Samaritan Evergreen Hospice

“Based on record review and interview, it was determined the agency failed to discuss in the IDT meeting and make efforts to resolve multiple missed Home Health Aide and Social Worker visits for 2 of 29 patient records reviewed (Patients #20 and #21). Findings: Patient #20: Review of a document titled “HOSPICE OUTPATIENT ADMIT 11/14/2023” revealed an order to provide services of Home Health Aide (HHA), Medical Social Worker (MSW), Skilled Nursing, Chaplain, and Case Manager to Patient #20. Review of a screen shot document titled “HHA Missed Visits” revealed “MSW - HOSPICE REASSESSMENT” missed days on “04/05/2024, 03/21/2024, 01/26/2024, 01/10/2024, 12/20/2023, 11/17/2023” and HHA “MISSED VISIT - HOSPICE” on “07/17/2024, 06/12/2024, 01/24/2024, and 01/17/2024.” The agency failed to provide documentation on efforts made by clinicians to resolve missed visits or discussion in IDT meetings. Patient #21: Review of a document titled with Patient 21’s name revealed Home Health Aide missed visits on “08/05/2024, 06/21/2024, 05/31/2024, 05/24/2024, 05/10/2024, 05/03/2024, 04/19/2024, 02/21/2023.” The agancy failed to provide documentation on efforts made by clinicians to resolve missed visits or discussion in IDT meetings. During an interview on 8/20/2024 at 2:00 PM with Employee #10 and Employee #11, the finding was discussed. No additional documentation was provided.”

“Based on observations, record review and interview during the survey, it was determined through on-going dialog with the Hospice House Manager and Emergency Management Coordinator that the facility failed to comply with the Federal, State and local EP requirements to establish and maintain a comprehensive EP program that includes development of an emergency preparedness plan and that the plan is reviewed and updated annually (CFR 42 Part 483113(a)) . Findings include: 1. On 8/2/2024, during survey between 11:42 am and 4:55 pm, the Hospice House Manager who was identified as the individual in charge, did not have immediate access to the Facility Emergency Plan (EP) and failed to provide the necessary documentation that demonstrates proficiency in the safeguarding of residents and staff during various emergencies situations. The initial EP presented to the surveyor at 12:10 pm was missing multiple components including an Emergency Policies and Procedures based on all hazards approach, Evacuation Procedures, Shelter-in-Place Procedures, Communications Plan, and Training and Testing program. At approximately 1:45 the Hospice House Manager was able to locate another EP Binder that contained some of the necessary EP components but was still incomplete (i.e. evacuation plan, shelter in place, policies and procedures). At approximately 4:00 the Samaritan Emergency Management Coordinator joined the survey and additional EP information was obtained although not readily available onsite at time of the survey. 2. On 8/2/2024, during record review between 12:10 pm and 4:45 pm, the facility failed to provide the necessary annual program review needed to ensure compliance. The last documented review was conducted in July 2022. These findings were confirmed by the Hospice House Manager and Emergency Management Coordinator at the time of discovery and reviewed at the exit conference”

“Based on observations and interview during the survey, it was determined through on-going dialog with the Hospice House Manager and Emergency Management Coordinator that the facility failed to comply with Federal, State and local EP requirements to establish and maintain a comprehensive EP program based on an all hazards approach and includes strategies for addressing emergency events identified by the risk assessment (CFR 42 Part 418.113 (a)(1)-(2)). Findings include: On 8/2/2024, during record review between 12:10 pm and 4:45 pm, the facility Hazard Vulnerability Assessment did not identify all risks that could impact the facility. For example the facility utilizes natural gas, however gas leaks were not identified as a risk that could impact the facility including a gas leak that could lead to an explosion and a policy and procedure to address the risk. These findings were confirmed by the Hospice House Manager and Emergency Management Coordinator at the time of discovery and reviewed at the exit conference”

“Based on document review and interview during the survey, it was determined through on-going dialog with the Hospice House Manager and Emergency Management Coordinator that the facility failed to comply with Federal, State and local EP requirements to establish and maintain a comprehensive EP program by developing and implementing policies and procedures base on the emergency plan and risk assessment (CFR 42 Part 483.113(b)). Findings include: On 8/2/2024, during record review between 12:10 pm and 4:45 pm, the facility failed to develop and implement EP policies and procedure, based on the risks identified in the Hazards Vulnerability Assessment (HVA) and the EP did not provide clear direction on how to access EP policies and procedures. These findings were confirmed by the Hospice House Manager and Emergency Management Coordinator at the time of discovery and reviewed at the exit conference”

“Based on document review and interview during the survey, it was determined through on-going dialog with the Hospice House Manager and Emergency Management Coordinator that the facility failed to comply with Federal, State and local EP requirements to establish and maintain a comprehensive EP program to provide that includes the provision of subsistence needs for staff and patients whether they evacuate or shelter in place (CFR 42 Part 483.113(b)(6)(iii)). Findings include: On 8/2/2024, during record review between 12:10 pm and 4:45 pm, the facility failed to provide evidence of a secure and stable patient environment in the event of an elongated emergency, to include: (iii) defined policies and/or protocols for medical, and pharmaceutical supplies of staff. These findings were confirmed by the Hospice House Manager and Emergency Management Coordinator at the time of discovery and reviewed at the exit conference”

