Mainehealth Home Health and Hospice

“Based on document reviews, observations, and interviews, it was determined that the Condition of Participation (“CoP”) for Drugs, Biologicals, Medical Supplies, and Durable Medical Equipment (§418.106) was in substantial compliance however, the following standard level requirement has not been met: §418.106(e) Labeling, disposing, and storing of drugs and biologicals. The hospice failed to meet professionally accepted standards for the handing, administration, and delivery of opioid medications. In a multi-residential care setting, Morphine syringes were observed to be stored in a clear plastic bag labeled only with the patient’s name and the name of the medication; the individual syringes were not labeled in accordance with accepted professional practice. According to the NPSG (National Patient Safety Guidelines) and Lippincott Procedures, both nationally recognized nursing standards, immediately after preparation, syringes should be labeled clearly with the name of the medication, concentration, dose, if the medication was diluted, expiration date and time if not being used immediately, date and time drawn and patient identifiers. Labeling medication is a standard of nursing practice and ensures patient safety. On 04/16/2025 at 10:08am, the Hospice Director, confirmed that “each prefilled syringe should be labeled in a private home or assisted living facility. If the facility is drawing up the medication and our staff is not verifying the facilities process, they should.” On 04/16/2025 at 12:28pm, the Hospice Director stated, “Did speak to another nurse in the field, they were not aware that the syringes should be labeled individually. This is a gap. We will address.” She provided a reference policy that is in development.”

“Based on document reviews and interviews, the Condition of Participation for Emergency Preparedness was not met as evidenced by the inpatient facility’s failure to establish and maintain a [comprehensive] Emergency Preparedness Program to develop an emergency preparedness program that included a detailed emergency plan, policies and procedures, training, and testing. This deficient practice has the potential to affect all patients, staff, volunteers, and visitors to the facility. On 06/21/2024 at 12:48 PM, The Sussman House Disaster Control plan was reviewed with the Chief Nursing Officer. She stated that she was not able to describe the program and verified that she was unable to provide the documented evidence of the requirements.”

“Based on document reviews, observations, and interviews, it was determined that the Condition of Participation (“CoP”) Infection Control was not met. The facility failed to ensure that all seven (7) inpatient hospice rooms were provided with appropriate screening on the patio doors that opened to the outside, to prevent insects, rodents, squirrels and other wildlife from entering. The facility failed to have systems in place identifying, monitoring and correcting environmental concerns that were cited in the recertification survey in 8/2021. This noncompliance has not been remediated, and there is currently no documented evidence of an active monitoring system to ensure that this environmental problem was identified, repaired and maintained. Findings: Standard: §418.60 also known as L-577 - Based on document reviews and observations, the facility failed to ensure that seven (7) of seven (7) inpatient hospice rooms had adequate screening on the patio doors. Standard: §418.60(a) also known as L-579 - Based on document reviews, observations and interviews, the facility failed to follow accepted standards of practice to prevent the transmission of infections. Standard: §418.60(b)(1) also known as L-580 - Based on document reviews and interviews, the facility failed to include infection control in their 2024 Hospice Quality Assessment and Performance Improvement Program. Standard: §418.60 (b)(2) also known as L-581 - Based on document reviews, observations and interviews, the facility failed to implement the appropriate action for an identified problem. Standard: §418.60(c) also known as L-582 - Based on document reviews and interviews, the facility failed to provide infection control education to all employees and contracted staff. The cumulative effect of these deficient practices resulted in noncompliance with this Condition of Participation.”

“Based on document reviews and interviews, the Condition of Participation (“CoP”) Compliance with Federal, State, and local laws and regulations related to the health and safety of patients was not met as evidenced by the facility’s failure to report an alleged abuse incident to the Division of Licensing per facility policy in one (1) of two (2) incidents reviewed. The facility policy titled Investigation of Abuse, Neglect or Exploitation by Staff within MaineHealth Facilities dated 7/7/2023, states in part, “...submit an initial report to DLRS (Division of Licensing and Regulatory Services for suspected abuse, neglect and exploitation within five (5) days of the initial APS (Adult Protective Services) or CPS (Child Protective Services), applies only to cases that are not discerned out using the Discernment Algorithm...” The MaineHealth Corporate Policy “Adverse Event Reporting”, last reviewed 7/7/2023 states in part, “It is the policy of MaineHealth to provide a safe environment for the delivery of high quality health care to our patients, residents and communities. The safety and well-being of patients, residents, care team members and the public have the highest priority ... . Ensure first and foremost that appropriate patient care has occurred and take immediate corrective action(s) to prevent recurrence, whenever possible ... . Report the event through the local chain of command if the event caused significant patient harm or has the potential to be a state-reportable event. a. Local chain of command should contact local Risk Management and inform of the potential need to report ... .” The MaineHealth Care at Home “Reporting of Abuse and Neglect” last reviewed 4/27/2022 states in part, “Pursuant to Maine State Statutes, all healthcare personnel, while acting in their professional capacity, must immediately report suspected abuse, neglect, or exploitation of an incapacitated or dependent adult. Employees immediately report actual or suspected cases to the Supervisor and document the abuse/neglect on the Occurrence Report. Report adult and dependent adult abuse, neglect or exploitation immediately to the Adult Protective Services Hotline ... .” 1. On 6/12/2024, the “MHCH Risk Files Breakdown Report” was reviewed. It stated the following: On 4/24/2024, a “Near miss - no harm - didn’t reach person - caught by chance” medication dispensing event was recorded. The description states the following: “RN [Registered Nurse] reported to manager that she had overheard the HHA [Home Health Aide], [Employee #], speaking to a family member of a patient (Patient #). RN overheard something about ‘30 minutes’ and later asked the family member what the discussion was about. Family member stated that the HHA had told her that the patient could have all the meds every 30 minutes and told the family member that she could press the button on the PCA [Patient-Controlled Analgesia] pump if she felt the patient needed it. Family member stated that the HHA [Home Health Aide] then pressed the bolus button on the PCA to dose the patient. Family member was a CNA [Certified Nursing Assistant] her whole life and immediately knew that he was not in his scope of practice.” Employee # was allowed to continue caring for all of the hospice patients that day. On 6/14/2024 at 10:17 AM, the Director of Quality, Compliance, and Innovation was interviewed in regard to this event. When asked why this event was not reported to the State and local bodies he stated that he didnt believe they reported this and didnt believe this was a reportable event. On 6/21/2024 at 12:34 PM, the Chief Nursing Officer (“CNO”) was interviewed in regard to this event. She stated the following: A family member approached the [Former Interim Sussman House Manager] and explained that the HHA/CNA was talking to the family about the PCA pump and providing education. He then pushed a dose of morphine on the pump. [The Director of Nursing] and I were there that day. At the end of the day, the [Former Interim Sussman House Manager] came to me and told me what the family told her, so I brought [Employee #] to the office. I asked him if he educated the patient and family about the pump and he said, yes. I asked him if he pushed the pump and medicated the patient and he said, yes. I explained to him that what he did was outside of his scope of service. Yes, he was allowed to continue caring for patients after the family told her what happened. At the end of the day, when I was notified, I told him to hold tight, I contacted Human Resources, told him he was on administrative leave, took his badge and we started the investigation. I told him, again, that what he did was outside his scope of service...he said, Ya, I know. It seems he may have had issues before this that were not managed, so he was not terminated as nothing was in his file. So, he was not terminated but he resigned from his full time position and went to a per diem status. Since then, he has not worked a shift and will soon be termed as he is not fulfilling his per diem responsibility. No, I did not report this incident to Adult Protective Services, the Division of Licensing and Certification or the CNA Registry. But now that I think of it, I should have. 2. On 6/12/2024, a partially completed, unsigned and undated Division of Licensing and Certification Reportable Incident Form was reviewed. It stated that on 11/08/2023, the MaineHealth Care at Home hospice social worker made a bereavement call to Patient #’s family member. During that call, the family member reported to the social worker the following: Registered Nurse (“RN”) # managed all the medications, filled the pill box and picked up the medications for them at the pharmacy. Patient # would be out of pain medications sometimes for several days. RN # took Patient #’s medications out of the home prior to his death. Patient # was in pain prior to his death, such that he chose to move his “Death with Dignity” date sooner than planned. Per Adult Protective Services documents, this event was reported by the Director of Quality, Compliance and Innovation on 11/17/2023, which is a duration of nine (9) days after the event. Help shape the future of iQIES. Click Here to participate in iQIES HCD Research or email us at iqies_hcd@cms.hhs.gov. View Resources QIES Technical Support Office Known Issues Validation Utility Tool System Requirements Medicare”

