Good Shepherd Homecare & Hospice Inc.

“Based on observation, record review, policy review and staff interview the Hospice agency failed to provide a revised plan of care including information from the patient’s updated comprehensive assessment and progress toward outcomes and goals for 1 of 19 patients (Patient 3) reviewed. Failure to revise the plan of care to meet the changing needs of the patient diminishes the quality of care and progress towards desired goals. Findings Include: Review of hospice policy titled “Physician Orders and Plans of Treatments” states “the Hospice Standing Orders are sent to the Primary Care Physician for review and approval.” ... “Once the signed Hospice Standing Orders are received, direct care staff may implement any and all items listed on the Hospice Standing Orders as needed.” ... “The contents of the diagnostic and therapeutic orders (plan of treatment) include:” ... “A description of the treatment and/or procedure to be done, including, when appropriate, the type, frequency, and duration.” ... “;Who is to perform the treatment or procedure.” ... “Type of equipment, if any, necessary in the provision of care.” Review of Patient 3’s record showed an admission date of 02/09/24 with a diagnosis of secondary malignant neoplasm to the brain (brain cancer) with a current certification period of 02/09/24 to 05/09/24. Review of a standing order dated 02/09/24 showed, “Institute skin regimen as needed: Breakdown; hydrogel/foam/transparent/film/gauze dressing, change as indicated.” No noted orders with parameters for frequency of dressing change, location, or dressing type used noted in clinical record. Review of the treatment administration record (TAR) in Patient 3’s record revealed there were no documented instructions or dressing changes in the record. Review of care plan dated 02/09/24, a team care plan dated 02/14/24, and a team care plan dated 02/28/24 found there was no care plan problem, goal, or interventions regarding wound care. Observation of Patient 3 during a home visit on 03/06/24 at 3:00 PM, showed the Certified Home Health Aide (CHHA) provided personal hygiene care when a foam dressing to the coccyx (tailbone) was identified. During an interview on 03/06/24 at 4:00 PM, Staff E, Registered Nurse (RN) stated that any treatments for the patients would be listed in the TAR including the specific wound care orders. Staff E stated that if the standing order is needed for breakdown prevention a dressing can be used at the judgement of the nurse. When questioned about the frequency of dressing change, the RN stated that the standard order is to change every 5 days and as needed if soiled or contaminated. During an interview on 03/07/24 at 11:30, Staff A, Executive Director (ED) and Staff B Clinical Director (CD), Staff A stated that when a standing order is started, regarding a wound dressing the dressing type and care instructions are to be written on the TAR. Staff A stated that the wound care and interventions provided should then be added to the care plan. Review of Patient 3’s medical record with Staff A, revealed no documentation of wound dressing found in the clinical record, TAR, or care plan.”

“Based on medical record review and staff interview the Hospice agency failed to ensure that the care and services are provided in accordance with the plan of care for 1 of 19 patients (Patient 1) reviewed. Failure to ensure that the care plan services are provided in accordance with the plan of care does not allow for optimal management of needs and progress towards desired goals of the hospice patient. Findings Include: No hospice policy found regarding scope and frequency of services necessary to meet patient and family needs upon request. Review of Patient 1’s record revealed Patient 1 admitted to hospice services on 10/13/23 with a primary diagnosis of Alzheimers disease with late onset with a current certification period of 01/11/24 to 04/10/24. Review of the Hospice certification plan of care orders dated 01/11/24 showed Certified Home Health Aide (CHHA) visit frequency of 1 time weekly for 12 weeks and Pastoral Care (PC) visit frequency of 1-3 times monthly for 3 months. Subsequent team care plan updates dated 01/17/24, 01/31/24, 02/14/24 and 02/28/24 show CHHA frequency of 1 time weekly for 12 weeks and PC frequency of 1-3 times monthly for 3 months. Review of the Registered Nurse (RN) narrative notes dated 01/10/24, 01/24/24, 02/07/24, and 02/23/24 showed the CHHA visits to continue 1-3 times weekly. Review of the CHHA visit history report showed Patient 1 received visits 3 times weekly routinely throughout this period. No PC visit noted during the month of February. There were no noted order changes in the record for the CHHA or PC frequencies during this period. Additional review of the PC visit notes during this time frame confirmed a visit occurrence on 01/31/24 and no additional PC visits during the month of February. During an interview on 03/07/24 at 11:30 AM, Staff A, Executive Director (ED) and Staff B Clinical Director (CD), Staff A, ED stated that the plan of care should be reflective of all the cares and updates being provided to patients. Staff A stated that the original admission order dated 10/13/23 showed a frequency for the CHHA visits of 1-3 times weekly and the current order should be the same. Current frequencies reviewed in the computer show 1-3 times weekly for the CHHA. However, upon review of the certification plan of care signed and dated 01/11/24 the CHHA frequency was confirmed to be 1 time weekly for 12 weeks and each team care plan update reflective of this frequency.”

