Caribbean Hospice Corp

“Based upon an Emergency Preparedness Program (EPP) survey performed on 01/18/2024 at 8:00 AM through 4:00 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. Findings include: During the review of the facilities Emergency Preparedness Program with the Operations Director ( employee #3) on 01/18/2024 at 10:30 AM it was noted that the facility failed to update the Plan at least every two years as required. Last approved POC update was performed on January 2021.”

“Based upon an Emergency Preparedness Program (EPP) survey performed on 01/18/2024 at 8/:00 AM through 4:00 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to develop an emergency preparedness plan that is based on the facility-based and community-based risk assessment using an “all-hazards” approach. Findings include: During the review of the facilities Emergency Preparedness Program with the Operations Director ( employee #3) on 01/18/2024 at 10:30 AM it was noted that the facility failed to include a facility and community based all hazard approach risk assessment. Facility referred to Health Care Coalitions hazard vulnerability (HVA) assessment as facilities HVA. Facility should perform its own community and facility based risk assessment.”

“Based upon an Emergency Preparedness Program (EPP) survey performed on 01/18/2024 at 8/:00 AM through 4:00 PM, 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. During the review of the facilities Emergency Preparedness Program with the Operations Director(employee #3) on 01/18/2024 it was noted that the facility failed to stablished policies and procedures to ensure and facilitate the support of volunteers and other healthcare professionals in an emergency as required under §418.113(b)(4).”

“Based upon an Emergency Preparedness Program (EPP) survey performed on 01/18/2024 at 8:00 AM through 4:00 PM, to evaluate emergency preparedness requirements for recertification, it was determined that the facility failed to develop and maintain policies and procedures related with the role of the facility under a waiver declared by the Secretary in accordance with section 1135 of the Act in the provision of care and treatment. Finding includes: During the review of the facilities Emergency Preparedness Program with Operations Director (employee #3) 01/18/2024 it was noted that the EP failed to include policies and procedures which outline the facility’s role in the provision of care and treatment under section 1135 waivers during a declared public health emergency in alternate care sites as required under §418.113(b)(6)(C)(iv).”

“Based on a recertification survey, three (3) Home Visit (H.V) with Records Reviewed and eleven (11) Record Reviewed (R.R) and interview with the Quality Coordinator employee #1, it was determined that the facility failed ensure that the care and service provided was in accordance with the plan of care related to Home Health Aid visit (HHA) for 2 out of fourteen record review R.R # 6 and #X. 2.H.V #2 is an 83-year-old female admitted on 12/12/2023 with diagnosis Alzheimers disease with late onset. During the record review performed on 01/18/2024 at 2:22 PM, it was determinate that the interdisciplinary group (IDG) in the plan of care performed on 01/17/2024 establish the following frequency for the services: two visits a week and as needed for the registered nurse (RN), three visits a week and as needed for the Home Health Aide (HHA), one visit a month and as needed for the Physician, two visits a month and as needed for the social worker and two visits a week and as needed for the Home Maker. No evidence was found during one of the HHA visits in the week of 12/18/2023 to 12/24/2023. Findings include: 1. R.R #6 is a 58-year-old male who was admitted on 01/03/2024 with a diagnosis of Amyotrophic Lateral Sclerosis. During the record review performed on 01/18/2024 at 11:40 AM it was identified that Interdisciplinary Group (IDG) plan of care performed on 01/07/2024 establish the following frequency for the services: 2 visits per week and as necessary (PRN) for the Registered Nurse, 3 visits per week for the Home Health Aide (HHA), 1 visit every 14 days and as necessary (PRN) for the Social Worker, 1 visit per month and as necessary (PRN) for the Counseling Services and 1 visit every 4-6 weeks/ PRN for the Physician Services. No evidence was found of the HHA visit since the services be assigned. During interview with the Quality Coordinator and IDG Coordinator employee #1 on 01/18/2024 at 12:00 pm state that this patient wants to receive his bath in a recliner chair and want that the HHA provide the bath there, with a wet tower as her mother due it, the HHA explain to the patient that not was the recommendation for security he dont want to accept. But no evidence was found for the HHA Intervention explaining this situation since 01/07/2024 that was assigned to the HHA until 01/17/2024 that was discuss the case in the IDG meeting.”

“Based on a recertification survey, observations made during three home visits (H.V), it was determined that the facility failed to follow an acceptable standard of infection control during the procedure of hand wash performed in 2 out of 3 home visits. Failed to comply with Department of health Administrative Order #284 established the use of artificial nails. (H.V#1 and H.V#2) Findings include: 1.H.V#1 is a 95-year-old female admitted on 01/12/2024 with diagnosis Alzheimers disease with late onset. The patient was visited on 01/18/2024 at 10:26 AM accompanied by facility nursing personnel (employee #2). During the visit the patient was observed bedridden and totally dependent on activities of daily living. a.The registered nurse (RN) (employee #5) after the hand washing procedure, she opened the door handle to enter the patient’s room without the protection of a napkin, she put on the gloves and then proceeded to perform the ulcer care procedure on the patient. During the hand washing performed, it was observed RN #5 that after touching the door handle, she did not use alcohol or hand sanitizer before doing the ulcer care procedure. The facility failed to follow the agency policies and procedure related to appropriate standards of infection control hand washing. During the observations area on 01/18/2024 at 10:26 AM the following was found: On 01/18/2024 during the tour of the patient room, the nurse (employee #5) with artificial nails. Facility failed to comply with Department of Health Administrative Order #284 which establishes the use of artificial nails, and length to avoid risk of contamination. 1.H.V #2 is an 83-year-old female admitted on 12/12/2023 with diagnosis Alzheimers disease with late onset. The patient was visited on 01/18/2024 at 11:00 AM accompanied by facility nursing personnel (employee #2). During the visit the patient was observed bedridden, Gastrostomy at #26 at 80 milliliters per hour (ml/hr) with Jevity 1.5 four cans and totally dependent on activities of daily living. a.The registered nurse (RN) (employee #6) during the hand washing procedure used soap and went under water without washing. The facility failed to follow policies and procedure related to appropriate standards of infection control for hand washing.”

“Based on a recertification survey, the review of documents related to the volunteer program performed on 01/18/2024 at 8:00 AM through 4:00 PM, it was determined that the facility failed to document and demonstrate viable and ongoing efforts to recruit and retain volunteers. Findings include: During the review of volunteer program on 01/19/2024 from 8:00 AM till 10:30 AM with the Operations Director (employee #3) evidence was provided that agency do not meet with the requirement to comply with the documentation and demonstrate viable and ongoing efforts to recruit and retain volunteers. The presented classified postings did not have evidence of dates posted.”