Every finding on record at Harbor Hospice of Beaumont LP

Based on interview and record review, the hospice failed ensure the registered nurse conducted an on-site visit to the patient's home no less frequently than every 14 days to supervise services provided by the hospice aide for 1 of 19 patients whose records were reviewed. (Patient #2) There were no hospice aide supervisory visit from 09/06/24 to 09/22/24 (17 days) for Patient #2. This failure has the potential of placing patients at risk of receiving ineffective and inappropriate hospice care and services. --- Findings include: Record review of the hospice plan of care for Patient #2 dated 08/14/24 to 11/11/24 included a physician's order for skilled nursing services once a week and hospice aide services three times a week. The SN Visit Note for Patient #2 dated 09/05/24 by RN A indicated a supervisory visit was conducted for the hospice CNA. The SN Visit Note for Patient #2 dated 09/19/24 by RN A did not indicate a supervisory visit was conducted for the hospice CNA. This visit was 14 days from the last supervisory visit. The SN Visit Note for Patient #2 dated 09/23/24 by RN A indicated a supervisory visit was conducted for the hospice CNA. The Visit Management Schedule for Patient #2 dated 09/05/24 to 09/23/24 did not indicated any other RN visits for supervision of the hospice aide. Record review of the clinical record for Patient #2 did not include a hospice aide supervisory visit from 09/06/24 to 09/22/24 (17 days). During an interview on 10/16/24 at 9:25 a.m., RN A said hospice aide supervisory visits were conducted standard every other week. RN A said she kept track of when hospice aide supervisory visits were done in the EHR system by reviewing the history of the visit note from the previous week. RN A reviewed Patient #2s clinical record and said the hospice aide supervisory dates for Patient #2 were conducted on 09/05/24 and 09/23/24. RN A said she was late on the hospice aide supervisory visit and that there should have been a hospice aide supervisory visit for Patient #2 between 09/05/24 and 09/23/24. RN A said sometimes her days got thrown off when the visit day of the week was changed. During an interview on 10/16/24 at 1:05 p.m., the Supervising Nurse said supervisory visits for hospice CNAs should be conducted every two weeks. The Supervising Nurse said the RNs were responsible for completing supervisory visits if the patient had CNAs. The Supervising Nurse said Patient #2 should have had a supervisory visit between 09/05/24 and 09/23/24. During an interview on 10/16/24 at 3:15 p.m., the Administrator said CNA supervisory visits should be conducted every 14 days. The Administrator said the RNs were responsible for ensuring supervisory visits were conducted for the hospice CNAs. The Administrator said Patient #2 should have had a supervisory visit conducted between 09/05/24 and 09/23/24. Record review of a Responsibilities/Supervision of Clinical Services policy dated 05/2024 revealed, ";... Hospice aide supervisory visits will be conducted on-site at least every 14 days by a hospice registered nurse. ..."

Reference: NFPA 101, Life Safety Code, 2012 Edition Chapter 19 Existing Health Care Occupancies 19.2 Means of Egress Requirements. 19.2.2 Means of Egress Components. 19.2.2.2 Doors. 19.2.2.2.1 Doors complying with 7.2.1 shall be permitted. Chapter 7 Means of Egress 7.2 Means of Egress Components. 7.2.1 Door Openings. 7.2.1.5 Locks, Latches, and Alarm Devices. 7.2.1.5.10 A latch or other fastening device on a door leaf shall be provided with a releasing device that has an obvious method of operation and that is readily operated under all lighting conditions. 7.2.1.5.10.2 The releasing mechanism shall open the door leaf with not more than one releasing operation, unless otherwise specified in 7.2.1.5.10.3, 7.2.1.5.10.4, or 7.2.1.5.10.6. Based on observation and interview, the facility failed to ensure that means of egress was continuously maintained free of all obstructions to full use in case of emergency. The facility failed to ensure the releasing mechanism for the latch on 1 of 4 exterior exits (at the front exterior exit) released with no more than one operation according to NFPA 101, 7.2.1.5.10.2 by having a dead bolt latch that created an additional operation to release this door. This deficient practice could affect the safety and health of patients , if doors along the means of egress cannot be released in a single operation, which subsequently can inhibit safe and prompt egress from the facility in an emergency requiring evacuation. Findings included: Observation on 10/14/21 at 1:20 p.m. of 1 of 4 exterior exits (at the front exterior exit) revealed that this exterior exit door was equipped with a dead bolt latch that created an additional operation to release this door in addition to the single action door lever that was already installed on this door. In an interview on 10/14/21 with Maintenance at the time of observation, he stated that he was responsible for the overall maintenance of the facility and stated that he was not aware that doors along the means of egress have to release with not more than one releasing operation.

