Hospicio Las Brisas

“Based on interviews with the facility billing director (employee # 1) and document review performed on October 22, 2025, from 1:00 PM to 2:00 PM, it was determined that the facility failed to ensure that an ongoing program for quality improvement and patient safety is defined, implemented, and maintained, and is evaluated annually. Findings include:1. A review of the Governing Body and Board of Directors regulations manual (May 1, 2023, revision) was done on October 22, 2025, at 1:00 PM. a. The board of directors’ standard agenda does not include the discussion of quality reports nor performance improvements projects reports. 2. A review of the Governing body and Board of Directors minutes records for 2024 and 2025 was done on October 22, 2025, at 1:30 PM.a. Neither of the minutes include discussion of quality reports nor performance improvements projects reports. This deficient practice was identified in all minutes reviewed: 7/12/2024, 10/11/2024, 1/10/2025, 4/10/2025, 7/10/2025, 10/10/2025. b. None of the minutes in 2024 nor 2025 include an annual evaluation of the quality program.”

“Based on interviews with the facility billing director (employee # 1) and document review performed on October 22, 2025, from 1:00 PM to 2:00 PM, it was determined that the Governing body and administrator failed to assume full authority and responsibility for the continuous quality assessment and performance improvement in the facility. Findings include:1. A review of the Governing Body and Board of Directors regulations manual (May 1, 2023, revision) was done on October 22, 2025, at 1:00 PM.a. The board of directors’ standard agenda does not include the discussion of quality reports nor performance improvements projects reports.2. A review of the Governing body and Board of Directors minutes records for 2024 and 2025 was done on October 22, 2025, at 1:30 PM. a. Neither of the minutes include discussion of quality reports nor performance improvements projects reports. This deficient practice was identified in all minutes reviewed: 7/12/2024, 10/11/2024, 1/10/2025, 4/10/2025, 7/10/2025, 10/10/2025.”

“Based on a recertification survey, interview, it was determined that the facility failed to ensure that core services, are provided directly by hospice employee related to spiritual counseling. Findings include: 1. During interview on 11/14/2023 at 8:45 AM the Quality Director employee #1 state that the facility has 15 Registered Nurse (RN), that 10 were facility employee, they have 2 License Practice Nurse (LPN), 5 social worker, and 1 spiritual counselor that was contract and have 4 physicians that 3 were contract. 2. The facility failed to provide core service Spiritual Counselor directly by hospice employees.”

“Based on the review of the facility’s services agreements and interview with the Quality Director (employee #1), it was determined that the facility failed to ensure that the services described in §418.72 Physical therapy, occupational therapy, and speech-language pathology are provided directly by the hospice or under arrangements. Findings include: 1. During interview on 11/14/2023 at 8:45 AM the Quality Director employee #1 state that the facility has 15 Registered Nurse (RN), that 10 were facility employee, they have 2 License Practice Nurse (LPN), 5 social worker, and 1 spiritual counselor that was contract and have 4 physicians that 3 was contract. The facility failed to provide core service Spiritual Counselor directly by hospice employees. 2. The facility quality director (employee #1) stated on 11/14/2023 at 8:15 AM during an interview that the facility lacks an agreement or contract with the services related to Occupational therapy, Physical therapy, and Speech - language pathology therapy. The quality director stated during an interview that the hospice lacks services for a long time because are difficult to hire under contract. 3. On 11/16/2023 at 1:00 PM the Governing Body President provide evidence of a resent agreement with a Home Care Facility to provide the service of PT, OT, and ST service if patient needed.”

“Based on the review of the facility’s services agreements and interviewed with the Quality Director (employee #1), it was determined that the facility failed to provide Occupational Therapy (OT), Physical Therapy (PT) and Speech Language Pathology Therapy (ST) Service which makes this this condition not met. b. On 11/16/2023 at 1:00 pm the Governing Body President provide evidence of a resent agreement with an Home Care Facility to provide the service of PT, OT and ST service if patient needed. Findings include: 1. The facility quality director (employee #1) stated on 11/14/2023 at 8:15 AM during an interview that the facility lacks an agreement or contract with the services related to Occupational therapy, Physical therapy and Speech - language pathology therapy. The quality director stated during interview that the hospice lacks the services long time because are difficult to hire under contract.”