“Based on observation and policy review the hospice agency failed to follow accepted standards of practice to prevent the transmission of infections and communicable diseases, including the use of standard precautions on 1 of 4 patients (Patient 1) observed. This deficient practice places all patients on service at risk for the potential transmission of infection and communicable disease. Findings Include: Review of hospice agency policy titled “Standard Precautions” states “Bag Technique: The bag contains designated clean, used, and dirty areas. Clean areas contain never-used supplies and/or equipment. Used/reusable areas contain clean reusable medical equipment” ... “Dirty areas are designated for contaminated materials (i.e., used equipment).” ... “When client care is completed, hands are washed, reusable equipment is cleaned, hands are rewashed, and equipment and supplies are returned to the bag.” Review of Patient 1s record revealed Patient 1 admitted to hospice services on 10/13/23 with a primary diagnosis of Alzheimers disease with late onset with a current certification period of 01/11/24 to 04/10/24. Observation on 03/06/24 at 9:35 AM, showed Staff C Registered Nurse (RN) applied hand sanitizer, applied gloves, and then assessed Patient 1’s vitals. After use of thermometer, oxygen saturation monitor, and blood pressure cuff Staff C placed the equipment inside the main compartment of her bag before disinfecting items. After fully completing the patient assessment Staff C then removed the used equipment from her bag and cleaned with antiseptic wipe and placed cleaned equipment within the same compartment of her bag that the dirty equipment was previously in. During an interview on 03/07/24 at 11:30 AM, with Staff A, Executive Director (ED) and Staff B, Clinical Director (CD), review of the “Standard Precautions” policy and visit observation performed on 03/06/24 of Staff C discussed. According to Staff A, all field staff are trained at time of orientation and annually to follow standard precautions when caring for any patients.”

“Based on medical record review and staff interview the hospice agency failed to ensure hospice aide supervisory visits were completed no less than every 14 days by registered nurse (RN) for 2 of 19 patients (Patient 1 and 2) as required. Failure to complete supervisory visits of hospice aide services has the potential to place patients at risk for inadequate quality of care to meet the changing needs of the patient. Findings Include: Patient 1 Review of Patient 1’s record revealed Patient 1 admitted to hospice services on 10/13/23 with a primary diagnosis of Alzheimers disease with late onset with a current certification period of 01/11/24 to 04/10/24. Review to the current plan of care showed Patient 1 received certified home health aide (CHHA) visits 1 time weekly for 12 weeks. The record showed a supervisory visit dated 02/07/24 and subsequent CHHA supervisory visit dated 02/23/24, 16 days between supervisory visits. Patient 2 Review of Patient 2’s record showed an admission date of 11/17/23 with a primary diagnosis of Alzheimers disease with a current certification period dated 02/15/24 to 05/15/24. Review to the current plan of care showed Patient 2 received CHHA visits 1-2 times weekly for 13 weeks. The record showed a CHHA supervisory visit dated 02/08/24 and subsequent CHHA supervisory visit dated 02/29/24, 21 days between the supervisory visits. During an interview on 03/07/24 at 11:30 AM, Staff A, Executive Director (ED) and Staff B, Clinical Director (CD), Staff A stated that CHHA supervisory visits are to be performed every 14 days and documented in the electronic record by the registered nurse with a “SUPERVISORY VISIT-CHHA clinical note”. Review of CHHA supervisory visits for Patient 1 and Patient 2 with ED and CD found dates to be correct and out of compliance with CHHA supervisory visit frequency requirement.”

