Compassionate Care Plus

“Based on observation and interview, it was determined the facility failed to have an approved design location under the Kitchen Hood Extinguishing System in accordance with National Fire Protection Association (NFPA) Standards. The deficient practice had the potential to affect one (1) of two (2) smoke compartments, staff, and six (6) residents. The facility had the capacity for 13 beds with a census of 3 on the day of the survey. The findings include: Observation, during the building inspection tour on 01/30/2025 at 11:48 AM, revealed the gas-fired cooking appliances located on the cooking line in the kitchen were not provided with an approved method that would ensure that the appliances were returned to an approved design location after they had been moved for maintenance and cleaning. Interview, on 01/30/2025 at 11:49 AM with the Plant Operations Manager, revealed the facility was not aware of the requirement for an approved method to ensure that the appliances were returned to an approved design location after maintenance or cleaning and did not have a system in place currently. The finding was verified by the Plant Operations Manager at the time of observation and the Chief Executive Officer at the exit conference on 01/30/2025. Actual NFPA Standard: NFPA 101 Life Safety Code, (2012) 18.3.2.5 Cooking Facilities. 18.3.2.5.1 Cooking facilities shall be protected in accordance with 9.2.3, unless otherwise permitted by 18.3.2.5.2, 18.3.2.5.3, or 18.3.2.5.4. 18.3.2.5.2* Where residential cooking equipment is used for food warming or limited cooking, the equipment shall not be required to be protected in accordance with 9.2.3, and the presence of the equipment shall not require the area to be protected as a hazardous area. 9.2.3 Commercial Cooking Equipment. Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless such installations are approved existing installations, which shall be permitted to be continued in service. Actual NFPA Standard: NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, (2011) 12.1.2 Installation. 12.1.2.1 All listed appliances shall be installed in accordance with the terms of their listings and the manufacturer’s instructions. 12.1.2.2* Cooking appliances requiring protection shall not be moved, modified, or rearranged without prior re-evaluation of the fire-extinguishing system by the system installer or servicing agent, unless otherwise allowed by the design of the fire extinguishing system. 12.1.2.3 The fire-extinguishing system shall not require reevaluation where the cooking appliances are moved for the purposes of maintenance and cleaning, provided the appliances are returned to approved design location prior to cooking operations, and any disconnected fire-extinguishing system nozzles attached to the appliances are reconnected in accordance with the manufacturer’s listed design manual. 12.1.2.3.1 An approved method shall be provided that will ensure that the appliance is returned to an approved design location.”

“Based on observation and interview, it was determined the facility failed to install a complete automatic sprinkler system in accordance with National Fire Protection Association (NFPA) Standards. The deficient practice had the potential to affect one (1) of two (2) smoke compartments, staff, and two (2) residents. The facility had the capacity for 13 beds with a census of 3 on the day of the survey. The findings include: Observation, during the building inspection tour on 01/30/2025 between 11:15 AM and 12:10 PM, revealed two (2) sprinklers missing the escutcheons, with one being in the kitchen dry storage closet, and the other located in the Human Resource Office. Interview, on 01/30/2025 at 12:11 PM with the Plant Operations Manager, revealed the facility was not aware the sprinklers were missing the escutcheons. The finding was verified by the Plant Operations Manager at the time of observation and the Chief Executive Officer at the exit conference on 01/30/2025. Actual NFPA Standard: NFPA 101 Life Safety Code, (2012) 19.3.5.1 Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5. 9.7.1 Automatic Sprinklers. 9.7.1.1* Each automatic sprinkler system required by another section of this Code shall be in accordance with one of the following: (1) NFPA 13, Standard for the Installation of Sprinkler Systems (2) NFPA 13D, Standard for the Installation of Sprinkler Systems in One- and Two-Family Dwellings and Manufactured Homes (3) NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies up to and Including Four Stories in Height NFPA 13 Standard for Installation of Sprinkler Systems, (2010) 6.2.7 Escutcheons and Cover Plates. 6.2.7.1 Plates, escutcheons, or other devices used to cover the annular space around a sprinkler shall be metallic or shall be listed for use around a sprinkler. 6.2.7.2* Escutcheons used with recessed, flush-type, or concealed sprinklers shall be part of a listed sprinkler assembly.”

