Via Health Partners - Cleveland

“Upon patient record review, 1 of 29 (Patient #2) 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 #2: During medication reconciliation at visit the following findings: 1. Hospice med profile indicated Nitrostat 0.4 mg 1 tab every 5 minutes NTE 3 tabs / ALF medication profile did not include this medication 2. ALF included Hydrocortisone 2.5% (rt arm), hyoscyamine 0.125 mg every 6 hours PRN, Morphine 5mg every 6 hours PRN. / Hospice medication profile did not include these medications.”

“Upon patient record review, 5 of 29 (Patients #2,11,15,21,22) 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 2: This patient had an APP Mattress. This were not included on the Plan of Care. Patient #11:The record reflected that this patient had an IV Pole. This was not included on the Plan of Care. Patient 15: The record reflected that this patient had oxygen and a walker. These were not included on the Plan of Care. Patients #21 and 22: The record reflected that this patient had an APP mattress and a nebulizer machine. These were not included on the Plan of Care.”

“Upon patient client record review, 1 of 29 (Patient #11) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #11: The Initial Nursing Comprehensive contained the answer “No” for patient receiving nutritional supplement. The next line indicated on the comprehensive patient receives 5-6 boluses per day. The Initial Plan of Care indicated this patient receives Nutren 0.07Kcal/mL. The Nursing Initial Comprehensive was not consistent.”

“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. On 04/09/26 during the tour of the TESTA building, it was observed that the emergency stop button for the generator was located inside the outdoor metal enclosure rather than in an external, readily accessible location. Staff confirmed that there was no remote stop station positioned outside the generator enclosure, which is not in compliance with NFPA 110 (2010 Edition), Section 5.6.5.6 requirements that all emergency generator sets have a remote manual stop station located outside the housing of the prime mover, where it is readily accessible and appropriately identified.”

“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 On 04/07/26, during a tour of the Wendover building, it was observed that the smoke compartment wall located above the double doors in the laundry hallway contained one unsealed penetration. Specifically, an insulated water pipe penetrated the gypsum board wall without an approved firestop system to maintain the integrity of the smoke barrier in accordance with NFPA 101 (2012 Edition), Section 19.3.6.1 Corridor Separation. This condition compromised the continuity of the smoke barrier by allowing a potential path for the transfer of smoke between smoke compartments.”

“Upon observation, there is no evidence the smoke compartmentation and control 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 Based on observations, the facility failed to maintain the fire-resistance rating of fire-rated barriers by ensuring penetrations were protected with an approved firestop system in accordance with NFPA 101 Life Safety Code, Section 19.3.7.6. which could allow the passage of smoke and fire through fire-rated assemblies, affecting multiple areas within the buildings. On 04/07/26, during a tour of the Wendover building, in the electrical room, three pipe penetrations through a 2-hour fire-rated assembly were observed without an approved firestop system. The penetrations lacked firestop material, compromising the fire-resistance rating of the barrier. On 04/09/26, during a tour of the TESTA building, the following conditions were observed that lacked firestop material, compromising the fire-resistance rating of the barrier, that included: 1. In the electrical room, a pipe penetration through the ceiling was sealed with foam that was not identified as an approved firestop material. 2. In the sprinkler room, an unsealed wall penetration was observed that contained flexible conduit with wiring, and was not protected with an approved firestop system.”

“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 During observations, the facility failed to maintain ventilation systems in accordance with NFPA 99 Health Care Facilities Code, Chapter 9, as well as NFPA 101 Life Safety Code, Sections 19.5.2.1 and 9.2, which could contribute to the spread of fire and smoke or indicate compromised system integrity, affecting the safety of patients, staff, and visitors. On 04/09/2026, during a tour of the TESTA location, it was observed that the air return located in the ceiling of the soiled linen room was heavily loaded with lint and debris. The accumulation of lint created a combustible condition within the ventilation system.”

“Upon observation, there was no evidence the electrical 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. New and existing Construction On 04/07/26 during a tour of the Wendover building, in a mechanical space, the air handling unit (AHU) shutdown relay junction box was observed with the cover missing, leaving electrical wiring exposed which was not in compliance with NFPA 101 (2012 Edition), Section 9.1.2, which references compliance with NFPA 70, (NEC) 314.25, requires that all junction boxes be provided with approved covers to protect wiring and prevent exposure to physical damage.”