“Based on record review, staff interview, and document review, it was determined the Hospice Agency failed to ensure all hospice standing orders used to direct patient services, were signed and dated by the Registered Nurse initiating and sending the orders to the physician for signature. This deficient practice failed to meet accepted standards of practice for orders and had the potential to place patients at risk for delay in services due to invalid orders. Findings Include: During Record Review for Patients 1 through 19, their admission documents revealed a document titled, “Hospice Standing Orders”, that had been sent to the physician for signature. However, 16 (Patients 1 - 5, and 9 - 19) of 19 patient records reviewed lacked a signature of the Registered Nurse initiating the orders, the orders also lacked a date that the orders were initiated by the nurse. During an interview on 03/06/24 at 2:50 PM, the Agency Administrator confirmed the above findings of the standing orders for hospice services not being signed and dated by the RN.”

“Based on record review, Policy review, and staff interview, it was determined the Hospice Agency failed to send a discharge summary to the attending physician for 2 of 2 live discharge patients (Patient 12 & 13) and 1 (Patient 14) of 1 patient who revoked the election of hospice services. This failed practice had the potential to affect patient safety and to place the patients at risk for adverse outcomes related to the lack of care coordination with other health care services. Findings Include: Review of Policy No. 2-22, titled, “Transfer, Referral and Discharge Criteria and Process”, contained no process directions for completing a discharge summary or when and how it would be sent to the physician. Patient 12 Review of Patient 12’s clinical record showed a Start of Care date of 07/25/23 and a Certification Period from 07/25/23 to 10/22/23. Review of visit notes showed that the agency discharged the patient on 10/22/23, indicating the patient had “graduated with little to no declining changes”. However, there was no evidence found in the record to indicate that a discharge summary had been sent to the physician as required. Patient 13 Review of Patient 13’s clinical record showed a Start of Care date of 10/31/23 and a Certification Period from 10/31/23 to 01/28/24. Review of visit notes showed that the agency discharged the patient on 01/28/24, indicating the patient had graduated due to “improvement on health”. However there was no evidence found in the record to indicate that a discharge summary had been sent to the physician as required. Patient 14 Review of Patient 14’s clinical record showed a Start of Care date of 06/12/23 and a Certification Period from 09/10/23 to 11/08/23. Review of visit notes showed that the patient signed a revocation form on 11/09/23. However, there was no evidence found in the record to indicate that a discharge summary had been sent to the physician as required. During an interview on 03/07/24 at 1:45 PM, the agency Administrator confirmed the above findings of not sending a discharge summary to the attending physician of live discharged and revoked patients.”

“Based on observation, policy review and interview the Hospice agency failed to provide a sanitary environment by following current standards of practice, including nationally recognized infection control precautions, and avoid sources and transmission of infections and communicable diseases. This deficient practice places immune compromised patients at greater risk of contracting disease or infection leading to a diminished quality of life. Findings Include: Review of hospice policy titled “Infection and/or Exposure Control Plan” states “The intent of the Infection and/or Exposure Control Plan includes but is not limited to” ... “Give direction to employees with regard to the care they provide in relation to infection control practices.” ... “Comply with all applicable state and federal regulations.” Observation during Hospice inpatient facility tour on 03/05/24 at 3:00 PM revealed that within the administrative portion of the building there is a supply room for home hospice patients. The room had 3 separate chambers within the area divided with 2 doors. Two of the rooms contained patient supplies with several items marked donated on packaging. The third room contained multiple 40-gallon biohazard bags full of trash and used patient equipment stacked within it. During an interview at the time of the observation, Staff A, Executive Director (ED) stated that the room is used for equipment and biohazard waste pickup from contracted waste and equipment companies. Further observation during the tour of the hospice house inpatient facility, there was a clean supply and linen room next to a soiled utility room with adjoining door between the two rooms. It was noted to be open prior to entry. Within the soiled utility room there were multiple shelves full of supplies with packaging marked donated within the room. During an interview on 03/06/24 at 3:00 PM, Staff G Certified Home Health Aide (CHHA) stated that the items in the soiled utility room were all donated from previous patients of the hospice and could be taken if unopened. When asked if these supplies were used with other patients, the CHHA stated that they are used but very rarely and only if needed. During an interview on 03/06/24 at 4:00 PM, Staff E Registered Nurse (RN) stated that supplies are donated from previous hospice patients and stated they are used for hospice patients in the facility rarely and only if needed and if there is not any in the new supply stock. During an interview on 03/07/24 at 11:30 AM, Staff A, Executive Director (ED) and Staff B Clinical Director (CD), Staff A stated that when a patient passes some families donate the remaining unopened supplies to the hospice and they are used for hospice patients when needed. Discussion had with Staff A regarding supplies donated from patients present potential infection or disease risk due to unknown storage method in patient homes, potential exposure to infection or disease of the patient being treated, and use of supplies with another immunocompromised patient. Further discussion with Staff A regarding the storage method of donated supplies within the soiled utility room where soiled linens, soiled equipment, and trash are stored for disposal.”