“Based on a re-certification survey, the review of thirty-two (32) credential files (C.F) with the Hospice Billing Director employee #2 performed on 11/15/20230 from 2:55 PM thru 3:40 PM, it was determined that the facility failed to ensure that 22 out of 32 employees who provide services have updated credential files related to Register Nurses (RN), Physicians, Social Worker (SW), Spiritual Advisor (SA), Physician (P), Nutritionist (N),Housekeeper (ALL) and Volunteers (V) as required in accordance with State and local laws related to the lack of Health Certificate, Hepatitis and Influenza Vaccines, Annual evaluation and criminal record (ALL, C.F #1, N. C.F #2, V.C.F #3, #4, SW C.F #5, #6, #8, RN C.F’s #11, #12, #13, #14, #15, #16, #17, #18, #19, #24, #25#28, P.C.F #30, #31 and #32). Findings include: 1. Review of thirty-two (32) credential files (C.F) of the hospice on 11/15/20230 from 2:55 PM thru 3:40 PM provided evidence of the following: a. Two out of thirty-two credential files did not contain evidence of updated Health Certificate (RN C.F #14, expired on 10/05/2023, and RN C.F. #24 expired on 11/09/2023. b. Three out of thirty-two credential files did not contain evidence of Hepatitis Vaccines, or the serology test (ALL C.F #1, V. C.F #3, #4). c. Two out of thirty-two credential files did not contain evidence of an updated Annual Evaluation (RN C.F #11, and #16). d. Three out of thirty-two credential files did not contain evidence of Influenza Vaccines administration or Exoneration, (N. C.F #2, V. C.F #3, #4, RN C.F #25, P C.F #31). e. Three out of thirty-two credential files did not contain evidence of Duties and Functions, (V C.F #3 #4 and #11). f. Three out of thirty-two credential files did not contain evidence of updated criminal record, (V.C.F #3, #4, #5, #6, #8, #11, #12, #13, #14, 16, #17, #18, #19, #24, #28, #30, #31 and #32). g. Three out of thirty-two credential files did not contain evidence of updated Cardiopulmonary Resuscitation (CPR) Certification (RN C.F. #15 , P.C.F #31 and #32).”

“Based upon an Emergency Preparedness Program (EPP) survey performed on 11/14/2023 at 12:30 PM through 4:45 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to implement a system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. Findings include: During the review of the facilities Emergency Preparedness Program with Quality Manager (employee #1) on 11/14/2023 at 1:30 PM it was noted that the EP failed to have written process for preserving patient information as required under §418.113(b)(5).”

“Based upon an Emergency Preparedness Program (EPP) survey performed on 11/14/2023 at 12:30 PM through 4:45 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to stablish policies and procedure for 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. Findings include: During the review of the facilities Emergency Preparedness Program with Quality Manager (employee #1) on 11/14/2023 at 1:30 PM it was noted that the EP failed to stablish 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 11/14/2023 at 12:30 PM through 4:45 PM, 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 Quality Manager (employee #1) on 11/14/2023 at 1:30 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 11/14/2023 at 12:30 PM through 4:45 PM, to evaluate emergency preparedness requirements, 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. Findings include: During the review of the facilities Emergency Preparedness Program with Quality Manager (employee #1) on 11/14/2023 at 1:30 PM it was noted that the EP failed to provide documentation of training on emergency preparedness policies and procedures to all new and existing staff.”