“Based on document reviews and interviews, the inpatient hospice facility failed to develop, establish and maintain a comprehensive Emergency Preparedness Plan that was reviewed, and updated at least every two (2) years. On 06/21/2024 at 12:48 PM, The Sussman House Disaster Control plan was reviewed with the Chief Nursing Officer (“CNO”). There is no documented evidence of when the Emergency Preparedness Plan was created for The Sussman House, as there is no date on the plan. Therefore, it is not possible to determine if the plan has been reviewed or updated. On 06/21/2024 at approximately 1:00 PM, the CNO confirmed that there is no date on the plan.”

“Based on document reviews and interviews, the inpatient hospice facility failed to ensure their plan included a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach and include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice’s ability to provide care. On 06/21/2024 at 12:48 PM, The Sussman House Disaster Control plan was reviewed with the Chief Nursing Officer (“CNO”). There was no documented evidence of a risk assessment for The Sussman House. On 06/21/2024 at approximately 1:15 PM, the CNO was asked if she could find the risk assessment and she stated, “No, I did not see that.””

“Based on document reviews and interviews, the inpatient hospice facility failed to review and update Emergency Preparedness policies and procedures, based on the Emergency Plan, the risk assessment and the communication plan, that were reviewed and updated at least every two (2) years. On 06/21/2024 at 12:48 PM, The Sussman House Disaster Control plan was reviewed with the Chief Nursing Officer (“CNO”). There was no documented evidence that the policies and procedures in the Emergency Preparedness Plan were reviewed and updated every two (2) years. On 06/21/2024 at approximately 1:00 PM, the CNO confirmed that there was no evidence that the policies and procedures in the Emergency Preparedness Plan were reviewed and updated every two (2) years.”

“Based on document reviews, interviews and observations, the inpatient hospice facility has failed to ensure that there are policies and procedures for the following: The provision of subsistence needs for hospice employees and patients, whether they evacuate or shelter in place, include, but are not limited to the following: (A) Food, medical, and pharmaceutical supplies; (B) Sewage and waste disposal. In addition, the inpatient hospice facility failed to ensure that there is enough food, water and pharmaceutical supplies if required to shelter in place. Findings: On 6/20/2024, the Sussman House Disaster Control Plan was reviewed. 6/20/2024 at 2:07 PM, the Former Interim House Manager was asked to see the provision of food and water at the facility. She took me to a storage closet and two (2) cupboards on each side of the refrigerator. I observed approximately thirty (30) eight (8)-ounce bottles of water, approximately fifteen (15) to twenty (20) granola bars, a half full box of saltines and a half full box of graham crackers. In the cabinets, there was soup, pasta, oatmeal, pancake mix, stuffing, cranberry sauce and several boxes of cake mix. On 6/20/2024 at 2:20 PM, the storage room and two (2) cupboards were inspected to ensure that the food there was not expired. The following was observed:- Chicken noodle soup Expiration 6/18/2024- Cranberry sauce Expiration 10/20/2023- Cranberry sauce Expiration 12/12/2023- Oatmeal Expiration 6/15/2024- Chicken broth Expiration 12/25/2023- Stuffing mix Expiration 2/6/2024- Oyster crackers Expiration 11/6/2023- Pancake Mix Expiration 1/8/2024- Gluten Free Pancake Mix Expiration 11/2022- Cream of Wheat Expiration 5/11/2024- Strawberry cake mix Expiration 4/27/2024- White cake mix Expiration 4/9/2024- Vanilla cake mix Expiration 8/11/2022- Unlabeled bag of what appeared to be cereal with no expiration date. The CNO did confirm that items were expired. On 6/21/2024 from 12:48 PM – 1:22 PM, the Sussman House Disaster Control Plan was reviewed with the Chief Nursing Officer (“CNO”). I asked her to verify that the emergency plan includes policies and procedures for the provision of subsistence needs including, but not limited to, food, water and pharmaceutical supplies for patients and staff by reviewing the plan. When asked if she agreed that there are not enough supplies or policies and procedures, she stated the following: You are correct, the supplies, policies and procedures are not here.”

“Based on document reviews and interviews, the inpatient hospice facility failed to develop and maintain an Emergency Preparedness communication plan that complied with Federal, State and local laws, that contained how the facility will coordinate patient care within the facility, across healthcare providers, with state and local public health departments and included how the facility interacts and coordinates with emergency management agencies and systems to protect patient health and safety in the event of a disaster. On 06/21/2024 at 12:48 PM, The Sussman House Disaster Control plan was reviewed with the Chief Nursing Officer (“CNO”). There is no documented evidence of a communication plan. On 06/21/2024 at approximately 1:20 PM, the CNO was asked if the inpatient hospice facility had a written communication plan and the dates of when the plan was last reviewed and updated. The CNO was also asked for documentation that showed the communication plan included a means of providing information about the facilitys needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee by reviewing the communication plan. The CNO stated, “No, I have not seen that.””

“Based on document reviews and interviews, the facility failed to provide documentation that they conducted and documented training and testing for nine (9) of ten (10) staff (Employee #1 - #6 and #8 - #10). In addition, there is no documented evidence that the training and testing program is reviewed and updated at least every two (2) years. This is a REPEAT deficient practice. Findings: 1. Training The MaineHealth Care at Home “Emergency Operations Plan”, last updated 6/2022 states in part, “Training program. The agency will:a. Provide initial training in emergency preparedness policies and procedures to all new employees, and individuals providing services under arrangement, consistent with their expected roles. b. Provide emergency preparedness training at least every 2 years. This will be done sooner if emergency preparedness policies and procedures are significantly updated. c. Periodically review and rehearse it’s emergency preparedness plan with agency employees, with special emphasis placed on carrying out the procedures necessary to protect patients, staff, and others. This will be done via the testing program. d. Demonstrate staff knowledge of emergency procedures. e. Maintain documentation of all emergency preparedness training.” On 6/13/2024 from 11:13 AM – 11:53 AM and 1:05 PM – 2:10 PM, ten (10) personnel records were reviewed with the Director of Human Resources (“HR”) and Former Interim Sussman House Manager. Of the records reviewed, no documented evidence of Emergency was provided for Employees #1 - #6 and #8 - #10. During the review, the Director of HR and the Former Interim Sussman House Manager confirmed the above findings. 2. Testing The MaineHealth Care at Home, “Emergency Operations Plan” states, in part, “The agency will conduct exercises to test the emergency plan at least annually ... Testing schedule: 2022: Tabletop exercise (plan of correction), Drill 2023: Tabletop exercise 2024: Drill The agency will update this plan in 2024.” On 6/20/2024, the documentation provided by the facility was reviewed. Since 8/26/2021, the documentation showed that testing of the Emergency Preparedness Plan was initiated from an actual emergency on 10/26/2023. There was no documented evidence that the training and testing program was reviewed and updated. On 6/21/2024 at approximately 2:00 PM, the Chief Nursing Officer was asked if she agreed that there was no other documentation provided to show testing of the Emergency Preparedness Plan or a review and update of the training and testing program. She stated, “I would agree that it is not there.””