“Based on interview and review of the Emergency Preparedness Plan (EPP), the Hospice, failed to develop and maintain an emergency preparedness plan (EPP) that is based on and includes a documented, facility-based and community-based risk assessment; utilizing an all-hazards approach that included strategies for addressing emergency events identified by the risk assessment. This deficient practice has the potential to place patients at risk for harm or injury during an emergency situation. Findings Include: Review of the EPP revealed that the ASC failed to develop the EPP based on a facility-based and community-based risk assessment. During an interview on 03/05/24 between at 9:00 AM and 5:30 PM, the Administrator confirmed that the EPP folder provided was not based on a facility-based and community-based risk assessment.”

“Based on review of the Emergency Preparedness Program (EPP) the Hospice failed to develop and maintain an emergency preparedness plan that addressed patient population, the services the facility has the ability to provide in an emergency; and continuity of operations including the delegation of authority and succession plan. This deficient practice has the potential to place patients at risk for harm or injury during an emergency situation. Findings Include: Review of the EPP failed to show that the Patient Population was addressed the Emergency Preparedness Program. During an interview on 03/05/24 between at 9:30 PM and 5:30 PM, the Administrator confirmed that the Patient Population was not addressed within the Emergency Preparedness Program.”

“Based on review of the Emergency Preparedness Program (EPP) the Hospice failed to develop and maintain an emergency preparedness plan that includes a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. This deficient practice has the potential to place patients at risk for harm or injury during an emergency situation. Findings Include: Review of the EPP failed to show there was an included process for cooperation and collaboration with local, tribal, regional, State and Federal emergency preparedness officials to maintain an integrated response during a disaster for the Emergency Preparedness Program. During an interview on 03/05/24 between at 9:30 PM and 5:30 PM, the Administrator confirmed there was no process for cooperation and collaboration with local, tribal, regional, State and Federal emergency preparedness officials to maintain an integrated response during a disaster for the Emergency Preparedness Program.”

“Based on review of the Emergency Preparedness Program (EPP) the Hospice failed to develop and implement policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section, that must be reviewed at least every annually. Findings Include: Review of the EPP failed to show policies and procedures for the EPP based on the risk assessment and communication plan. During an interview on 03/05/24 between at 9:30 PM and 5:30 PM, the Administrator confirmed there were no policies and procedures based on the EPP risk assessment and communication plan.”

“Based on interview and policy review the Hospice failed to develop and implement emergency preparedness policies and procedures that includes procedures to inform State and local emergency preparedness officials about homebound Hospice patients in need of evacuation from their residences at any time due to an emergency situation based on the patient’s medical and psychiatric condition and home environment. Findings Include: Review of the agencies Emergency Preparedness Program (EPP) on 03/05/23 between at 9:30 AM and 5:30 PM, failed to provide plans which addressed the procedures to inform State and local emergency preparedness officials about homebound Hospice patients in need of evacuation from their residences at any time due to an emergency situation based on the patient’s medical and psychiatric condition and home environment. During an interview on 03/05/24 between at 9:00 AM and 5:30 PM, the Administrator confirmed there were no plans which addressed the procedures to inform State and local emergency preparedness officials about homebound Hospice patients in need of evacuation from their residences at any time due to an emergency situation based on the patient’s medical and psychiatric condition and home environment.”

