Every finding on record at Granite VNA, Inc.

NFPA 101 LIFE SAFETY CODE (2012 edition)7.2.9.4 Emergency generators providing power to emergency lighting systems shall be installed, tested and maintained in accordance with NFPA 110 STANDARD for EMERGENCY and STANDBY POWER SYSTEMS (2010 edition).7.9.3.1.1 Testing of the emergency lighting systems shall be permitted to be conducted as follows: (1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds. (2) The test interval shall be permitted to be extended beyond 30 days with the approval of the AHJ (Authority Having Jurisdiction). (3) Functional testing shall be conducted annually for a minimum of 1 1/2 hours if the emergency lighting system is battery powered. (4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1 (1) and (3). NFPA 110 STANDARD for EMERGENCY and STANDBY POWER SYSTEMS (2010 edition)7.3 Lighting7.3.1 The level 1 or level 2 EPS (Emergency Power Supply) equipment locations shall be provided with battery powered emergency lighting.This requirement shall not apply to units located outdoors in enclosures that do not include walk in access. Based on observations and interview, it was determined the facility failed to ensure that one Automatic Transfer Switch (ATS) location was equipped with battery powered emergency lighting, and two battery powered emergency lighting units failed to operate when the testing button was activated. --- Based on observations and interview during tour on 10/26/23 between 10:45 a.m. and 11:15 a.m. with Staff A (Plant Operations Manager) revealed the ATS switchgear was located in the lower-level electrical room and failed to have a battery powered emergency lighting unit installed. Additionally, the battery powered emergency lighting units located in the lower-level storage room and the upper-level corridor, outside room #8, failed to operate when the testing button was activated. Interview on 10/26/23 with Staff A confirmed the above findings, locations, and existing conditions.

Based on record review and interview during tour, it was determined the facility failed to ensure fire drills were conducted on a quarterly basis for the second and third shift. --- Record review on 10/26/23 between 8:30 a.m. and 10:45 a.m. with Staff A (Plant Operations Manager) and Staff B (Vice President, Hospice) revealed the documentation of the second shift fire drills failed to include the previous quarter, and the third shift documentation failed to include multiple fire drills. The fire drill dates and times are as follows: 2nd shift drills- 3:00 p.m. to 11:00 p.m: 3rd quarter not conducted. 06/27/23 4:45 p.m. 03/31/23 10:20 p.m. 01/25/23 5:10 p.m. 11/18/22 5:10 p.m. 09/28/22 3:35 p.m. 3rd shift drills: 11:00 p.m. - 7:00 a.m: 08/28/23 04:12 a.m. 2nd quarter not conducted. 1st quarter not conducted. 12/14/22 05:16 a.m. 3rd quarter not conducted. 04/19/22 06:00 a.m. 1st quarter not conducted. 12/24/21 06:35 a.m. 3rd quarter not conducted. 06/02/21 01:00 a.m. Interview on 10/26/23 with Staff A and Staff B confirmed the above findings and available documentation.

Based on record review and interview, it was determined the facility failed to ensure the Emergency Generator had received the 3-year 4-hour load bank testing and that the Automatic Transfer Switch (ATS) received the annual inspection and testing for the previous two years. --- Record review during tour on 10/26/23 between 8:30 a.m. and 10:45 a.m. with Staff A (Plant Operations Manager) revealed documentation for the last required Emergency Generator 4-hour load bank testing and documentation of the previous two years of ATS inspection and testing failed to be located or available for review. Interview on 10/26/23 with Staff A confirmed the above findings and available documentation

Based on interview and record review it was determined that the facility failed to provide supervisory visits of the hospice aide every 14 days in 2 of 15 patient's reviewed for hospice aide visits in a final sample of 23 (Patient identifiers are #7 and #20). Findings include: --- Patient #7 Review on 10/26/23 of Patient #7's Hospice Plan of Care for certification period of 9/16/23 to 12/14/23 revealed physician's orders for the hospice aide as follows: -On 9/16/23 weekly aide visits for 3 times a week for 1 week. -On 9/16/23 an order for aide visits 3 times a week for 12 weeks beginning on 9/24/23. Review on 10/26/23 of Patient #7's Scheduled visits from the aide revealed visits were conducted on 9/18/23, 9/20/23, 9/23/23, 9/25/23, 9/27/23, 9/29/23, 10/2/23, 10/4/23, 10/6/23, 10/9/23 and 10/11/23. Review on 10/26/23 of Patient #7's Skilled Nursing Visit Notes revealed a supervisory visit on 10/11/23. Interview on 10/26/23 at 10:08 a.m. with Staff D (Chief Hospice Officer) confirmed the above findings. Patient #20 Review on 10/26/23 of Patient #20's Hospice Plan of Care for certification period of 9/15/23 to 12/13/23 revealed physician's orders for the hospice aide as follows: -On 9/15/23 weekly aide visits for 13 weeks. This order was discontinued on 9/19/23. -On 9/19/23 an order for aide visits 3 times a week for 12 weeks beginning on 9/24/23. Review on 10/26/23 of Patient #20's Scheduled visits from the aide revealed visits were conducted on 9/19/23, 9/25/23, 9/27/23, 9/29/23, 10/4/23, 10/11/23, 10/13/23, 10/16/23, 10/18/23, 10/20/23 and 10/23/23. Review on 10/26/23 of Patient #20 Skilled Nursing Visit Notes revealed a supervisory visit on 10/24/23. Interview on 10/26/23 at 9:45 a.m. with Staff C (Physical Therapy Quality) confirmed the above findings. Interview on 10/26/23 at 10:05 a.m. with Staff D (Chief Hospice Officer) confirmed the above findings.

Based on observation, interview, and review of manufacturer's instructions, it was determined that the facility failed to label opened glucometer control solution bottles with expiration dates to ensure glucometers were in safe operating condition for 2 of 2 glucometers reviewed at 2 of 2 branches observed. --- Findings include: Hospice Headquarters Observation on 10/24/23 at approximately 9:00 a.m. of opened high and low control solution bottles revealed no opened dates or open expiration dates. Interview on 10/24/23 at approximately 9:00 a.m. with Staff A (Director of Home Health/Hospice Care) confirmed the above finding. Review of control solution manufacturer's instructions, dated 1/2015, revealed: "Discard after 3 months from opening date." Hospice House Observation on 10/24/23 at approximately 9:30 a.m. of opened high and low control solution bottles revealed no opened dates or no open expiration dates. Interview on 10/24/23 at approximately 9:30 a.m. with Staff B (Hospice House Manager) confirmed the above finding. Review of control solution manufacturer's instructions, dated 2017, revealed: ";Discard any unused control solution 90 days after first opening or after expiration date." Review of the facility's policy titled, "Safe and Appropriate Use of Medical Equipment and Supplies", revision date 3/22/23, revealed: "5. The following equipment used by clinical personnel will have routine and preventative maintenance as defined in the manufacturer's guidelines: A. Home glucose monitors."