“Based on document reviews and interviews, the facility failed to provide evidence of Emergency Preparedness training for nine (9) of ten (10) personnel files that were reviewed (Employee #1 - #6 and #8 - #10). Findings: The MaineHealth Care at Home “Emergency Operations Plan”, last updated 6/2022 states in part, “Training program. The agency will:a. Provide initial training in emergency preparedness policies and procedures to all new employees, and individuals providing services under arrangement, consistent with their expected roles. b. Provide emergency preparedness training at least every 2 years. This will be done sooner if emergency preparedness policies and procedures are significantly updated. c. Periodically review and rehearse it’s emergency preparedness plan with agency employees, with special emphasis placed on carrying out the procedures necessary to protect patients, staff, and others. This will be done via the testing program. d. Demonstrate staff knowledge of emergency procedures. e. Maintain documentation of all emergency preparedness training.” On 6/13/2024 from 11:13 AM – 11:53 AM and 1:05 PM – 2:10 PM, ten (10) personnel records were reviewed with the Director of Human Resources (“HR”) and Former Interim Sussman House Manager. Of the records reviewed, no documented evidence was provided for Employees #1 - #6 and #8 - #10. During the review, the Director of HR and the Former Interim Sussman House Manager confirmed the above findings.”

“Based on document reviews and interviews, the facility failed to conduct the required testing using the Emergency Preparedness Plan. Findings: On February 7, 2024, between 9:30 am and 12:00 pm, a surveyor, with the Maintenance Director present, observed the following: 1. The Emergency Preparedness Plan testing section did not show that this facility participated the required full-scale or community-based exercises in the last calendar year. Maintenance Director confirmed that they haven’t used the Plan during an emergency or planned exercise since 2019. 2. The Emergency Preparedness Plan testing section did not show that this facility conducted a mock disaster drill or tabletop exercise in the last calendar year. Maintenance Director confirmed that they haven’t used the Plan for a drill or planned exercise since 2019. The surveyor confirmed these findings with the Maintenance Director at the time of the record review. The MaineHealth Care at Home, “Emergency Operations Plan” states, in part, “The agency will conduct exercises to test the emergency plan at least annually ... Testing schedule: 2022: Tabletop exercise (plan of correction), Drill 2023: Tabletop exercise 2024: Drill The agency will update this plan in 2024.” On 6/20/2024, the documentation provided by the facility was reviewed. Since 8/26/2021, the documentation showed that testing of the Emergency Preparedness Plan was initiated from an actual emergency on 10/26/2023. There was no other documented evidence that the testing of the Emergency Preparedness Plan. On 6/21/2024 at approximately 2:00 PM, the Chief Nursing Officer was asked if she agreed that there was no other documentation provided to show testing of the Emergency Preparedness Plan. She stated, “I would agree that it is not there.””

“Based on document reviews and interviews, the inpatient hospice facility failed to ensure that verified violations were reported to State and local bodies having jurisdiction (including to the State survey and certification agency) within five (5) working days of becoming aware of the violation for two (2) of three (3) incidents reviewed. Findings: The MaineHealth Corporate Policy “Adverse Event Reporting”, last reviewed 7/7/2023 states in part, “It is the policy of MaineHealth to provide a safe environment for the delivery of high quality health care to our patients, residents and communities. The safety and well-being of patients, residents, care team members and the public have the highest priority ... . Ensure first and foremost that appropriate patient care has occurred and take immediate corrective action(s) to prevent recurrence, whenever possible ... . Report the event through the local chain of command if the event caused significant patient harm or has the potential to be a state-reportable event. a. Local chain of command should contact local Risk Management and inform of the potential need to report ... .” The MaineHealth Care at Home “Reporting of Abuse and Neglect” last reviewed 4/27/2022 states in part, “Pursuant to Maine State Statutes, all healthcare personnel, while acting in their professional capacity, must immediately report suspected abuse, neglect, or exploitation of an incapacitated or dependent adult. Employees immediately report actual or suspected cases to the Supervisor and document the abuse/neglect on the Occurrence Report. Report adult and dependent adult abuse, neglect or exploitation immediately to the Adult Protective Services Hotline ... .” 1. On 6/12/2024, the “MHCH Risk Files Breakdown Report” was reviewed. It stated the following: On 4/24/2024, a “Near miss - no harm - didn’t reach person - caught by chance” medication dispensing event was recorded. The description states the following: “RN [Registered Nurse] reported to manager that she had overheard the HHA [Home Health Aide], [Employee #], speaking to a family member of a patient (Patient #). RN overheard something about ‘30 minutes’ and later asked the family member what the discussion was about. Family member stated that the HHA had told her that the patient could have all the meds every 30 minutes and told the family member that she could press the button on the PCA [Patient-Controlled Analgesia] pump if she felt the patient needed it. Family member stated that the HHA [Home Health Aide] then pressed the bolus button on the PCA to dose the patient. Family member was a CNA [Certified Nursing Assistant] her whole life and immediately knew that he was not in his scope of practice.” Employee # was allowed to continue caring for all of the hospice patients that day. On 6/14/2024 at 10:17 AM, the Director of Quality, Compliance, and Innovation was interviewed in regard to this event. When asked why this event was not reported to the State and local bodies he stated that he didnt believe they reported this and didnt believe this was a reportable event. On 6/21/2024 at 12:34 PM, the Chief Nursing Officer (“CNO”) was interviewed in regard to this event. She stated the following: A family member approached the [Former Interim Sussman House Manager] and explained that the HHA/CNA was talking to the family about the PCA pump and providing education. He then pushed a dose of morphine on the pump. [The Director of Nursing] and I were there that day. At the end of the day, the [Former Interim Sussman House Manager] came to me and told me what the family told her, so I brought [Employee #] to the office. I asked him if he educated the patient and family about the pump and he said, yes. I asked him if he pushed the pump and medicated the patient and he said, yes. I explained to him that what he did was outside of his scope of service. Yes, he was allowed to continue caring for patients after the family told her what happened. At the end of the day, when I was notified, I told him to hold tight, I contacted Human Resources, told him he was on administrative leave, took his badge and we started the investigation. I told him, again, that what he did was outside his scope of service...he said, Ya, I know. It seems he may have had issues before this that were not managed, so he was not terminated as nothing was in his file. So, he was not terminated but he resigned from his full time position and went to a per diem status. Since then, he has not worked a shift and will soon be termed as he is not fulfilling his per diem responsibility. No, I did not report this incident to Adult Protective Services, the Division of Licensing and Certification or the CNA Registry. But now that I think of it, I should have. 2. On 6/12/2024, a partially completed, unsigned and undated Division of Licensing and Certification Reportable Incident Form was reviewed. It stated that on 11/08/2023, the MaineHealth Care at Home hospice social worker made a bereavement call to Patient #’s family member. During that call, the family member reported to the social worker the following: Registered Nurse (“RN”) # managed all the medications, filled the pill box and picked up the medications for them at the pharmacy. Patient # would be out of pain medications sometimes for several days. RN # took Patient #’s medications out of the home prior to his death. Patient # was in pain prior to his death, such that he chose to move his “Death with Dignity” date sooner than planned. Per Adult Protective Services documents, this event was reported by the Director of Quality, Compliance and Innovation on 11/17/2023, which is a duration of nine (9) days after the event.”

