Every finding on record at S & R Hospice Corp

Based on recertification survey, medical records review observations, review of credential files and interview with infection control officer (employee#7), and facility services nursing supervisor ( 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 during the COVID-19 pandemic. 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 02/15/2022 thru 02/17/2022, from 8:00 AM thru 3:00 PM: a.Facility develop a screening process to mitigate the risk of COVID-19 exposure to patients and visitors. This screening process include a document that pertains to COVID-19 signs and symptoms or exposure risk factors to reduce the risk of COVID-19 exposure and spread. During interview on 02/17/2022 at 11:50 AM infection control officer (employee#7) stated that a lot of information included in the screening process document are implicit on every home visit personnel assessment performed during home visits. However, this exclusive COVID-19 screening process are not fully implemented. b. It was identified that facility had 171 employees. Of those 171 employees, 41 employees did not receive the COVID-19 booster (third vaccine) accordingly with dispositions of the established by Puerto Rico Department of Health Administrative Order (OE-2021-87) established on 12/31/2021. Those 41 employees provide direct care and/or home care services as explained by the infection control officer (employee#7) and facility services nursing supervisor (employee#4) on interview on 02/17/2022 at 11:00 AM. c. Accordingly with information provided during interview on 02/17/2022 at 11:10 AM by the infection control officer (employee#7) and facility services nursing supervisor (employee#4) facility had working a Spiritual Counselor responsible for the provision of spiritual care services to patients and families/caregivers of the hospice; directly and through coordination of care with hospice team members. This employee notify facility on 08/23/2021 that he refuses to receive COVID-19 vaccination due to religious beliefs and religious convictions. Facility then proceed to request a negative COVID-19 test results accordingly with dispositions of the established by Puerto Rico Department of Health Administrative Order (OE-2021-075). d. No evidence was found documented or provided related with a weekly (every seven days) negative COVID-19 test results. For the month of September 2021, only two negative COVID-19 test results was found (dated September 3, 2021 and September 10, 2021), for the month of October, 2021 only two COVID-19 test results was found ( dated October 01, 2021 and October 8, 2021), for the month of November 2021 no negative COVID-19 test results was found, for the month of December 2021 only three negative COVID-19 test results was found ( dated December 07, 2021,December 14, 2021 and December 29, 2021), for the month of January 2022 only one COVID-19 test results was found ( dated January 07, 2022 ).

Based on recertification survey, observations, review of credential files and interview with infection control officer (employee #7),and facility services nursing supervisor ( employee #4) 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 during COVID-19 pandemic. Findings include: 1. A mechanism to ensure that facility promote the use of personal protective equipment and 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 02/15/2022 thru 02/17/2022, from 8:00 AM thru 3:00 PM: a.During the review of nasopharyngeal and orotracheal suction procedures on 02/15/2022 at 1:25 PM and interview with infection control officer (employee#7), and facility services nursing director (employee #4) 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 (aerosol) of body fluids. During the review of this policy both employees infection control officer (employee#7), and facility services director ( employee #4) 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..