S & R Hospice Corp

“Based upon an Emergency Preparedness Program (EPP) survey performed on 01/14/2025 at 8:30 AM through 3:00 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 Recruitment Official (employee #8) and Executive Director (employee #9) on 01/14/2024, 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.”

“Based upon an Emergency Preparedness Program (EPP) survey performed on 01/14/2024 at 8:30 AM through 3:30 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 Recruitment Official (employee #8) and Executive Director (employee #9) on 01/14/2024, 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 01/14/2025 from 8:30 AM through 3:30 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 Recruitment Official (employee #8) and Executive Director (employee #9) on 01/14/2024, 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 01/14/2025 at 8:30 PM to 3:30 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 Recruitment Official (employee #8) and Executive Director (employee #9) on 01/14/2024, 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 on the home visits (HV) conducted and the policy and procedures reviewed on 01/14/2025, it was determined that the facility did not ensure that accepted standards of practice were followed to prevent the transmission of infections and the use of standard precautions for 1 out of 4 home visits. (HV#3). Findings include: 1.During the home visit conducted on 01/14/2025, the following was observed: a. On 01/14/2025 at 10:55 AM, it was observed at home visit # 3 that the humidifier tank connected to the H tank regulator had mold on filter area.”

“Based on fifteen (15) records reviewed (R.R) and four 4 Home Visit (H.V.)with the nurse supervisor employee #1, interview with the Billing Officer employee #4, it was determined that the facility failed to notified to CMS and request and through a CMS 855A to the National Government Services (NGS) to adds 7 hospice multiple locations before providing hospice care and services to Medicare patients at those 7 locations. Findings Include: 1.During the entrance conference with the nurse supervisor (employee #1), it was request the list of the active patients. The facility provided 8 list of active patient, in the main office of Isabella 17 patients and 7 satellite office in Yauco with 36 patients, San Sebastian with 33 patients, Ponce with 18 patients, Trujillo Alto with 9 patients, Cabo Rojo with 29 patients, Hatillo with 10 patients, and Aguada with 26 patients. During interview on 01/14/2025 at 2:00 PM when the surveyor ask if the facility completed a CMS855A for those 7 multiple locations before providing hospice care and services to Medicare patients at those locations, the Billing Officer employee #4 state that she tried to request the CMS855A, but the system did not permitted, due to the provider certification end more later, and the system did not permitted. 2. No evidence of the CMS approval letter of the 7 Multiple location office was provided during the survey. 3.When arrive to the State agency office, no evidence was found in the iQIES system that the facility have any satellite office or request it through a CMS855A the adding of those 7 multiple locations. 4.The facility fail to request Medicare approval of the seven multiple location before proving services to Medicare patients at those seven (7) multiple location.”