“Based on review of the Emergency Preparedness Plan (EPP) and interview, the Hospice failed to develop and implement policies and procedures to address the role of the ASC under a waiver declared by the Secretary, to provide care and treatment at an alternate care site as identified by the emergency management officials. This deficient practice has the potential to affect all the patients in the facility. Findings Include: Review of the facilities Emergency Preparedness Plan (EPP) on 3/05/24 between 9:30 PM and 5:30 PM failed to ensure there were policies and procedures which address the role of the ASC under a waiver declared by the Secretary, to provide care and treatment at an alternate care site as identified by the emergency management officials. During an interview on 03/05/24 between at 9:00 AM and 5:30 PM, the Administrator confirmed there were no policies and procedures which address the role of the ASC under a waiver declared by the Secretary, to provide care and treatment at an alternate care site as identified by the emergency management officials.”

“Based on review of the Emergency Preparedness Program (EPP) the Hospice failed to develop and maintain an emergency preparedness training and testing program that is based on the emergency plan, its risk assessment and the communication plan. Findings Include: Review of the EPP failed to show a training and testing program that is based on the emergency plan, its risk assessment and the communication plan for the Emergency Preparedness Program. During an interview on 03/05/24 between at 9:30 AM and 5:30 PM, the Administrator confirmed there was no training and testing program that is based on the emergency plan, its risk assessment and the communication plan for the Emergency Preparedness Program.”

“Based on review of the Emergency Preparedness Plan (EPP) and interview, the Hospice, failed participate in a full-scale exercise that is community-based or conduct a facility-based functional exercise every 2 years to test their EPP. Failure to conduct or participate in an exercise that is community-based or conduct a facility-based functional exercise has the potential to place patients and staff at risk for harm during an emergency situation. Findings Include: Review of the EPP showed the ASC failed to conduct any exercise to test the emergency plan annually. During an interview on 03/05/24 between at 9:30 AM and 5:30 PM, the Administrator confirmed the ASC failed to conduct an exercise to test the emergency plan annually.”

“Based on observation and staff interview, the facility failed to provide exit access that is arranged so that exits are readily accessible at all times. The deficient practice renders the exiting obstructed and impeded to a full instant use, affecting all patients, staff and visitors in 2 of 2 smoke zones. Findings Include: On 03/05/24 it is observed, 1. At 1:39 PM the two south exit doors from the dining/kitchen area were both equipped with a thumb turn dead bolt lock device. The Administrator was present during the survey and acknowledged the findings. Review of the following NFPA Standard revealed: Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side, unless otherwise permitted by one of the following: (1) Locks complying with 19.2.2.2.5 shall be permitted. (2) Delayed-egress locks complying with 7.2.1.6.1 shall be permitted. (3) Access-controlled egress doors complying with 7.2.1.6.2 shall be permitted. (4) Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted. (5) Approved existing door-locking installations shall be permitted. 2012 NFPA 101, 19.2.2.2.4”

“Based on observation and interview, the facility did not provide and maintain a complete fire alarm system to alert all occupants of an emergency as required by National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 21.3.4.1 and 9.6. The deficient practice of not providing a complete fire alarm system did not ensure all occupants would be alerted to a fire event affecting all patients, visitors and staff in 2 of 2 smoke zones. Findings Include: On 03/05/24 it was observed, 1. At 1:52 PM the circuit to the Fire Alarm System was not equipped with a breaker lock, preventing the unauthorized access to the system power supply. The Administrator was present and acknowledged the findings.”

“Based on observation and staff interview, the facility failed to maintain the fire alarm system as required by NFPA 72. This deficient practice fails to ensure reliability of the alarm system in the event of an emergency, affecting all patients, visitors and staff in 2 of 2 smoke zones. Findings Include: During the review of the fire alarm annual inspection report on 03/05/24 it is observed: 1. There is no record of smoke detector sensitivity testing noted on the annual inspection reports dating back to 2020. The Administrator was present and acknowledged the findings.”

“Based on observation, the facility failed to provide smoke detection in all rooms or spaces open to the corridor. This deficient practice affects the response of the fire alarm system in the event of a fire in this area affecting all patients in 2 of 2 smoke zones. Findings Include: On 03/05/24 the following was observed, 1.The resident laundry room was open to the corridor and did not have a smoke detector(s) installed and was part of the corridor without a complete corridor smoke detection system.Reference NFPA 101 Section 19.3.6.1 (B), 18.3.6.1 (B) Corridors shall be separated from all other areas unless: the corridors onto which the spaces open in the same smoke compartment are protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4”

“Based on document review and staff interview, the facility failed to conduct fire drills as required and properly record the results and facts related to the fire drills. This deficient practice affects the ability of the staff to properly respond in the event of an actual emergency affecting all patients in 2 of 2 smoke zones. Findings Include: During document review between the hours of 10:00 AM and 12:30 PM the following was observed: 1. The fire drills conducted in quarters 2, 3 and 4 of 2023 were not conducted activating the horns and strobes of the system. The Administrator was present and acknowledged the findings.”

