T J Samson Community Hospital Home Care Hospice

“Based on observation and interview the facility failed to maintain the means of egress 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 eight (8) beds with a census of two (2) on the day of the survey. Findings include: Observation, during the building inspection tour on 01/22/2025 at 1:25 PM, revealed three (3) lights mounted to the ceiling with an extended chain located in the front hall, left wing, and right wing that were not above six (6) feet, eight (8) inches from the finished floor. Interview, on 01/22/2025 at 1:26 PM with the Maintenance Director, revealed the facility was unaware the lights were installed to low. The finding was verified by the Maintenance Director at the time of observation and the Administrator at the exit conference on 01/22/2025. Actual NFPA Standard: NFPA 101 Life Safety Code, (2012) 7.1.5* Headroom. 7.1.5.1 Means of egress shall be designed and maintained to provide headroom in accordance with other sections of this Code, and such headroom shall be not less than 7 ft 6 in. (2285 mm), with projections from the ceiling not less than 6 ft 8 in. (2030 mm) with a tolerance of −3⁄4 in. (−19 mm), above the finished floor, unless otherwise specified by any of the following: (1) In existing buildings, the ceiling height shall be not less than 7 ft (2135 mm) from the floor, with projections from the ceiling not less than 6 ft 8 in. (2030 mm) nominal above the floor. (2) Headroom in industrial equipment access areas as provided in 40.2.5.2 shall be permitted.”

“Based on observation and interview, it was determined the facility failed to maintain discharge from exits 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 eight (8) beds with a census of two (2) on the day of the survey. The findings include: Observation, during the building inspection tour on 01/22/2025 at 1:30 PM, revealed the exit discharge outside the center back exit door did not terminate directly at a public way. Interview, on 01/22/2025 at 1:31 PM with the Maintenance Director, revealed the facility was not aware of the requirement for exits to terminate directly at a public way. The finding was verified by the Maintenance Director at the time of observation and the Administrator at the exit conference on 01/22/2025. Actual NFPA Standard: NFPA 101 Life Safety Code, (2012) 7.7 Discharge from Exits. 7.7.1* Exit Termination. Exits shall terminate directly, at a public way or at an exterior exit discharge, unless otherwise provided in 7.7.1.2 through 7.7.1.4.”

“Based on observation and interview, it was determined the facility failed to install and maintain exit signage 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 eight (8) beds with a census of two (2) on the day of the survey. The findings include: Observation, during the building inspection tour on 01/22/2025 at 1:20 PM, revealed the doors for the Resident Room Patio Doors and the Front Patio Door were not equipped with a No Exit sign. The doors would likely be mistaken for an exit in the event of an emergency. Interview, on 01/22/2025 at 1:21 PM with the Maintenance Director, revealed the facility was unaware No exit signage was required on doors to the outside if they could be confused as an exit. The finding was verified by the Maintenance Director at the time of observation and the Administrator at the exit conference on 01/22/2025. Actual NFPA Standard: NFPA 101 Life Safety Code, (2012) 18.2.10 Marking of Means of Egress. 18.2.10.1 Means of egress shall have signs in accordance with Section 7.10, unless otherwise permitted by 18.2.10.3 or 18.2.10.4 7.10.2 Directional Signs. 7.10.8.3* No Exit. 7.10.8.3.1 Any door, passage, or stairway that is neither an exit nor a way of exit access and that is located or arranged so that it is likely to be mistaken for an exit shall be identified by a sign that reads as follows: NO EXIT 7.10.8.3.2 The NO EXIT sign shall have the word NO in letters 2 in. (51 mm) high, with a stroke width of 3⁄8 in. (9.5 mm), and the word EXIT in letters 1 in. (25 mm) high, with the word EXIT below the word NO, unless such sign is an approved existing sign. 7.10.9 Testing and Maintenance. 7.10.9.1 Inspection. Exit signs shall be visually inspected for operation of the illumination sources at intervals not to exceed 30 days or shall be periodically monitored in accordance with 7.9.3.1.3. 7.10.9.2 Testing. Exit signs connected to, or provided with, a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance with 7.9.3.”

“Based on observation and interview, the facility failed to maintain the automatic sprinkler system 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 eight (8) beds with a census of two (2) on the day of the survey. The findings include: Observation, during the building inspection tour on 01/22/2025 at 1:10 PM, revealed the facility failed to calibrate or replace sprinkler gauges located on the sprinkler riser every five (5) years. The gauges were dated 2018 and 2019. Interview, on 01/22/2025 at 1:11 PM with the Maintenance Director, revealed the facility was aware the sprinkler system gauges were not replaced within the previous five (5) years and was unsure why the vendor did not replace the gauge. The finding was verified by the Maintenance Director at the time of observation and the Administrator at the exit conference on 01/22/2025. Actual NFPA Standard: NFPA 101 Life Safety Code, (2012) 9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. Actual NFPA Standard: NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, (2011) 5.1.1.1 This chapter shall provide the minimum requirements for the routine inspection, testing, and maintenance of sprinkler systems. 5.1.1.2 Table 5.1.1.2 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance. Table 5.1.1.2 Summary of Sprinkler System Inspection, Testing, and Maintenance Inspection Gauges (dry, preaction, and deluge systems) Weekly/monthly 5.2.4.2, 5.2.4.3, 5.2.4.4 Control valves Table 13.1 Waterflow alarm devices Quarterly 5.2.5 Valve supervisory alarm devices Quarterly 5.2.5 Supervisory signal devices (except valve supervisory switches) Quarterly 5.2.5 Gauges (wet pipe systems) Monthly 5.2.4.1 Hydraulic nameplate Quarterly 5.2.6 5.3.2* Gauges. 5.3.2.1 Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. 5.3.2.2 Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced.”

