Hospicio Divina Misericordia Corp

“Based upon an Emergency Preparedness Program (EPP) survey performed on 01/15/2025 from 8:00 AM through 3:30 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 a disaster or emergency situation. Findings include: During the review of the facilities Emergency Preparedness Program with the CEO (employee #1) and facility Supervisor (employee #2) on 01/15/2024, 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 01/15/2025 from 8:00 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 the CEO (employee #1) and facility Supervisor (employee #2) on 01/15/2024,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 01/15/2025 from 8:00 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 the CEO (employee #1) and facility Supervisor (employee #2) on 01/15/2024, 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 01/15/2025 from 8:00 AM through 3:30 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to have policies and procedures describing the system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains the availability of records. Findings include: During the review of the facilities Emergency Preparedness Program with with the CEO (employee #1) and facility Supervisor (employee #2) on 01/15/2024, it was noted that the EP failed to have written process for preserving patient information as required under §418.113(b)(4).”

“Based upon an Emergency Preparedness Program (EPP) survey performed on 01/15/2025 from 8:00 AM through 3:30 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to develop arrangements with other facilities or other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services. Findings include: During the review of the facilities Emergency Preparedness Program with the CEO (employee #1) and facility Supervisor (employee #2) on 01/15/2024, it was noted that the EP failed to have written arrangements with other facilities or other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients.”

“Based upon an Emergency Preparedness Program (EPP) survey performed on 01/15/2025 from 8:00 AM through 3:30 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 set and risk assessment. Findings include: During the review of the facilities Emergency Preparedness Program with the CEO (employee #1) and facility Supervisor (employee #2) on 01/15/2024, it was noted that the EP failed to develop and maintain an emergency preparedness training and testing program based on the facilities risk assessment. The facility did not have a testing program to validate acquired knowledge for trainings.”

“Based on observation, interview and police and procedure reviewed, three (3) home visits (H.V) performed on 01/15/2025 in company of Registered Nurse (employee #4), it was determined that the facility failed to ensure that the Licensed Practical Nurse (LPN) provide privacy to the patient for 1 out of 3 (H.V #3). Findings include: During the home visit #3 at 9:30 AM to 10:20 AM, the following was observed: 1.H.V #3 is an 86-year-old male admitted 01/11/2024 with diagnosis of Pulmonary Fibrosis. The home visit was performed on 01/15/2025 at 9:34 AM with the Licensed Practical Nurse (LPN) (employee #3). 2. During the bed bath procedure performed by LPN she did not provide privacy to the patient, open window and open door were observed. 3. During the bed bathing procedure LPN placed a small towel that only covered the genital area and left the rest of the body uncovered. 4.The facility failed to provide privacy to the patient during the bed bath procedure.”

“Based on observation, interview and police and procedure reviewed, three (3) home visits (H.V) performed on 01/15/2025 in company of Registered Nurse (employee #4), it was determined that the facility failed to ensure that the Licensed Practical Nurse (LPN) complies with standard practice precautions to prevent the transmission of infectious agents 1 out of 3 (H.V #3) during the bed-bath procedure and a visit to the wear house surgical supplies. Findings include: During a home visit #3 at 9:30 AM to 10:20 AM, the following was observed: 1.H.V #3 is an 86-year-old male admitted 01/11/2024 with diagnosis of Pulmonary Fibrosis. The home visit was performed on 01/15/2025 at 9:34 AM with the Licensed Practical Nurse (LPN) (employee #3). During the home visit with the (employee #3) it was observed the following: a. At 9:34 AM, the Licensed Practical Nurse (LPN) (employee #3) placed the case without using a under pad. b. At 9:36 AM, the employee #3 do not disinfect non-critical equipment before and after patient use. c. At 9:38 AM, the employee #3 perform hand washing in approximately to five (5) to eight (8) seconds before bathing the patient. d. At 9:52 AM, during the patient’s bed bathing, employee #3 failed on four (4) occasions to perform water changes in accordance with policy and four (4) glove changes. e. At 10:08 AM, after finishing the bed bath, employee #3 washes her hands for approximately to five (5) to (8) seconds. The facility failed to ensure the practice of standard precautions, prevention and transmission of infections. 3. On 01/15/2025 at 3:20 PM during the visit to the warehouse facilities the following was identified: a. The supply of medical-surgical material is observed four boxes directly on the floor. b. The observed boxes contain medical-surgical equipment, the first contains 18 boxes of urinary catheters, the second contains 1 box of serums-intravenous fluids, the third 10 boxes of Towel drapes and the fourth contains 10 boxes of syringes and 10 boxes of tongue depressors. c. The executive director stated that they were under construction and that usually the equipment was not placed directly on the floor. The facility did not provide the policy for the management of medical-surgical equipment in the warehouse facilities. 2. During the home visit conducted on 01/15/2024, the following was observed: a. On 01/15/2025 at 9:45 AM, it was observed at home visit # 3 that the humidifier tank connected to oxygen concentrator showed signs of mold in its inside. b. On 01/15/2025 at 9:45 AM, it was observed at home visit # 3 that the concentrator breathing vents were covered with dust indicating lack of maintenance and disinfection.”

“Based on the review of documents related to the volunteer program and interview with the CEO (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 01/15/2024 at 2:30 PM, the facility did not have did written evidence of the calculation of comparison of voluntary hours worked versus hours of direct care to patients that evidence compliance with the five (5) percent.”

“Based on a recertification survey, the review sixteen credential files (C. F.), it was determined that the facility failed to ensure that 7 out of 16 employees who provide services have updated credentials related to Nurses (NCF), Home Health Aide (HHACF), Speech Language (STCF), Occupational Therapist (OTCF), Counseling Spiritual (CSCF), Storage Medical Supplies and Durable Medical Equipment (SMS&DMECF) and Secretary (SCF), as required by State and Local laws. Findings include: 1. On 01/15/2025 at 11:30 AM during review of the credential file it was identify the following: a. Six out of sixteen credential files did not contain updates Health Certificate in the credential file expired on 09/13/2024(SMS&DMECF#1), 09/13/2024(SCF#2), 06/22/2024(OTCF#3), 04/21/2024(CSCF#8), 09/12/2024(NCF#9) and 11/15/2024(NCF#11). b. One out of sixteen credential files did not contain evidence of Hepatitis B Vaccines (SMS&DMECF#1). c. Three out of sixteen credential files did not contain evidence of influenza Vaccines or Exoneration, (OTCF#3, STCF#5 and CSCF#8). d. One out of sixteen credential files did not contain updates CPR in the credential filed expired on 04192024, (HHA#13).”