Every finding on record at Edward W. Sparrow Hospital Association

Observed in Building Tour. There were low voltage cables supported by the sprinkler piping above ceiling on the 2nd Floor by the entrance to Stair 3. This was acknowledged by the Facilities Manager. This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. The corrective action taken needs to be included in the organization's Evidence of Standards Compliance submission. Observed in Building Tour. There was a hole in the smoke barrier approximately 12 x 12 above ceiling on the second floor outside Room 1224. This was acknowledged by the Facilities Manager. The surveyor discussed the Life Safety deficiency with the organization, and it was determined that the following ILSMs will be implemented until the deficiency has been resolved and according to the organization's ILSM policy: Observed in Building Tour. There was a low voltage cable supported by the sprinkler piping above ceiling on the 2nd Floor by the Southside Conference Room. This was acknowledged by the Facilities Manager. The surveyor discussed the Life Safety deficiency with the organization, and it was determined that the following ILSMs will be implemented until the deficiency has been resolved and according to the organization's ILSM policy:

Observed in Record Review. In 2 of 10 patient records reviewed, During the record review, in RR Active 1 and 2 the Hospice surveyor observed that there was no initial bereavement assessment as required. This was validated in a discussion with and observation by the Nurse Educator and the Home Hospice Clinical Manager.

Observed in Individual Tracer. During visit Hospice Home visit 2, the Hospice surveyor observed that the SN did not change gloves after finishing the physical assessment at the feet and then examined the patient's posterior and put ointment on the open wound with the same contaminated gloves. This was validated in a discussion with and observation by the Home Care Clinical Manager.

Observed in Document Review. During the Volunteer program session, the Hospice surveyor observed that there was no documentation of monthly recruitment efforts as required. This was validated in a discussion with the Hospice Director.