“Based on document reviews, observations and interviews, the facility failed to use data collected to monitor the effectiveness and safety of services and quality of patient care as evidenced by the inpatient hospice facility patio doors being opened with no appropriate protection from birds, insects, rodents and other animals entering patient rooms since the last recertification survey in 2021 and the cleaning schedule for the facility not being carried out consistently. Finding: On 6/14/2024, a review of the 2024 MHCH Hospice Performance Improvement Plan (MaineHealth Care at Home) was conducted. This plan did not contain any indicators that referenced the physical plant and environment at the inpatient hospice facility. From 8/26/2021(the last recertification) through 6/21/2024 (a duration of 1,030 days), the inpatient hospice facility failed to ensure the doors to the outside in all seven (7) patient rooms on the inpatient unit in Sussman House had appropriate screens. This failure provided an opportunity for outside wildlife (i.e. birds, chipmunks, squirrels, etc.) and insects to enter the patient rooms; therefore, potentially spreading communicable diseases and bringing in sources of infection. On 6/21/2024 an interview was conducted with a Hospice Aide on duty at the inpatient facility. She was asked how long she had worked there, and she stated next month it would be a year. Then she was asked if the patio doors in patient rooms had been opened to the outside while she has been working there and she stated yes.”

“Based on document reviews, observations and interviews, the inpatient hospice facility failed to follow accepted standards of practice to prevent the transmission of infections and communicable diseases, as evidenced by seven (7) of seven (7) patient rooms in the inpatient facility with patio doors that open to the outside, with no appropriate screening to prevent the introduction of insects, rodents, birds and other animals from entering patient rooms. In addition, the inpatient hospice facility failed to provide evidence of required daily cleaning of patient rooms for six (6) of six (6) patient rooms used (Room #2 - #7). On 6/20/2024, the “CNA Daily Checklist” for the inpatient hospice facility was reviewed. It requires staff to initial when the following tasks are completed: Check/Fill Paper Towels; Check/Fill Toilet Paper; Check/Fill Soap Dispenser; Check/Fill Gloves; Check/Change Needle Bucket; Wipe Down Table Tops; Sanitize Sinks; Clean Shower Stall; Clean Toilet; Dry Mop Room; Wet Mop Room; Vacuum Carpet; and Empty Trash. The checklist forms between 5/01/2024 through 6/19/2024 revealed the following: Room #2 - On the following days, there was no documented evidence that the required tasks were completed when patients were in the room: 5/09/2024 through 5/12/2024, 5/15/2024, 5/21/2024, 5/22/2024, 6/05/2024, 6/08/2024, and 6/09/2024. Room #3 - On the following days, there was no documented evidence that the required tasks were completed when patients were in the room: 4/03/2024 through 4/09/2024, 4/11/2024, 4/12/2024, 5/24/2024 through 5/26/2024, 6/07/2024, 6/08/2024, and 6/12/2024 through 6/17/2024. Room #4 - On the following days, there was no documented evidence that the required tasks were completed when patients were in the room: 5/01/2024 through 5/20/2024, 5/24/2024 - 5/28/2028, 5/31/2024, 6/02/2024 through 6/06/2024 and 6/09/2024 and 6/09/2024 through 6/18/2024. Room #5 - On the following days, there was no documented evidence that the required tasks were completed when patients were in the room: 5/08/2024 through 5/23/2024, 5/28/2024, 5/29/2024, 6/01/2024, 6/05/2024, 6/06/2024, 6/11/2024 and 6/12/2024. Room #6 - On the following days, there was no documented evidence that the required tasks were completed when patients were in the room: 5/01/2024, 5/11/2024 through 5/20/2024 and 6/7/2024. Room #7 - On the following days, there was no documented evidence that the required tasks were completed when patients were in the room: 5/01/2024 through 5/07/2024, 5/25/2024, 5/26/2024 and 6/07/2024. On 6/20/2024, the Chief Nursing Officer that the forms were not complete and agreed that there was no documented evidence that the rooms were properly cleaned.”

“Based on document reviews, observations and interviews 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 hospice’s quality assessment and performance improvement program. Findings: The 2024 MaineHealth Care at Home (MHCAH) Hospice Performance Improvement Plan last reviewed on 6/13/2024, it stated in part, “Scope: MHCAH community and inpatient hospice. This document is intended to summarize the MHCAH hospice improvement plan. This plan was developed by the MHCAH hospice team and approved by the MHCAH Board Quality and Safety Committee...” This plan did not include infection prevention. The 2024 MaineHealth Care at Home (MHCAH) Infection Prevention Plan stated in part, “Evidence-based infection prevention practice by clinicians during each patient care encounter is the major way to prevent the spread of infection to patients and among health care personnel. Continued reinforcement of infection prevention practices provides the framework of MHCAH’s infection prevention strategy. By utilizing standard and transmission-based precautions.” On 6/11/2024 at 11:32 AM, a tour of the inpatient hospice facility was conducted with the House Manager. Two (2) of seven (7) patient rooms were occupied. The screenings, that consisted of two (2) panels, applied on the inside of the door with double sided tape were not enclosed, did not reach the floor, did not fit the door and were not capable of preventing wildlife, insects or other varmint. Two (2) of the screening panels had tears in them. In one (1) patient room, there was no screening for the door. On 6/11/2024, during the tour with the House Manager, she confirmed the above findings. On 6/21/2024 at 11”15 AM, an interview via Teams was conducted with Mary Smith, Infection Preventionist and Clinical Educator for MHCAH. She was asked the following: Q - Are you involved in the Infection Control program at the Sussman House? A - No, not very specifically. Q - Can you speak about the Infection Control policies at the Sussman House? A - The Sussman House has more infection prevention policies, my knowledge about the specifics of the Sussman House is limited. Q - How do you ensure that the Infection Control plan/policies/procedures are implemented? A - I am not sure, maybe they work with Pen Bay Hospital. Q - Are you aware that the screens placed to protect patients from varmint is not protecting the patients? A - I am not aware of a screen issue at the Sussman House, but it could be an oversight on my part. SHAPE \* MERGEFORMAT”

