Tri-Cities Chaplaincy Hospice

“Based upon observation and staff interviews on May 29, 2024, during approximately 0915 and 1100 hours the facility has failed to maintain their automatic and manual fire alarm system in accordance with NFPA 72. This could result a failure of the fire alarm system to properly operate in the event of a fire, which would endanger the patients, staff, and/or visitors within the facility. Findings include: Facility was unable to provide documentation of smoke detector sensitivity report. Facility provided documentation of service on September 7 and 21, 2022 but documentation did not include complete results of testing. Panel C circuit 15 was not locked allowing access to the fire alarm system circuit disconnect. The above was discussed and acknowledged by facility staff.”

“Based on observation and staff interview on May 29, 2024, between approximately 0915 and 1100 hours the facility has failed to have a written procedure for instituting an approved fire watch in the event of a failure of the fire alarm system. This could result in an inadequate fire watch which may result in a delay of fire detection and suppression, potentially endangering patients, staff, and/or visitors within the facility. Findings include: Facility was unable to provide a fire watch procedure if the fire alarm system is out of service for greater than 4 hours. The above was discussed and acknowledged by facility staff.”

“Based on documentation review, observation and staff interview on May 29, 2024, during the physical tour of the facility between approximately 0915 and 1100 hours, the facility has failed to maintain the fire sprinkler system as required. This could result in the failure of the fire sprinkler system to operate properly in the event of a fire and allow the fire to increase in size and intensity which would endanger the patients, staff, and/or visitors within the facility. Findings include: Facility was unable to provide documentation of second quarter 2023 fire sprinkler system inspection. Facility was unable to provide documentation of sample testing on quick response fire sprinkler heads greater than 20 years old. Facility was unable to provide documentation of annual forward flow testing of the fire system backflow within the past twelve months. Facility was unable to provide documentation of fire sprinkler system internal pipe inspection within the past five years. Fire sprinkler head escutcheon rings were missing in the following locations: Soiled Utility across from Room 8 Corridor outside Room 8 Storage across from Room 104 Kitchen - fire sprinkler heads had excessive particulate on them. Room 9 - fire sprinkler head had paint on it. The above was discussed and acknowledged by facility staff.”

“Based on documentation review, observation and staff interview on May 29, 2024, during document review between approximately 0915 and 1100 hours the facility has failed to have a written procedure for instituting an approved fire watch in the event of a failure of the fire sprinkler system. This could result in an inadequate fire watch which may result in a delay of suppression, potentially endangering patients, staff, and/or visitors within the facility. Findings include: Facility was unable to provide procedure if fire sprinkler system is out of service for greater than 10 hours. The above was discussed and acknowledged by facility staff.”

“Based on observation and staff interview on May 29, 2024, during approximately 0915 and 1100 hours, the facility has failed to maintain electric equipment in a safe manner and in accordance with NFPA 70. This could endanger patients, staff, and visitors in the building by risk of fire, electrocution, or other harm. Findings include: Medication Room - access to electrical panel was obstructed by medication cart. Breakroom - appliances were plugged into multiplug adapters in two locations. Maintenance Office/Riser Room - open junction box behind the fire sprinkler riser. The above was discussed and acknowledged by facility staff.”

“Based upon documentation review and staff interviews on May 29, 2024, between approximately 0915 and 1100 hours, the facility has failed to maintain and test fire and smoke dampers in accordance with NFPA 80 and NFPA 105. This could result in failure of the dampers to operate and close in the event of a fire, allowing the spread of the products of combustion from one compartment to another, endangering the patients, staff, and/or visitors. Findings include: Facility was unable to provide documentation of fire/smoke damper testing within the past four years. The above was discussed and acknowledged by facility staff.”

“Based on observation and staff interview on 05/29/2024 the facility has failed to maintain a written plan for the protection of all patients, staff and visitors and for their evacuation in the event of an emergency. At a minimum a written care occupancy fire safety plan shall provide for the following: (1) Use of alarms (2) Transmission of alarms to fire department (3) Emergency phone call to fire department (4) Response to alarms (5) Isolation of fire (6) Evacuation of immediate area (7) Evacuation of smoke compartment (8) Preparation of floors and building for evacuation (9) Extinguishment of fire Findings include: Facility was unable to provide an evacuation plan that includes both full and partial evacuation. The above was discussed and acknowledged by facility staff.”

“Based upon documentation review and staff interviews on May 29, 2024, between approximately 0915 and 1100 hours, the facility has failed to fully maintain and test the emergency generator in accordance with NFPA 110. This could result in a failure of the emergency power system which would leave the facility without egress and work lighting in the event of a power failure which in turn would endanger the patients, staff, and/or visitors within the facility. Findings include: Facility was unable to provide documentation of the emergency generator diesel fuel testing within the past twelve months. Facility was unable to provide documentation of four hour continuous load test of the emergency generator within the past three years. The above was discussed and acknowledged by facility staff.”

“Based on observation and staff interviews on May 29, 2024, during approximately 0915 and 1100 hours, the facility has failed to ensure all electrical wiring is in accordance with NFPA 70 and that extension cords are not used as a substitute for fixed wiring of a structure. This could result in an electrical hazard due to misuse or prolonged use of an extension cord, endangering the patients, staff, and/or visitors within the facility. Findings include: Room 104 - multiplug adapter was plugged into another multiplug adapter. Room 4 - a non-medical grade multiplug adapter was in use by patient bed. The above was discussed and acknowledged by facility staff.”

“Based on documentation review, observation and staff interviews on May 29, 2024, between approximately 0915 and 1100 hours the facility has failed to provide policies for the testing, repairs, and modifications of patient care related electrical equipment as required. This could result in the failure of the patient care related electrical equipment to operate properly which would endanger the patients, staff, and/or visitors within the facility. Finding include: Facility was unable to provide inventory log with testing dates on all patient care related electrical equipment. Facility was unable to provide training of staff responsible for testing and maintenance of patient care related electrical equipment. Facility was unable to provide a policy for testing, repairs and maintenance of patient care related electrical equipment. The above was discuss with and acknowledged by facility staff.”

“Based on documentation review and staff interview on May 29, 2024, between approximately 0915 and 1100 hours the facility has failed to provide documentation of personnel concerned with the application, maintenance, and handling of medical gases and cylinders that are trained on the risk and provide continuing education. Failure to provide training and continuing education on the safe handling and use of gases and cylinders could place patients, visitors, and staff at risk of oxygen malfunctions. Findings include: The facility was unable to provide documentation of guidelines and training of staff on medical gas risks and safety. The above was discussed and acknowledged by the facility staff.”