Hospicio En El Hogar Fe Y Esperanza De Puerto Rico

“Based on a recertification survey, review of documents, activities and policies related with Quality assessment and performance improvement (QAPI) program with facility Administrator (employee #2), on 12/13/23 at 2:30 PM, it was determined that the facility failed to evidence the development, implementation, evaluation, and maintenance of an effective, ongoing, Hospice wide, data-driven Quality Assessment Performance Improvement- QAPI program. The Hospice governing body did not ensure that the program reflects the complexity of its organization and services; involves all Hospice services (including those services provided under contract or arrangement); focuses on indicators related to improved palliative outcomes and takes action to demonstrate improvement in hospice performance. The Hospice did not maintain documentary evidence of its quality assessment and performance improvement program, which makes this Condition of Participation: §418.58 Quality Assessment and Performance Improvement (QAPI) Not Met. (Cross Reference Tags: L562, L 566, L571, L574). Finding include: 1. Facility failed to promote that information from performance being achieved published on the Medicare.gov Hospice compare is used to identify gaps in execution. 2. Facility failed to maintain performance improvement activities that are focus on high risk, high volume, or problem -prone areas. 3. Facility failed to develop implement and evaluate performance improvement projects. 4. Failed to ensure that an ongoing program for quality improvement is implemented, maintained and evaluated annually.”

“Based on a recertification survey, four (4) home visits ( HV) with records review (R.R), fifteen records reviewed, interviews and observations, it was determined that the facility failed to maintains and document an effective, organization-wide Infection Control Program that educate, protects patients, families, visitors and hospice personnel by preventing and controlling infections and communicable diseases, failed to maintain surveillance data routinely reviewed and monitored, failed to evidence that took appropriate corrective actions needed to be taken based on the data analysis, and failed to provide infection control education to employees, contracted providers, patients, and family members and others caregivers. Findings include: 1. On 12/12/2023 at 9:30 AM the Infection Control Manual was reviewed and provide evidence that the last revision of the manual was performed on 12/08/2021. The manual lacks an Index, the date when implemented, and the signature of the Administrator, Medical Director, and the Official Infection Control Nurse. 2. On 12/12/2023 at 9:40 AM the Nurse Administrator (employee #2) provide documentation related to the Infection Control minutes. She states that the facility had an Infection Control Committee until January 2021. She provides evidence that only one meeting on March 18/2020 at 1:00 PM and on January 28,2021 at 1:00 PM. Via Zoom. 3. On 12/14/2023 at 8:30 AM on interview with the Nurse Administrator (employee #2) refer: At this moment the facility lacks Infection Control Nurse and did not have infection control committee since 2022 because the infection control nurse resigned and at this moment the facility administration did not designate a nurse for this position. 4. On 12/14/2023 at 9:00 AM during the review of the documents provide by the facility Executive Director (employee # 3) the hospice did not provide evidence of an active Infection Control Program for all of the offices located on different locations.”

“Based on recertification survey review of review of 22 employees credential files and interview with Administrator (employee #2) during survey process perform from 12/12/23 through 12/14/23 from 8:00 AM thru 4:00 PM, it was determined that facility failed to ensure that each employee credential file comply with state and local laws credential requirements. This deficient practice was identified in 6 out of 7 credential files of register nurses, 1 out of 1 credential file of licensed practical nurse, 2 out of 4 credential files of social worker, 1 out of 2 credential file of spiritual counselor and 3 out 3 credential files of homemaker. Findings include: 1. Credential files of register nurses #1. #2, #3, #4, # 6 and # 7 lack evidence of competence and performance evaluation for year 2023. 2. Credential file of licensed practical nurse #8 lack of evidence of competence and performance evaluation for year 2023. 3. Credential file of register nurse #6 lack of evidence of updated Cardiopulmonary Resuscitation Certificate. 4. Credential files of social workers #1 and #4 lack of evidence of competence and performance evaluation for year 2023. 5. Credential file of spiritual counselor # 2 lack of evidence of competence and performance evaluation for year 2023. 6. Credential files of homemakers # 1, #2 and #3 lack of evidence of competence and performance evaluation for year 2023.”

“Based upon an Emergency Preparedness Program (EPP) survey performed on 12/12/2023 at 8:30 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 Administrator ( employee #2) on 12/12/2023 from 1:00 PM it was noted that the facility failed to update the Plan at least every two years as required. Last update of the EOP was performed on 04/05/2021.”

“Based upon an Emergency Preparedness Program (EPP) survey performed on 12/12/2023 at 8:30 AM through 4:00 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 #2) on 12/12/2023 at 1:00 PM 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. No communication has been established with Regional HCC.”