“Based on document reviews and interviews, the facility failed to ensure the plan for implementing the appropriate actions that are expected to result in improvement and disease prevention were carried out related to the lack of screening on the patio doors of all patient rooms in the inpatient hospice facility. Finding: On 6/11/2024 at 11:32 AM, a tour of the inpatient hospice facility was conducted with the House Manager. Two (2) of seven (7) patient rooms were occupied. The screenings, that consisted of two (2) panels, applied on the inside of the door with double sided tape were not enclosed, did not reach the floor, did not fit the door and were not capable of preventing wildlife, insects or other varmint. Two (2) of the screening panels had tears in them. In one (1) patient room, there was no screening for the door. Per their acceptable plan of correction on 10/01/2021 stated, in part, the following: The Sussman House staff will be responsible to report to the house supervisor, any physical damage to the building or safety concern as soon as they identify it but never later than at the end of the shift. The Sussman House Manager will be responsible to assess the damage/safety concern and institute corrective action as soon as possible. Physical assessment for installation of screens on the outside of the seven (7) patient care rooms at the Sussman House was conducted by the Pen Bay Physical Plant Supervisor on 9/27/2021. Screens for each room have been ordered. Installation will be completed no later than 11/01/2021. On 6/11/2024, during the tour with the House Manager, she confirmed the above findings. On 6/21/2024 at 1:30 PM, an interview was conducted with a Home Health Aide (HHA) working on the inpatient facility, regarding the patio doors in patient rooms. She stated that she had worked there for about a year. She was asked if the patio doors had been opened while she worked there and she stated yes. On 6/21/2024 at 1:35 PM an Interview via Teams was conducted with Mary Smith, Infection Preventionist and Clinical Educator for MHCAH. She stated the following: Q - Are you involved in the Infection Control program at the Sussman House? A - No, not very specifically. Q - Can you speak about the Infection Control policies at the Sussman House? A - The Sussman House has more infection prevention policies, my knowledge about the specifics of the Sussman House is limited. Q - How do you ensure that the Infection Control plan/policies/procedures are implemented? A - I am not sure, maybe they work with Pen Bay Hospital. Q - Are you aware that the screens placed to protect patients from varmint is not protecting the patients? A - I am not aware of a screen issue at the Sussman House, but it could be an oversight on my part. During the survey conducted at the inpatient facility in 2021, the issue of no screening for the patio doors was identified. The plan for appropriate action developed by the facility, was to utilize screening on each patio door when open, and thus eliminating the entrance of birds, insects, rodents, etc.”

“Based on document reviews and interviews, the facility failed to provide infection control education to employees and contracted providers in five (5) of ten (10) personnel files reviewed (Employee #1, #3, #6, #8 and #10). Findings: The MaineHealth Care at Home “Hospice Orientation and Training” last approved 7/23/2021 states in part, “1. All hospice staff attend the first day of the MHCAH [MaineHealth Care at Home] Orientation. a. Staff complete required education modules on Infection, Safety and Compliance, Emergency Preparedness, Hazard Communications and HIPAA Privacy.” On 6/13/2024 at 11:13 AM, personnel files were reviewed with the Director of Human Resources and the Former Interim House Manager. There was no documented evidence that Employee #1, #3, #6, #8 and #10’ personnel files contained the required education. On 6/13/2024 at approximately 11:30 AM, the above findings were confirmed with the Former Interim House Manager.”

“Based on document reviews and interviews, the facility failed to 1) Provide evidence of a policy and procedure that requires all licensed professionals to participate in the hospice’s quality assessment and performance improvement program; and 2) Ensure that licensed professionals participated in the hospice’s quality assessment and performance improvement program in seven (7) of seven (7) licensed staff personnel files reviewed (Employee #1, #3, #4, #6, #7, #9 and #10). Finding: On 6/13/2024 at 11:13 AM, personnel files were reviewed with the Director of Human Resources and the Former Interim House Manager. It was confirmed that there was no documented evidence that Employee #1, #3, #4, #6, #7, #9 and #10) personnel files contained the required information during the review. ·”

“Based on document reviews and interviews, the facility failed to ensure that Hospice Aide’s received at least twelve (l2) hours of in-service training during each 12-month period in one (1) of three (3) Hospice Aide personnel files reviewed (Employee #5). Finding: The MaineHealth Care at Home “Hospice Orientation and Training” last approved 7/23/2021 states in part, “Hospice Aides are required to complete 12 hours in a 12-month period”. On 6/13/2024 at 11:13 AM, personnel files were reviewed with the Director of Human Resources and the Former Interim House Manager. This review revealed that Employee #5 was hired on 8/09/2021. There was no documented evidence that Employee #5 received the required education. On 6/13/2024 at approximately 11:30 AM, the Former Interim House Manager confirmed the above finding.”

“Based on document review and interviews, the facility failed to ensure that the personnel files contained documentation that Hospice Aide’s (“HA”) received twelve (12) hours of in-service education each year in one (1) of three (3) HA files reviewed (Employee #5). Finding: The MaineHealth Care at Home “Hospice Orientation and Training” last approved 7/23/2021 states in part, “Hospice Aides are required to complete 12 hours in a 12-month period”. On 6/13/2024 at 11:13 AM, personnel files were reviewed with the Director of Human Resources and the Former Interim House Manager. This review revealed that Employee #5 was hired on 8/09/2021. There was no documented evidence that Employee #5 has received the required education. On 6/13/2024 at approximately 11:30 AM, the Former Interim House Manager confirmed the above finding.”

“Based on document reviews and interviews, the facility failed to ensure orientation was provided about the hospice philosophy to all employees and contracted staff who have patient and family contact in ten (10) of ten (10) personnel files reviewed (Employee #1 - #10). The MaineHealth Care at Home “Hospice Orientation and Training” last approved 7/23/2021 states in part, “MHCAH [MaineHealth Care at Home] provides an educational program that offers a comprehensive overview of hospice philosophy and hospice care. ... All direct service hospice staff, including those who deliver 20 hours or less of hospice care and contracted service providers, must have four (4) hours of hospice orientation. The education program must include the following subjects: a. Hospice philosophy b. Family dynamics c. Pain and symptom management d. Grief, loss and transition e. Psychological perspectives on death and dying f. Spirituality g. Communication skills h. Volunteer roles i. Multidisciplinary management Before staff can provide direct care, they must complete the four hours of orientation training that includes, but is not limited to: a. Hospice philosophy b. Personal death awareness c. Communication skills d. Personal issues e. Identification of hospice resource people f. Stress management g. Ethics h. Stages of dying i. Funeral arrangements. “ On 6/13/2024 at 11:13 AM, personnel files were reviewed with the Director of Human Resources and the Former Interim House Manager. There was no documented evidence that the employee files contained the required education. On 6/13/2024 at approximately 11:30 AM, the above findings were confirmed with the Former Interim House Manager.”

“Based on document reviews and interviews, the facility failed to assess the skills and competence of all individuals furnishing care in six (6) of ten (10) personnel files reviewed (Employee #1 - #3, #5, #7, and #8). Findings: The MaineHealth Care at Home “Hospice Aide Competency Evaluation Program, Orientation and Training” policy, last approved 7/23/2021 states in part, “A Hospice aide may furnish hospice aide services on behalf of MHCAH [MaineHealth Care at Home] Hospice only after that individual has successfully completed a competency evaluation program ... . The RN [Registered Nurse] documents the competency evaluation on the Hospice Aide Competency Evaluation Form and submits to HR [Human Resources] for filing in the personnel files.” On 6/13/2024 at approximately 2:00 PM, the Former Interim House Manager stated that competencies must be done by all nurses, as well. She provided the MHCAH “Clinical Hospice Nurse Self-Assessment and Clinical Competency” form that is expected to be in all of the nurses personnel files, when completed. On 6/13/2024 at approximately 2:15 PM, the Former Interim House Manager confirmed that there was no documented evidence of competencies for the Hospice Aides and the Registered Nurses reviewed and confirmed the above findings.”

