Memorial Home Care Services/Hospice Services

“Based on record review and interview, the hospice failed to ensure the integrated health care system reviewed and updated their emergency preparedness plan (including hospice) every two years from the previous review. Failure to review and update the emergency preparedness plan every two years from the previous review puts patients, staff and visitors at risk of harm from changes to hazard vulnerabilities, or other unidentified issues that the health care system could address as a result of an organized review of the plan. Findings included: 1. Document review of the heath care system’s emergency preparedness plan titled, “Yakima Valley Memorial Hospital Emergency Operations Plan”, last reviewed 05/21/21, showed that at least biennially, YVMH (Yakima Valley Memorial Hospital) conducts and documents a review of the EOP (Emergency Operations Plan) and associated components. 2. On 05/13/24 at 4:00 PM, Surveyor #7 interviewed the health care system’s Regulatory Program Administrator (Staff #701) about the review of the emergency preparedness plan. Staff #701 acknowledged that the plan had not been reviewed and updated since 2021, and stated that the plan was undergoing review, but not yet completed. 3. On 05/15/24 at 10:00 AM, Surveyor #7 completed a remote interview with the health care system’s Director of Emergency Preparedness (Staff #702) regarding the inclusion of the hospice agency (and hospice care center) in the health care system’s overall emergency preparedness plan. Staff #702 stated that the plan with the review date of 05/21/21 represented the current emergency plan and that the system would continue to review the plan to determine if the hospice agency would remain under the integrated plan or if there will be a change.”

“Based on record review and interview, the agency failed to update policies and procedures (P&Ps) to comply with the Washington State Tuberculosis (TB) infection control program by conducting the annual TB risk assessments using the department-approved form on 4 of 4 volunteers (Staff #601, #602, #603, and #604). Failure of the agency to comply with developing, updating, and implementing required P&Ps on TB screening and education may place the patients and staff at risk of TB exposure. References: Washington Administrative Code (WAC) 246-335-625 Personnel, contractor, and volunteer policies. (14) Infection control practices, communicable disease testing, and vaccinations. Policies and procedures must include, at minimum: (c) Tuberculosis (TB) infection control program. Key elements include but are not limited to: (i) Conducting a TB risk assessment for all new employees upon hire. Agencies must use a tuberculosis risk assessment form provided by the department. Based on risk assessment results, determine the agency’s responsibility to conduct TB testing of new employees. If TB testing is required, follow the department’s tuberculosis risk assessment form testing recommendations; (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 the agencys 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. Findings included: 1. Document review of the agency policy titled, “;TB Control Plan,” (Effective Date 12/2021) lacked the state requirements for conducting a TB risk assessment using the department-approved form for all personnel on hire and annually. 2. Record review on 4 of 4 volunteer files showed: a. Staff #601 was hired as a volunteer on 12/03/09. There was no documentation in the records to show that the agency completed a TB risk assessment using the department-approved form in 2023. b. Staff #602 was hired as a volunteer on 10/03/13. There was no documentation in the records to show that the agency completed a TB risk assessment using the department-approved form in 2023. c. Staff #603 was hired as a volunteer on 02/06/23. There was no documentation in the records to show that the agency completed a TB risk assessment using the department-approved form on hire. d. Staff #604 was hired as a volunteer on 03/02/07. There was no documentation in the records to show that the agency completed a TB risk assessment using the department-approved form in 2023. 3. On 05/14/23 at 3:00 PM, Surveyor #6 interviewed the agencys Supervisor of Non-Clinical Services (Staff #605) about the missing requirements in the agencys P&P and the missing department-approved TB risk assessments in the personnel records. Staff #605 stated that the P&P is managed by the hospital Employee Health Department and the agency was unable to provide documentation of the missing TB risk assessments in the personnel files.”

“Based upon observation and staff interviews on May 14, 2024 between approximately during the physical tour of the facility between approximately 0945 and 1115 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. Finding include: LS panel breaker 35 - fire alarm system breaker lock required. The above was discussed with facility staff.”

“Based on observation and staff interview on May 14, 2024 during the physical tour of the facility between approximately 0945 and 1115 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: Exterior Storage Room - storage encroached on the 18” clearance from fire sprinkler head potentially inhibiting sprinkler discharge. The above was discussed with facility staff.”

“Based on observation and staff interviews on May 14, 2024 during document review between approximately 0945 and 1115 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. Findings include: Facility failed to activate the fire alarm system on July 20, 2023, January 12, 2024 and April 18, 2024 during fire drills at 2000 hours. Fire drills conducted between 0600 and 2100 hours must include activation of the fire alarm system. The above was discussed with facility staff.”

“Based upon record review and staff interviews on May 14, 2024 between approximately 0945 and 1115 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 monthly load testing of the emergency generator in February 2024. The above was discussed with facility staff.”

“Based on observation and staff interview on May 14, 2024 during the physical tour of the facility between approximately 0945 and 1115 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: Multidisciplinary Station - a multiplug cube was plugged into a multiplug adapter. Medical Director’s Office - appliance was plugged into a multiplug adapter. The above was discussed with facility staff.”