Every finding on record at Franciscan Hospice

Based on observation, document review and interview, the hospice failed to meet the requirements of the Life Safety Code of the National Fire Protection Association (NFPA), 2012 edition. Failure to meet the Life Safety Code of the National Fire Protection Association risks injury to patients, staff, and visitors during a fire. --- Refer to deficiencies written on the Hospice Life Safety Code inspection report # 231417-L1, dated 05/12/2026.

Based upon observations and staff interviews on 05/12/2026 between approximately 0800 to 1100 hours the facility has failed to maintain fire resistive construction of the building capable of resisting the passage of smoke and fire into other compartments. This could allow the toxic product of combustion to move out of a room and into the exit access corridor and the smoke compartment which would endanger the patients, staff, and/or visitors within the facility. --- The findings include:In the main electrical room by the front desk non-fire rated spray foam was being used to fill penetrations in the surrounding walls. These walls were verified as fire barriers vie the building plans. The above was discussed and acknowledged by the facility maintenance staff.

Based upon observations and staff interviews on 05/12/2026 between approximately 0800 to 1100 hours the facility has failed to maintain the exit discharge free of obstructions and with an all-weather surface.  This could cause an inability or delay in the evacuation of residents in the event of an emergency which would endanger patients, staff, and/or visitors. --- The findings include, but are not limited to:The exit discharge from the Home Health Admin Office emergency exit door is not level.  The egress landing for this exit door is no longer flat and has cracked causing tripping hazards. NFPA 101 7.1.6.2.The above was discussed and acknowledged by the facility staff.

Based upon observations and staff interviews on 5/12/26 between approximately 0900 to 1100hours the facility has failed to maintain records of testing for the emergency battery backup lighting. This could result in the failure of the battery powered backup lighting in the event of a power outage and render the means of egress dark. This could result delayed egress and in tripping and fall injuries to patients, staff, and/or visitors. --- The findings include:Facility is unable to provide documentation for the annual 90 minute power test for the emergency lights.The above was discussed and acknowledged by the Maintenance Director.

Based on observation and staff interview on 05/12/2026 between approximately 0800 to 1100 hours the facility has failed to maintain their automatic and manual fire alarm system in accordance with NFPA 72.  This could result a failure of the fire alarm system to properly operate in the event of a fire, which would endanger the patents, staff, and/or visitors within the facility. --- The findings include:-Facility is unable to provide documentation for semi-annual battery testing and visual alarm system inspections. NFPA 72 (2010) 14.3.1 and 14.4.5.The above was discussed and acknowledged by the Maintenance Director.

Based upon record review and staff interviews on 05/12/2026 between approximately 0800 to 1100 hours the facility has failed to have a written procedure for instituting an approved fire watch in the event of a failure of the fire alarm system. This could result in an inadequate fire watch which may result in a delay of fire detection and suppression, potentially endangering patients, staff, and/or visitors within the facility. --- The findings include: The fire watch policy was not approved because it failed to state that fire watch rounds are to be conducted at 15 minute intervals per the AHJ's requirement. The above was discussed and acknowledged by the Maintenance Director.

Based upon record review and staff interviews on 05/12/2026 between approximately 0800 to 1100 hours the facility has failed to provide fire drill records reflecting drills being conducted on all shifts for each quarter for the past 12 months.  This could potentially result in the staff not responding in a coordinated manner in the event of a fire or other emergency and endangering patients, staff, and/or visitors. --- The findings include:-The facility failed to provide documentation for a fire drill on each shift, in each quarter of the previous 12 months. As a 24/7 facility the requirement would exceed the provided documentation of a single day, swing and NOC shift drill per quarter, to cover each scheduled designated duty period where substantially different groups of employees work.The above was discussed and acknowledged by the Maintenance Director.

Based on observation and staff interview on 05/12/2026 between approximately 0800 to 1100 hours the facility failed to prohibit the use of combustible decorations of flammable material. This could result in the rapid spread of smoke and fire in the event of ignition which could potentially endanger the patients, staff, and/or visitors within the facility. --- The findings include:There were candles located in the following spaces: The Manager of Clinical Service OfficeThe Home Health Administration office The above was discussed and acknowledged by the facility staff.

Based upon observations and staff interviews on 05/12/2026 between approximately 0800 to 1100 hours the facility failed to restrict the use of extension cords and non-approved power strips in their facility. This could endanger patients, staff, and visitors in the facility due to the increased fire risk. --- The findings include: An extension cord was installed in a permanent fashion in the Manager of Clinical Services office.  The above was discussed and acknowledged by the facility staff.

