Incompass Healthcare

“PHYSICAL ENVIRONMENT CFR(s): 482.41 The hospital must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community. This Condition is not met as evidenced by: 44532 Based on record review, observation and interview, the facility failed to ensure the means of egress through the double door set in the crisis stabilization unit was readily accessible for clients without a clinical diagnosis requiring specialized security measures; failed to ensure 1 of over 3 hazardous area doors, such as storage rooms, were provided with properly working self-closing devices; and failed to provide written documentation or other evidence the sprinkler system components had been inspected and tested for 3 of 4 quarters. The cumulative effect of these systemic problems resulted in the facility’s inability to ensure the provision of quality health care in a safe environment.”

“CONTRACTED SERVICES CFR(s): 482.12(e)(2) The hospital must maintain a list of all contracted services, including the scope and nature of the services provided. This Standard is not met as evidenced by: 44532 Based on document review and interview, the facility failed to maintain a list of all contracted services. Findings include: 1. The facility lacked or failed to produce documentation of a list of contracted services. 2. On 05-20-2025 at 1350 hours, staff A7 (Director of Quality) confirmed that they did not have a list of contracted services and no documentation was provided by the end of survey.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(f)(2)(vii) [The hospital must require appropriate staff to have education, training, and demonstrated knowledge based on the specific needs of the patient population in at least the following:] (vii) The use of first aid techniques and certification in the use of cardiopulmonary resuscitation, including required periodic recertification. This Standard is not met as evidenced by: 44532 Based on document review and interview, the facility failed to ensure personnel completed CPR (Cardiopulmonary Resuscitation) recertification for 3 of 7 [N3 (Mental Heath Technician), N5 (Mental Heath Technician), and N7 (Registered Nurse)] personnel files reviewed. Findings include: 1. Policy titled, First Aid & CPR Policy # 912, Last Reviewed: 07/26/2021, indicated the following: Select staff members are required to be trained in CPR in accordance with his or her Learner Profile on Relias (staff documented training) and then on a bi-annual basis thereafter. These select staff are all inpatient unit staff members. 2. Review of N3, N5, and N7 personnel files and Relias indicated CPR training was dated greater than bi-annual. 3. Interview on 05/21/2025, with A2 (Inpatient Supervisor) confirmed N3, N5, and N7 lacked having an updated CPR certificate.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 48061 Based on document review, observation, and interview, facility nursing staff failed to label an opened multidose insulin vial with an opened date and expiration date, and failed to ensure the narcotics key was in the possession of a licensed nurse at all times. Findings include: 1 Facility procedure titled: NovoLog Manufacturers Guideline, last revised 3/2023 indicated after a vial has been opened it is be thrown away after 28 days, even if the vial contains insulin. 2. Facility policy titled, “Medication Storage, Loss, Theft”, no policy number, last revised 11/3/2023, indicated under Steps: 1. Medication will be stored in the locked medication cart or emergency drug kit (EDK) in a locked medication room with the medication nurse holding the key. Personnel licensed to administer medications will be allowed in the medication room, and others are permitted to enter under the direct supervision of licensed personnel, when necessary. 3. During observation tour on 5/20/25 at approximately 11:30 pm this writer observed in the medication room the controlled substance/narcotic key located in the lock of the controlled medication drawer. This writer observed in the medication refrigerator an opened vial of insulin without an indicated opened date on the vial. Without an opened date this writer was unable to determine the discard date of the opened vial. 4. In interview on 5/20/2025 at approximately 11:30 am with N2 (Registered Nurse) confirmed the narcotic/medication key should be with the medication nurse at all times but was not. N2 confirmed the multidose insulin vial found in the medication fridge was not marked with an opened date, cannot confirm when the insulin was last used, nor if there is a policy for labeling or discarding multidose medication vials. 5. In interview on 5/20/25 at approximately 4:30 pm with A2 (Inpatient Supervisor) confirmed the facility does not currently have policies for multidose patient medication at this time.”

“FORMULARY SYSTEM CFR(s): 482.25(b)(9) A formulary system must be established by the medical staff to assure quality pharmaceuticals at reasonable costs. This Standard is not met as evidenced by: 44532 Based on document review and interview, the facility failed to provide an approved formulary. Findings include: 1. Policy titled, Formulary Policy #: 703, Last Reviewed: 07/10/2023. Indicated to determine the nature and scope of pharmaceuticals prescribed, ordered, or dispensed by the facility and to ensure safe and appropriate procedures for the use of pharmaceuticals in treating the facilities patients. The inpatient unit shall use the same formulary utilizing a contract pharmacy. 2. The facility lacked documentation of a formulary or failed to produce documentation of an approved formulary. 3. On 05-21-2025 at 1500 hours, staff A7 (Director of Quality) confirmed that they did not have an approved medication formulary.”