Reference: NFPA 101, Life Safety Code, 2012 Edition 19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6. NFPA 101, 9.6 Fire Detection, Alarm, and Communications Systems. 9.6.1.3 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use. 9.6.1.5 To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code. a) NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition Chapter 14 Inspection, Testing, and Maintenance 14.4 Testing 14.4.5 Testing Frequency. 14.4.5.3 In other than one- and two-family dwellings, sensitivity of smoke detectors and single- and multiple-station smoke alarms shall be tested in accordance with 14.4.5.3.1 through 14.4.5.3.7. 14.4.5.3.1 Sensitivity shall be checked within 1 year after installation. 14.4.5.3.2 Sensitivity shall be checked every alternate year thereafter unless otherwise permitted by compliance with 14.4.5.3.3. b) NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition Chapter 10 Fundamentals 10.5 Power Supplies. 10.5.5 Primary Power Supply. 10.5.5.2 Circuit Identification and Accessibility. 10.5.5.2.3 For fire alarm systems the circuit disconnecting means shall have a red marking. c) NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition Chapter 10 Fundamentals 10.18 Documentation. 10.18.2 Completion Documents. 10.18.2.4 Verification of Compliant Installation. Where required, compliance of the completed installation with the requirements of this Code, as implemented via the referring code(s), specifications, and/or other criteria applicable to the specific installation, shall be certified by a qualified and impartial third-party organization acceptable to the authority having jurisdiction. d) NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition Chapter 17 Initiating Devices 17.14 Manually Actuated Alarm-Initiating Devices. 17.14.5 Manual fire alarm boxes shall be installed so that they are conspicuous, unobstructed, and accessible. Based on observation and interview, the facility failed to ensure that the fire alarm system was tested and maintained according to an approved program complying with the requirements of NFPA 72, 14.4.5.3.3, 10.5.5.2.3, 10.18.2.4, and 17.14.5 as referred to by NFPA 101 , 9.6.1.3, 9.6.1.5, and 19.3.4.1. a) The facility failed to provide any documentary evidence that a smoke detector sensitivity test (either within 1-year of installation or every other year thereafter) for 1 of 1 fire alarm systems since the system was installed on 10/3/06. b) The facility failed to ensure that the disconnecting means for 1 of 1 fire alarm systems had a red marking. c) The facility failed to ensure that a fire alarm installation certificate for 1 of 1 fire alarm systems was conspicuously posted at the main fire alarm panel . d) The facility failed to ensure that that manual fire alarm box at 1 of 4 exterior exits (at the front exit) was unobstructed. These deficient practices could affect the safety and health of patients, if the fire alarm system is not properly maintained to adequately protect individuals from fire and smoke hazards. Findings include: Observation on 10/14/21 at 11:10 a.m. revealed a fire alarm system with a smoke detection system was installed throughout and serving the entire facility with the main panel located inside of the facility near the front exterior entrance. a) Observation on 10/14/21 at 11:10 a.m. of all of the facility documentation and at the main fire alarm panel of the fire alarm system revealed that there was a lack of any documentation that a smoke detector sensitivity test (on the smoke detectors installed throughout the facility) had been done since the fire alarm system was installed on 10/3/06. In an interview on 10/14/21 at 3:45 p.m. with the Regional Director, ADON and Maintenance at the exit conference, they stated that Maintenance was responsible for the overall maintenance of the fire alarm system. In a separate interview with Maintenance at the exit conference, he stated that he was not aware that the sensitivity test had not been done and didn't know that it was missed. b) Observation on 10/14/21 at 12:30 p.m. of the disconnecting means for the fire alarm system in the Electrical Room adjacent to the Front Receptionist area revealed that this disconnecting means lacked a red marking. In an interview on 10/14/21 at 3:45 