“Based upon an Emergency Preparedness Program (EPP) survey performed on 12/12/2022 at 1:00 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 Administrator (employee #2) on 12/12/2023 at 1:00 PM 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 12/12/2023 at 8:30 AM through 4:00 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 Administrator (employee #2) on 12/12/2023 at 1:00 PM 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 12/12/2023 at 8:30 AM to 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. Findings include: During the review of the facilities Emergency Preparedness Program with the Administrator (employee #2) on 12/12/2023 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 12/12/2023 at 1:00 PM 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 the Administrator (employee #2) on 12/12/2023 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 upon an Emergency Preparedness Program (EPP) survey performed on 12/12/2023 from 8:30 AM to 4:00 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 Administrator (employee #2) on 12/12/2023 at 1:00 PM 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 §484.102(c) of the Emergency Preparedness.”

“Based upon an Emergency Preparedness Program (EPP) survey performed on 12/12/2023 at 8:00 AM through 4:00 AM, to evaluate emergency preparedness requirements for recertification, it was determined that the facility failed develop and maintain an emergency preparedness training and testing program based on the emergency plan. Findings include: During the review of the facilities Emergency Preparedness Program with the Administrator (employee #2) on 12/12/2023 at 1:00 PM it was noted that the EP failed to develop and maintain a emergency preparedness training and testing program based on the facilities risk assessment.”

“Based upon an Emergency Preparedness Program (EPP) survey performed on 12/12/2023 at 1:00 PM through 4:00 PM, to evaluate emergency preparedness requirements for recertification, it was determined that the facility failed to 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 Findings include: During the review of the facilities Emergency Preparedness Program with the Administrator (employee #2) on 12/12/2023 at 1:00 PM through 4:00 PM it was noted that the facility failed to provide documentation of training on emergency preparedness policies and procedures to all new and existing staff.”

“Based on a recertification survey, process perform from 12/12/23 through 12/14/23 from 8:00 AM thru 4:00 PM, review of documents, activities and policies related with Quality assessment and performance improvement (QAPI) program, interview with the facility Administrator (employee #2 ) it was determined that the facility failed to promote that information from performance being achieved published on the Medicare.gov Hospice compare is used to identify gaps in execution. Findings include: 1.The following findings were identified while discuss with facility Administrator (employee #2) on 12/13/2023 at 3:55 PM hospice compare measures published on Medicare.gov Hospice compare last update November 22, 2023: In the Medicare.gov Hospice compare quality of patient care quality measure, related with the percentage of patients who received visits from a register nurse or medical social worker on at least 2 of the final 3 days of their life facility did not compare favorably with Puerto Rico average percent or national average percent. During survey procedures on review of Quality assessment performance improvement (QAPI) program activities it was request to the facility Administrator (employee #2) evidence of the medicare.gov Hospice compare data analysis, discussion, and establishment of activities to improve in areas where the achievement does not compare favorably with the same industry. The facility Administrator (employee #2) stated in an interview on 12/13/23 at 3:39 PM that facility did download the information published on medicare.gov Hospice compare who include data used to determine the standards of quality health care. She stated that the facility did not review the information and did not perform a deep analysis and did not identify gaps in execution or probable cause for the non-favorably comparison. During an interview on 12/13/23 at 3:45 PM facility Administrator (employee #2) stated that facility did not have an appointed QAPI officer since April 2022 when the assigned QAPI officer resign. Since April 2022 the QAPI committee has not met. She stated that since then facility is in the process of recruit a new QAPI officer to be assigned for the analysis and discussion of findings published on medicare.gov Hospice compare on the QAPI committee meetings to establish QAPI program activities based on the gaps in execution or probable cause for the non-favorably comparison.”

“Based on a recertification survey, process perform from 12/12/23 through 12/14/23 from 8:00 AM thru 4:00 PM, review of documents, activities and policies related with Quality assessment and performance improvement (QAPI) program, and interview with facility Administrator (employee #2), it was determined that the facility failed to maintain performance improvement activities that are focus on high risk, high volume, or problem -prone areas. Findings include: 1. During review of QAPI program information on 12/13/23 at 3:30 PM, the following was identified: a. The Hospice shows evidence of some quality indicators measured, analyzed, and tracked, however did not have evidence to apply a process to screen and establish priorities with focus on high risk, high volume, or problem -prone areas. b. During interview on 12/13/23 at 3:45 PM facility Administrator (employee #2) stated that facility did not have an appointed QAPI officer since April 2022 when the assigned QAPI officer resign. Since April 2022 she as Administrator (employee #2) performs surveillance on some quality indicators, but did not analyze, and tracked, or apply a process to screen and establish priorities with focus on high risk, high volume, or problem -prone areas. QAPI committee has not met. She stated that since then facility is in the process of recruiting a new QAPI officer to be assigned for the analysis and discussion of findings published on medicare.gov Hospice compare on the QAPI committee meetings in order to establish QAPI program activities based on the gaps in execution or probable cause for the non-favorably comparison.”