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 44532 Based on observation and interview, the facility failed to ensure the means of egress through the double door set in the crisis stabilization unit was readily accessible for clients without a clinical diagnosis requiring specialized security measures. Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side unless otherwise permitted by LSC 19.2.2.2.4. Door-locking arrangements shall be permitted in accordance with 19.2.2.2.5.2. Based on observation and interview, the facility failed to ensure 1 of over 3 hazardous area doors, such as storage rooms, were provided with properly working self-closing devices. This deficient practice could affect more than 5 residents, as well as staff and visitors in the near the nurse’s office area. Findings include: Based on observations and interviews during a tour of the facility with the Safety and Security Coordinator (SSC) and Director of Quality Improvement (DOQ) on 05/19/25 at 3:30 p.m. the double doors separating the Full Crisis Unit from the Mobil Crisis Unit, marked from each side as a facility exit, was magnetically locked and could be opened with panic hardware from the Mobil Crisis side. However, the doors could only be opened from the Full Crisis side without the use of a badge or special key. The aforementioned doors were not connected to the hospital’s fire alarm system and this part of the facility did not have a fire alarm system. The DOQ stated the arrangement with the doors was added during a recent remodel/refresh of this part of the facility. This finding was acknowledged by the SSC and DOQ at the time of observation and again at the exit conference with the SSC and DOQ each present. Based on the facility tour and interview with the Safety and Security Coordinator (SSC) and Facilities Maintenance Manager (FMM) on 05/19/25 at 3:45 p.m., an office/room the facility was using as the nurse’s station was greater than 50 square feet and contained a number of combustible items, such as, paper, and over 8 large cardboard boxes. The corridor door to this office/room/nurse’s station was not equipped with a self-closing device and did not self-close and latch into the door frame. This finding was acknowledged by the SSC and FMM at the time of observation and again at the exit conference with the SSC and Director of Quality present.”

“LIFE SAFETY FROM FIRE CFR(s): 482.41(b)(1)(2)(3) (b) Standard: Life safety from fire. (1) Except as otherwise provided in this section— (i) The hospital must meet the applicable provisions and must proceed in accordance with the Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4.) Outpatient surgical departments must meet the provisions applicable to Ambulatory Health Care Occupancies, regardless of the number of patients served. (ii) Notwithstanding paragraph (b)(1)(i) of this section, corridor doors and doors to rooms containing flammable or combustible materials must be provided with positive latching hardware. Roller latches are prohibited on such doors. (2) In consideration of a recommendation by the State survey agency or Accrediting Organization or at the discretion of the Secretary, may waive, for periods deemed appropriate, specific provisions of the Life Safety Code, which would result in unreasonable hardship upon a hospital, but only if the waiver will not adversely affect the health and safety of the patients. (3) The provisions of the Life Safety Code do not apply in a State where CMS finds that a fire and safety code imposed by State law adequately protects patients in hospitals. This Standard is not met as evidenced by: 44532 1. Based on record review and interview, the facility failed to provide written documentation or other evidence the sprinkler system components had been inspected and tested for 3 of 4 quarters. LSC 4.6.12.1 requires any device, equipment or system required for compliance with this Code be maintained in accordance with applicable NFPA requirements. Sprinkler systems shall be properly maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 4.3.1 requires records shall be made for all inspections, tests, and maintenance of the system components and shall be made available to the authority having jurisdiction upon request. 4.3.2 requires that records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date. NFPA 25, 5.2.5 requires that waterflow alarm devices shall be inspected quarterly to verify they are free of physical damage. NFPA 25, 5.3.3.1 requires the mechanical waterflow alarm devices including, but not limited to, water motor gongs, shall be tested quarterly. 5.3.3.2 requires vane-type and pressure switch-type waterflow alarm devices shall be tested semiannually. Findings include: Based on review of the quarterly sprinkler system inspection records with the Safety and Security Coordinator (SSC) and Facilities Maintenance Manager (FMM) on 05/19/25 at 3:15 p.m., only 1 (dated 06/13/24) of the required 4 quarterly sprinkler inspections was available for review. During an interview at the time of record review, the FMM acknowledged there was no written documentation available to show the sprinkler system had been inspected three of the four quarters stating that they had only had one inspection per year since he began working at the facility a few years ago. During a tour of the Riser Room on 05/20/25 at 10:05 a.m., hang tags from the sprinkler company indicated that only the aforementioned inspection was conducted. Previous hangtags from several years earlier revealed that once upon a time four quarterly inspections were conducted on the sprinkler system. The FMM stated he would contact the facility’s sprinkler provider and begin 4 quarterly inspections immediately. 2. Based on observation and interview, the facility failed to ensure 1 of 1 sprinkler systems were provided with spare sprinklers, a spare sprinkler cabinet and a sprinkler wrench on the premises. NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition, Section 5.4.1.4 states a supply of spare sprinklers (never fewer than six) shall be maintained on the premises so that any sprinklers that have been operated or damaged in any way can be promptly replaced. The sprinklers shall correspond to the types and temperature ratings of the sprinklers on the property. The sprinklers shall be kept in a cabinet located where the temperature in which they are subjected will at no time exceed 100 degrees Fahrenheit. A special sprinkler wrench shall be provided and kept in the cabinet to be used in the removal and installation of sprinklers. Findings include: Based on the facility tour and interview with the Safety and Security Coordinator (SSC) and Facilities Maintenance Manager (FMM) on 05/20/25 at 10:10 a.m., there was one spare sprinkler cabinet in the riser room that included in excess of 15 spare sprinklers; 7 or more of which were not in their own protected slot. They were stored loose in and on the cabinet and not secured in holders. Based on interview at the time of the observation, the FMM agreed the spare sprinkler cabinet had spare sprinklers not in protected slots. This finding was acknowledged by the SSC and FMM at the time of observation and again at the exit conference with the SSC and Director of Quality present.”

