Every finding on record at Central Wyoming Hospice Program

Based on medical record review and staff interview, the agency failed to ensure a registered nurse supervised the home health aide (HHA) at least every 14 days for 3 of 5 sample patients (#1, #16, #17). The findings were: --- Review of the medical record for patient #1 showed the patient resided at home and was admitted to hospice care on 9/16/22. Further review showed the patient had orders for a HHA and had been seen by a HHA 1-3 times per week. During the initial certification period of 9/16/22-12/14/22 one supervisory visit was made on 12/12/22. Review of the medical record for patient #16 showed the patient lived at home and was admitted to hospice care on 3/31/22. Further review showed the patient had orders for a HHA and had been seen by a HHA 1-3 times per week. The agency failed to supervise the HHA during the certification period of 9/22/22-11/20/22 and for the certification period of 11/21/22-1/19/23 as of the date of survey. Review of the medical record for patient #17 showed the patient lived at home and was admitted to hospice care on 12/8/21. Further review showed the patient had orders for and had been seen by a HHA 1-3 times per week. Further review showed during the certification period of 10/4/22-12/2/22, one supervisory visit was made on 11/7/22 and none for the certification period of 12/3/22-1/31/23 as of the date of survey. Interview with the director of clinical services on 12/19/22 at 11:10 AM verified the outpatient manager was aware of potential non-compliance and talked to the nursing staff about it last summer.

Based on medical record review and staff interview, the agency failed to ensure that each patient's medical record included a signed copy of the notice of patient rights for 18 of 18 sample patients (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18). The findings were: --- Review of the medical record for patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17 and #18 showed no evidence of a signed copy of the notice of patient rights. Interview with the executive director on 12/22/22 at 10:45 AM confirmed current agency practice did not include putting a signed copy of the patient rights in the medical record.

Based on observation, staff interviews and facility policy review, the facility failed to ensure that all controlled drugs listed in Schedules II, III, IV, and V of the Comprehensive Drug Abuse Prevention and Control Act of 1976 were stored in locked compartments within a secure storage area for 1 of 2 controlled drug storage compartments at the Chapman hospice home. The findings were: --- Observation of the medication room at Chapman hospice home showed a medication refrigerator that contained controlled substances and was "secured" with a plastic, breakaway, tamper seal and no lock. Interview with RN #9 on 12/20/22 at 2:15 PM revealed the medication refrigerator contained controlled substances for hospice outpatients that preferred to not have the controlled substances stored in their home. Interview with the outpatient manager on 12/21/22 at 9 AM verified the refrigerator contained controlled substances for hospice outpatients and the plastic, breakaway "lock" was to indicate the refrigerator was opened rather than to secure it and limit access to the contents. Interview with the executive director on 12/22/22 at 11 AM confirmed the medication room was locked and considered a secure area but the controlled substances were not stored in locked compartments within the secured area. Review of the facility policy "OP Medication Fridge Checklist/Reminders" dated 8/12/22 showed the refrigerator "lock" consisted of a break away lock with a "lock number"... "In the event the fridge is found with the lock broken/unsecure, 2 RN's would inventory the medications, report the breach and "apply another lock and record the lock number on the Fridge Lock Check form."

Based on observation, review of temperature logs, staff interview, and agency policy review, the agency failed to ensure proper food storage for 2 of 2 inpatient hospice homes. The Kloefkorn home had a census of 6 patients and the Chapman home had a census of 3 patients. The findings were: --- Observation during the building tour of Kloefkorn hospice home on 12/20/22 at 11:30 AM showed a binder in the kitchen for the December food temperatures and the refrigerator and freezer temperatures. Multiple omissions had occurred for several days for the month including temperatures of patient food and the refrigerator and the freezer used for patient food storage. Interview with HHA #9 on 12/20/22 at 12:15 PM verified there were temperatures omitted from the log but she "did not work those days" and could not explain why they had not been recorded. Observation during the building tour of the Chapman hospice home on 12/20/22 at 1:55 PM showed a binder in the kitchen for the December food temperatures and the refrigerator and freezer temperatures. There were multiple omissions on the food temperature log and 12 of 21 days of December showed no temperature recorded for the refrigerator log, 12 of 21 days of December showed no temperature recorded on the pantry refrigerator log, and 12 of 21 days of December showed no temperature recorded for Freezer #1. An additional observation showed two pans of minestrone soup on the kitchen counter that were neither hot nor cold to the touch. Interview with employee #10 on 12/20/22 at 2:00 PM verified the soup had been donated to the home and it arrived "about noon." Review of the facility's policy "Food Care and Preparation" revised 3/20213,"...the cook/HHA will monitor and log the temperature of all refrigerators and freezers daily." Further review showed "potentially hazardous food will be cooled within 2 hours from 140 degrees F to 70 degrees F."