“Based on record review and interview, the facility failed to conduct fire drills quarterly for each shift in accordance with National Fire Protection Association (NFPA) Standards. The deficient practice had the potential to affect two (2) of two (2) smoke compartments, staff, and all residents. The facility had a capacity of 13 beds with a census of 3 on the day of the survey. The findings include: Record review, on 01/30/2025 at 1:55 PM of the facility’s fire drill records for the 12-month period prior to the survey, revealed the facility failed to conduct fire drills during the second (2nd) shift hours of the second (2nd) and fourth (4th) quarter of 2024, and the first (1st) shift hours of the first (1st) and third (3rd) quarter of 2024. Interview, on 01/30/2025 at 1:56 PM with the Plant Operations Manager, revealed the facility was not aware of the fire drill requirements. The finding was verified by the Plant Operations Manager at the time of record review and by the Chief Executive Officer at the exit interview on 01/30/2025. Actual NFPA Standard: NFPA 101 Life Safety Code, (2012) 19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions.”

“Based on record review and interview, the facility failed to maintain the receptacles in patient areas in accordance with National Fire Protection Association (NFPA) Standards. The deficient practice had the potential to affect two (2) of two (2) smoke compartments, staff, and all residents. The facility had the capacity for 13 beds with a census of 3 on the day of the survey. The findings include: Record review, of the plug retention testing records on 01/30/2025 at 2:10 PM, revealed non-hospital grade receptacles located in resident areas throughout the facility did not have annual retention and polarity testing. Interview, on 01/30/2025 at 2:11 PM with the Plant Operations Manager, revealed the facility was not aware the non-hospital grade receptacles in the resident areas required annual testing. The finding was verified by the Plant Operations Manager at the time of record review and by the Chief Executive Officer at the exit conference on 01/30/2025. Actual NFPA Standard: NFPA 99 Health Care Facilities Code, (2012) 6.3.4.1 Maintenance and Testing of Electrical System. 6.3.4.1.1 Where hospital-grade receptacles are required at patient bed locations and in locations where deep sedation or general anesthesia is administered, testing shall be performed after initial installation, replacement, or servicing of the device. 6.3.4.1.2 Additional testing of receptacles in patient care rooms shall be performed at intervals defined by documented performance data. 6.3.4.1.3 Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months. 6.3.4.1.4 The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch (see 6.3.2.6.3.6). For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators. 6.3.4.1.5 After any repair or renovation to an electrical distribution system, the LIM circuit shall be tested in accordance with 6.3.3.3.2.”

