Puerto Rico Home Health

“Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility’s needs in the event of an emergency. This Standard is not met as evidenced by: Based upon an Emergency Preparedness Program (EPP) survey performed on 01/28/2025 at 8:30 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 s disaster or emergency situation. Findings include: During the review of the facilities Emergency Preparedness Program with the Administrator (employee #1) on 01/28/2025 at 9:30 AM 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 §484.102 of the Emergency Preparedness.”

“Homebound HHA/Hospice Inform EP Officials CFR(s): 484.102(b)(2) §418.113(b)(2), §460.84(b)(4), §484.102(b)(2) [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] *[For homebound Hospice at §418.113(b)(2), PACE at §460.84(b)(4), and HHAs at §484.102(b)(2):] The procedures to inform State and local emergency preparedness officials about [homebound Hospice, PACE or HHA] patients in need of evacuation from their residences at any time due to an emergency situation based on the patient’s medical and psychiatric condition and home environment. This Standard is not met as evidenced by: Based upon an Emergency Preparedness Program (EPP) survey performed on 01/28/2025 at 9:30 AM, 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 patient’s medical or psychiatric condition and home environment. Findings include: During the review of the facilities Emergency Preparedness Program with the Administrator (employee #1) on 01/28/2025 at 9:30 AM, 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 residence at any time due to an emergency as required under §484.102(b)(2).”

“Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This Standard is not met as evidenced by: Based upon an Emergency Preparedness Program (EPP) survey performed on 01/28/2025 at 9:30 AM, to evaluate emergency preparedness requirements, it was determined that the facility failed to ensure policies and procedures to facilitate the support of volunteers and other healthcare professionals in an emergency. Findings include: During the review of the facilities Emergency Preparedness Program with the Administrator (employee #1) on 01/28/2025, it was noted that the facility failed to establish policies and procedures to ensure and facilitate the support of volunteers and other healthcare professionals in an emergency as required under §484.102(b)(5).”

“Methods for Sharing Information CFR(s): 484.102(c)(4)-(5) §403.748(c)(4)-(6), §416.54(c)(4)-(6), §418.113(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §482.15(c)(4)-(6), §483.73(c)(4)-(6), §483.475(c)(4)-(6), §484.102(c)(4)-(5), §485.68(c)(4), §485.542(c)(4)-(6), §485.625(c)(4)-(6), §485.727(c)(4), §485.920(c)(4)-(6), §491.12(c)(4), §494.62(c)(4)-(6). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (4) A method for sharing information and medical documentation for patients under the [facility’s] care, as necessary, with other health providers to maintain the continuity of care. (5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under §484.102(c), CORFs under §485.68(c)] (6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility’s] care as permitted under 45 CFR 164.510(b)(4). *[For RNHCIs at §403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI’s care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative. *[For RHCs/FQHCs at §491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility’s care as permitted under 45 CFR 164.510(b)(4). This Standard is not met as evidenced by: Based upon an Emergency Preparedness Program (EPP) survey performed on 01/28/2025 at 9:30 AM, to evaluate emergency preparedness requirements for recertification, it was determined that the facility failed to provide a method for sharing information and medical documentation for patients under the facility’s care, as necessary, with other health care providers to maintain the continuity of care. Findings include: During the review of the facilities Emergency Preparedness Program with the Administrator (employee #1) on 01/28/2025, it was noted that the facility failed provide a written method for sharing information and medical documentation for patients under the facility’s care, as necessary, with other health care providers to maintain the continuity of care as required under §484.102(c)(4)-(5).”