“Based on document reviews and interviews, the inpatient hospice facility failed to maintain current and accurate records of the receipt and disposition of controlled drugs. Finding: The MaineHealth Care at Home “Storage and Access of Controlled Substances” policy, last approved 9/29/201 states in part, “When a controlled substance is removed from the Med Dispense or the refrigerator it will be recorded on a Controlled Substance Record of Use Sheet. This record will include the patient’s name, drug name, strength of drug, date and time that the medication was removed from the unit, the amount removed from the unit, the amount given to the patient, the amount remaining and the nurse’s initials.” In addition, it states “When a nurse administers any amount of the remaining drug it will be recorded on Controlled Substance of Use Sheet. i. The nurse will record the date and time, leave the amount from med dispense blank, indicate the amount given, the amount remaining and initials. The Controlled Substance Record of Use Sheet is used at the end of shift count to verify the presence and amount left of the medication. The sheet will also be used in the documentation of wasted or destroyed medications.” 1. On 6/11/2024 at approximately 11:30 AM, the Controlled Substance of Use Sheets were reviewed for the current controlled medications. This review revealed the following: Sixty eight (68) of the seventy five (75) administrations of controlled medications were not dated properly; Seven (7) of the seventy five (75) administrations of controlled medications did not have a time; Seventy (70) of the seventy five (75) administrations of controlled medications placed information in the med dispense column; Forty four (44) of the of the seventy five (75) administrations of controlled medications did not record the amount given; Three (3) of the seventy five (75) administrations of controlled medications did not record a signature; Three (3) of the seventy five (75) administrations of controlled medications had lines through the entire row, which would indicate an error, but there was no signature/initials and no date; and There were no shift counts documented on the Controlled Substance of Use Sheet on any of the controlled medications. On 6/11/2024 at 1:40 PM, a second surveyor observed the above findings. On 6/11/2024 at approximately 2:00 PM, the Former Interim House Manager and House Manager confirmed the above findings. 2. On 6/20/2024 at 10:10 AM, Patient #38’s medication waste and destruction log in the medical record was reviewed with the the Chief Nursing Officer (“CNO”). This review revealed the following: Dilaudid 4mg/ml - No documented evidence of a date or time of destruction, both nurses did not initial the destruction and it stated that there is 2mg of unused medication, but documented that “93.5 wasted”. Dilaudid bag 2mg/ml - No documented evidence of a date or time of destruction and both nurses did not initial the destruction. Hydromorphone 1mg/ml - No documented evidence of a date or time of destruction. Hydromorphone 1mg/ml - No documented evidence of a date or time of destruction. Dilaudid 2mg/ml - No documented evidence of a complete date of destruction. Hydromorphone 2mg/ml - No documented evidence of a date or time of destruction. The CNO confirmed, during the review, that the medication waste and destruction log was not documented properly.”

“Based on document reviews and interviews, the inpatient hospice facility failed to ensure that medication for a patient was administered by the following individuals: (i) A licensed nurse, physician, or other health care professional in accordance with their scope of practice and State law; (ii) An employee who has completed a State-approved training program in medication administration; and (iii) The patient, upon approval by the interdisciplinary group for one (1) of thirty eight (38) patients reviewed (Patient #38). Finding: On 6/12/2024, the “MHCH Risk Files Breakdown Report” was reviewed. It stated the following: On 4/24/2024, a “Near miss - no harm - didn’t reach person - caught by chance” medication dispensing event was recorded. The description states the following: “RN [Registered Nurse] reported to manager that she had overheard the HHA [Home Health Aide], [Employee #], speaking to a family member of a patient (Patient #). RN overheard something about ‘30 minutes’ and later asked the family member what the discussion was about. Family member stated that the HHA had told her that the patient could have all the meds every 30 minutes and told the family member that she could press the button on the PCA [Patient-Controlled Analgesia] pump if she felt the patient needed it. Family member stated that the HHA [Home Health Aide] then pressed the bolus button on the PCA to dose the patient. Family member was a CNA [Certified Nursing Assistant] her whole life and immediately knew that he was not in his scope of practice.” Employee # was allowed to continue caring for all of the hospice patients that day. On 6/21/2024 at 12:34 PM, the Chief Nursing Officer (“CNO”) was interviewed in regard to this event. She stated the following: A family member approached the [Former Interim Sussman House Manager] and explained that the HHA/CNA was talking to the family about the PCA pump and providing education. He then pushed a dose of morphine on the pump. [The Director of Nursing] and I were there that day. At the end of the day, the [Former Interim Sussman House Manager] came to me and told me what the family told her, so I brought [Employee #] to the office. I asked him if he educated the patient and family about the pump and he said, yes. I asked him if he pushed the pump and medicated the patient and he said, yes. I explained to him that what he did was outside of his scope of service. Yes, he was allowed to continue caring for patients after the family told her what happened. At the end of the day, when I was notified, I told him to hold tight, I contacted Human Resources, told him he was on administrative leave, took his badge and we started the investigation. I told him, again, that what he did was outside his scope of service...he said, Ya, I know. It seems he may have had issues before this that were not managed, so he was not terminated as nothing was in his file. So, he was not terminated but he resigned from his full time position and went to a per diem status. Since then, he has not worked a shift and will soon be termed as he is not fulfilling his per diem responsibility. No, I did not report this incident to Adult Protective Services, the Division of Licensing and Certification or the CNA Registry. But now that I think of it, I should have. The CNO confirmed that the Hospice House Aide administered morphine to Patient #38.”

“Based on document reviews, interviews and observations, the inpatient hospice facility failed to store controlled medication in accordance with the policy. Finding: The MaineHealth Care at Home “Storage and Access of Controlled Substances” last approved 9/29/2017 states in part, “Controlled substances are stored in the medication room under a two lock system. Access to the room requires username, password and fingerprint authorization. This door is secured at all times. The second lock is dependent on the storage needs of the medication and whether it is a drug that is stock inventory in the Med Dispense unit.” On 6/12/2024 at 12:57 PM, the medication room was observed with the Former Hospice House Manager and the House Manager. They confirmed that the room is accessed via the employees badge. The Former Hospice House Manager opened an unlocked drawer took a key out to unlock the cabinet with the controlled medications. She stated that the Med Dispense unit has been out of service for several months. On 6/12/2024 at approximately 1:00 PM, the House Manager confirmed that in order to access the controlled medications, there is only one (1) lock with the door to entry.”