“Based on record review and interview, the facility failed to maintain documentation of inspections on the Patient Care Related Electrical Equipment (PCREE) in accordance with National Fire Protection Association (NFPA) Standards. The deficient practice had the potential to affect two (2) of two (2) smoke compartments, staff, and all residents. The facility had a capacity for 13 beds with a census of 3 on the day of the survey. The findings include: Record review, of the PCREE testing documentation on 01/30/2025 at 2:20 PM, revealed there was no documentation for the testing of the PCREE in use throughout the facility. Interview, on 01/30/2025 at 2:21 PM with the Plant Operations Manager, revealed the facility was not aware of the PCREE testing requirements and had not had the testing completed at the time of the survey. The finding was verified by the Plant Operations Manager at the time of record review and by the Chief Executive Officer at the exit interview on 01/30/2025. Actual NFPA Standard: NFPA 99 Health Care Facilities Code, (2012) 3.3.137 Patient-Care-Related Electrical Equipment. Electrical equipment appliance that is intended to be used for diagnostic, therapeutic, or monitoring purposes in a patient care vicinity. 10.5.2.1 Testing Intervals. 10.5.2.1.1 The facility shall establish policies and protocols for the type of test and intervals of testing for patient care-related electrical equipment. 10.5.2.1.2 All patient care-related electrical equipment used in patient care rooms shall be tested in accordance with 10.3.5.4 or 10.3.6 before being put into service for the first time and after any repair or modification that might have compromised electrical safety. 10.5.3 Servicing and Maintenance of Equipment. 10.5.3.1 The manufacturer of the appliance shall furnish documents containing at least a technical description, instructions for use, and a means of contacting the manufacturer. 10.5.3.1.1 The documents specified in 10.5.3.1 shall include the following, where applicable: (1) Illustrations that show the location of controls (2) Explanation of the function of each control (3) Illustrations of proper connection to the patient or other equipment, or both (4) Step-by-step procedures for testing and proper use of the appliance (5) Safety considerations in use and servicing of the appliance (6) Precautions to be taken if the appliance is used on a patient simultaneously with other electric appliances (7) Schematics, wiring diagrams, mechanical layouts, parts lists, and other pertinent data for the appliance (8) Instructions for cleaning, disinfection, or sterilization (9) Utility supply requirements (electrical, gas, ventilation, heating, cooling, and so forth) (10) Explanation of figures, symbols, and abbreviations on the appliance (11) Technical performance specifications (12) Instructions for unpacking, inspection, installation, adjustment, and alignment (13) Preventive and corrective maintenance and repair procedures 10.5.3.1.2 Service manuals, instructions, and procedures provided by the manufacturer shall be considered in the development of a program for maintenance of equipment. 10.5.6 Record Keeping - Patient Care Appliances. 10.5.6.1 Instruction Manuals. 10.5.6.1.1 A permanent file of instruction and maintenance manuals shall be maintained and be accessible. 10.5.6.2* Documentation. 10.5.6.2.1 A record shall be maintained of the tests required by this chapter and associated repairs or modifications. 10.5.6.2.2 At a minimum, the record shall contain all of the following: (1) Date (2) Unique identification of the equipment tested (3) Indication of which items have met or have failed to meet the performance requirements of 10.5.6.2 10.5.6.3 Test Logs. A log of test results and repairs shall be maintained and kept for a period of time in accordance with a health care facility’s record retention policy. 10.5.8 Qualification and Training of Personnel. 10.5.8.1* Personnel concerned for the application or maintenance of electric appliances shall be trained on the risks associated with their use. 10.5.8.1.1 The health care facilities shall provide programs of continuing education for its personnel. 10.5.8.1.2 Continuing education programs shall include periodic review of manufacturers’ safety guidelines and usage requirements for electrosurgical units and similar appliances. 10.5.8.2 Personnel involved in the use of energy-delivering devices including, but not limited to, electrosurgical, surgical laser, and fiberoptic devices shall receive periodic training in fire suppression. 10.5.8.3 Equipment shall be serviced by qualified personnel only.”

“Based on record review, interview, and agency policy review, the agency failed to ensure that the comprehensive assessment was completed by the Chaplain within five days of admission for one of 19 patients (P15) whose records were reviewed. Failure to complete the comprehensive assessment within five days had the potential for new patients to have unmet psychosocial or spiritual needs addressed in a timely manner. This had the potential to affect the 74 patients who were currently receiving hospice services and all future hospice patients/patient family units. Findings include: Review of P15’s “Resident Profile,” located in the electronic medical record (EMR), revealed P15 was admitted to the hospice agency on 08/27/24. Review of the admission assessments for P15, located in the “Clinical Documents” tab of the EMR, revealed no documented evidence that the Chaplain completed the initial comprehensive assessment within five days of P15s admission. During an interview on 01/30/25 at 11:30 AM, the Administrator confirmed that the comprehensive admission assessment was not completed by the Chaplain within five days of the admission for P15. The Administrator stated all new admissions are required to have a comprehensive assessment completed by all disciplines with five days of their admission. Review of the policy titled, “Assessment: Initial and Comprehensive,” dated March 2024, revealed, “. . . The initial and comprehensive assessment is to be initiated by the nurse within 24 hours of admission, and by the Chaplain and Social Worker by five days from admit date . . .””

