Every finding on record at Allied Services Hospice LLC

Based on observation and interview, it was determined the facility failed to maintain the emergency generator which serves the entire center. Findings include:1. Observation on July 10, 2024, at 10:45 a.m., revealed the facility's emergency generator lacked a remote emergency stop station, located externally from the generator. Exit interview with the Facilities Manager and Assistant VP of Facilities on July 10, 2024, at 11:00 a.m., confirmed the lack of the generator emergency stop station.

Based on review of hospice policy/procedure and documentation, and based on interview with the Executive Director (ED (Administrator)-Employee #14), Inpatient Unit Director (IPU Director-Employee #15), Director of Nursing (DON-Employee #16) and the Clinical Director (CD-Employee #17), the hospice failed to ensure documentation was maintained which provided evidence IPU narcotic counts were completed in accordance with hospice policy/procedure for two (2) of two (2) IPU's. (Scranton and Meade St. (Wilkes-Barre) IPU's) --- Findings include: On June 27, 2024 at approximately 10:07 AM, review of hospice policy IU-11.0, titled "Inpatient Unit Pharmaceutical Services, Medication Administration and Storage revealed the following under "Procedure": 5. The inpatient unit provides accountability for patient's drugs and biologicals including... a. Accounting for all drugs... c. Narcotic counts which occur at the change of each shift occur using the Hospice IPU Narcotic Count by Shift sheet... On June 25, 2024 at approximately 11;20 AM, review of Scranton IPU "Hospice IPU Narcotic Count by Shift" sheet documentation failed to reveal that staff initials/signature had been entered under the ";Oncoming" and/or ";Outgoing" columns on the following shifts and dates in 2024: -8:00 AM to 4:00 PM Shift: January 2, February 4 and 29, March 7, 15 and 24, April 19, and May 23, 24 and 27, 2024; and -4:00 PM to12:00 AM Shift: January 21, February 4 and 7, March 11, May 7 and 24, 2024. On June 26, 2024 at approximately 9:01 AM, review of Meade St. IPU "Hospice IPU Narcotic Count by Shift" sheet documentation failed to reveal that staff initials/signature had been entered under the ";Oncoming" and/or ";Outgoing" columns on the following shifts and dates in 2024: -12:00 AM to 8:00 AM Shift: January 1, 9, 14 and 31, February 24, March 15, April 7, 11, 21 and 25, May 10, 20 and 23, June 8 and 11, 2024; -8:00 AM to 4:00 PM: January 11, 16 and 26, February 9, 11, 18 and 23, April 11, 17 and 26, May 13 and 17, and June 5, 8, 11, 15, 18, 19 and 24, 2024; and -4:00 PM to 12:00 AM: January 3, 5, 8, and 10, February 18, March 13, 27 and 31, April 26, May 15 and 21, and June 3, 2024. During interview conducted on June 28,, 2024 at approximately 3:20 PM, the ED, IPU Director, DON and CD confirmed narcotic count documentation had not been completed in accordance with hospice policy/procedure for the Scranton and Meade St. IPU's for the above referenced shifts and dates.