“Based on document reviews and interviews the facility failed to ensure that the Core Staffing requirements for the Inpatient Hospice facility were met for fourteen (14) of the thirty-eight (38) days reviewed. The Core and Contingency Staffing Sussman House Policy, lasted approved 7/23/2021 states in part, “...II. Purpose: To assure that a system is in place to determine staffing requirements that reflect the needs of patients admitted to the Sussman House...IV. Procedure: 1-3 inpatients require one (1) Registered Nurse and one (1) Hospice Aide per shift; if there are three (3) inpatients and two (2) respite patients then one (1) Registered Nurse and two (2) Hospice Aides are required per shift; 4-7 inpatients require one to two (1-2) Registered Nurses and one to two (1-2) Hospice. Aides per shift; and five to six (5-6) inpatients plus one to two (1-2) respite patients require two (2) Registered Nurses and one to two (1-2) Hospice Aides per shift. Review of the Actual Staffing and Census from 5/5/2024 thru 6/11/2024 revealed the following: 5/7/2024 - the census was 3 inpatients and the 7am to 7pm shift was missing a Hospice Aide 5/10/2024 - the census was 5 inpatients and 2 respite patients and both the 7am to 7pm and the 7pm to 7am shifts were missing one Registered Nurse 5/11/2024 - the census was 5 inpatients and 2 respite patients and both the 7am to 7pm and the 7pm to 7am shifts were missing one Registered Nurse 5/12/2024 - the census was 3 inpatients and 2 respite patients and both the 7am to 7pm and the 7pm to 7am shifts were missing one Hospice Aide 5/13/2024 - the census was 5 inpatients and 1 respite patient and both the 7am to 7pm and the 7pm to 7am shifts were missing one Registered Nurse 5/14/2024 - the census was 5 inpatients and the 7am to 7pm shift was missing one Registered Nurse 5/17/2024 - the census was 5 inpatients and the 7am to 3pm shift was missing 1 Hospice Aide 5/21/2024 - the census was 3 inpatients and 1 respite patient and the 7pm to 7am shift was missing 1 Registered Nurse 5/27/2024 - the census was 3 inpatients and 1 respite patient and the 7pm to 7am shift was missing 1 Hospice Aide 5/31/2024 the census was 3 inpatients and the 7am to 7pm shift was missing 1 Hospice Aide 6/1/2023 - the census was 2 inpatients and the 7am to 3pm shift was missing 1 Hospice Aide 6/2/2024 - the census was 2 inpatients and the 7am to 7pm shift was missing 1 Registered Nurse 6/6/2024 - the census was 4 inpatients and 2 respite patients and the 7am to 3pm shift was missing 1 Hospice Aide 6/7/2024 - the census was 5 inpatients and 1 respite patient and both the 7am to 7pm and the 7pm to 7am shifts were missing one Registered Nurse. On 6/14/2024, these findings were confirmed by the Chief Nursing Officer.”

“Based on observations and interviews, the inpatient hospice facility failed to ensure the doors to the outside in all seven (7) patient rooms on the inpatient unit in Sussman House had appropriate screens. This failure provided an opportunity for outside wildlife (i.e. birds, chipmunks, squirrels, etc.) and insects to enter the patient rooms; therefore, potentially creating an unsafe environment. In addition, one (1) of seven (7) wooden benches located outside of the patient room in a private garden area had broken both of the arm rests, with the unattached broken pieces on the bench seat. This failure to observe the broken pieces and report and fix them created an unsafe environment. This is a REPEAT deficient practice. Findings: 1. On 6/20/2024, the “CNA Daily Checklist” for the inpatient hospice facility was reviewed. It requires staff to initial when the following tasks are completed: Check/Fill Paper Towels; Check/Fill Toilet Paper; Check/Fill Soap Dispenser; Check/Fill Gloves; Check/Change Needle Bucket; Wipe Down Table Tops; Sanitize Sinks; Clean Shower Stall; Clean Toilet; Dry Mop Room; Wet Mop Room; Vacuum Carpet; and Empty Trash. The checklist forms between 5/01/2024 through 6/19/2024 revealed the following: Room #2 - On the following days, there was no documented evidence that the required tasks were completed when patients were in the room: 5/09/2024 through 5/12/2024, 5/15/2024, 5/21/2024, 5/22/2024, 6/05/2024, 6/08/2024, and 6/09/2024. Room #3 - On the following days, there was no documented evidence that the required tasks were completed when patients were in the room: 4/03/2024 through 4/09/2024, 4/11/2024, 4/12/2024, 5/24/2024 through 5/26/2024, 6/07/2024, 6/08/2024, and 6/12/2024 through 6/17/2024. Room #4 - On the following days, there was no documented evidence that the required tasks were completed when patients were in the room: 5/01/2024 through 5/20/2024, 5/24/2024 - 5/28/2028, 5/31/2024, 6/02/2024 through 6/06/2024 and 6/09/2024 and 6/09/2024 through 6/18/2024. Room #5 - On the following days, there was no documented evidence that the required tasks were completed when patients were in the room: 5/08/2024 through 5/23/2024, 5/28/2024, 5/29/2024, 6/01/2024, 6/05/2024, 6/06/2024, 6/11/2024 and 6/12/2024. Room #6 - On the following days, there was no documented evidence that the required tasks were completed when patients were in the room: 5/01/2024, 5/11/2024 through 5/20/2024 and 6/7/2024. Room #7 - On the following days, there was no documented evidence that the required tasks were completed when patients were in the room: 5/01/2024 through 5/07/2024, 5/25/2024, 5/26/2024 and 6/07/2024. On 6/20/2024, the Chief Nursing Officer that the forms were not complete and agreed that there was no documented evidence that the rooms were properly cleaned. 2. On 6/11/2024 at 11:32 AM, a tour of the inpatient hospice facility was conducted with the House Manager. Two (2) of seven (7) patient rooms were occupied. The screenings, that consisted of two (2) panels, applied on the inside of the door with double sided tape were not enclosed, did not reach the floor, did not fit the door and were not capable of preventing wildlife, insects or other varmint. Two (2) of the screening panels had tears in them. In one (1) patient room, there was no screening for the door. Per their acceptable plan of correction on 10/01/2021 stated, in part, the following: The Sussman House staff will be responsible to report to the house supervisor, any physical damage to the building or safety concern as soon as they identify it but never later than at the end of the shift. The Sussman House Manager will be responsible to assess the damage/safety concern and institute corrective action as soon as possible. Physical assessment for installation of screens on the outside of the seven (7) patient care rooms at the Sussman House was conducted by the Pen Bay Physical Plant Supervisor on 9/27/2021. Screens for each room have been ordered. Installation will be completed no later than 11/01/2021. On 6/11/2024, during the tour with the House Manager, she confirmed the above findings.”

“Based on document reviews, observations and interviews, the inpatient hospice facility failed to ensure real or potential threats to the health and safety of the patients, others, and property were addressed as evidence by 1) The seven (7) patio doors in the inpatient hospice facility having inadequate screening that was unable to protect the patients, others, and property from outside wildlife (i.e. birds, chipmunks, squirrels, etc.) when the patio doors were opened; and 2) The broken bench outside of a patient room. Findings: On 6/11/2024 at 11:32 AM, a tour of the inpatient hospice facility was conducted with the House Manager. Two (2) of seven (7) patient rooms were occupied. The screenings, that consisted of two (2) panels, applied on the inside of the door with double sided tape were not enclosed, did not reach the floor, did not fit the door and were not capable of preventing wildlife, insects or other varmint. Two (2) of the screening panels had tears in them. In one (1) patient room, there was no screening for the door. Per their acceptable plan of correction on 10/01/2021 stated, in part, the following: The Sussman House staff will be responsible to report to the house supervisor, any physical damage to the building or safety concern as soon as they identify it but never later than at the end of the shift. The Sussman House Manager will be responsible to assess the damage/safety concern and institute corrective action as soon as possible. Physical assessment for installation of screens on the outside of the seven (7) patient care rooms at the Sussman House was conducted by the Pen Bay Physical Plant Supervisor on 9/27/2021. Screens for each room have been ordered. Installation will be completed no later than 11/01/2021. On 6/11/2024, during the tour with the House Manager, she confirmed the above findings.”