“Based on interview and document review the facility failed to properly inspect and maintain the fire doors in accordance with NFPA 80. Failure to maintain fire rated doors creates a potential for heat, smoke and harmful gases to spread beyond the area of fire origin into other areas of the facility affecting all patients, visitors and staff in 2 of 2 smoke zones. Findings Include: During the survey on 03/05/24, the following observations were made: 1) The four fire rated doors of the two stairwells were found not to have been annually tested or inspected as required. It should be noted all four doors did, however, fully self-close and latch when tested without apparent defect to the doors at time of survey. The Administrator was present and acknowledged the findings. Review of the following NFPA Standard revealed: Fire door assemblies shall be visually inspected from both sides to assess the overall condition of door assembly. 2010 NFPA 80, 5.2.4.1 As a minimum, the following items shall be verified: (1) No open holes or breaks exist in surfaces of either the door or frame. (2) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so equipped. (3) The door, frame, hinges, hardware, and noncombustible threshold are secured, aligned, and in working order with no visible signs of damage. (4) No parts are missing or broken. (5) Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7. (6) The self-closing device is operational; that is, the active door completely closes when operated from the full open position. (7) If a coordinator is installed, the inactive leaf closes before the active leaf. (8) Latching hardware operates and secures the door when it is in the closed position. (9) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame. (10) No field modifications to the door assembly have been performed that void the label. (11) Gasketing and edge seals, where required, are inspected to verify their presence and integrity. 2010 NFPA 80, 2.4.2”

“Based on record review and staff interview the facility failed to provide a documented maintenance and testing program for electrical systems. This deficient practice prevents the facility from ensuring that electrical systems are maintained and testing as required by NFPA 99 Health Care Facilities and could adversely affect all patients, visitors and staff in 2 of 2 smoke zones. Findings Include: During document review on 03/05/24 between 10:00 AM and 5:30 PM, it was revealed there is no documented annual inspection and exercising of main and feeder circuit breakers. During the inspection, it was observed: 1. At 1:29 PM the electrical panels in the transfer switch room were blocked from access by storage within 30 inches. The Administrator was present and acknowledged the findings. Review of the following NFPA Standard revealed: Main and feeder circuit breakers shall be inspected annually, and a program for periodically exercising the components shall be established according to manufacturer’s recommendations. 2012 NFPA 99, 6.4.4.1.2.1 Review of the following NFPA Standard revealed: A written record of inspection, performance, exercising period, and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction. 2012 NFPA 99, 6.4.4.2”

“Based on observation and staff interview, the facility failed to properly protect, and store compressed gasses as required by NFPA 99. The deficient practice would affect all patients, visitors, and staff in 2 of 2 smoke zones. Findings Include:During the survey conducted on 03/05/24, the following was noted,1. It was observed at 2:02 PM, there are 6 unsecured oxygen cylinders in the Oxygen room.The Administrator was present and acknowledged the findings.NFPA standard: Containers shall be stored, used, and operated in accordance with the manufacturer’s instructions and labeling. Containers shall not be placed in the following areas: (1) Where they can be tipped over by the movement of a door (2) Where they interfere with foot traffic (3) Where they are subject to damage from falling objects (4) Where exposed to open flames and high temperature. (NFPA 99), 11.7.3NFPA standard: A precautionary sign, readable from a distance of 1.5 m (5 ft), shall be displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum: CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING. (NFPA 99), 11.4NFPA standard : Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or materials by one of the following: (1) Minimum distance of 6.1 m (20 ft) (2) Minimum distance of 1.5 m (5 ft) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems (3) Enclosed cabinet of noncombustible construction having a minimum fire protection rating of 1/2 hour. (NFPA 99) 11.3.2.3”