Home Health & Hospice Care

“Based on observations and interview, it was determined the facility failed to ensure one 90-minute fire rated door assembly could automatically close to a full latched and secured position. Observations during tour on 11/26/24 between 12:30 p.m. and 1:00 p.m. with Staff A (Clinical Operations Manager) revealed the 90-minute fire rated door assembly, located between the facilities maintenance/storage garage and the administration egress corridor, failed to be able to close to a full latched position. The strike plate on the 90-minute fire rated door frame assembly had been completely taped over, preventing the door from latching in the closed position. Interview on 11/26/24 with Staff A confirmed the above findings, location, and existing conditions.”

“NFPA 101 Life Safety Code7.9.3 Periodic Testing of Emergency Lighting Equipment7.9.3.1 Required emergency lighting systems shall be tested in accordance with one of the three options offered by 7.9.3.1.1, 7.9.3.1.2, or 7.9.3.1.3.7.9.3.1.1 Testing of the required emergency lighting systems shall be permitted to be conducted as follows:(1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds, except as otherwise permitted by 7.9.3.1.1.(2).(2) The test interval shall be permitted to be extended beyond 30 days with the approval of the AHJ.(3) Functional testing shall be conducted annually for a minimum of 1 1/2 hours if the emergency lighting system is battery powered.(4) The emergency lighting system shall be fully operational for the duration of the test.(5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. NFPA 110 STANDARD for EMERGENCY and STANDBY POWER SYSTEMS (2010 edition)7.3 Lighting7.3.1 The level 1 or level 2 EPS (Emergency Power Supply) equipment locations shall be provided with battery powered emergency lighting.This requirement shall not apply to units located outdoors in enclosures that do not include walk in access. Based on observations and interview, the facility failed to ensure a battery powered emergency lighting unit was located at the Automatic Transfer Switch (ATS) location for the emergency Generator. Observations during tour on 11/26/24 between 12:10 p.m. and 12:20 p.m. with Staff A (Clinical Operations Director) revealed the Automatic Transfer Switch (ATS) for the emergency Generator, is located in the main Electrical room, accessed through the main laundry room, failed to have any emergency lighting located within the Electrical distribution room or in proximity to the ATS. Interview on 11/26/24 with Staff A confirmed the above findings, available lighting, and the ATS switchgear location.”

“NFPA 101 Life Safety Code (2012 edition)7.10.1.1 Means of egress shall be marked in accordance with section 7.10 where required in chapters 11 through 43.7.10.1.2.1 Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign that is readily visible from any direction of exit access.7.10.9 Testing and Maintenance7.10.9.1 Inspection. Exit signs shall be visibly inspected for operation of the illumination sources at intervals not exceeding 30-days or shall be periodically monitored in accordance with 7.9.3.1.37.10.9.2 Testing. Exit signs connected to, or provided with, a battery-operated emergency illumination source, where required in 7.10, shall be tested and maintained in accordance with 7.9.3 Based on record review and interview, it was determined the facility failed to ensure the battery back-up emergency EXIT signs, located throughout the facility, were tested for 30-seconds on a monthly basis and 90-minutes on an annual basis. Record review during tour on 11/26/24 between 8:30 a.m. and 10:30 a.m. with Staff A (Clinical Operations Director) revealed the documentation of monthly and annual battery back-up “EXIT” sign testing failed to be available for review, for the previous 24-months. Interview on 11/26/24 with Staff A and Staff B (Property Manager) confirmed the above findings and available documentation.”

“NFPA 72 National Fire Alarm and Signaling Code (2010 edition)17.5.3 Detector Coverage17.5.3.1 Total (Complete) Coverage. Where required by laws, codes, or standards, and unless otherwise modified by 17.5.3.1.1 through 17.5.3.1.5, total coverage shall include all rooms, halls, storage areas, basements, attics, lofts, spaces above suspended ceilings, and other subdivisions and accessible spaces, as well as the inside of all closets, elevator shafts, enclosed stairways, dumbwaiters shafts and chutes. Based on observations and interview, it was determined the facility failed to ensure one smoke detector was correctly mounted to the ceiling and mounting bracket. Observations during tour on 11/26/24 between 11:30 a.m. and 11:40 a.m. with Staff A (Clinical Operations Director) revealed the smoke detection device, located on the Boiler room ceiling (Administration Wing), was hanging from the power and alarm wires but failed to be clipped in place onto the mounting bracket. Interview on 11/26/24 with Staff A confirmed the above findings, location, and existing conditions.”

