Every finding on record at Adr Hospice, LLC

Based on document review and interview, the facility failed provide update the emergency preparedness (EP) plan per requirements of 42 CFR §418.113. Findings Include: On 5/31/23 at 11:41 AM, the facility failed to provide updated (2019 or 2018) the emergency preparedness (EP) plan. Documentation review revealed the facility provided an EP plan dated from the year of 2017. The finding was acknowledged by the Administrator and Maintenance Supervisor verified this observation during the exit interview on 5/31/23.

Based on record review and interviews, the facility failed to properly perform fire drills in accordance with NFPA 101 sections 19.7.1.6 and 19.7.1.7. This deficiency affected all residents in the facility on the day of survey. Findings include: On 5/31/23, at 11:45 AM, record review revealed the facility failed to produce documentation of a fire drill performed during the 1st and 2nd quarters of 2nd shift (hours of 7:00 PM-7:00 AM) for current year of 2023. The finding was acknowledged by the Administrator and Maintenance Supervisor verified this observation during the exit interview on 5/31/23.

Based on the review of documentation, the facility failed to properly document records of testing the generator annually as directed by NFPA 99 sections 6.4.4.1.1.3 and 6.4.4.2. This deficient practice had potential of affecting the entire facility on the day of facility survey. Findings include: On 5/31/23 at 11:30 AM, the facility failed to produce documentation for year (2022) and current year 2023 annual testing and service of the generator. The facilitys last annual test of the generator was documented and performed January of 2021. The finding was acknowledged by the Administrator and Maintenance Supervisor during the exit interview on 5/31/23.