Based on record review and interview, the agency failed to update its policies and procedures to remain compliant with state licensing requirements for Tuberculosis (TB) infection control program for 18 of 18 personnel files reviewed. Failure of the agency to comply with developing, updating, and implementing required policies and procedures (P&Ps) on TB screening may place the patients and staff at risk of TB exposure. . --- Findings included: Reference: Washington Administrative Code (WAC) 246-335-525 (15) (c): Tuberculosis (TB) infection control program. Key elements include, but are not limited to: (i) Conducting a TB risk assessment for all new employees upon hire. Agencies must use a tuberculosis risk assessment form provided by the department. Based on risk assessment results, determine the agency's responsibility to conduct TB testing of new employees. If TB testing is required, follow the department's tuberculosis risk assessment form testing recommendations; (ii) Conducting an annual assessment of new TB risk factors for all employees. Agencies must use a tuberculosis risk assessment form provided by the department. Based on risk assessment results, determine agency's responsibility to conduct TB testing of employees. Retesting should only be done for persons who previously tested negative and have new risk factors since the last assessment. 1. Document review of the agency policy titled, ";Employee Health TB Screening, Surveillance, And Post Exposure Protocol," (Policy No. 8991189, Effective Date 02/2023), showed the policy lacked the state requirements for conducting a TB risk assessment using the department-approved form for all personnel on hire and annually. 2. On 07/10/23, Surveyor #6 reviewed personnel files for 5 volunteers (Staff #614, #615, # 616, #617, and #618) and on 07/12/23, Surveyor #1 reviewed personnel files for 13 staff members (Staff #601, #602, # 603, #604, #605, #606, #607, #608, #609, #610, #611, #612, and #613). The review showed: a. Staff #601 was hired on 03/01/21. The record contained no evidence that the agency conducted a TB risk assessment using the department-approved form on hire, in 2022, and in 2023. b. Staff #602 was hired on 11/16/20. The record contained no evidence that the agency conducted a TB risk assessment using the department-approved form on hire, in 2021 and 2022. c. Staff #603 was hired on 11/03/03. The record contained no evidence that the agency conducted a TB risk assessment using the department-approved form in 2019, 2020, 2021, and 2022. d. Staff #604 was hired on 02/29/2000. The record contained no evidence that the agency conducted a TB risk assessment using the department-approved form in 2021, 2022, and 2023. e. Staff #605 was hired on 06/13/16. The record contained no evidence that the agency conducted a TB risk assessment using the department-approved form in 2019, 2020, 2021, 2022, and 2023. f. Staff #606 was hired on 10/03/21. The record contained no evidence that the agency conducted a TB risk assessment using the department-approved form on hire and in 2022. g. Staff #607 was hired on 07/20/15. The record contained no evidence that the agency conducted a TB risk assessment using the department-approved form in 2019, 2020, 2021, and 2022. h. Staff #608 was hired on 09/10/12. The record contained no evidence that the agency conducted a TB risk assessment using the department-approved form in 2019, 2020, 2021, and 2022. i. Staff #609 was hired on 02/27/14. The record contained no evidence that the agency conducted a TB risk assessment using the department-approved form in 2019, 2020, 2021, 2022, and 2023. j. Staff #610 was hired on 09/02/06. The record contained no evidence that the agency conducted a TB risk assessment using the department-approved form in 2019, 2020, 2021, and 2022. k. Staff #611 was hired on 01/04/11. The record contained no evidence that the agency conducted a TB risk assessment using the department-approved form in 2019, 2020, 2021, 2022, and 2023. l. Staff #612 was hired on 01/28/19. The record contained no evidence that the agency conducted a TB risk assessment using the department-approved form on hire, in 2020, 2021, 2022, and 2023. m. Staff #613 was hired on 01/03/22. The record contained no evidence that the agency conducted a TB risk assessment using the department-approved form on hire and in 2023. n. Staff #614 was hired as a volunteer on 06/25/21. The record contained no evidence that the agency conducted a TB risk assessment using the department-approved form on hire, in 2022, and 2023. o. Staff #615 was hired as a volunteer on 08/27/19. The record contained no evidence that the agency conducted a TB risk assessment using the department-approved form on hire, in 2020, 2021 and 2022. p. Staff #616 was hired as a volunteer on 06/21/19. The record contained no evidence that the agency conducted a TB risk assessment using the department-approved form on hire, in 2020, 2021, 2022, and 2023. q. Staff #617 was hired on 02/22/22. The record contained no evidence that the agency conducted a TB risk assessment using the department-approved form on hire and in 2023. r. Staff #618 was hired on 01/06/22. The record contained no evidence that the agency conducted a TB risk assessment using the department-approved form on hire and in 2023. 3. On 07/12/23 at 11:00 AM, Surveyor #1 interviewed the agencys Regional Director (Staff #620) and the Employee Health Director (Staff #622) about the missing TB risk assessments using the department-approved form in the personnel records. Staff #620 and #622 stated that the agency follows the hospital policy, and they were not aware of the TB Risk assessment screening form and the WAC regulations. The agency is working to update its TB risk assessment P&P. .

