Help for Health Hospice

“Based on document review and staff interview, the facility failed to provide a policy or procedure for the role of the Hospice under a waiver declared by the Secretary in the provision of care and treatment at an alternate care site as required in accordance with §418.113(b)(6)(iv). Failure to provide a policy or procedure for the role of the Hospice in the care and treatment at an alternate care site could result in inadequate care for residents at an alternate care site. The deficiency has the potential to affect all residents. Document review on 10/10/24 starting at 12:40 PM revealed that the facility did not have documentation available to demonstration that the Emergency Preparedness Plan (EPP) had a policy or procedure for addressing the role of the facility under a waiver declared by the Secretary in the provision of care and treatment at an alternate care site. Interview with the administrator at the time of the observation confirmed the deficiency, but indicated that they were unaware of the requirement. Interview with the administrator at the time of the exit confirmed the deficiency.”

“Based on document review and staff interview, the facility failed to conduct all required training of the Emergency Preparedness Plan (EPP) as required in accordance with §418.113(d)(1)(i). Failure to provide all required training of the EPP could result in inadequate or incorrect response from staff in the event of an emergency. The deficiency has the potential to affect all residents, staff, and visitors. Document review on 10/10/24 starting at 12:40 PM revealed that no documentation was available to demonstrate that the facility was conducting initial training of the EPP policies and procedures with new hospice employees. Interview with the administrator at the time of the observation confirmed the deficiency, but indicated that they were unaware of the requirement. Interview with the administrator at the time of the exit confirmed the deficiency.”

“Based on document review and staff interview, the facility failed to test and maintain the fire sprinkler system in accordance with the 2012 NFPA 101, Life Safety Code, and 2011 NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection System. Failure to properly test and maintain the fire sprinkler system could result in a failure of the system, resulting in injury or death in the event of a fire. The deficiency affected the fire sprinkler system, and could potentially affect all residents, staff, and visitors. Document review on 10/10/2024 starting at 12:00 PM revealed that the facility failed to perform quarterly testing of the fire sprinkler system. No documentation was available at the time of the survey to demonstrate that the water flow alarm and supervisory signal devices were tested in the last twelve (12) months. The water flow alarm and supervisory signal devices shall be tested quarterly. Interview with the maintenance director at the time of the observation confirmed the deficiency, and indicated that they were unaware of the requirement. Interview with the administrator at the time of the exit confirmed the deficiency. Ref: 2011 NFPA 25 5.3.3.1, 5.2.5, 13.3.3.5 Document review on 10/10/2024 starting at 12:00 PM revealed that the facility failed to perform annual testing of the fire sprinkler system. No documentation was available at the time of the survey to demonstrate that the annual main drain test or annual backflow preventer test were conducted in the last twelve (12) months. The fire sprinkler main drain and backflow preventer shall be tested annually. Interview with the maintenance director at the time of the observation confirmed the deficiency, and indicated that they were aware of the requirement. Interview with the administrator at the time of the exit confirmed the deficiency. Ref: 2011 NFPA 25 13.2.5, 13.6.2.1 Document review on 10/10/2024 starting at 12:00 PM revealed that the facility failed to perform annual testing of the fire sprinkler anti-freeze branch. No documentation was available at the time of the survey to demonstrate that the annual freezing point of the anti-freeze system was tested in the last twelve (12) months. The fire sprinkler anti-freeze branch freezing point shall be tested annually. Interview with the maintenance director at the time of the observation confirmed the deficiency, and indicated that they were unaware of the requirement. Interview with the administrator at the time of the exit confirmed the deficiency. Ref: 2011 NFPA 25 5.3.4”

“Based on document review and staff interview, the facility failed to test and maintain the Essential Electrical System (EES) in accordance with the 2012 NFPA 99, Health Care Facilities, and 2010 NFPA 110, Standard for Emergency and Standby Power Systems. Failure to properly test and maintain the EES could result in a failure of the system, resulting in injury or death in the event of an emergency. The deficiency affected the EES, and could potentially affect all residents, staff, and visitors. Document review and staff interview on 10/10/2024 starting at 12:00 PM revealed that the facility failed to perform the monthly 30 minute load test of the EES. No documentation was available at the time of the survey to demonstrate that the facility was running the emergency generator every month for thirty (30) minutes under the building load. The EES shall be tested monthly for thirty (30) minutes under the available load from the facility. Interview with the maintenance director at the time of the observation confirmed the deficiency, but indicated that they were unaware of the requirement. Interview with the administrator at the time of the exit confirmed the deficiency. Ref: 2012 NFPA 99 6.4.4.1.1.4; 2010 NFPA 110 8.4.2 Document review and staff interview on 10/10/2024 starting at 12:00 PM revealed that the facility failed to perform the semi-annual inspection and testing of the emergency generator batteries. No documentation was available at the time of the survey to demonstrate that the facility was conducting inspections and tests of the emergency generator batteries. The generator associated with the EES shall have its batteries inspected and specific gravity tested once every six (6) months. Interview with the maintenance director at the time of the observation confirmed the deficiency, but indicated that they were unaware of the requirement. Interview with the administrator at the time of the exit confirmed the deficiency. Ref: 2012 NFPA 99 6.4.4.1.1.4; 2010 NFPA 110 8.3.7.1”

“Based on review of policies and staff interview, the facility failed to develop written policies and procedures for the management and disposal of controlled drugs in the patient’s home. The community hospice census was 2. The findings were: 1. Review of the facility’s policy “Controlled Drugs,” reviewed 10/22, showed it did not address the management and disposal of controlled drugs in the patient’s home. 2. During an interview on 10/10/24 at 10:50 AM the administrator stated the facility did not have any additional policies that would address the management and disposal of controlled drugs in the patient’s home.”

“Based on review of policies, staff interview, and medical record review, the facility failed to provide a copy of the hospice’s policies on the management and disposal of controlled drugs to the patient or representative for 2 of 2 sample patients (#1, #2). The finding were: 1. Review of the facility’s policy “Controlled Drugs,” reviewed 10/22, showed it did not address the management and disposal of controlled drugs in the patient’s home. 2. During an interview on 10/10/24 at 10:50 AM the administrator stated the facility did not have any additional policies that would address the management and disposal of controlled drugs in the patient’s home. 3. Medical record review revealed the following concerns: a. Patient #1 had physician orders for medications including Morphine sulfate and Lorazepam (both controlled medications). There lacked evidence the patient or representative was provided a copy of the facility’s controlled drugs policy. b. Patient #2 had physician orders for medications including Fentanyl patch, Morphine Sulfate, and Lorazepam (all controlled medications). There lacked evidence the patient or representative was provided a copy of the facility’s controlled drugs policy.”

“Based on medical record review and staff interview, the facility failed to document in the medical record that the facility’s policies and procedures related to the management and disposal of controlled medications was provided for 2 of 2 sample patients (#1, #2). The findings were: 1. Medical record review revealed the following concerns: a. Patient #1 had physician orders for medications including Morphine sulfate and Lorazepam (both controlled medications). There lacked evidence the patient or representative was provided a copy of the facility’s controlled drugs policy. b. Patient #2 had physician orders for medications including Fentanyl patch, Morphine Sulfate, and Lorazepam (all controlled medications). There lacked evidence the patient or representative was provided a copy of the facility’s controlled drugs policy. 2. During an interview on 10/10/24 at 10:50 AM the administrator confirmed the medical records lacked evidence the patient or representative was given information on the facility’s controlled medications policy.”