Hospicio Toque De Amor

“Based upon an Emergency Preparedness Program (EPP) survey performed on 12/06/2022 at 8:30 AM to 4:30 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 Human Resources Director (employee #4) on 12/06/2023 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 12/06/2023 at 8:30 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 Human Resources Director (employee #4) on 12/06/2023 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 12/06/2023 at 9:00 AM through 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 Human Resources Director (employee #4) on 12/06/2023 it was noted that the facility failed to have in place a written communication plan of how the facility coordinates patient care and how the facility interacts and coordinate with emergency management systems to protect health and safety of patients as required under §418.113(c).”

“Based upon an Emergency Preparedness Program (EPP) survey performed on 12/06/2023 at 9:00 AM through 4:00 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to develop primary / alternate means for communication with HHAs 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 Human Resources Director (employee #4) on 12/06/2023 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 upon an Emergency Preparedness Program (EPP) survey performed on 12/06/2023 at 8:30 AM through 4:00 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to conduct exercises to test the emergency plan annually. Findings include: During the review of the facilities Emergency Preparedness Program with the Human Resources Director on 12/20/2022 at 2:30 PM it was noted that the facility failed to conduct an additional exercise opposite to the natural disaster event ( Hurricane Fiona) contemplated as one exercise. The facility did not comply with multiple exercise during a two year time period.”

“Based on a recertification survey, three home visits (HV) with records review, eleven records reviewed (RR), administrative documents review, policies and procedures (P&P’s) review, interview with the facility clinical manager and quality assessment officer (employee #3), during a survey process performed from 12/05/2023 thru 12/06/2023, from 8:00 AM thru 4:00 PM, 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. 1.The following findings were identified while discuss with facility clinical manager and quality assessment officer (employee #3) on 12/06/2023 at 1:55 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 quality assessment officer 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 clinical manager and quality assessment officer (employee #3) stated on interview on 02/21/19 at 11:39 AM that facility 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 reviews the information but did not perform a deep analysis where they identify gaps in execution or probable cause for the non-favorably comparison. During the interview on 12/06/2023 at 2:30 PM facility clinical manager and quality assessment officer (employee #3) stated that facility periodically download the information published on medicare.gov Hospice compare. Quality assessment officer (employee #3) also stated that facility did not have indicators on their quality assessment performance improvement plan to identify gaps in execution and analyze these gaps to establish improvement plan and activities to make changes and to improve the quality of care provided to patients.”

“Based on a recertification survey, three (3) Home Visit (H.V.) to performed observation of nursing care with nursing personnel (employee #2) and (employee #1), interview with facility clinical manager (employee #3), and human resources officer (employee #4) it was determined that the agency failed to ensure that nursing personnel follow agency infection control policies and procedures and follow acceptable standard of practice for infection control during the ulcer care. This deficient practice was identified in 2 out of 3 home visits (H.V. #1, and #2). Review of facility policy Employees Personnel Appearance and Dress Code last review in December 2023 on 12/06/2023 at 1:25 PM with facility human resources officer (employee #4) evidence that this policy establishes a dress code with provisions that must be maintained by personnel providing direct care and services. This policy establishes provision to be maintained with the scrub suit pants used by these personnel. Review of facility policy Employees Personnel Appearance and Dress Code last review in December 2023 on 12/06/2023 at 2:00 PM with facility clinical manager (employee #3), evidence that this policy establishes that personnel providing direct care and services must maintain nails with clear light colors in case that they use nail polish. 1.During home visit to HV#2 with nursing personnel (employee #1) on 12/05/2023 at 11:15 AM where the nurse provide gastrostomy care it was observed that she had a green shiny nail polish. 2.During home visit to HV#1 with nursing personnel (employee #2) on 12/06/2023 at 9:45 AM where the nurse provide ulcer care it was observed that she had scrub suit pants trouser hem that drags directly on the floor. This promotes that the hem of the pants collects all the dirt from the floor where this nurse walks. 3. Facility human resources officer (employee #4) stated on interview on 12/06/2023 at 1:30 PM that nursing personnel assigned to provide patient direct care must use neutral and subdued nail polish and that this nail polish must not be chip off to avoid harboring germs beneath. She also stated that nursing personnel are not authorized to wear dark shinny color nail polish. Ulcer care policy and procedures last update in December 2023 was reviewed with facility clinical manager (employee #3), on 12/06/2023 at 2:00 PM. During the review the facility clinical manager (employee #3), stated on interview that if is feasible clean field when nursing personnel provide ulcer care, with items and supplies to be used during wound care must be prepared in a separate area and not directly on patients bed to prevent cross contamination with patients belongings and bed sheets. 4. H.V. #1 is an 82-year-old female who was admitted on 09/26/2023 with a Diagnosis of Senile Degeneration of Brain. This patient had a stage 2 ulcer on the sacral area and Right Trochanter. According to the Plan of care last reviewed on 11/27/2023 by the interdisciplinary team, the patient has Nursing services with a frequency of 2 visits per week and as necessary to assess patient and provide ulcer care. During the H.V. performed on 12/05/2023 at 9:45 AM with nursing personnel (employee #2) the following was observed: a.Nursing personnel (employee #2) prepare clean field with ulcer care items and supplies directly on the left bottom side of patient bed. This practice promotes contamination of materials, items, and supplies. 5. H.V. #2 is a 95-year-old male who was admitted on 11/05/2023 with a Cerebral Infarction. This patient had a gastrostomy to provide a route for tube feeding. According to the Plan of care last reviewed on 11/22/2023 by the interdisciplinary team, the patient has Nursing services with a frequency of 2 visits per week and as necessary to assess patient and provide services. During the H.V. performed on 12/05/2023 at 11:15 AM with nursing personnel (employee #1) the following was observed: a.Nursing personnel (employee #1) prepare clean field with items and supplies to be use to provide care to the skin around the gastrostomy stoma, directly on the bottom of patient bed. This practice promotes contamination of materials, items, and supplies.”