“Based on observations and interview during the survey, it was determined through on-going dialog with the Hospice House Manager that the facility failed to comply with Federal, State and local EP requirements to establish and maintain a comprehensive EP program that includes policies and procedures for safe evacuation of the facility (CFR 42 Part 483.113(b)(6)(ii)). Findings include: On 8/2/2024, during record review between 12:10 pm and approximately 2:00 pm, the Hospice House Manager that was identified as the individual in charge in the event of an emergency did not have readily available access to evacuation procedures. These findings were confirmed by the Hospice House Manager at the time of discovery and reviewed at the exit conference”

“Based on observations and interview during the survey, it was determined through on-going dialog with the Hospice House Manager and Emergency Management Coordinator that the facility failed to comply with Federal, State and local EP requirements to establish and maintain a comprehensive EP program that includes a means to shelter in place for patients, staff and volunteers (CFR 42 Part 483.113(b)(6)(i)). Findings include: On 8/2/2024, during record review between 12:10 pm and 4:45 pm, the facility failed to provide the policy and procedure documentation that includes a means for sheltering all patients, staff, and volunteers who remain in the facility in the event an evacuation cannot be executed. These findings were confirmed by the Hospice House Manager and Emergency Management Coordinator at the time of discovery and reviewed at the exit conference”

“Based on observations and interview during the survey, it was determined through on-going dialog with the Hospice House Manager and Emergency Management Coordinator that the facility failed to comply with Federal, State and local EP requirements to establish and maintain a comprehensive EP program that includes contact information for Emergency Officials and other sources of assistance (CFR 42 Part 483.113(c)(2)). Findings include: On 8/2/2024, during record review between 12:10 pm and 4:45 pm, the facility did not have current and updated Emergency Officials contact information. Surveyor does not have the ability to confirm all of the facilities emergency officials and sources of assistance contact information, however the Department of State Fire Marshal’s information including phone, email, and website was more than 5 years old. These findings were confirmed by the Hospice House Manager and Emergency Management Coordinator at the time of discovery and reviewed at the exit conference.”

“Based on observations and interview during the survey, it was determined through on-going dialog with the Hospice House Manager and Emergency Management Coordinator that the facility failed to comply with Federal, State and local EP requirements to establish and maintain a comprehensive EP program for an integrated health care system (CFR 42 Part 483.113(e)). Findings include: On 8/2/2024, during record review between 12:10 pm and 4:45 pm, the Emergency Management Coordinator indicated that the facility is part of an Integrated Healthcare System. Staff indicated that the EP is an integrated plan for all Samaritan facilities. The facilities EP was not specific to the facility Staff indicated the facility relies on assistance from Samaritan staff that are not located on site but responds to emergencies as they are able. The facility failed to provide evidence that the facility meets the following requirements for an integrated EP plan: 1. Demonstrate that each separately certified facility within the system actively participated in the development of the unified and integrated EP program. 2. Be developed and maintained in a manner that takes into account each separately certified facility’s unique circumstances, patient populations and services offered. 3. Demonstrate that each separately certified facility is capable of actively using the unified and integrated EP program and is in compliance. 4. Include a unified and integrated EP plan that is based on a community-based and facility-based all hazards approach . 5. Include integrated policies and procedures based on the all hazards risk analysis. These findings were confirmed by the Hospice House Manager and Emergency Management Coordinator at the time of discovery and reviewed at the exit conference.”

“Based on observations, record review and interview during the survey, it was determined through on-going dialog with the Hospice House Manager that the facility failed to ensure the automatic sprinkler and standpipe systems were continuously maintained, inspected and tested in a reliable operating condition for entire building. This resulted in the potential for system failure during fire emergencies (LSC 19.3.5, 9.7.5, 9.7.7, 9.7.8, NFPA 25). Findings include: On 8/2/2024, during survey of physical environment between 3:15 pm and 3:50 pm, there were gaps between the fire sprinkler escutcheon and the ceiling on fire sprinkler heads throughout the facility. This would allow for the spread of fire and smoke to other areas of the facility. Surveyor was accompanied by the Hospice House Manager who acknowledged the existence of these conditions.”

“Based on observations, interviews and record review during the survey, it was determined through on-going dialog with the Hospice House Manager that the facility failed to provide fire drills for all staff affecting the entire building. This resulted in the potential for inadequate staff knowledge during fire emergencies, potentially exposing residents to smoke and fire in the facility (LSC 19.7.1.4 – 19.7.1.7). Findings include: 1. On 8/2/2022, during record review between 12:10 pm and 4:45 pm, facility documentation presented to the surveyor by the facility showed that fire drills for day and night shifts in 2023 and 2024 were at random times throughout the shifts. Fire drills were for day shift were conducted at 9:30 am, 9:15 am, and 10:15 am; fire drills for night shift were conducted at 6:30 am, 6:35 am, and 6:00 am; which demonstrates that fire drills were conducted in a manner that created a pattern, instead of on different times throughout the shifts. 2. On 8/2/2022, during record review between 12:10 pm and 4:45 pm, facility documentation presented to the surveyor showed incomplete fire drill forms for the facility. Fire drill forms were missing items such as but not limited to the number of simulated occupants evacuated from the affected smoke compartment, time to complete the simulated evacuation from the affected smoke compartment to an unaffected smoke compartment, specific type of fire simulated, specific location of simulated fire and Staff Performance during the drill. 3. On 8/2/2022, during record review between 12:10 pm and 4:45 pm, the facility had no documentation for a fire drill conducted for night shift in the 4th quarter of 2023. Surveyor was accompanied by the Hospice House Manage who acknowledged the existence of these conditions.”