Every finding on record at Compass Regional Hospice

It is required that the hospice inpatient facility has documented and dated written reports of Life Safety Code fire drills at varied times on all shifts. This standard was not met as evidenced by document review and interview. Document 1: "For new and existing healthcare units, Fire Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. 19.7.1.6, Life Safety Code 101, 2012 Edition. Document 2: Facility policy is not reflective of the NFPA - 101- 2012 Edition verbiage as evidenced in the current agency policy, which stated in part, "Fire drills are conducted one time per quarter, following a rotating schedule for each shift (ex. 1st quarter day shift, 2nd quarter night shift). During the visit of the General Inpatient Unit on 1/29/2023, a review of agency documents revealed no fire drills were conducted per quarter per shift. the fire drill log did not reflect drills for the night shift staff for quarter 1, 2023, or quarter 3, 2023. An interview with the Facilities Director confirmed that there was no documentation that the evening shift had conducted fire drills for quarter 1 and quarter 3., 2023.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as: Hand hygiene. This standard was not met as evidenced by interview and observation. In 1 of 4 (25%) home visits it was observed that hand hygiene was not followed in accordance with the agency's CDC guidelines. Home Visit 2: During home visit with the Chaplain conducted on 11/29/2023, it was observed that the chaplain did not sanitized hands after touching the television remote control to turn down the volume. The chaplain then clasped the bed rails with both hands while engaging in spiritual conversation. then holding the patient's hands while leading prayer. The chaplain was observed not sanitizer his hands after touching the remote, side rails or patient. During interview after the home visit with the Senior Clinical Manager, who was in attendance for the visit confirmed that it was not evident that the Chaplain sanitized hands as per the Center for Disease Control (CDC) standards adopted by the agency. The Senior Clinical Manager stated that they follow the CDC guidelines for hand hygiene. CDC Core Practices (Table) Item # 5 a states all or in part, hand sanitation is conducted, (bullet point a-) " Immediately before touching the patient". Chaplin visit. Did not sanitize hands after turning down the TV from the remote control and touched the bed rail before holding hands with the patient.

It is required that the hospice inpatient facility provides meals to each patient that are palatable, attractive, and served at the proper temperature. This standard was not met as evidenced by observation and interview. During the inpatient facility tour conducted on 11/29/2023, there was no documentation of a tracking log to document hot foods temperatures at 140 degrees Fahrenheit or above and cold foods at 41 degrees Fahrenheit or below when served. Ann interview with the kitchen staff revealed that they had not been recording food temperatures to ensure that both the hot and cold food were at the proper temperatures prior to delivery to the unit. An interview with the Inpatient Unit Manager (IPU), confirmed when patient food trays were delivered to the unit, there was no temperature logs that documented the food was delivered to the patient bedside at the proper temperatures. An interview with the Quality Assurance Manager said that the staff "reheats what they need too in the microwave." There was no documented evidence to track the food or beverage items temperatures as they are served to patients.