Based on observation and staff interview in the Kloefkorn Building, the facility failed to maintain means of egress in accordance with the 2012 NFPA 101, Life Safety Code. Failure to maintain means of egress as required could delay egress resulting in injury or death during an emergency. The deficiencies affected one (1) on numerous exits from the facility. The findings were: Observation on 12/20/2022 at 3:20 PM at the Kloefkorn main entrance revealed an exterior exit door that could only be opened with an employee badge. The door was provided with a sign indicating that it was equipped with a delayed egress system, but did not activate when door hardware was engaged. Interview with the human resources and facility maintenance manager at the time of observation acknowledged the deficiency, and indicated they were unaware of the requirement. Interview with the facility administrator at the time of exit acknowledged the deficiency. Ref: 2012 NFPA 101, Section 19.2.2.2.4; 7.2.1.5.3; 7.2.1.6.1 Based on observation and staff interview in the Chapmen Building, the facility failed to maintain means of egress in accordance with the 2012 NFPA 101, Life Safety Code. Failure to maintain means of egress as required could delay egress from the building during an emergency resulting in injury or death. The deficiency affected two (2) of numerous exits. The findings were: Observation on 12/20/2022 at 2:36 PM at the west rear (south facing) exit revealed that the sidewalk was covered with snow. It was further observed that the pathway for the west exit would take you to this section of sidewalk. Interview with human resources and facility maintenance manager at time of observation acknowledged the deficiency, and indicated they were not aware of the requirement. Interview with the facility administrator at the time of exit acknowledged the deficiency. REF: 2012 NFPA 101, Sections: 19.7.3.1; 7.1.10.1

Based on observation and staff interview in the Kloefkorn Building, the facility failed to maintain egress doors in accordance with the 2012 NFPA 101, Life Safety Code. Failure to maintain egress doors as required could impede egress during an emergency, which may result in injury or death. The deficiency could impact all residents, staff and visitors in the area. The findings were: Observation on 12/20/2022 at 2:55 PM at the Kloefkorn kitchen exit revealed that the delayed egress locking system failed to operate as designed. When tested, the system failed to emit an audible alarm indicating an irreversible process to release the door had begun. Interview with the human resources and facility maintenance manager at the time of observation acknowledged the lack of an audible alarm, and indicated they were not aware of the requirement. Interview with the facility administrator at the time of exit acknowledged the deficiency.

Based on observation and staff interview in the Chapmen Building, the facility failed to provide a self-closing door that latched in accordance with the 2012 NFPA 101, Life Safety Code. Failure to provide a latching self-closing door as required could contribute to the spread of smoke or fire during an emergency, resulting in injury or death of occupants. The deficiency could impact all residents, staff and visitors located in the areas identified. The findings were: Observation on 12/20/2022 at 2:29 PM at the Chapmen storage room, next to the nurses station, revealed that the door was equipped with a self-closing device and had been propped open with a door wedge. Interview with the nurse at the nurses station revealed that the door was typically propped open, and that it was not propped open for active and ongoing inventory tasks. Interview with the human resources and facility maintenance manager at the time of observation acknowledged the deficiency, and indicated they were aware of the requirement. Interview with the facility administrator at the time of exit acknowledged the deficiency. REF: 2012 NFPA 101: Section 7.2.1.8.2

