Luz de Esperanza Home Care Inc

Base on staff interview and credential file reviewed performed on 11/21/2025 at 1:25PM to 1:30PM, it was found that the facility failed to supervise the social worker assistant by a social worker with a master or doctoral degree.

The facility failed to ensure policies and procedures to facilitate the support of volunteers and other healthcare professionals in an emergency.

The facility failed to develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws.

The facility failed to receive information about phone numbers and entities whom to contact to file a grievance, to have in place mechanisms who promote the right of the patient and representative (if any), to be informed of the rights in a language and manner the individual understands and to…

The facility failed to evidence the development, implementation, evaluation, and maintenance of an effective, ongoing, Home Health Agency (HHA)-wide, data-driven QAPI program.

The facility failed to maintain and document an infection control program which has as its goal the prevention and control of infections and communicable diseases which makes this Condition of Participation: §484.70 Infection Prevention and Control Not Met.

The facility failed to organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and…

The facility failed to develop and maintain an emergency preparedness plan with specific approach to the location of the facility and surroundings.

The facility failed to develop and maintain an updated emergency preparedness plan.

The facility failed to develop the policy and procedure to inform the local emergency official about a homebound Home Health Agency (HHA) patients' in need of evacuation.

The facility failed to provide evidence of policies and procedures to contact local authorities in the case the facility cannot establish communications with on duty staff or patients Findings include: The facility did not provide evidence of the policies and procedures to contact local authorities…

The facility failed to develop policies and procedures for medical documentation that preserves patient information, protects confidentiality of patient information and secures and maintains availability of records.

The facility failed to ensure that the policies and procedures are develop to facilitate the support of volunteers and other healthcare professionals in an emergency.

The facility failed to develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws.

The facility failed to develop and maintain an emergency preparedness plan.

The facility did not provide evidence of an emergency preparedness training and testing.

The facility failed to develop and maintain an emergency preparedness training program.

The facility failed to conduct exercises to test the emergency plan.

The facility failed to design and implement QAPI that must at least be capable of showing measurable improvement on indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care.

The facility failed to include in the QAPI program quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program.

The facility failed to maintain performance improvement activities that are focused on indicators related with patient outcomes and all Home Health Agency (HHA) services.

The facility failed to ensure that one or more specific quality improvement projects are undertaken each year.

The facility failed to demonstrate that the Home Health Agency (HHA) governing body is responsible for ensuring that an ongoing program for quality improvement and patient safety is defined, implemented, and maintained.

The facility failed to ensure that accepted standards of practice, to prevent the transmission of infections and communicable diseases are adopted as part of the infection prevention control program.

The facility failed to maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the Home Health Agencys' (HHAs) quality assessment and performance improvement (QAPI)…

The facility failed to ensure that the Home Health Agency (HHA) must provide infection control education to staff.

The facility failed to have in place a complete mechanism to comply with the standard of supervision of skilled professional assistants for 1 out of 4 records reviwed (RR#2) Findings include: 1. During record review #2 on 10/24/19 at 3:00 pm, the following was identified: a.

The governing body failed to be accountable for the overall management of operations at the facility as evidenced by failure to be in compliance with the requirements at Condition of Parcticipation (COP): §484.50 Patient Rights , §484.65 Quality Assessment and Performance Improvement ( QAPI) …

Facility failed to appoint a clinical manager to provide oversight of all patient care services and personnel as required by regulation.

The facility failed to promote patient's right to receive information about HHA's transfer and discharge policies to persons who have limited English proficiency and accessible to individuals with disabilities.

The facility failed to promote patient's right to receive contact information for the Home Health Agency (HHA) administrator, including the administrator's name, business address, and business phone number in order to receive complaints.

The facility failed to promote patient's right to receive information related with rights and responsibilities in the individual's primary or preferred language and in a manner the individual understands, free of charge, with the use of a competent interpreter if necessary, no later than the…

The facility failed to promote patient's right to receive written notice of the patient's rights and responsibilities and the Home Health Agency's (HHA) transfer and discharge policies within 4 business days of the initial evaluation visit.

The facility failed to promote patient's right to receive information about phone numbers and entities whom to contact to file a grievance.

The facility failed to promote patient's right to be informed of the right to access auxiliary aids and language services, and how to access these services.

The facility failed to comply with requirements related with abuse and neglect provisions Findings include: 1. During review of patient rights policies related with abuse and neglect on 10/26/19 at 10:00 am, the following was identified: a.

The facility failed to maintain performance improvement activities that are focus on high risk, high volume, or problem -prone areas.

The facility failed to consider incidence, prevalence, and severity of problems when select indicators for performance improvement activities.

The facility failed to maintain an immediate correction of any identified problem that directly or potentially threaten the health and safety of patients.

The facility failed to have a mechanism in place to ensure that actions aimed at performance improvement, are implemented and that those actions, are measured its success to ensure that improvements are sustained.

Facility failed to appoint a clinical manager to provide oversight of all patient care services and personnel as required by regulation.

The facility failed to ensure that all discipline credential files are in compliance with applicable federal and local law for health agencies related to personnel credential files (C.F).

The facility failed to appoint a qualified pre-designated person, authorized in writing by the administrator and the governing body, to assumes the same responsibilities and obligations as the administrator, when the administrator is not available.