Based on record review and interview, the agency failed to update its policies and procedures to remain compliant with state licensing requirements for 15 of 18 personnel files reviewed. . Failure to maintain and implement policies and procedures consistent with state home health regulations puts patients at risk of physical and/or psychological harm from inadequate or substandard care. . --- Findings included: Reference: Washington Administrative Code (WAC) 246-335-525 (6): Criminal history background checks and disclosure statements for personnel, contractors, volunteers, students, and any other individual associated with the licensee having direct contact with children under sixteen years of age, people with developmental disabilities or vulnerable persons, according to RCW 43.43.830 through 43.43.842 and the following: (b) Disclosure statements must be approved by the department. (c) All criminal history background checks and disclosure statements required under this chapter must be renewed within two years from the date of the previous check. 1. Document review of the agency policy titled, "Background & Disclosure, 125," (Policy No. 8095778, Effective Date 05/2020) showed that the policy failed to include the requirement to use the department-approved disclosure statement every two years from the date of the previous check. 2. On 07/10/23, Surveyor #6 reviewed personnel files for 5 volunteers (Staff #614, #615, # 616, #617, and #618) and on 07/12/23, Surveyor #1 reviewed personnel files for 13 staff members. (Staff #601, #602, # 603, #604, #605, #606, #607, #608, #609, #610, #611, #612, and #613). The review showed: a. Staff #601 was hired on 03/01/21. There was no evidence the agency completed a department-approved disclosure statement on hire and in 2023. b. Staff #602 was hired on 11/16/20. There was no evidence the agency completed a background check and a department-approved disclosure statement on hire and in 2022. c. Staff #603 was hired on 11/03/03. There was no evidence the agency completed a department-approved disclosure statement in 2019 and 2021. d. Staff #604 was hired on 02/29/2000. There was no evidence the agency completed a department-approved disclosure statement in 2020 and 2022. e. Staff #605 was hired on 06/13/16. There was no evidence the agency completed a department-approved disclosure statement in 2020 and 2022. f. Staff #606 was hired on 10/03/21. There was no evidence the agency completed a department-approved disclosure statement on hire. g. Staff #607 was hired on 07/20/15. There was no evidence the agency completed a department-approved disclosure statement in 2019 and 2021. h. Staff #608 was hired on 09/10/12. There was no evidence the agency completed a background check and a department-approved disclosure statement in 2020 and 2022. i. Staff #609 was hired on 02/27/14. There was no evidence the agency completed a department-approved disclosure statement in 2020 and 2022. j. Staff #610 was hired on 09/02/06. There was no evidence the agency completed a department-approved disclosure statement in 2020 and 2022. k. Staff #611 was hired on 01/04/11. There was no evidence the agency completed a department-approved disclosure statement in 2019, 2021, and 2023. l. Staff #612 was hired on 01/28/19. There was no evidence the agency completed a department-approved disclosure statement on hire, in 2021, and 2023. n. Staff #614 was hired as a volunteer on 06/25/21. There was no evidence the agency completed a department-approved disclosure statement on hire. o. Staff #615 was hired as a volunteer on 08/27/19. There was no evidence the agency completed a department-approved disclosure statement on hire and in 2021. p. Staff #616 was hired as a volunteer on 06/21/19. There was no evidence the agency completed a department-approved disclosure statement on hire and in 2021. 3. On 07/12/23 at 11:00 AM, Surveyor #1 interviewed the agencys Human Resource Manager (Staff #611) and the Regional Director (Staff #620) about the missing department-approved disclosure statements in the personnel records. Staff #611 stated that they were not aware that the disclosure statements theyre currently using was incorrect. Staff #611 and #620 stated that the agency will update their P&P and use the department-approved disclosure statement. This is a REPEAT CITATION, previously cited on the last CMS survey completed on 04/26/21.