“Based on re-certification survey, the review of fourteen (14) credential files (C.F) with the Hospice Human Resource (employee #4) performed on 12/06/2023 from 2:00 PM thru 4:00 PM , it was determined that the facility failed to ensure that 9 out of 14 employees who provide services have updated credential files related to Register Nurses (RN), Social Workers (SW), Speech Pathologist, House keepers, Nutritionist, Occupational Therapist and Physical Therapist as required in accordance with State and Local Laws related to the lack of Annual Evaluations, Health Certificate, Hepatitis and Influenza Vaccine and Law 300 Back Ground Check. Annual Evaluations RNs, CF’s #1, #2, #3), SW CF’s #4 and Physical Therapist CF #14, Health Certificate (C.F #2 and #11), Hepatitis Vaccine CF’s #9, #11 and #12), Influenza Vaccine CF #11 and Law 300 Back Ground Check (CFs #3, #9 and #13). Findings include: Review of fourteen (14) credential files (C.F) of the hospice on 12/06/2023 and provided evidence of the following: Four (4) of fourteen (14) credential files did not contain evidence of updated Annual Evaluation (RN’s CF #1, #2 and #3), (SW #4) and PT#14). Three (3) of fourteen (14) credential files did not contain evidence of Hepatitis Vaccine or the serology test (CF #9, #11and #12). One (1) of fourteen (14) credential files did not contain evidence of Influenza Vaccine (CF#11). Three (1) of fourteen(14) credential files did not contain evidence of updated Law 300 Back Ground Check (CF#3, #9 and #13).”

“Based on fourteen (14) records review (RR) with three home visits with records reviewed and interview, it was determined that the facility failed to ensure that the physician reviews and complies with the policies and procedures related to patient care for 1 out of 14 records reviewed. (R.R #12). Findings include: 1. R.R. #12 is and 90 years old female patient admitted on 06/20/2023 with a diagnosis of Cardiovascular Heart Failure (CHF). The record was selected for record review on 12/06/2023 at 10:30 AM for physician services. The clinical record provide evidence that the patient has total dependent of daily activities (ADL), disoriented, confused, lethargic, tachycardia, urine and fecal incontinence with Foley catheter #20, poor appetite, respiratory therapy with Atroven .02% every 8 hours and Oxygen with nasal canula at 3 liters /as needed (PRN), dry skin with cutaneous eruption and left gluteal laceration. a. On August 11, 2023 at 9:00 PM the accordance of the on call registered nurse (employee #7) wrote goes to the patient house at 9:00 PM. The nurse took the vital signs and written B/P in blank, Pulse 50, Temperature 36.2. The subjective fact: Respiratory difficulty and Objective fact: change in color and nasal flutter. At 9:00 PM written: Client was observed with respiratory difficulty with Pulse: 50, Saturation: 49 and Respiration: 13. She notified the physician (employee #8) by telephone and she ordered increase oxygen at 5 liters and the nurse performed the physician order. She written: Patient observed without vital sings: Pulse: 0 and Oxygen Saturation: 0. Then she notified the physician (employee #8) and certified the death. b. The physician is not accessible when the nurse performed the call to notify the patient death. c. The register nurse on call note lacks of the result and the follow up. This section was maintain in blank. d. During the interview with the with the Clinical Manager (employee #3) and Human Recourse (employee #4) performed on 12/06/2023 at 10:30 AM related to the evaluation prior to declare the patient dead. The physician is the professional who assume the responsibility when the patient dies and perform the death certificate. e. No evidence was found of physicians progress notes, spiritual counseling, social worker and nursing related to the date of patient death.”