“Based on recertification survey review of documents, activities and policies related with Quality assessment and performance improvement (QAPI) program with facility Administrator (employee #2) during survey process perform from 12/12/23 through 12/14/23 from 8:00 Am thru 4:00 PM, it was determined that facility failed to develop implement and evaluate performance improvement projects. Findings include: QAPI facility policy and procedure related with performance improvement projects last review in November 2023 establish that facility will perform performance improvement projects after the determination of general situations and processes that affect patients, services, billing, and administrative areas. Review of documents and activities related to the QAPI program with facility Administrator (employee #2) on 12/13/23 at 3:05 PM evidence that facility did not perform any performance improvement project for years 2022 and 2023.”

“Based on recertification survey review of documents, activities and policies related with Quality assessment and performance improvement (QAPI) program with facility Administrator (employee #2) during survey process perform from 12/12/23 through 12/14/23 from 8:00 AM thru 4:00 PM, it was determined that facility failed to ensure that an ongoing program for quality improvement is implemented, maintained and evaluated annually. Findings include: QAPI facility policy and procedure related with performance improvement projects last review on November 2023 establish that facility must maintain an ongoing QAPI program capable of showing measurable improvement in indicators related to improved palliative outcomes and hospice services. Review of documents and activities related with the QAPI program with facility Administrator (employee #2) on 12/13/23 at 3:15 PM evidence that facility measure, and track quality indicators related with improved palliative outcome and services during year 2022 and 2023. However, the facility did not analyze and discuss findings in a forum as the QAPI committee monthly. During an interview on 12/13/23 at 3:35 PM facility Administrator (employee #2) stated that facility did not have an appointed QAPI officer since April 2022 when the assigned QAPI officer resign. Since April 2022 the QAPI committee has not met. She stated that since then the facility is in the process of recruiting a new QAPI officer to be assigned for the analysis and discussion of findings in monthly QAPI committee meetings.”

“Based on recertification survey review of 19 medical records, policies procedures and interview with Administrator (employee #2) during survey process perform from 12/12/23 through 12/14/23 from 8:00 AM thru 4:00 PM, it was determined that facility failed to offer bereavement counseling services following the death of a patient. This deficient practice was identified in 1 out of 19 records reviewed (RR #16). Findings include: 1. Bereavement services policy and procedures last review on November 23, 2023, establish that bereavement services must be available after patient death to patient and relatives up to 12 months after death. 2. RR # 16 is a 90-year-old female patient admitted on 09/08/23 with a diagnosis of Liver Cirrhosis. During review of the medical record with the Administrator (employee #2) on 12/13/23 at 9:55 AM it was identified that patient die on 10/30/23, after patient death bereavement services had not been offered to patients relatives. During the interview on 12/13/23 at 10:10 AM the Administrator stated that bereavement is not available for this patient because the facility did not have a spiritual counselor available. The spiritual counselor assigned for the geographical (East) area where patients relatives are located resign on May 2023 and since then facility is in the process of recruiting a new spiritual counselor. The facility failed to provide services to deal with affliction, loss, and grief to family members of patient #16 after patients death.”