Based upon observations and staff interviews on 7/10/2023 between approximately 0900 to 1200 hours the facility has failed to maintain the facility in accordance with NFPA 101 (2012) 19.1. --- The findings include: The clinical division manager's office had a candle. The chaplain's office had a candle. Facility wide there are space heaters in power-strips. Facility staff acknowledged the findings.

Based upon observations and staff interviews on 7/10/2023 between approximately 0900 to 1200 hours the facility has failed to maintain records of testing for the emergency battery backup lighting. This could result in the failure of the battery powered backup lighting in the event of a power outage and render the means of egress dark. This could result in tripping and fall injuries to patients, staff and/or visitors. --- The findings include: The facility was unable to produce monthly emergency lighting test records for July-December of the previous year. The facility was unable to produce an annual 90 minute emergency test record for the past calendar year. Facility staff acknowledged the findings.

Based upon record review and staff interviews on 7/10/2023 between approximately 0900 to 1200 hours the facility has failed to conduct testing/maintenance of the hood and duct fire suppression equipment protecting the commercial cooking equipment. This could result in the failure of the system to operate properly which would endanger the patients, staff, and/or visitors within the facility. --- The findings include: The facility could not produce records of any kitchen hood cleanings. The facility could not produce the second semi-annual kitchen suppression inspection and testing report. They provided one for June 2023, but not any previous. Facility staff acknowledged the findings.

Based on observation and staff interview on 7/10/2023 between approximately 0900 to 1200 hours the facility has failed to have their fire alarm system installed in accordance with the references NFPAs and in a manner that is approved. This could result in a fire not being detected by the fire alarm system, possible leading to harm and delayed evacuation. --- The findings include: The following areas had smoke detectors within 36 inches of a vent. Operations Home Health office Main nurses station North nurses station Facility staff acknowledged the findings.

Based on observation and staff interview on 7/10/2023 between approximately 0900 to 1200 hours the facility has failed to have appropriate testing of the fire alarm system which result in the failure to notify staff of a problem with the fire alarm system. This could lead to the system not functioning as intended and lead to people within the building not being notified of a fire. --- The findings include: The annual fire alarm report did not include all items required per NFPA 72. The person who conducted the annual fire alarm inspection is not legally allowed to conduct fire alarm testing and inspection in Washington State. Facility staff acknowledged the findings.

Based on observation and staff interview on 7/10/2023 between approximately 0900 to 1200 hours the facility has failed to have a written procedure for instituting an approved fire watch in the event of a failure of the fire alarm system. This could result in an inadequate fire watch which may result in a delay of fire detection and suppression, potentially endangering patients, staff, and/or visitors within the facility. --- The findings include: The facility could not produce a fire watch policy. Facility staff acknowledged the findings.

Based on observation and staff interview on 07/10/2023 between approximately 0900 to 1200 hours the facility has failed to maintain the fire sprinkler system as required. This could result in the failure of the fire sprinkler system to operate properly in the event of a fire and allow the fire to increase in size and intensity which would endanger the rpatients, staff, and/or visitors within the facility. --- The findings include: The facility could not produce the following. The 3rd quarterly sprinkler inspection The forward flow The 5 year inspection The 3 year full trip The sprinkler paperwork indicated that the sprinkler system had anti-freeze, but nothing to say if it was the legally allowed kind. Facility staff acknowledged the findings.

Based on observation and staff interview on 7/10/2023 between approximately 0900 to 1200 hours the facility has failed to have a written procedure for instituting an approved fire watch in the event of a failure of the fire sprinkler system. This could result in an inadequate fire watch which may result in a delay of fire detection and suppression, endangering patients, staff, and/or visitors within the facility. --- The findings include: The facility could not produce a fire watch policy. Facility staff acknowledged the findings.

Based on observation and staff interview on 7/10/2023 between approximately 0900 to 1200 hours the facility has failed to maintain doors without impediments to their closing and latching. This could result in a delay in getting the door to the room closed in the event of a fire. This could result in toxic products of combustion getting into the room and into the exit corridor which would endanger the patients, staff, and/or visitors within the smoke compartment. --- The findings include: The HH38 corridor door did not close and latch when tested. Facility staff acknowledged the findings.

Based on observation and staff interview on 7/10/2023 between approximately 0900 to 1200 hours the facility has failed to maintain electric equipment in a safe manner and in accordance with NFPA 70. This could endanger people in the building by risk of fire, electrocution, or other harm. --- The findings include: There is a broken outlet by the clinic division manager's office. Facility staff acknowledged the findings.