“Information on Occupancy/Needs CFR(s): 484.102(c)(6) §403.748(c)(7), §416.54(c)(7), §418.113(c)(7) §441.184(c)(7), §482.15(c)(7), §460.84(c)(7), §483.73(c)(7), §483.475(c)(7), §484.102(c)(6), §485.68(c)(5), §485.68(c)(5), §485.727(c)(5), §485.542(c)(7), §485.625(c)(7), §485.920(c)(7), §491.12(c)(5), §494.62(c)(7). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (7) [(5) or (6)] A means of providing information about the [facility’s] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For ASCs at 416.54(c)]: (7) A means of providing information about the ASC’s needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For Inpatient Hospice at §418.113(c):] (7) A means of providing information about the hospice’s inpatient occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. This Standard is not met as evidenced by: Based upon an Emergency Preparedness Program (EPP) survey performed on 01/28/2025 at 9:30 AM, to evaluate emergency preparedness requirements for recertification, it was determined that the facility failed to have written means of providing information about the facility’s occupancy, needs, and its ability to provide assistance. Findings include: During the review of the facilities Emergency Preparedness Program with the Administrator (employee # 1) on 01/28/2025 at 9:30 AM, it was noted that the facility failed to have written procedures of providing information about the facility’s occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.”

“EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, “Organizations” under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This Standard is not met as evidenced by: Based on an Emergency Preparedness Program (EPP) survey performed on 01/28/2025 at 9:30 AM, 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. Findings include: During the review of the facilities Emergency Preparedness Program with the Administrator (employee #1) on 01/28/2025 at 9:30 AM 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 develop a training programed in accordance with the vulnerabilities identified on the HVA. No testing mechanism was presented to validate knowledge was identified.”

“EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, “Organizations” under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF’s emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This Standard is not met as evidenced by: Based on an Emergency Preparedness Program (EPP) survey performed on 01/28/2025 at 9:30 AM, to evaluate emergency preparedness requirements, it was determined that the facility failed to provide initial training in emergency preparedness policies and procedures that are consistent with their roles in an emergency to all new and existing staff, individuals providing services under arrangement, and volunteers. Findings include: During the review of the facilities Emergency Preparedness Program with the Administrator (employee # 1) on 01/28/2025 at 9:30 AM, it was noted that the facility failed to provide documentation of training on emergency preparedness policies and procedures to all new and existing staff.”

