St Joseph Hospice of Southern Mississippi, LLC

“Upon observation, there was no evidence the hospice inpatient facility tests their power systems in accordance with NFPA 99 and NFPA 110 including the maintenance and testing of alternate power sources and transfer inspection and testing and maintenance and testing of circuitry. Per NFPA 110-2010, 5.6.5.6 All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation located outside the room housing the prime mover, where so installed, or elsewhere on the premises when the prime mover is located outside the building. The enclosed metal generator did not have manual emergency stop located outside the enclosure. There was a “run, auto, off” switch located in metal enclosure .”

“Upon patient record review, 3 of 21 (Patients #1,2,12) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #1: During medication reconciliation at home visit the following did not match medication profile-Alendronate 70mg daily listed on profile/per husband and patient is no longer taking. Tums gummy 250 mg daily listed on profile/per husband and patient is no longer taking. Tylenol (acetaminophen) 325 mg 1 tab daily listed on profile/on hand in home is 650 mg tablets only. Patient #2: During medication reconciliation at home visit the following did not match medication profile-Toprol XL 25 mg 1 tab daily/on hand the prescription bottle read 1/2 tab daily and Trazodone 50 mg 1/2 tab at bedtime/On hand the prescription bottle read “as needed”. Patient #12: This patient is prescribed Acetaminophen 650mg every 8 hours as needed. Acetaminophen 650mg suppositories 1 suppository every 4 hours as needed and Hydrocodone/Acetaminophen 10/325 one tablet every six hours as needed. The medication profile did not specify a maximum dose of acetaminophen within 24 hours.”

“Upon patient record review, 1 of 21 (Patient #1) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient’s plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #1: MSW visit frequency indicated “PRN visits only upon family request” This frequency did not include a baseline visit frequency for the MSW (IDG 3/11/26).”

“Upon patient record review, 6 of 21 (Patients #3,7,8,9,11,15) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient #3: This patient had a alternating pressure mattress and side rails x2. These were not included on the Plan of Care. Patient #7: The record reflected that this patient had a cane and walker. These were not included on the Plan of Care. Patient #8: The record reflected that this patient had a Hoyer Lift and walker. These were not included on the Plan of Care. Patient #9: The record reflected that this patient had a Hoyer Lift, over-bed-table and wheelchair. These were not included on the Plan of Care. Patient #11: The record reflected that this patient had a bedside commode This item was not included on the Plan of Care. Patient #15: The record reflected that this patient had an over-bed-table and walker. These were not included on the Plan of Care.”

“Upon observation, there was no evidence the hospice inpatient facility tests their power systems in accordance with NFPA 99 and NFPA 110 including the maintenance and testing of alternate power sources and transfer inspection and testing and maintenance and testing of circuitry. During review of generator testing logs for the previous 12 months revealed monthly generator exercises were conducted for approximately 10–15 minutes per occurrence. NFPA 110 (2010 edition), Section 8.4.2, requires generators to be exercised under load for a minimum of 30 continuous minutes. NFPA 99 (2012 edition), Section 6.4.4.1.1.4, requires compliance with NFPA 110 testing requirements for essential electrical systems.”

“Upon observation, there is no evidence building construction is provided consistent with the 2012 editions of the LSC of the National Fire Protection Association and NFPA 99. If the building has a common wall with a nonconforming building, the common wall is a fire barrier having at least a two hour fire resistance rating constructed of materials as required for the addition. Communicating openings in dividing fire barriers required by 19.1.1.4.1 shall be permitted only in corridors and shall be protected by approved self-closing fire doors assemblies. Existing construction: During building tour, it was observed that storage was maintained less than 18 inches below automatic sprinkler deflector, which could obstruct sprinkler discharge in the following areas: Outpatient storage (diapers stacked), Janitor closet (paper towels stacked) and /Kitchen area (paper towels and party platters).”

“Upon observation, there is no evidence the corridor walls and doors of a facility is provided consistent with the 2012 editions of the LSC of the National Fire Protection Association and NFPA 99. Hospices are exempt from chapter 19.3.6.3.5 “exception number 1 and 2 and 19.3.6.3.6 number 2”. If recommended by state survey agency, CMS may waive for periods deemed appropriate, specific provisions of the LSC which, if rigidly applied, would result in unreasonable hardship to the hospice, but only if the waiver would not adversely affect the health and safety of patients. The provisions of the adopted edition of the Life Safety Code do not apply in a State if CMS finds that a fire and safety code imposed by State law adequately protects patients in hospices. Existing Construction 1. During building tour it was observed, that the North Exit door assembly was not maintained in accordance with NFPA 80, as clearance at the top of the door exceeded allowable limits (6.3.1.7). 2. The facility failed to ensure fire door assemblies were inspected and tested annually, and failed to maintain written documentation of such inspections, in accordance with NFPA 101 (2012) Section 7.2.1.15.2 and NFPA 80 (2010) Sections 5.2.1 and 5.2.2.”

“Upon observation, there is no evidence the interior finish of a facility is provided consistent with the 2012 editions of the LSC of the National Fire Protection Association and NFPA 99. Hospices are exempt from chapter 19.3.6.3.5 “exception number 1 and 2” and 19.3.6.3.6 number 2. If recommended by state survey agency, CMS may waive for periods deemed appropriate, specific provisions of the LSC which, if rigidly applied, would result in unreasonable hardship to the hospice, but only if the waiver would not adversely affect the health and safety of patients. The provisions of the adopted edition of the Life Safety Code do not apply in a State if CMS finds that a fire and safety code imposed by State law adequately protects patients in hospices. Existing Construction During building tour, it was observed that ceiling tiles were observed to be water-stained x1 and misaligned, creating gaps in the ceiling membrane. This condition indicates a failure to maintain building components in a safe and reliable condition and may allow the passage of smoke. This is not in accordance with NFPA 101 (2012), Sections 19.3.3.2 and 4.6.12, which require interior finish materials to be maintained and building components to be in good repair. These areas included: • Nursing station/conference room • West wing near rooms #10, #14 • Near north door (stained) • North wing (missing tile) • South hallway”

“Upon observation, there was no evidence the automatic sprinkler system of a facility is provided consistent with the 2012 editions of the LSC of the National Fire Protection Association and NFPA 99. The provisions of the adopted edition of the Life Safety Code do not apply in a State if CMS finds that a fire and safety code imposed by State law adequately protects patients in hospices. Existing Construction During building tour, the portable fire extinguishers are inspected quarterly. Per NFPA 101 (2012) 9.7.4.1 monthly inspections are required. These portable fire extinguishers were found throughout the building (i.e. Nurse station/Conference room, west wing, janitor closet, North wing, lobby, South hall and attic space).”