and infection control officer (employee#4), on 02/10/2022 at 9:00 AM if facility develop and implement structure (policies, procedures, mechanisms) to follow instructions established by Puerto Rico Department of Health in the administrative Memo 2021-013 of December, 2021 and updated on January 19, 2022 related with COVID-19 home test management and report. Services director (employee #3) and infection control officer (employee#4), on 02/10/2022 at 9:20 AM that facility had not develop this type of mechanism yet.