“Based on interview, record review, and policy review, the hospice agency failed to ensure a Chaplain attended interdisciplinary group (IDG) meetings for five of 19 sampled patients (Patient (P) 4, P19, P8, P13, and P15) whose records were reviewed. This had the potential to cause the patients’ spiritual and/or psychosocial needs to be unmet. Findings include: Review of agency’s policy titled, “Interdisciplinary Team Meetings Home Program,” last reviewed November 2024, revealed, “. . . IDT meetings are to be attended by the Medical Director . . . Chaplain (CH) . . . “ 1. Review of P4’s electronic medical record (EMR) revealed P4 was admitted to hospice services on 11/22/24 with a terminal diagnosis of end stage renal disease. Review of P4’s IDG meeting notes, located in the “Clinical Documents” tab of the EMR, revealed a Chaplain did not attend P4’s IDG meeting on 12/20/24. 2. Review of P19’s EMR revealed P19 was admitted to hospice services on 07/24/24 with a terminal diagnosis of malignant neoplasm of the rectum. Review of P19’s IDG meeting notes, located in the “Clinical Documents” tab of the EMR, revealed a Chaplain did not attend P19’s IDG meeting on 12/13/24. 3. Record review revealed P8 was admitted to the hospice agency on 06/24/24. Review of IDG meeting notes, located in the “Clinical Documents” tab of the EMR, revealed no documented evidence that the Chaplain attended the IDG meetings on 08/09/24, 09/20/24, and 01/24/25. 4. Record review revealed P13 was admitted to the hospice agency on 01/24/24. Review of IDG meeting notes, located in the “Clinical Documents” tab of EMR, revealed no documented evidence that the Social Worker (SW) or Chaplain attended the IDG meeting on 05/03/24. 5. Record review revealed P15 was admitted to the hospice agency on 08/27/24. Review of IDG meeting notes, located in the “Clinical Documents” tab of EMR, revealed no documented evidence that the Chaplain attended the IDG meetings on 09/05/24, 10/11/24, and 01/09/25. During an interview on 01/27/25 at 4:25 PM, the Director of Home Care confirmed the EMR lacked evidence that a Chaplain attended the IDG meetings held on 12/20/24, and 12/23/24. The Director of Home Care stated “Since [P4] didn’t have Chaplain services ordered; I didn’t think a Chaplain was required for IDG meetings. [P19] wanted a private Chaplain to attend but that Chaplain was not available to attend.” The Director of Home Care confirmed the expectation was for all core services to be represented during the IDG meetings.”

“Based on interview, record review, and policy review, the hospice agency failed to ensure changes to the plan of care (POC) were updated in the electronic medical record (EMR) for one of two sampled patients (Patient (P) 6) residing in skilled nursing facilities (SNF). This had the potential to affect 68 patients. Findings include: Review of P6’s EMR revealed P6 was admitted to hospice services on 01/13/25 with a terminal diagnosis of unspecified protein-calorie malnutrition. Review of P6’s “Care Plan Problem Details,” dated 01/13/25, indicated P6 was prescribed Lorazepam (for agitation/restlessness), 2 milligram/milliliter (mg/ml) .25 ml by mouth, every 4 hours. Review of the “Resident Profile,” from the skilled nursing facility (SNF) where P6 resided, revealed that P6 was prescribed, “Lorazepam Oral Concentrate, 2 MG/ML 0.5 ML by mouth, every 4 hours.” Review of P6’s “Monthly Medication Administration Record,” dated January 2025, from the SNF’s EMR, indicated P6 was receiving Lorazepam Oral Concentrate, 2 mg/ml 0.5 ml by mouth, every 4 hours. During a home visit to the SNF where P6 resided, an interview with RN1 was conducted. RN1 stated, “I noticed the change in the patient’s medication during my last visit, but I forgot to update the patient’s electronic medical record.” Review of facility policy “Nursing Home: Change of Condition,” approved 02/24/22, revealed “Change of Condition . . . when patient’s condition requires medication changes . . . Any changes in condition is to be noted in the hospice notes and documented in the patient’s medical record . . .””