“NFPA 10 Standard for Portable Fire Extinguishers (2010 edition) 7.1.1 Responsibility. The owner or designated agent or occupant of a property in which fire extinguishers are located shall be responsible for inspection, maintenance, and recharging.7.1.2.3 Persons performing 31-day inspections shall not be required to be certified.7.2.1.2 Fire extinguishers shall be inspected either manually or by means of an electronic monitoring device / system at a minimum of 30-day intervals. Based on observations and interview, it was determined the facility failed to ensure two fire extinguishers received monthly physical inspections for one month. Observations during tour on 11/26/24 between 10:30 a.m. and 1:00 p.m. with Staff A (Clinical Operations Director) revealed the facility has a total of 13 separate fire extinguishers located throughout the facility. The annual fire extinguisher inspections were conducted on 12/07/23 with two fire extinguishers failed to be inspected for the month of January of 2024 (according to the inspection tag affixed to each individual extinguisher). One extinguisher was located in the Administration service corridor and the other was located outside the employee’s Conference room. Interview on 11/26/24 with Staff A confirmed the two locations and inspection tags.”

“Based on observations and interview, it was determined the facility failed to ensure one hazardous area was maintained to resist the passage of smoke or the effects from fire. Observations during tour on 11/26/24 between 11:30 a.m. and 11:50 a.m. with Staff A (Clinical Operations Director) revealed the main Electrical room, a 60-minute fire rated enclosure, has at least four new unprotected Flexible Metal Conduits (FMC) penetrating through the fire rated ceiling into the building’s attic compartment. The open annular space around the four conduits will not resist the passage of smoke or the effects from fire. The original electrical FMC penetrations are sealed with a Hilti fire stopping system. Interview on 11/26/24 with Staff A confirmed the above findings, locations, and unsealed penetrations.”

“NFPA 90 A5.4.7 Installation5.4.7.1 Fire dampers, including their sleeves: smoke dampers: and ceiling dampers shall be installed in accordance with the conditions of their listings and the manufacturer’s installation instructions and the requirements of NFPA 80, Standard for Fire Doors and other Opening Protective’s. NFPA 80 (2010 edition)19.4 Periodic Inspection and Testing.19.4.1 Each damper shall be tested and inspected 1 year after installation.19.4.1.1 The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shall be every 6 years. Based on observations, record review and interview, it was determined the facility failed to ensure that one fire damper was operated, tested and inspected every 4 years. Observations during tour on 11/26/24 between 11:30 a.m. and 11:45 a.m. with Staff A (Clinical Operations Director) revealed the facilities main Electrical Room, located in the laundry department, is a 1-hour fire rated assembly with a 1-hour fire damper installed in the upper portion of the wall (approximately 12” x 14”) failed to have any documentation or tags affixed to the damper showing if/when the damper has ever received an additional testing or operation. Interview on 11/26/24 with Staff A confirmed the above findings, location, and available documentation.”

“NFPA 80 Standard for Fire Doors and Other Opening Protective’s (2010 edition) 5.2 Inspections5.2.1 Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ (Authority Having Jurisdiction).5.2.4 Swinging Doors with Builders Hardware or Fire Door Hardware5.2.4.1 Fire door assemblies shall be visually inspected from both side to assess the overall condition of the door assembly.5.2.4.2 As a minimum, the following items shall be verified:(1) No open holes or breaks exist in surfaces of either the door or frame.(2) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so equipped.(3) The door, frame, hinges, hardware, and non-combustible threshold are secured, aligned, and in working order with no visible signs of damage.(4) No parts are missing or broken.(5) Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7.(6) The self closing device is operational; that is, the active door completely closes when operated from the full open position.(7) If a coordinator is installed, the inactive leaf closes before the active leaf.(8) Latching hardware operates and secures the door when it is in the closed position.(9) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame.(10) No field modifications to the door assembly have been performed that void the label.(11) Gasketing and edge seals, where required, are inspected to verify their presence and integrity. Based on record review and interview, it was determined the facility failed to ensure that the annual Fire Door inspections were performed for the calendar years of 2022, 2023, and 2024, for at least seven rated (labeled) fire door assemblies.. Record review during tour on 11/26/24 between 8:30 a.m. and 10:30 a.m. with Staff A (Clinical Operations Director) and Staff B (Property Manager) revealed the following seven fire rated door assemblies that failed to have an annual (documented) fire door inspection: The Oxygen transfilling/manifold room has a 3-hour fire rated door assembly. The Garage separation wall has a 90-minute fire rated door assembly. The main laundry room corridor wall has a 90-minute fire rated door assembly. The sprinkler riser room corridor wall has a 60-minute fire rated door assembly. The Oxygen storage closet in the patient wing (East) has a 60-minute fire rated door assembly. The clean Utility room (East) has a 60-minute fire rated door assembly. The Clean Utility room (West) has a 60-minute fire rated door assembly. Interview on 11/26/24 with Staff A and Staff B confirmed the above findings and available documentation.”