“A Life Safety Code Recertification Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 482.41(b). Survey Date: 05/19/25 - 05/20/25 Facility Number: 005176 Provider Number: 154011 AIM Number: 200147890A At this Life Safety Code survey, Community Mental Health Center was found not in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 482.41(b), Life Safety from Fire and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies. The Community Mental Health Center was located on the non-sprinklered first floor, East Wing, of a three story, partially sprinklered hospital with a basement of Type I (332) construction. There is a 2 hour fire separation wall between the hospital and the Community Mental Health Center. The facility has a fire alarm system with smoke detection in the corridors, spaces open to the corridors, and hard-wired smoke detectors in all patient sleeping rooms. The facility has a capacity of 16 and had a census of 11 at the time of this survey. Quality Review completed on 05/28/25”

“Egress Doors CFR(s): NFPA 101 Egress Doors Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements: CLINICAL NEEDS OR SECURITY THREAT LOCKING Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times. 18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6 SPECIAL NEEDS LOCKING ARRANGEMENTS Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation. 18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4 DELAYED-EGRESS LOCKING ARRANGEMENTS Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted. 18.2.2.2.4, 19.2.2.2.4 ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 This Standard is not met as evidenced by: 43492 Based on observation and interview, the facility failed to ensure the means of egress through the double door set in the crisis stabilization unit was readily accessible for clients without a clinical diagnosis requiring specialized security measures. Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side unless otherwise permitted by LSC 19.2.2.2.4. Door-locking arrangements shall be permitted in accordance with 19.2.2.2.5.2. This deficient practice could affect over 15, staff and visitors if needing to exit the facility. Findings include: Based on observations and interviews during a tour of the facility with the Safety and Security Coordinator (SSC) and Director of Quality Improvement (DOQ) on 05/19/25 at 3:30 p.m. the double doors separating the Full Crisis Unit from the Mobil Crisis Unit, marked from each side as a facility exit, was magnetically locked and could be opened with panic hardware from the Mobil Crisis side. However, the doors could only be opened from the Full Crisis side without the use of a badge or special key. The aforementioned doors were not connected to the hospital’s fire alarm system and this part of the facility did not have a fire alarm system. The DOQ stated the arrangement with the doors was added during a recent remodel/refresh of this part of the facility. This finding was acknowledged by the SSC and DOQ at the time of observation and again at the exit conference with the SSC and DOQ each present.”

“Hazardous Areas - Enclosure CFR(s): NFPA 101 Hazardous Areas - Enclosure Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. 19.3.2.1, 19.3.5.9 Area Automatic Sprinkler Separation N/A a. Boiler and Fuel-Fired Heater Rooms b. Laundries (larger than 100 square feet) c. Repair, Maintenance, and Paint Shops d. Soiled Linen Rooms (exceeding 64 gallons) e. Trash Collection Rooms (exceeding 64 gallons) f. Combustible Storage Rooms/Spaces (over 50 square feet) g. Laboratories (if classified as Severe Hazard - see K322) This Standard is not met as evidenced by: 43492 Based on observation and interview, the facility failed to ensure 1 of over 3 hazardous area doors, such as storage rooms, were provided with properly working self-closing devices. This deficient practice could affect more than 5 residents, as well as staff and visitors in the near the nurse’s office area. Findings include: Based on the facility tour and interview with the Safety and Security Coordinator (SSC) and Facilities Maintenance Manager (FMM) on 05/19/25 at 3:45 p.m., an office/room the facility was using as the nurse’s station was greater than 50 square feet and contained a number of combustible items, such as, paper, and over 8 large cardboard boxes. The corridor door to this office/room/nurse’s station was not equipped with a self-closing device and did not self-close and latch into the door frame. This finding was acknowledged by the SSC and FMM at the time of observation and again at the exit conference with the SSC and Director of Quality present.”

“Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This Standard is not met as evidenced by: 43492 Based on record review and interview, the facility failed to maintain 1 of 1 fire alarm systems in accordance with NFPA 72, as required by LSC 101 Sections 19.3.4.5.1 and 9.6. NFPA 72, Section 14.3.1 states that unless otherwise permitted by 14.3.2, visual inspections shall be performed in accordance with the schedules in Table 14.3.1, or more often if required by the authority having jurisdiction. Table 14.3.1 states that the following must be visually inspected semi-annually: a. Control unit trouble signals b. Remote annunciators c. Initiating devices (e.g. duct detectors, manual fire alarm boxes, heat detectors, smoke detectors, etc.) d. Notification appliances e. Magnetic hold-open devices This deficient practice could affect all building occupants. Findings include: Based on records review and interview with the Safety and Security Coordinator (SSC) and Hospitals Facilities Maintenance Manager on 05/19/25 at 1:30 p.m. no documentation could be provided regarding a visual semi-annual fire alarm system inspection. The Hospitals Maintenance Manager stated that the facility was not aware of the 6-month visual inspection requirement. The UNITY HOUSE is located in a portion of the building where the fire alarm system is maintained by the hospital. The hospital staff stated that they would need to get a points list developed and a semiannual inspection scheduled in their Computer Maintenance Monitoring System. This finding was acknowledged by the SSC at the time of observation and again at the exit conference with the SSC and Director of Quality present.”

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Standard is not met as evidenced by: 43492 1. Based on record review and interview, the facility failed to provide written documentation or other evidence the sprinkler system components had been inspected and tested for 3 of 4 quarters. LSC 4.6.12.1 requires any device, equipment or system required for compliance with this Code be maintained in accordance with applicable NFPA requirements. Sprinkler systems shall be properly maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 4.3.1 requires records shall be made for all inspections, tests, and maintenance of the system components and shall be made available to the authority having jurisdiction upon request. 4.3.2 requires that records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date. NFPA 25, 5.2.5 requires that waterflow alarm devices shall be inspected quarterly to verify they are free of physical damage. NFPA 25, 5.3.3.1 requires the mechanical waterflow alarm devices including, but not limited to, water motor gongs, shall be tested quarterly. 5.3.3.2 requires vane-type and pressure switch-type waterflow alarm devices shall be tested semiannually. This deficient practice could affect all residents, staff, and visitors in the facility. Findings include: Based on review of the quarterly sprinkler system inspection records with the Safety and Security Coordinator (SSC) and Facilities Maintenance Manager (FMM) on 05/19/25 at 3:15 p.m., only 1 (dated 06/13/24) of the required 4 quarterly sprinkler inspections was available for review. During an interview at the time of record review, the FMM acknowledged there was no written documentation available to show the sprinkler system had been inspected three of the four quarters stating that they had only had one inspection per year since he began working at the facility a few years ago. During a tour of the Riser Room on 05/20/25 at 10:05 a.m., hang tags from the sprinkler company indicated that only the aforementioned inspection was conducted. Previous hangtags from several years earlier revealed that once upon a time four quarterly inspections were conducted on the sprinkler system. The FMM stated he would contact the facility’s sprinkler provider and begin 4 quarterly inspections immediately. 2. Based on observation and interview, the facility failed to ensure 1 of 1 sprinkler systems were provided with spare sprinklers, a spare sprinkler cabinet and a sprinkler wrench on the premises. NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition, Section 5.4.1.4 states a supply of spare sprinklers (never fewer than six) shall be maintained on the premises so that any sprinklers that have been operated or damaged in any way can be promptly replaced. The sprinklers shall correspond to the types and temperature ratings of the sprinklers on the property. The sprinklers shall be kept in a cabinet located where the temperature in which they are subjected will at no time exceed 100 degrees Fahrenheit. A special sprinkler wrench shall be provided and kept in the cabinet to be used in the removal and installation of sprinklers. This deficient practice could affect all residents and staff in the facility. Findings include: Based on the facility tour and interview with the Safety and Security Coordinator (SSC) and Facilities Maintenance Manager (FMM) on 05/20/25 at 10:10 a.m., there was one spare sprinkler cabinet in the riser room that included in excess of 15 spare sprinklers; 7 or more of which were not in their own protected slot. They were stored loose in and on the cabinet and not secured in holders. Based on interview at the time of the observation, the FMM agreed the spare sprinkler cabinet had spare sprinklers not in protected slots. This finding was acknowledged by the SSC and FMM at the time of observation and again at the exit conference with the SSC and Director of Quality present.”