Based on observation and staff interview on 7/10/2023 between approximately 0900 to 1200 hours the facility has failed to ensure dampers in the facility were inspected and provided necessary maintenance at least every four years in accordance with NFPA 90A. LSC 9.2.1 requires heating, ventilating and air conditioning (HVAC), ductwork and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems. NFPA 90A, 2012 Edition, Section 5.4.8.1 states fire dampers shall be maintained in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. NFPA 80, 2010 Edition, Section 19.4.1 states each damper shall be tested and inspected 1 year after installation. The test and inspection frequency shall be every 4 years. If the damper is equipped with a fusible link, the link shall be removed for testing to ensure full closure and lock-in-place if so equipped. The damper shall not be blocked from closure in any way. All inspections and testing shall be documented, indicating the location of the fire damper, date of inspection, name of inspector and deficiencies discovered. The documentation shall have a space to indicate when and how the deficiencies were corrected. This deficient practice could affect all patients, staff, and visitors. --- The findings include: The facility could not produce records of fire/smoke damper testing. Facility staff acknowledged the findings.

Based on observation and staff interview on 7/10/2023 between approximately 0900 to 1200 hours the facility has failed to maintain a written plan for the protection of all patients, staff and visitors and for their evacuation in the event of an emergency. At a minimum a written care occupancy fire safety plan shall provide for the following: (1) Use of alarms (2) Transmission of alarms to fire department (3) Emergency phone call to fire department (4) Response to alarms (5) Isolation of fire (6) Evacuation of immediate area (7) Evacuation of smoke compartment (8) Preparation of floors and building for evacuation (9) Extinguishment of fire --- The findings include: The facility could not produce a fire evacuation plan. Facility staff acknowledged the findings.

Based on observation and staff interview on 7/10/2023 between approximately 0900 to 1200 hours the facility has failed to provide fire drill records reflecting drills being conducted on all shifts for each quarter for the past 12 months. This could potentially result in the staff not responding in a coordinated manner in the event of a fire or other emergency and endangering patients, staff and/or visitors. --- The findings include: The facility has only been activating the fire alarm once a year. The facility has not been receiving confirmation from the monitoring company that they are receiving the fire alarm transmission. Approximately 1/2 of the fire drills have the same starting point. Facility staff acknowledged the findings.

Based upon observations and staff interviews on 7/10/2023 between approximately 0900 to 1200 hours the facility has failed to test all fire rated doors in accordance with NFPA 80. This could lead to the doors not functioning as required in a fire, endangering those inside the building. --- The findings include: The facility could not produce an annual door inspection in compliance with NFPA 80. The annual door inspection did show failures and did not include corrective actions. Facility staff acknowledged the findings.

Based on observation and staff interview on 7/10/2023 between approximately 0900 to 1200 hours the facility failed to keep records or conduct maintenance on their hospital grade receptacles and non-hospital grade receptacles. This could cause an increased risk of fire due to the non-maintenance of the electrical system. --- The findings include: The facility could not produce receptacle testing in compliance with NFPA 99 6.3.4. Facility staff acknowledged the findings.

Based on observation and staff interview on 7/10/2023 between approximately 0900 to 1200 hours the facility has failed to maintain and test the emergency generator in accordance with NFPA 110. This could result in a failure of the emergency power system which would leave the facility without egress and task lighting in the event of a power failure which would endanger the patients, staff, and/or visitors within the facility. --- The findings include: The facility could not produce any weekly generator inspections. The facility could not produce any monthly testing records from July to December of the previous year. The facility could not produce records of the 4 hour load bank. The facility could not provide records that provided they were running the generator at 30% of the name plate rating for 30 minutes monthly. The facility could not produce records of the 1.5 hour load bank. Facility staff acknowledged the findings.

Based on observation and staff interview on 7/10/2023 between approximately 0900 to 1200 hours the facility failed to restrict the use of extension cords and non-approved power strips in their facility. This could endanger people in the facility due to the increased fire risk. --- The findings include: The physician's office by the piano has daisy-chaining. The bottle dispenser is plugged into a plug adapter. The small conference room has an extension cord running through the wall to the TV/Computer. Facility staff acknowledged the findings.

Based on observation and staff interview on 7/10/2023 between approximately 0900 to 1200 hours the facility has failed to provide documentation of personnel concerned with the application, maintenance, and handling of medical gases and cylinders that are trained on the risk and provide continuing education. Failure to provide training and continuing education on the safe handling and use of gases and cylinders could place patients, visitors, and staff at risk of oxygen malfunctions. --- The findings include: The facility could not produce records of staff training on compressed gas cylinders. Facility staff acknowledged the findings.