Evergreen Health Hospice Care

“. Based on record review and interview, the agency failed to operationalize its policies and procedures to comply with agency-wide and state licensing requirements for Tuberculosis (TB) infection control program for 8 of 8 personnel files reviewed. Failure of the agency to comply with the agency and state requirements for TB screening may place the patients and staff at risk of TB exposure. . Findings included: Reference: Washington Administrative Code (WAC) 246-335-625 (14) (c): Tuberculosis (TB) infection control program. Key elements include, but are not limited to: (ii) Conducting an annual assessment of new TB risk factors for all employees. Agencies must use a tuberculosis risk assessment form provided by the department. Based on risk assessment results, determine agency’s responsibility to conduct TB testing of employees. Retesting should only be done for persons who previously tested negative and have new risk factors since the last assessment. 1. Document review of the agency policy titled, “;Immunity/Vaccination and Tuberculosis Screening Requirements,” (Policy No: 20412, Revised Date 09/03/2019), showed that annual TB screening will consist of the completion of the TB symptom questionnaire within one year of the employees baseline TB screening. 2. On 12/12/23, Surveyor #6 reviewed personnel files for 8 staff members (Staff # 603, #604, #605, #606, #607, #608, # 609, and #610). The review showed: a. Staff #603 was hired on 04/18/22. The record contained no evidence that the agency conducted a TB risk assessment using the department-approved form in 2023. b. Staff #604 was hired on 09/24/18. The record contained no evidence that the agency conducted a TB risk assessment using the department-approved form in 2022, and 2023. c. Staff #605 was hired on 08/05/13. The record contained no evidence that the agency conducted a TB risk assessment using the department-approved form in 2022. d. Staff #606 was hired on 02/22/11. The record contained no evidence that the agency conducted a TB risk assessment using the department-approved form on hire and in 2021, 2022, and 2023. e. Staff #607 was hired on 11/18/19. The record contained no evidence that the agency conducted a TB risk assessment using the department-approved form in 2022. f. Staff #608 was hired on 08/25/08. The record contained no evidence that the agency conducted a TB risk assessment using the department-approved form in 2022. g. Staff #609 was hired on 11/30/20. The record contained no evidence that the agency conducted a TB risk assessment using the department-approved form in 2022. h. Staff #610 was hired on 02/12/18. The record contained no evidence that the agency conducted a TB risk assessment using the department-approved form in 2022. 3. On 12/12/23 at 2:00 PM, Surveyor #6 interviewed the agencys Manager of Employee Health (Staff #615) about the missing TB risk assessments using the department-approved form in the personnel records. Staff #615 acknowledged the findings and stated that the agency could not provide the missing documents. .”

“Based on observation and staff interview on 12/11/2023 between approximately 0930 to 1330 hours the facility has failed to have appropriate testing of the fire alarm system which result in the failure to notify staff of a problem with the fire alarm system. This could lead to the system not functioning as intended and lead to people within the building not being notified of a fire. The findings include: The facility could not produce a smoke detector sensitivity test report. The fire alarm breaker is not locked and red. Facility staff acknowledged the findings.”

“Based on observation and staff interview on 12/11/2023 between approximately 0930 to 1330 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. The findings include: The facility could not produce quarterly sprinkler inspections for the 2-4th quarters. The facility could not produce a 5 year internal pipe and gauges replacement inspection report. The facility could not produce a forward flow for their backflow. Facility staff acknowledged the findings.”

“Based on observation and staff interview on 12/11/2023 between approximately 0930 to 1330 hours the facility has failed to maintain doors without impediments to their closing and latching. This could result in a delay in getting the door to the room closed in the event of a fire. This could result in toxic products of combustion getting into the room and into the exit corridor which would endanger the patients, staff and/or visitors within the smoke compartment. The findings include: The doors to the facility kitchen to the corridor do not close. Facility staff acknowledged the findings.”

“Based on observation and staff interview on 12/11/2023 between approximately 0930 to 1330 hours the facility has failed to ensure dampers in the facility were inspected and provided necessary maintenance at least every four years in accordance with NFPA 90A. LSC 9.2.1 requires heating, ventilating and air conditioning (HVAC), ductwork and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems. NFPA 90A, 2012 Edition, Section 5.4.8.1 states fire dampers shall be maintained in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. NFPA 80, 2010 Edition, Section 19.4.1 states each damper shall be tested and inspected 1 year after installation. The test and inspection frequency shall be every 4 years. If the damper is equipped with a fusible link, the link shall be removed for testing to ensure full closure and lock-in-place if so equipped. The damper shall not be blocked from closure in any way. All inspections and testing shall be documented, indicating the location of the fire damper, date of inspection, name of inspector and deficiencies discovered. The documentation shall have a space to indicate when and how the deficiencies were corrected. This deficient practice could affect all patients, staff, and visitors. The findings include: The facility could not produce a fire/smoke damper inspection report. Facility staff acknowledged the findings.”

“Based on observation and staff interview on 12/11/2023 between approximately 0930 t0 1330 hours the facility has failed to maintain a written plan for the protection of all residents, 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 The findings include: The facility could not produce a fire response plan specific to the facility including all of the above steps including call to 911, evacuation of the smoke compartment, and evacuation of the floor. Facility staff acknowledged the findings .”

“Based on observation and staff interview on 12/11/2023 between approximately 0930 to 1330 hours the facility has failed to provide fire drill records reflecting drills being conducted on all shifts for each quarter for the past 12 months. This could potentially result in the staff not responding in a coordinated manner in the event of a fire or other emergency and endangering patients, staff and/or visitors. The findings include: The facility could not produce documentation of the facility contacting the monitoring company to determine if the monitoring company received the fire alarm activation. Facility staff acknowledged the findings.”

“Based on observation and staff interview on 12/11/2023 between approximately0930 to 1130 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. The findings include: The facility could not produce evidence that they had conducted training for those concerned with the application, maintenance and handling of medical gas. Facility staff acknowledged the findings and stated it had not been done.”