p.m. with the Regional Director, ADON and Maintenance at the exit conference, they stated that Maintenance was responsible for the overall maintenance of the fire alarm system. In a separate interview with the Regional Director and Maintenance at the exit conference, they stated that they were not aware of the disconnecting means for the fire alarm systems lacking a red marking and that it was overlooked. c) Observation on 10/14/21 at 12:35 p.m. of the main fire alarm panel of the fire alarm system revealed that there was a lack of a fire alarm installation certificate that was conspicuously posted at the main fire alarm panel. In an interview on 10/14/21 at 3:45 p.m. with the Regional Director, ADON and Maintenance at the exit conference, they stated that Maintenance was responsible for the overall maintenance of the fire alarm system. In a separate interview with the Maintenance at the exit conference, he stated that he was aware that this fire alarm certificate was missing and that he has been trying to obtain this certificate from his fire alarm contractor for some time and that he hasn't received anything from his fire alarm contractor as of yet. d) Observation on 10/14/21 at 12:40 p.m. of the manual fire alarm box at the front exterior exit revealed that this manual fire alarm box was visually obstructed by a large plant . In an interview on 10/14/21 at 3:45 p.m. with the Regional Director, he stated that Maintenance was responsible for the overall maintenance of the fire alarm system. In a separate interview with the Maintenance at the exit conference, he stated that he was aware of this large plant at this location that was blocking the manual pull box and that a member of Management wanted the plant at this location for aesthetics.

Reference: NFPA 101, Life Safety Code, 2012 Edition 19.3.5.1 Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5. NFPA 101, 9.7 Automatic Sprinklers and Other Extinguishing Equipment. 9.7.1 Automatic Sprinklers. 9.7.1.1 Each automatic sprinkler system required by another section of this Code shall be in accordance with one of the following: (1) NFPA 13, Standard for the Installation of Sprinkler Systems NFPA 13, Standard for the Installation of Sprinkler Systems, 2010 Edition Chapter 7 System Requirements 7.1 Wet Pipe Systems. 7.1.1 Pressure Gauges. 7.1.1.2 Pressure gauges shall be installed above and below each alarm check valve or system riser check valve where such devices are present. Based on observation and interview, the facility failed to provide an approved automatic sprinkler system according to NFPA 13, 7.1.1.2 as referred to by NFPA 101, 19.3.5.1 and 9.7.1.1(1) . The facility failed to provide a supply side gauge for 1 of 2 sprinkler risers (the wet sprinkler riser) that measures the incoming water supply pressure. This deficient practice could affect the safety and health of patients, if the wet sprinkler system is not properly installed to measure any changes of incoming water pressure (or a lack thereof) that could adversely affect the performance of this sprinkler system and its ability to adequately protect individuals from fire and smoke hazards . Findings included: Observation on 10/14/21 at 1:05 p.mm revealed a complete NFPA 13 fire sprinkler system was installed throughout the facility. Also revealed, the system consisted of two subsystems; a wet sprinkler system which provided coverage for the occupied space below ceiling and a dry sprinkler system which provided coverage for the combustible attic. Observation on 10/14/21 at 1:05 p.m. of 1 of 2 sprinkler risers (the wet sprinkler riser) revealed that there was a lack of a supply side gauge for this sprinkler riser either on the wet riser itself or at the main line that fed both the wet and dry sprinkler system before it splits into the wet and dry side. Two sprinkler gauges were installed on the dry sprinkler system riser, however this is after the sprinkler system splits off into the wet and dry systems. In an interview on 10/14/21 with Maintenance at the time of observation, he stated that he was responsible for the overall maintenance of the two sprinkler systems and that he was not aware of the lack of a supply side gauge for 1 of 2 sprinkler risers (the wet sprinkler riser) that measured the incoming water supply pressure.