“Based on document reviews and interviews, the inpatient hospice facility failed to follow current standards of practice, including nationally recognized infection control precautions, and avoid sources and transmission of infections and communicable diseases for twenty-five (25) of thirty-eight (38) patients admitted from 5/1/2024 through 6/19/2024 (Patient #14 - #38). In addition, from 8/26/2021(the last recertification) through 6/21/2024 (a duration of 1,030 days), the inpatient hospice facility failed to ensure the doors to the outside in all seven (7) patient rooms on the inpatient unit in Sussman House had appropriate screens. This failure provided an opportunity for outside wildlife (i.e. birds, chipmunks, squirrels, etc.) and insects to enter the patient rooms; therefore, potentially spreading communicable diseases and bringing in sources of infection. On 6/11/2024 at 11:32 AM, a tour of the inpatient hospice facility was conducted with the House Manager. Two (2) of seven (7) patient rooms were occupied. The screenings, that consisted of two (2) panels, applied on the inside of the door with double sided tape were not enclosed, did not reach the floor, did not fit the door and were not capable of preventing wildlife, insects or other varmint. Two (2) of the screening panels had tears in them. In one (1) patient room, there was no screening for the door. Per their acceptable plan of correction on 10/01/2021 stated, in part, the following: The Sussman House staff will be responsible to report to the house supervisor, any physical damage to the building or safety concern as soon as they identify it but never later than at the end of the shift. The Sussman House Manager will be responsible to assess the damage/safety concern and institute corrective action as soon as possible. Physical assessment for installation of screens on the outside of the seven (7) patient care rooms at the Sussman House was conducted by the Pen Bay Physical Plant Supervisor on 9/27/2021. Screens for each room have been ordered. Installation will be completed no later than 11/01/2021. On 6/11/2024, during the tour with the House Manager, she confirmed the above findings.”

“Based on document reviews and interviews, the inpatient hospice facility failed to follow current standards of practice, including nationally recognized infection control precautions, and avoid sources and transmission of infections and communicable diseases for twenty-five (25) of thirty-eight (38) patients admitted from 5/1/2024 through 6/19/2024 (Patient #14 - #38). In addition, from 8/26/2021(the last recertification) through 6/21/2024 (a duration of 1,030 days), the inpatient hospice facility failed to ensure the doors to the outside in all seven (7) patient rooms on the inpatient unit in Sussman House had appropriate screens. This failure provided an opportunity for outside wildlife (i.e. birds, chipmunks, squirrels, etc.) and insects to enter the patient rooms; therefore, potentially spreading communicable diseases and bringing in sources of infection. Findings: 1. 2. On 6/11/2024 at 11:32 AM, a tour of the inpatient hospice facility was conducted with the House Manager. Two (2) of seven (7) patient rooms were occupied. The screenings, that consisted of two (2) panels, applied on the inside of the door with double sided tape were not enclosed, did not reach the floor, did not fit the door and were not capable of preventing wildlife, insects or other varmint. Two (2) of the screening panels had tears in them. In one (1) patient room, there was no screening for the door. Per their acceptable plan of correction on 10/01/2021 stated, in part, the following: The Sussman House staff will be responsible to report to the house supervisor, any physical damage to the building or safety concern as soon as they identify it but never later than at the end of the shift. The Sussman House Manager will be responsible to assess the damage/safety concern and institute corrective action as soon as possible. Physical assessment for installation of screens on the outside of the seven (7) patient care rooms at the Sussman House was conducted by the Pen Bay Physical Plant Supervisor on 9/27/2021. Screens for each room have been ordered. Installation will be completed no later than 11/01/2021. On 6/11/2024, during the tour with the House Manager, she confirmed the above findings.”

“Based on observation, interview and record review, the long-term care facility failed to maintain a training and testing program for Emergency Preparedness Plan in accordance with 42 CFR 483.73 Findings: On 06/14/24, between 9:30 AM and 12:00 PM, a surveyor, with the Director of Quality and Compliance and House Manager present, observed the following: 1. The was no evidence in the emergency preparedness plan of the training and testing program that is required in accordance with the plan for staff training and testing of the emergency preparedness plan. The surveyor confirmed this finding with the Director of Quality and Compliance and House Manager at the time of the observation.”

“Based on observations, the facility failed to ensure that doors at the means of egress meet the requirements of NFPA 101 life safety code 2012 edition section 19.2.2.2 under requirements for door locks, latches, and alarm devices. Findings: On 6/14/2024, between 9:00 am and 12:30 pm, a surveyor, with the House Manager, Director of Quality Compliance, Facilities Physical Plant, and Chief Nurse present, observed the following: 1. The main hall exit doors nearest to the nurses station were equipped with a barrel bolt locking system at the top of the door frame requiring special knowledge, or rendering incapability of unlocking the doors. The surveyor confirmed these findings with the House Manager, Director of Quality Compliance, Facilities Physical Plant, and Chief Nurse at the time of observation.”

“Based on observations, the facility failed to ensure that doors in a smoke barrier are self-closing and kept in a closed position unless held open with a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment on activation of the fire alarm system per the requirements of NFPA 101 life safety code 2012 edition section 19.2.2.2.9. Findings: On 6/14/2024, between 9:00 am and 12:30 pm, a surveyor, with the with the House Manager, Director of Quality Compliance, Facilities Physical Plant, and Chief Nurse present, observed the following: 1. The fire rated door separating smoke compartments leading into the clinical area was found propped open with a wedge, not allowing the door to close in the event of an emergency situation. The surveyor confirmed these findings with the House Manager, Director of Quality Compliance, Facilities Physical Plant, and Chief Nurse at the time of observation.”

“Based on record review, the long-term care facility failed to ensure that fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift per NFPA 101, Life Safety Code, 2012 Edition, Section 19.7.1.4 through 19.7.1.7 Findings: On 6/14/2024, between 9:30 AM and 12:30 PM, surveyor, with the House Manager, Director of Quality Compliance, Facilities Physical Plant, and Chief Nurse present, observed the following: 1. The facility failed to produce any record of completion of any fire drills during the last 12 months. The surveyor confirmed this finding with the House Manager, Director of Quality Compliance, Facilities Physical Plant, and Chief Nurse at the time of the observation.”

“Based on observations, the facility failed to ensure that fire door assemblies are inspected and tested annually in accordance with NFPA 80 2010 edition standard for fire doors and other opening protectives. Findings: On 6/14/2024, between 9:00 am and 12:30 pm, a surveyor, with the with the House Manager, Director of Quality Compliance, Facilities Physical Plant, and Chief Nurse present, observed the following: 1. The facility was unable to provide any record of inspection and testing of fire doors by a person possessing knowledge or training. The establishment of a door inspection program is needed for the facility. The surveyor confirmed these findings with the House Manager, Director of Quality Compliance, Facilities Physical Plant, and Chief Nurse at the time of observation.”

“Based on interview and observation on 06/14/2024 between hours of 9:30 am and 12:30 pm. this surveyor accompanied with Physical Plant employee and the House Manager, did observe the following: Findings: 1. No generator annunciator panel at a readily observed location by operating personnel at a regular workstation such as a nurses station. When this surveyor asked the Physical Plant Employee if they had a remote annunciator at any nurses station, The Physical Plant employee informed this surveyor that they did not have a remote annunciator for the generator. The surveyor confirmed these observations with the Physical Plant employee and the House Manager at the time of the observation.”