“Based on record review and interview the facility failed to maintain the piped in oxygen system 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 eight (8) beds with a census of two (2) on the day of the survey. The findings include: Record review, on 01/22/2025 at 1:40 PM, revealed a piped in oxygen system with no documentation of the inventory of what the facility contained, no maintenance, or inspection schedule. Interview, on 01/22/2025 at 1:41 PM with the Director of Maintenance, revealed the facility was unable to source oxygen when the system was new, so they decided not to use it but left the system in service. The facility does want to keep the system in place so will add maintenance and inspection schedule to the system. The finding was verified by the Maintenance Director at the time of record review and the Administrator at the exit conference on 01/22/2025. Actual NFPA Standard: NFPA 99 Health Care Facilities Code, (2012) 5.2.13 Category 2 Operation and Management. Category 2 systems shall comply with 5.1.14. 5.1.14.2.1* General. Health care facilities with installed medical gas, vacuum, WAGD, or medical support gas systems, or combinations thereof, shall develop and document periodic maintenance programs for these systems and their subcomponents as appropriate to the equipment installed. 5.1.14.2.2 Maintenance Programs. 5.1.14.2.2.1 Inventories. Inventories of medical gas, vacuum, WAGD, and medical support gas systems shall include at least all source subsystems, control valves, alarms, manufactured assemblies containing patient gases, and outlets. 5.1.14.2.2.2* Inspection Schedules. Scheduled inspections for equipment and procedures shall be established through the risk assessment of the facility and developed with consideration of the original equipment manufacturer recommendations and other recommendations as required by the authority having jurisdiction. 5.1.14.2.2.3 Inspection Procedures. The facility shall be permitted to use any inspection procedure(s) or testing methods established through its own risk assessment. 5.1.14.2.2.4 Maintenance Schedules. Scheduled maintenance for equipment and procedures shall be established through the risk assessment of the facility and developed with consideration of the original equipment manufacturer recommendations and other recommendations as required by the authority having jurisdiction. 5.1.14.2.2.5 Qualifications. Persons maintaining these systems shall be qualified to perform these operations. Appropriate qualification shall be demonstrated by any of the following: (1) Training and certification through the health care facility by which such persons are employed to work with specific equipment as installed in that facility (2) Credentialing to the requirements of ASSE 6040, Professional Qualification Standard for Medical Gas Maintenance Personnel (3) Credentialing to the requirements of ASSE 6030, Professional Qualification Standard for Medical Gas Systems Verifiers”

“Based on interview, record review, and review of agency policy, the hospice agency failed to ensure the facility interdisciplinary group (IDG) meetings included at a minimum the physician, Registered Nurse (RN), social worker (SW) and Chaplain in attendance for seven of 19 patients (Patient (P14, P15, P16, P1, P4, P5, and P7) whose records were reviewed from a total sample of 19.. Failure to include multiple IDG members in the meetings presents a potential inability to accurately evaluate the patients progress in meeting goals of care. This had the potential to affect the 28 patients who were currently receiving hospice services and all future hospice patients/patient family units. Findings include: 1. Record review revealed P14 was admitted to the hospice agency on 11/04/2024. Review of IDG meeting notes, located in the “Clinical Documents” tab of electronic medical record (EMR), revealed no documented evidence that the Chaplain attended the IDG meetings on 01/08/2025, 12/18/2024, and 12/31/2024. 2. Record review revealed P15 was admitted to the hospice agency on 04/01/2024. 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 01/08/2025, 12/18/2024, and 12/31/2024. 3. Record review revealed P16 was admitted to the hospice agency on 04/05/2024. 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 11/13/2024, 12/18/2024, and 12/31/2024. 4. Record review revealed P1 was admitted to the hospice agency on 01/07/2025. Review of IDG meeting notes, located in the “Clinical Documents” tab of the EMR, revealed no documented evidence that the Chaplain attended the IDG meeting on 01/08/2025. 5. Record review revealed P4 was admitted to the hospice agency on 12/05/2023. 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 12/11/2024, 12/21/2024, and 01/08/2025. 6. Record review revealed P5 was admitted to the hospice agency on 06/22/2023. 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 12/11/2024 and 01/08/2025. 7. Record review revealed P7 was admitted to the hospice agency on 07/18/2024. 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 for 12/28/2024 and 01/08/2025. During an interview on 01/20/2025 at 3:44 PM, the Clinical Director stated, “[His/her] name [Chaplain] should be in the meeting notes if he/she was present in the room at the time the patients were discussed.” During an interview on 01/21/2025 at 1:45 PM, the Chaplain was asked why he/she was not signed in as attending the IDG meetings. The Chaplain stated, “I attend every one of them [IDG meetings], unless I am called away to the hospital. I don’t see all of the patients, as they have their own ministers.” The Chaplain was asked how he/she was made aware of the meetings and any plan of care changes if he/she was not in attendance. The Chaplain stated, “They will call me and educate me on the patients who were discussed.” Review of the January 2024 agency policy titled, “Hospice-Interdisciplinary Team (IDG) revealed, “. . . [Hospice Agency] will designate an interdisciplinary team (IDT) who will provide and supervise the care and services offered and provided by the program . . . PROCEDURES . . . The [hospice agency] interdisciplinary Team will include a minimum of a medical director, a registered nurse, a medical social worker, and a pastoral or other counselor. The patient, family member, volunteer, patient’s chosen pastor or disciplines involved in care as well as the hospice aide may be included in the interdisciplinary team as designated by each patient’s needs and expressed wishes. Each member of the interdisciplinary team will be responsible for participation in establishing the plan of care, provision of supervision of hospice care and services, periodic review and updating the plan of care for each patient receiving hospice. IDT meetings will occur no less often than every 15 calendar days . . . “”