1. Based on observation and staff interview in the Chapmen Building, the facility failed to maintain fire alarm systems in accordance with the 2012 NFPA 101, Life Safety Code and the 2010 NFPA 72, National Fire Alarm Code. Failure to maintain fire detection systems as required could result in injury or death during an emergency. The deficiency affected one (1) of numerous requirements for the fire alarm system. The findings were: Observation on 12/20/2022 at 2:08 PM at the fire annunciator panel revealed that the Underwriter's Laboratory (UL) certification for the fire alarm expired on 31 March 2021. Interview with the human resources and facility maintenance manager at the time of the observation acknowledged the deficiency, and indicated they were not aware of the requirement. Interview with the facility administrator at the time of exit acknowledged the deficiency. REF: 2012 NFPA Sections 19.3.4.1; 9.6.1.3 2010 NFPA 72 Section 26.3.4.3 2. Based on document review and staff interview in the Chapmen Building, the facility failed to test and maintain the fire alarm system in accordance with the 2010 NFPA 72, National Fire Alarm and Signaling Code, Failure to test and maintain the fire alarm system could result in injury or death in the event of a fire. The deficiency affected the fire alarm system. The findings were: Document review on 12/20/2022 at 4:00 PM revealed that the fire alarm system batteries were inspected once in the last twelve (12) months. The fire alarm system batteries are required to be inspected every six (6) months. Interview with the facility administrator at the time of observation acknowledged the deficiency, and indicated they were aware of the requirement. Interview with the facility administrator at the time of exit acknowledged the deficiency. REF: 2010 NFPA 72 Table 14.3.1(3)(d)

Based on document review and staff interview in both the Kloefkorn and Chapmen buildings, the facility failed to test and maintain the fire sprinkler system in accordance with the 2011 NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, Failure to test and maintain the fire sprinkler system could result in injury or death in the event of a fire. The deficiency affected the fire sprinkler system. The findings were: Document review on 12/20/2022 at 4:05 PM revealed that the facility failed to maintain records of sprinkler contractor visits for the past 4 quarters. Further interview with the human resources and facility maintenance manager revealed that the fire sprinkler contractor failed to preform ordered inspection in one (1) of the past four (4) quarters (June '22). Interview with the human resources and facility maintenance manager at the time of observation acknowledged the deficiency, and indicated they were aware of the requirement. Interview with the facility administrator at the time of exit acknowledged the deficiency. REF: 2011 NFPA 25

Based on records review and staff interview in both the Kloefkorn and Chapmen Buildings, the facility failed to document the inspection and testing of the fire doors installed throughout the facility. The deficient practice affected the entire facility. The findings were: Record review and staff interview on 12/20/22 at 4:30 PM, revealed that the facility had failed to fully document inspecting and testing fire-rated doors throughout the facility by a qualified person. Interview with the human resources and facility maintenance manager at the time of observation acknowledged the missing documentation, and indicated they were not aware of the requirement. Interview with the facility administrator at the time of exit acknowledged the deficiency. Ref: 2012 NFPA 101, Sections 8.3.3.1 2010 NFPA 80, Sections 5.2.1, 5.2.3, 5.2.4

Based on observation and staff interview in the Chapmen Building, the facility failed to maintain gas cylinder storage in accordance with the 2012 NFPA 99, Health Care Facilities Code. Failure to maintain gas cylinder storage as required could result in injury or death. The deficiency affected one (1) of numerous rooms in the facility. The findings were: Observation on 12/20/2022 at 2:33 PM at the Chapmen oxygen storage room revealed several oxygen cylinders standing unsecured on the floor. Interview with the human resources and facility maintenance manager at the time of observation acknowledged the unsecured oxygen cylinder and indicated they were not aware of the requirement. Interview with the facility administrator at the time of exit acknowledged the deficiency. REF: 2012 NFPA 99; Section 11.6.2.3(11) Based on observation and staff interview in the Kloefkorn Building, the facility failed to maintain gas cylinder storage in accordance with the 2012 NFPA 99, Health Care Facilities Code. Failure to maintain gas cylinder storage as required could result in injury or death. The deficiency affected one (1) of numerous rooms in the facility. The findings were: Observation on 12/20/2022 at 3:32 PM at the Kloefkorn oxygen storage room revealed multiple oxygen cylinders standing unsecured on the floor. Interview with the facility administrator at the time of observation acknowledged the unsecured oxygen cylinder and indicated they were aware of the requirement. Interview with the facility administrator at the time of exit acknowledged the deficiency. REF: 2012 NFPA 99; Section 11.6.2.3(11)