“NFPA 110 Standard for Emergency and Standby Power Systems 5.6.5.6 All installations shall have a remote manual stop station of a type to prevent inadvertent operation located outside the room housing the prime mover, or where so installed, or elsewhere on the premises where the prime mover is located outside the building. 8.3.3 A written schedule for routine maintenance and operational testing of the EPSS shall be maintained.8.3.4 A permanent record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained and readily available.8.3.8 A fuel quality test shall be performed at least annually using tests approved by ASTM (Acceptable Standard Testing Methods) standards.8.4.1 EPSS’s, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly.8.3.7 Storage batteries, including electrolyte levels or battery voltage, used in connection with systems shall be inspected weekly and maintained in full compliance with manufacturers specifications.8.3.7.1 Maintenance of lead acid batteries shall include the monthly testing and recording of electrolyte specific gravity. Battery conductance testing shall be permitted in lieu of the testing of specific gravity when applicable or warranted.8.3.7.2 Defective batteries shall be replaced immediately upon discovery of defects.8.4.9 Level 1 Emergency Power Standby Systems (EPSS) shall be tested at least once within every 36-months.8.4.9.1 Level 1 EPSS shall be tested continuously for the duration of it’s assigned class.8.4.9.2 Where the assigned class is greater than 4-hours, it shall be permitted to terminate the test after 4 continuous hours.8.4.9.3 The test shall be initiated by operating at least one transfer switch test function and then by operating the test function of all remaining Automatic Transfer Switch’s (ATS), or by opening all switches or breakers supplying normal power to all ATS’s that are part of the EPSS being tested.8.4.9.5.1 For a diesel powered EPS, loading shall not be less than 30 percent of the nameplate kW rating of the EPS. A supplemental load bank shall be permitted to be used to meet or exceed the 30 percent requirement.8.4.9.6 The test required in 8.4.9 shall be permitted to be combined with one of the monthly tests required by 8.4.2 and one of the annual tests required by 8.4.2.3 as a single test.8.4.9.7 Where the test required in 8.4.9 is combined with the annual load bank test, the first 3 hours shall be at not less than the minimum loading required by 8.4.9.5 and the remaining hour shall be at not less than 75 percent of the nameplate kW rating of the EPS. Based on record review, observations, and interview, it was determined the facility failed to ensure the emergency Generator is equipped with an emergency “stop” button located outside the generator housing, failed to ensure monthly load testing and battery testing is documented for review, annual load testing if required, (unable to determine without load testing documents) is documented for review, and the 3-year 4-hour load bank testing failed to be conducted within the previous four years. Record review and observations during tour on 11/26/24 between 8:30 a.m. and 10:30 a.m. with Staff A (Clinical Operations Director) and Staff B (Property Manager) revealed the emergency Generator, located behind the facilities garage, failed to be equipped with an emergency “stop” button on the exterior of the Generator housing. Required documentation of monthly load testing and battery testing (with available load) failed to be available for at least the previous 24-months, and records of the required 3-year 4-hour load bank testing failed to be located for at least the previous four years. Weekly visual inspections of the emergency Generator failed to be conducted. Interview on 11/26/24 with Staff A and Staff B confirmed the above findings, existing conditions, and available documentation. Additionally, Staff B revealed the emergency Generator does automatically run on monthly basis under the available load but the operating documentation is not recorded or retained.”