“Based on a recertification survey, the Inservice personnel training review with facility Quality Director (employee #1), it was determined that the facility failed to ensure that all facility personnel know all type of violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property to alert and report to the administrator when occur. Findings include: During the review of the personnel training program on 11/14/2023 at 1:00 PM it was found that the facility provides personnel training related to facility policy and protocol of fraud and abuse between October and November 2023. This training does not include the definition of all type of abuse and the component to ensure the prevention and identification of possible case of abuse and how and when to report allegations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse by anyone furnishing services on behalf of the hospice. On 11/16/2023 at 2:30 PM employee #1 provide evidence of the facility abuse and neglect protocol, however no evidence was provided related to the personnel attendance list to the training of the Abuse and Neglect Protocol.”

“Based on a recertification survey, the review of documents related to the volunteer program with the Quality Director employee #1, 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 11/14/2023 at 2:00 PM till 3:30 PM with the Quality Director employee #1, 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. In the last 6-month June 2023 through October 2023 evidence was provided that the facility does not comply with the 5% of cost on volunteer services as evidence: In May 2023, the percent of Volunteer hour was 2.5%, In June 2023, the percent of Volunteer hour was 0.56%, In July 2023, no evidence was provided of the percent of Volunteer hour, In August 2023, the percent of Volunteer hour was 0.98%, In September 2023, the percent of Volunteer hour was 1.35%, In October 2023, no evidence was provided of the percentage of Volunteer hours.”

“Based on a recertification survey, the review of policies/procedures and documents reviewed with the Quality Director employee #1, it was determined that the Governing Body ensure the provision of all hospice services and updated credential files of their personnel. Findings include: 1. During interview on 11/14/2023 at 8:45 AM the Quality Director employee #1 state that the facility has 15 Registered Nurse (RN), that 10 were facility employee, they have 2 License Practice Nurse (LPN), 5 social worker, and 1 spiritual counselor that was contract and have 4 physicians that 3 was contract. The facility failed to provide core service Spiritual Counselor directly by hospice employees. 2. The facility quality director (employee #1) stated on 11/14/2023 at 8:15 AM during an interview that the facility lacks an agreement or contract with the services related to Occupational therapy, Physical therapy, and Speech - language pathology therapy. The quality director stated during an interview that the hospice lacks services for a long time because are difficult to hire under contract. 3. The facility failed to ensure that 22 out of 32 employees who provide services have updated credential files related to Register Nurses (RN), Physicians, Social Worker (SW), Spiritual Advisor (SA), Physician (P), Nutritionist (N),Housekeeper (ALL) and Volunteers (V) as required in accordance with State and local laws related to the lack of Health Certificate, Hepatitis and Influenza Vaccines, Annual evaluation and criminal record (ALL, C.F #1, N. C.F #2, V.C.F #3, #4, SW C.F #5, #6, #8, RN C.F’s #11, #12, #13, #14, #15, #16, #17, #18, #19, #24, #25#28, P.C.F #30, #31 and #32).”

“Based on recertification survey, the review of policies and procedures, observations and visual revision of a facility drugs and biological storage with the agency pharmacy assistant ( employee #4), it was determined that the agency failed to ensure that all drugs and biological are stored and managed according to State and Local Law, secure nursing practice and infection control measures ( Local Law: Pharmacy Law of Puerto Rico Law Number 247 of September 3, 2004 Article 1.03 Definitions (d) Botiquin and Secretary of Health Regulated Number #91 Article IV and Law Number 24 June 4, 1987 according to amendment to regulate the Respiratory Practice Care in Puerto Rico). Findings include: On 11/16/2023 at 9:30 AM the medication stock was reviewed with the pharmacist assistance (employee #4) and provided evidence of two medication’s flask of Metronidazole tablets USP 500 mgs. with expiration date was August 31, 2023 Lot. 2104732, one of the flask was observed open, the pharmacist assistance removed the two medication flask. No evidence of medication list with expiration date. The hospice did not have a system to ensure that the drugs and biologicals labeled in accordance with currently accepted professional practice and must include expiration date. A Policy and procedure related to the secure practice procedures that includes drug management related to the storage of drugs to ensure proper temperature and light exposure, expiration dates and safety was not provided.”