Reference: NPFA 101, Life Safety Code, 2012 Edition 19.3.5.1 Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5. NFPA 101, 9.7 Automatic Sprinklers and Other Extinguishing Equipment. 9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition Chapter 5 Sprinkler Systems 5.4 Maintenance. 5.4.1 Sprinklers. 5.4.1.4 A supply of spare sprinklers (never fewer than six) shall be maintained on the premises so that any sprinklers that have operated or been damaged in any way can be promptly replaced. 5.4.1.4.2 The sprinklers shall be kept in a cabinet located where the temperature in which they are subjected will at no time exceed 100°F (38°C). Based on observation and interview, the facility failed to ensure that 2 of 2 sprinkler systems (wet and dry) were inspected, tested, and maintained according to NFPA 25, 5.4.1.4.2 as referred to by NFPA 101, 19.3.5.1 and 9.7.5 . The facility failed to ensure that the spare sprinkler heads were installed in a location (in this case the exterior sprinkler riser room) where temperatures would at no time exceed 100°F. This deficient practice could affect the safety and health of patients, if both sprinkler systems are not properly maintained to adequately protect individuals from fire and smoke hazards. Findings included: Observation on 10/14/21 at 1:05 p.m. revealed a complete NFPA 13 fire sprinkler system was installed throughout the facility. Also revealed, the system consisted of two subsystems; a wet sprinkler system which provided coverage for the occupied space below ceiling and a dry sprinkler system which provided coverage for the combustible attic space. Observation on 10/14/21 at 1:05 p.m. of the spare sprinkler head box located in the exterior sprinkler riser room at the front exterior of the facility revealed that these spare sprinkler heads were installed in a room that was not climate controlled and, thus, was subjected to temperatures that could exceed 100°F at any given time. In an interview on 10/14/21 with Maintenance at the time of observation, he stated that he is responsible for the overall maintenance of the two sprinkler systems and that he was not aware of the spare sprinkler head box needing to be located in a space where temperatures would not exceed 100°F.

Reference: NFPA 101, Life Safety Code, 2012 Edition 19.3.5.12 Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1. NFPA 101, 9.7.4.1 Where required by the provisions of another section of this Code, portable fire extinguishers shall be selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. NFPA 10, Standard for Portable Fire Extinguishers, 2010 Edition Chapter 7 Inspection, Maintenance, and Recharging of Portable Fire Extinguishers 7.2 Inspection. 7.2.1 Frequency. 7.2.1.2 Fire extinguishers shall be inspected either manually or by means of an electronic monitoring device/system at a minimum of 30-day intervals. Based on observation, record review, and interview, the facility failed to inspect all portable fire extinguishers (provided throughout the facility) at minimum of 30-day intervals according to NFPA 10, 7.2.1.2 as referred to by NFPA 101, 19.3.5.12 and 9.7.4.1 . The facility failed to inspect all portable fire extinguishers provided throughout the facility for the months of September 2020, October 2020, March 2021 and May 2021. This deficient practice could affect the safety and health of patients, if the portable fire extinguishers are not inspected on a monthly basis for any damage or impairments that could affect performance of the portable fire extinguishers. Findings included: Observation on 10/14/21 at 10:45 a.m. revealed portable fire extinguishers were provided throughout the facility for the protection of the facility. Record review of all of the tags attached to portable fire extinguishers provided throughout the building revealed that there were no monthly inspections recorded as being conducted for the months of September 2020, October 2020, March 2021 and May 2021. In an interview on 10/14/21 with Maintenance at the time of record review, he stated that he was responsible for the overall maintenance of the portable fire extinguishers throughout the facility. He further stated that he knew that these monthly inspections were overlooked but was overwhelmed with other tasks that were occurring at these times that the monthly inspections were supposed to be done.