“Based on recertification survey review of 19 medical records, policies procedures and interview with Administrator (employee #2) during survey process perform from 12/12/23 through 12/14/23 from 8:00 AM thru 4:00 PM, it was determined that facility failed to perform assessment of the patient and family spiritual needs. This deficient practice was identified in 5 out of 19 cases reviewed (RR #1, #3, #7, #8 and RR#16). 6. RR #1 is a 88 year old patient admitted on 7/13/2023 with a diagnosis of Cerebrovascular Accident (CVA). During review the medical record on 12/13/2023 at 2:30 PM with the Nurse Administrator (employee #2) it was identified that the patient did not receive spiritual services and no evidence of initial assessment of the patient and family spiritual needs programed to July/14/2023 because the Spiritual Counselor resignation. The initial assessment programed on September/ 22/ 2023 per a new Spiritual Counselor was performed however when the counselor visit the patient home the patient family exonerated the spiritual service. 7. RR #3 is a 86 years old patient admitted on 2/23/2023 with diagnosis of Alzheimer. During review the medical record on 12/13/2023 at 3:00 PM with the Nurse Administrator (employee #2) it was identified that the patient initial assessment was performed on 2/24/2023 and then on 3/29/2023 however, did not receive spiritual services on April, May, July and August of 2023 because the spiritual counselor exonerated. Findings include: 1. Spiritual counseling services policy and procedures last review on November 23,2023 establish that spiritual counseling services must be available before and after patient death to patient and relatives. 2. RR # 7 is a 68-year-old female patient admitted on 11/23/23 with a diagnosis of Alzheimer Disease. When patient was admitted a frequency of visits of 2 times per week for the register nurse, 1 time per month for the social worker,1 time per month for the spiritual counselor and 1 time per month for the physician was established by the interdisciplinary group. During review of the medical record with the Administrator (employee #2) on 12/13/23 at 11:00 AM it was identified that spiritual counselor has not made a visit to the patient since admission to the hospice program. During interview on 12/13/23 at 11:30 AM the Administrator stated that this spiritual counselor service is not available for this patient because facility did not have a spiritual counselor available. Spiritual counselor assigned for the geographical area (East) where this patient is located resign in May 2023 and since then facility is in the process of recruiting a new spiritual counselor. 3. RR # 8 is an 82-year-old female patient admitted on 10/11/23 with a diagnosis of Senile Degeneration of Brain. When patient was admitted a frequency of visits of 2 times per week for the register nurse, 1 time per month for the social worker,1 time per month for the spiritual counselor and 1 time per month for the physician was established by the interdisciplinary group. During review of the medical record with the Administrator (employee #2) on 12/13/23 at 10:00 AM it was identified that spiritual counselor has not made a visit to the patient since admission to the hospice program. During the interview on 12/13/23 at 10:30 AM the Administrator stated that this spiritual counselor service is not available for this patient because the facility did not have a spiritual counselor available. The spiritual counselor assigned for the geographical (East) area where this patient is located resign in May 2023 and since then facility is in the process of recruiting a new spiritual counselor. 4. RR # 16 is a 90-year-old female patient admitted on 09/08/23 with a diagnosis of Liver Cirrhosis. When patient was admitted a frequency of visits of 2 times per week for the register nurse, 1 time per month for the social worker,1 time per month for the spiritual counselor and 1 time per month for the physician was established by the interdisciplinary group. During review of the medical record with the Administrator (employee #2) on 12/13/23 at 9:50 AM it was identified that spiritual counselor has not made a visit to the patient since admission to the hospice program. During the interview on 12/13/23 at 10:00 AM the Administrator stated that this spiritual counselor service is not available for this patient because the facility did not have a spiritual counselor available. The spiritual counselor assigned for the geographical (East) area where this patient is located resign on May 2023 and since then facility is in the process of recruiting a new spiritual counselor. 5. Facility failed to make all reasonable efforts to facilitate visits by local clergy, pastoral counselors or other individuals who can support patients spiritual needs.”

“Based on a recertification survey, the review of documents related to the volunteer program with the facility Vice President (employee #3), 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 12/12/2023 at 10:00 AM till 12:00 PM with the facility Vice President (employee #3), no evidence was provided that agency has viable and ongoing efforts to recruit and retain volunteers on on going facilities activities or on social media or local newspapers.”

“Based on a recertification survey, the review of documents related to the volunteer program with the facility Vice President (employee #3), 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 12/12/2023 at 10:00 AM till 12:00 PM with the Vice President (employee #3), evidence was provided that agency do not meet with the requirement to comply with a minimal of 5 % of cost services from the total patient care hours of all paid hospice employees and contract staff. a. The evidence presented by the facility consists of the months of January to March 2022. There is no evidence of the use of volunteers after these dates. In March 2022, the percent of Volunteer hour was 24% In February 2022, the percent of Volunteer hour was 24% In January 2022, the percent of Volunteer hour was 31%”

“Based on recertification survey review of 22 employees credential files and interview with Administrator (employee #2) during survey process perform from 12/12/23 through 12/14/23 from 8:00 AM thru 4:00 PM, it was determined that facility failed to ensure that a criminal background check is performed to all hospice employees who have direct patient contact or access patients records. This deficient practice was identified in 18 out of 18 credential files reviewed of facility employees and 4 out of 4 contracted employees. Findings include: 1. During review of employees and contracted employees credential files with facility Administrator on 12/13/23 at 2:30 PM it was identified that none of these credential files had evidence of a criminal background check. 2. During interview on 12/13/23 at 3:00 PM with facility Administrator (employee #2) that facility has not yet established a mechanism to ensure that all hospice employees who have direct patient contact or access patients records provide evidence of a criminal background check. As an alternate method for inquiry employees criminal background check facility request Law 300 (Verification of criminal history or crimes related with minors and elderly people) and criminal record review performed by Puerto Rico state police.”