Pathways Hospice

“Upon patient record review, 6 of 30 (Patients #1,2,4,5,9,18) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #1: During the medication reconciliation the following discrepancies were found with Hospice/SNF- • Hospice indicated Acetaminophen 500 mg 1-tab / SNF profile Acetaminophen 500mg 2-tabs • Hospice medication not listed / SNF Ropinirole 0.25 mg QDM • MiraLAX 17 gm powder with no diluent indicated • Hospice Seroquel 25 mg @ bedtime / SNF Seroquel 12.5 BID • Hospice Loratadine 10 mg QD / SNF med not listed on profile • Hospice Lorazepam 0.5 mg / SNF med not listed on profile Patient #2: During the medication reconciliation the following discrepancies were found with Hospice/SNF- • Hospice Multi-Vitamin / SNF Multi-Vitamin with Minerals • Hospice O2 1-5 L/min / SNF 2L/min Patient #4: During the medication reconciliation the following discrepancies were found with Hospice/SNF- • Hospice not listed / SNF Biotene artificial saliva • Hospice Voltaren QID / SNF Treatment not listed • Hospice Hydroxyzine 25 mg / SNF medication not listed Patients #5, 9, 18: MiraLAX 17 gm powder order with no diluent indicated”

“Upon patient record review, 1 of 30 (Patient #12) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #12: The Aide care plan indicated shower and tub bath. There was no modifier on when to perform these tasks.”

“Upon observation, there is no evidence building construction is provided consistent with the 2012 editions of the LSC of the National Fire Protection Association and NFPA 99. If the building has a common wall with a nonconforming building, the common wall is a fire barrier having at least a two hour fire resistance rating constructed of materials as required for the addition. Communicating openings in dividing fire barriers required by 18.1.1.4.1 shall be permitted only in corridors and shall be protected by approved self-closing fire doors assemblies. New construction Based on record review, the hospice inpatient facility failed to ensure that required fire-rated door assemblies in the new construction area were inspected and tested annually and that documentation of the inspections was maintained, in accordance with NFPA 101, 2012 edition, 7.2.1.15.2 and NFPA 80, 2010 edition, 5.2.1. Failure to maintain annual fire door assembly inspection documentation may affect the reliability of required fire-rated openings and fire/smoke compartment protection.”

“Upon observation, there is no evidence the smoke compartmentation and control of a facility is provided consistent with the 2012 editions of the LSC of the National Fire Protection Association and NFPA 99. The provisions of the adopted edition of the Life Safety Code do not apply in a State if CMS finds that a fire and safety code imposed by State law adequately protects patients in hospices. New Construction During observation of the smoke barrier swinging door pairs serving the smoke compartments in Patient Hall 1–6 and Patient Hall 7–12, both pairs of smoke barrier doors were noted to have excessive vertical clearance gap at the meeting edges between the paired doors. The observed gaps exceeded the allowable clearance permitted by NFPA 80 Section 6.3.1.7 and the doors were not provided with adequate rabbets, bevels, or astragals to minimize the opening as required by NFPA 101 Section 18.3.7.8. This deficient practice could affect the integrity of the smoke barrier and the facility’s ability to resist the movement of smoke during a fire event.”

“Upon observation, there was no evidence construction, maintenance, and safety equipment at the facility is provided consistent with the 2012 editions of the LSC of the National Fire Protection Association and NFPA 99. The provisions of the adopted edition of the Life Safety Code do not apply in a State if CMS finds that a fire and safety code imposed by State law adequately protects patients in hospices. (Reference inpatient kitchen) New Construction During observations, 1. In the Kitchen, a HVAC-related unprotected penetration was observed in the ceiling tile assembly. The penetration was not properly sealed or protected to maintain the integrity of the fire-resistance-rated ceiling assembly and was not in compliance with NFPA 101 2012 edition Chapter 8.3.5.1 which requires fire-resistance rated ceilings to be continuous, properly sealed, and maintained with protected penetrations. 2. In the family kitchen/dining area, the kitchen exhaust hood was noted to have missing grease filters and was not in accordance with NFPA 101, 2012 Edition, Section 18.3.2.5, which references Section 9.2.3 and requires commercial cooking operations to comply with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations.”

“Upon observation, there was no evidence the automatic sprinkler system of a facility is provided consistent with the 2012 editions of the LSC of the National Fire Protection Association and NFPA 99. The provisions of the adopted edition of the Life Safety Code do not apply in a State if CMS finds that a fire and safety code imposed by State law adequately protects patients in hospices. New Construction During observations in the kitchen, a storage box was placed 15.5” below a sprinkler deflector which is less than the required minimum of 18 inches below sprinkler deflectors, potentially obstructing the sprinkler discharge pattern in accordance with NFPA 101 (2012 Edition), Section 18.3.5.4 and 9.7.1.1* which references NFPA 13 for required clearances below sprinkler deflectors.”

“Upon observation, there was no evidence the illumination and emergency power of a facility is provided consistent with the 2012 editions of the LSC of the National Fire Protection Association and NFPA 99. The provisions of the adopted edition of the Life Safety Code do not apply in a State if CMS finds that a fire and safety code imposed by State law adequately protects patients in hospices. New Construction During observations, 1. In the bathroom of Patient Room 6, the emergency call system pull cord was observed wrapped around the shower curtain and was not readily accessible which was not in compliances with NFPA 101 Life Safety Code, Section 18.3.4 which requires patient safety features, including nurse call systems, to be maintained and ensure accessibility and proper operation. 2. The manual fire alarm pull station located at the charge nurse desk was obstructed by a decorative item, limiting unobstructed access to the device. The obstruction could delay manual activation of the fire alarm system during an emergency event and was not in compliance with NFPA 101, 2012 Edition, Section 18.3.5.4.1, which references Section 9.6 and requires fire alarm systems to be installed, inspected, tested, and maintained in accordance with NFPA 72.”