“Based on interview and record review, it was determined that the hospice agency failed to ensure that visit frequencies were provided in accordance with the plan of care for 3 of 23 charts reviewed in a final sample of 23 patients (Patient Identifiers are #16, #20 and #23). Findings include: Patient #16 Review on 11/20/24 of Patient #16’s Hospice Plan of Care, updated 9/24/24, revealed a physician’s order dated 9/22/24 to 12/7/24 for Skilled Nursing (SN) 2 visits every week for 11 weeks. Review on 11/20/24 of Patient #16’s visits for the certification period 9/12/24 to 12/10/24 revealed there were only 1 SN visits during the weeks of 9/22/24-9/28/24; 9/29/24-10/5/24; and 10/13/24-10/19/24. Further review revealed there were no notes regarding why there were missed visits and no documentation that the practitioner was notified. Interview on 11/20/24 at 1:12 p.m. with Staff B (Quality Registered Nurse) confirmed the above findings. Patient #20 Review on 11/19/24 of Patient #20 Hospice Plan of Care, dated 9/11/24, revealed a physician’s order for [Hospice] Aide (HA) 2 visits every week (dated 9/8/24 to 11/9/24) for 9 weeks and for SN 1 visit every week for 9 weeks (dated 9/8/24 to 11/9/24). Review on 11/19/24 of Patient #20’s visits for the week of 9/8/24 to 9/14/24 revealed no SN visit and only 1 HA visit. Further review revealed a HA missed visit note on 9/10/24 that read “Scheduling Error”. There were no notes regarding why there were missed visits and no documentation that the practitioner was notified. Interview on 11/20/24 at 10:30 a.m. with Staff C (Registered Nurse) confirmed the above findings. Patient #23 Review on 11/20/24 of Patient #23’s Hospice Recertification Plan of Care, dated 9/26/24, revealed a physician’s order for HA 2 visits every week for 13 weeks dated 9/22/24 to 12/21/24. Review on 11/20/24 of Patient #23’s visits for the week of 10/6/24 to 10/12/24 revealed there were no HA visits and for 11/10/24 to 11/16/24 there was only 1 HA visit made. Further review revealed the following: on 10/9/24 “...Missed Visit... scheduling issue, provider ill and building restrictions...”; on 10/10/24 “...Missed visit... provider ill, building restrictions...”; on 11/13/24 “... Cancel Rsn [reason] Provider... is out...” and on 11/11/24 “... Appointment information... canceled...”. There was no documentation that the provider was notified of the missed visits. Interview on 11/20/24 at 1:00 p.m. with Staff C confirmed the above findings. Review on 11/20/24 of the facility’s undated policy titled “Missed Visits” revealed: “...To put a process in place for when patients have an alteration to their plan of care resulting in their visit frequency not being met for the week...Patient driven circumstance - any reason that the patient gives for not being able to keep an appointment with the agency... Agency driven circumstance - any reason the agency may have for cancelling an appointment with a patient such as: clinician call out, error in scheduling, staff convenience, etc... Procedure... 1). All patient driven missed visits need to be reported to the case manager of patient... The [Licensed Nursing Assistant]/Scheduler will document the request and who they reported it to... 2. All patient driven missed visits need to be documented in the clinical record by the person receiving the information. The reason, who you spoke with, time, and education given should be included. 3. Patient who cancel two or more visits with in a four-week period require provider notification... B. Agency Driven Circumstances: 1. The clinician must notify the provider of all agency driven missed visits with in 24 hours if there is no ability to make up the visit in the same week. Patients and/or caregivers need to also be made aware and agree with the missed visit. The clinician must document that they accept the cancellation...” Interview on 11/20/24 at 1:45 p.m. with Staff D (Staff Development) revealed the above policy went into effect on 11/14/24 and that the facility did not have a policy regarding missed visit prior to this date.”

“Based on observation and interview, it was determined that the facility failed to ensure that all controlled drugs were stored in locked compartments within the secured medication storage area for 3 of 3 medication rooms observed at the Community Hospice House (Patient Identifiers are #7 and #24). Findings include: North Medication Room Observation on 11/19/24 at approximately 10:15 a.m. of the North Medication Room revealed an unlocked refrigerator containing Resident #7’s 2 vials of Lorazepam 2 milligrams (mg)/1 milliliter (ml). Interview on 11/19/24 at approximately 10:15 a.m. with Staff A (Nurse Manager) confirmed the above findings. Observation on 11/19/24 at approximately 10:19 a.m. of the North Medication Room revealed an unlocked cabinet door containing medications for Patient #7 and Patient #24, including the controlled medications hydromorphone and phenobarbital. Interview on 11/19/24 at approximately 10:19 a.m. with Staff A confirmed the above findings and stated the cabinet lock was broken. South Medication Room Observation on 11/19/24 at approximately 10:20 a.m. of the South Medication Room revealed an unlocked refrigerator that contained a facility emergency lock box with approximately 16 vials of Lorazepam in it. Further observation revealed an attached key on the emergency lock box that would open it. Interview on 11/19/24 at approximately 10:20 a.m. with Staff A confirmed the above findings. Interview on 11/19/24 at 12:05 p.m. with Staff D (Staff Development) revealed that the facility did not have a policy/procedure for medication storage, including controlled medications, for the Community Hospice House. East Medication Room Observation on 11/19/24 at 10:30 a.m. of the East Medication Room revealed keys to the locked cabinets containing patient medications, including controlled medications. Interview on 11/19/24 at 10:30 a.m. with Staff A (Nurse Manager) confirmed the above findings. Staff A stated that the keys would also unlock the north and south medication rooms, which contained controlled medications. Staff A also stated that the keys should not have been left in the medication room.”