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on observation, interview and police and procedure reviewed, three (3) home visits (H.V) performed on 01/28/2025 in company of Registered Nurse (employee #2), it was determined that the facility failed to ensure that the Registered Nurse (RN) complies with standard practice precautions to prevent the transmission of infectious agents for 2 out of 3 home visits during the urinary catheter insertion procedure and local ulcer care. (H.V #1 and H.V #2) 2. H.V # 2 is a 70-year-old male patient admitted on 08/18/2023 with diagnosis of Chronic Ulcer other part right foot with other severity, Peripheral vascular diseases, Osteomyelitis right ankle and foot, Disorders of muscle, Hypertension, Familial hypercholesterolemia, Acquired absence of left great toe, Dependence on wheelchair, long term current use of oral hypoglycemic drugs, Long term current drug therapy and History of falling. The patient was visited on 01/28/2025 at 11:55 A.M accompanied by the facility quality coordinator (employee #4) and the register nurse (R.N #3). The R.N. enters the patient’s room with a material case and a folding table, opening the table and putting on the left side of the patient’s toes then enter her right hand in her material case, takes out a blue pad and put inside the folding table, then put her material case and a plastic bag with materials containing materials used to provide the ulcer care. She enters her right hand a second time on her material case true outside liquid hand soap, one blue pad, hand towels and various pairs of blue gloves then put the gloves inside the table. She goes to the bathroom with liquid soap, blue pad and hand towels, she puts blue on the right side of the bathroom sink then puts liquid soap and hand towels inside the blue pad. She opens the faucet and puts a portion of hand soap drying her hands per twenty-five seconds rinse and dry. She gets a blue pad covering the hand soap and goes to the patient room, she puts the hand soap with the blue pad on the interior of the material case. She put a pair of gloves and then puts another pair of gloves over the first gloves then she organized the materials removed gloves put another pair of gloves over the first gloves entering her hands inside the material case take a thermometer, sphygmomanometer, blood pressure and oximeter disinfected then removed the first gloves and take patient vital signs. The nurse removed a pair of gloves and put a second pair of gloves over the first gloves and disinfected the equipment then with the same gloves put the equipment inside the material case. Then removed the first gloves and put another pair of gloves over, however, did not wash her hands with soap and water and did not use hand sanitizer. She puts the materials’ gloves, Apticoat, gauzes, wound cleanser and a bottle of saline solution over the table and the same blue pad. Then with the same gloves entering her hands inside the material case take a scissor disinfected, then introduce her hands on the interior of the yellow bag removed materials adhesive tape and bandage puts on the table, then removed one pair of gloves and put another pair over the first gloves. She opens the package of gauze and adds wound cleanser then cut the dressing and discard, then did not remove her gloves and with the same gloves takes a clean gauze and clean the ulcer, discard the gauze and take another clean gauze but did not remove her used gloves and drys the ulcer. She removed the first pair of gloves and put another pair over the first gloves and measured the ulcer. Then she removed her two pairs of gloves but did not wash her hands or used hand sanitizer to introduce her hands on the interior of the material case take out the computer and writes. Then the register nurse (employee #3) enter her hands on the interior of the material case, take a hand sanitizer and applied on her hands then puts double gloves then she enters her hands in the interior of the plastic bag and take a gauzes applied a wound cleanser and cleaning a ulcer care again discard gauze, dry with other gauze removed gloves and put a pair of gloves over the first gloves dry again, then she cut a piece of Apti coat and put on the ulcer, removed her gloves and put another pair of gloves over the first gloves then she covered the ulcer with gauzes and covered with adhesive tape and covered with bandage. The nurse removed gloves cleaning a bottle of wound cleanser with humidifier towels. She cleans her hands with humidifier towels then puts double gloves disinfected with the scissors. Then the piece of ApTi coat not used, she put in the transparent plastic bag with clean gloves and gauzes. Then she removed the blue pad of the table, removed her gloves and discarded, closed the table but did not disinfect. She has a blue pad, liquid soap and hand towel and washed her hands per twenty seconds and performed the same initial procedure. 3. The nurse failed to follow acceptable standards of infection control during the procedures of ulcer care. 1.HV #1 is a 74-year-old male admitted on 10/11/2024 with a diagnosis of benign prostatic hyperplasia. The patient was visited on 01/28/2025 at 10:14 AM until 11:50 AM accompanied by a registered nurse from the facility (employee #2). During the visit the patient was observed to be alert and oriented, bedridden and fully dependent for activities of daily living. The patient has an indwelling urinary catheter for four years with a physician’s order for a change every 15 days. The patient was being visited by employee #2 to provide the urinary catheter change. The facility provided a policy named “INSERCIÓN DE FOLEY CATETER” that was reviewed on 01/28/2025 at 12:15 PM and states the order of the catheter intervention. The order of the process is incorrect and do not have data info references. The facility provided a policy called “PROTOCOLO LAVADO DE MANOS CON AGUA Y JABÓN” that was reviewed on 01/28/2025 at 12:15 PM. It did not specify how long hand washing with soap and water should last. a) Employee #2 was observed to wash her hands with hand sanitizer prior to opening the sterile urinary catheter kit. b) Employee #2 was observed to create a sterile field and proceeded to clean the patient’s foreskin prior to lubricate the urinary catheter. c) It was noted that employee #2 did not tighten the urinary catheter to the patient’s thigh upon completion of insertion. d) Employee #2 failed 2 of 3 opportunities to wash her hands with soap and water. · CDC guidelines state that the correct order is as follows: 1. Perform hand hygiene immediately before (and after) insertion 2. Use appropriate antiseptic or sterile solution for peri-urethral cleaning, remove gloves and perform hand hygiene after peri-urethral cleaning and prior to insertion 3. Set up a sterile field 4. Use sterile gloves, drapes, sponges 5. Use appropriate antiseptic single-use packet of lubricant jelly for catheter tip 6. Secure the device 7. Keep collection bag below bladder level **If the catheter is accidentally contaminated, discard it, and obtain a new sterile catheter (or kit) https://www.cdc.gov/infection-control/media/pdfs/Strive-CAUTI104-508.pdf#:~:text=Urinary%20Catheter%20Insertion · CDC and APIC guidelines state that the hand washing with soap and water should last between 15 to 20 seconds.”