“Upon observation, there was no evidence the exits and egress 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 On 04/07/26 during a tour of the Wendover building, it was observed that: 1. Two vital sign carts were positioned in the corridor in front of the nurses’ station. The carts were connected to electrical outlets for charging, were not in use at the time of observation, and remained unattended for greater than 30 minutes which was not in accordance with NFPA 101 (2012 Edition), Section 19.2.3 requirements that corridors remain clear and unobstructed to ensure safe and immediate use in the event of an emergency and Section 7.1.10 requires that the means of egress be continuously maintained free of all obstructions or impediments. 2. Patient sleeping rooms with glass doors leading to a patio enclosed by a brick wall were not provided with “NO EXIT” signage. These doors could be mistaken for an exit; however, they did not discharge to a public way which could mislead occupants during an emergency, delaying evacuation and affecting the safety of patients, staff and visitors, and was not in compliance with NFPA 101 (2012 Edition), Section 19.2.10, which references Section 7.10.8.3.2, requiring doors or passageways that could be mistaken for exits to be marked with a “NO EXIT” sign. The sign must display the words “NO EXIT” in letters 2 inches high with a stroke width of 3/8 inch, and the word “EXIT” in letters 1 inch high placed below the word “NO,” unless the sign is an approved existing sign.”

“Upon observation, there was no evidence the fire alarm systems 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 On 04/07/26 during a tour of the Wendover building, the following deficiencies were observed: 1. Inside the main entrance door, on the left side while facing the door opening, a wheelchair was positioned directly in front of a fire alarm pull station, obstructing access to the device and was not in compliance with NFPA 101 Life Safety Code, Section 19.3.4.1, which requires fire alarm systems to be installed and maintained in accordance with NFPA 72 National Fire Alarm and Signaling Code. NFPA 72 requires initiating devices to be accessible and unobstructed. 2. In patient rooms 5 and 15, bathroom emergency call system pull cords were observed to terminate greater than 6 inches above the finished floor, reducing accessibility for patients requiring assistance, and was not in compliances with NFPA 101 Life Safety Code, Section 19.3.4 which requires patient safety features, including nurse call systems, to be maintained and ensure accessibility and proper operation. 3. The Fire Alarm Control Panel (FACP) cabinet contained exposed wiring and not in compliance with NFPA 72 National Fire Alarm and Signaling Code Sections 10.5.1 and 10.5.5 which require equipment to be installed in a neat and workmanlike manner and protected from physical damage. Additionally, NFPA 99 Health Care Facilities Code Section 6.3.2.2.8 requires electrical components of essential systems to be installed safely, and NFPA 101 Life Safety Code Section 9.6.1.3 requires fire alarm systems to be installed, tested, and maintained in accordance with NFPA 72”

“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 On 04/09/26, during a tour of the TESTA building, it was observed that the kitchen, identified as a hazardous area, had three unsealed penetrations in the ceiling. Specifically, one sprinkler head was missing an escutcheon trim plate, and two additional openings were present in the ceiling where recent work had been completed on fluorescent light fixtures which demonstrated a failure to maintain the the fire-resistive integrity of a hazardous area enclosure and was not in compliance with with NFPA 101 (2012 Edition), Section 19.3.2.1, which requires hazardous areas to be protected by fire barriers constructed to resist the passage of smoke and fire, and Section 8.5.6.2, which requires penetrations to be protected to maintain the fire-resistance rating of the barrier.”

“Upon observation, there was no evidence the hospice investigates all adverse events, incidents, accidents, variances or unusual occurrences that involve patient care and develops a plan of correction to prevent the same or similar event from occurring again. Patient#3: The record indicates on 6/14/25 patient passed away. The SN was not allowed to attend the death per family request. Agency documented family called ambulance and paramedic pronounced patient in the home. Family called the funeral home. Agency policy states “incident report should be prepared for all occurrences that are not consistent with the ordinary and customary operations”.”