Hospice of the Piedmont Inc.

“Upon patient record review, 1 of 35. (Patient #24) 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 #24, Admitted to IPU GIP 1/12/24. Order for VO IPU volunteer to provide support to patient and /or family per patient/caregiver request as directed by RN, SW, or VOL Coordinator. PRN frequency not acceptable as base visit frequency.”

“Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. In 2 of 6 patient visits, staff failed to follow acceptable standards of practice. Patient #2: RN placed equipment (stethoscope, BP cuff, thermometer) on patient OBT without wiping the surface before or after use and placing it there again. RN returned to kitchen and placed used equipment on kitchen island with no barrier and did not clean surface before or after. RN changed incontinent brief and cleaned stool off patient with disposable wipes as family assisted. RN failed to remove dirty gloves before shifting covers and placing patient on bed pan. Patient #6: Nurse applied gloves without washing hands or sanitizing first. After working around the room and gathering supplies and touching patient linens, SN typed short entry on tablet without changing gloves or sanitizing first x2. She did sanitize hands 3rd time, but keyboard was not cleaned. RN leaned in as performing wound care and patient toes pressed up against her uniform for several seconds.”

“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. Upon review of inspection records dated 7/2023, it was stated “battery tested poorly.” A recommendation was added to replace the battery, there is no evidence in the maintenance records that the battery has been replaced. Upon monthly inspection December 20, 2023 it was reported that the generator radiator has a leak, the facility reports that parts have not been received at this time, and repairs have not been completed.”

“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 During the inspection at The Hospice House of High Point, it is noted that the cross corridor doors within the smoke compartment of the 200 hall do not resist the passage smoke. It was further noted at the inspection of The Randolph Hospice House, it is noted that the cross corridor doors within the smoke compartment of the service hall do not resist the passage of smoke.”

“Upon observation, there was no evidence the building service equipment 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 The agency did not prohibit the use of electrical space heaters, according to NFPA 99 19.7.8 During the survey, it was noted that 2 electrical space heaters were found at the main nursing station, in use. One was under a desk, the other on top of a work station. A third heater was found in a back room utilized for documenting and placed in a corner, on a counter and between computer screens. An additional unplugged heater was found sitting on a “bar stool” at the entrance of the same confined room for documenting. There are no additional exits to the room.”

“Upon observation, there was no evidence the hazardous areas of a facility are 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 It is noted during the inspection at the Hospice Home at High Point that portable, non-secure alcohol based hand-rub devices are placed on counter tops in room 202, 206, and 207. The devices are adjacent to potential sources of ignition, a light switch on the right and an electrical outlet on the left. They also present a hazard of being knocked off of the counter creating a potential spill of flammable/combustible liquids. In addition, (Reference inpatient kitchen) Existing Construction During inspection of the facility, it was noted that bulk alcohol-based hand-rub dispensers are on portable mini stands and not mounted to a wall, they are placed on a counter that contains a light switch that is frequently used and impeding easy access to the light switch, creating greater risk of spill of a flammable liquid and in violation of NFPA30 requirements of the 8.7.3.1 code. Flammable liquids should be stored in approved containers and cabinets that are designed to prevent leaks and spills.”

“Upon observation, there was no evidence the illumination and emergency power 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 NFPA 99-2012, section 6.3. 2.2. 1.3 (A), circuit breaker panels to Category 1 and Category 2 rooms must be secured against unauthorized access. It is observed at the Hospice House of High Point that the electrical panels that control patient rooms are located in an employee access walkway that leads from the main corridor of the facility to the outside/delivery area of the facility. The doorways are not locked and non-employee delivery personnel have access to the control panels.”

“Upon observation, there was no evidence the smoking regulations of a facility are 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 The agency policy for Hospice Home of Piedmont, indicates a no smoking policy in place across the campus. During the LSC inspection it was witnessed 5 ashtrays evident in the seating area, back porch located off of 200 hall team desk. Three of the ashtrays are open to air, there is shrubbery and dried pine needle straw along the porch setting of the facility in the observed smoking area. There are no metal containers with self-closing cover devices into which ashtrays can be emptied.”

“Upon observation, there was no evidence the inpatient facility has adequate supply of hot water at all times and include plumbing fixtures with control valves that automatically regulate the temperature of hot water used by patients. During the inspection at Hospice House of High Point, room 206 was noted that the water temperature at the patient hand sink registered 130 degrees and is out of the range of safe use of 110 degrees. In addition, during the inspection at facility #1 room #202 the water temperature in the room was noted to be 130 degrees.”

“Upon observation, there was no evidence the hospice inpatient facility furnishes meals to each patient that are consistent with the patient’s plan of care, nutritional needs and therapeutic diet, palatable, attractive and served at the proper temperature, obtained, stored, prepared, distributed and served under sanitary conditions. It was noted during the inpatient inspection of Hospice Home at High Point and The Randolph Hospice House, dry food storage does not meet acceptable guidelines of the US Food & Drug Administration: • Date all foods when they arrive. • Keep older food at the front of shelving to be used first. • Store all food at least 18 inches away from the outer walls. • Storage area need to be dry, cool, well-lit, ventilated and vermin proof. • Storage areas must be protected from moisture and direct sunlight. • Keep food protected during storage. It was noted that canned goods located on storage shelves at both locations included items that were not dated and past the expiration date for consumption. Food storage at the Hospice Home of Piedmont are stored on a wire shelf against an outer wall within the main kitchen area and are subject to temperature changes from the cooking area, less than 10 feet away and the dishwashing area within 5 feet away. Packages of dry goods including pasta, oatmeal, crackers, gravy mix and cereal were not sealed or stored in sealable containers.”