Reference: NFPA 101, Life Safety Code, 2012 Edition Chapter 19 Existing Health Care Occupancies 19.3 Protection 19.3.7 Subdivision of Building Spaces. 19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a minimum 1/2-hour fire resistance rating, unless otherwise permitted by one of the following: (1) This requirement shall not apply where an atrium is used, and both of the following criteria also shall apply: (a) Smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with 8.6.7(1)(c). (b) Not less than two separate smoke compartments shall be provided on each floor. (2) Smoke dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air-conditioning systems where an approved, supervised automatic sprinkler system in accordance with 19.3.5.8 has been provided for smoke compartments adjacent to the smoke barrier. NFPA 101, Life Safety Code, 2012 Edition 8.5 Smoke Barriers. 8.5.2 Continuity. 8.5.2.1 Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier, or by use of a combination thereof. 8.5.6 Penetrations. 8.5.6.1 The provisions of 8.5.6 shall govern the materials and methods of construction used to protect through-penetrations and membrane penetrations of smoke barriers. 8.5.6.2 Penetrations for cables, cable trays, conduits, pipes, tubes, vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a smoke barrier, or through the ceiling membrane of the roof/ceiling of a smoke barrier assembly, shall be protected by a system or material capable of restricting the transfer of smoke . Based on observation and interview, the facility failed to ensure that 2 of 3 smoke barriers were constructed to restrict the transfer of smoke according to NFPA 101, 8.5.2.1, 8.5.6.1, and 8.5.6.2 as referred to by 19.3.7.3. a) The facility failed to ensure that 7 penetrations (3-2-inch pipes, 1-1/2-inch pipe, and 3-1-inch pipes) at the barrier wall above the Men's and Women's Restrooms (facing Resident Bedroom #20) were completely sealed with an intumescent firestop system . b) The facility failed to ensure that 8 penetrations (6-1-inch rigid pipes and a 2-inch HVAC condensate lines) at the barrier wall facing Resident Bedroom #30 were completely sealed with an intumescent firestop system . These deficient practices could affect the safety and health of patients, if barrier walls are not properly maintained to adequately protect individuals from fire and smoke hazards. Findings included: a) Observation on 10/14/21 at 11:35 a.m. of the barrier wall above the Men's and Women's Restrooms (facing Resident Bedroom #20) revealed that this barrier wall had 7 penetrations (3-2" pipes, 1-1/2" pipe, and 3-1" pipes) that were not completely sealed with an intumescent firestop system . In an interview on 10/14/21 with Maintenance at the time of observation, he stated that he was responsible for the overall maintenance of the barrier walls at the facility and stated that he was not aware of these unsealed penetrations and that the last life safety code surveyor that surveyed the building made no mention of these penetrations needing to have an intumescent firestop system. b) Observation on 10/14/21 at 11:55 a.m. of the at the barrier wall facing Resident Bedroom #30 revealed that this barrier wall had 8 penetrations (6-1" rigid pipes and a 2 HVAC condensate line) that were not completely sealed with an intumescent firestop system . In an interview on 10/14/21 with Maintenance at the time of observation, he stated that he was responsible for the overall maintenance of the barrier walls at the facility and stated that he was not aware of these unsealed penetrations.

Reference: NFPA 99, Health Care Facilities Code, 2012 Edition 6.4.4 Administration (Type 1 EES). 6.4.4.1 Maintenance and Testing of Essential Electrical System. 6.4.4.1.1 Maintenance and Testing of Alternate Power Source and Transfer Switches. 6.4.4.1.1.3 Maintenance shall be performed in accordance with NFPA110, Standard for Emergency and Standby Power Systems, Chapter 8. 6.5.4 Administration (Type 2 EES). 6.5.4.1 Maintenance and Testing of Essential Electrical System. 6.5.4.1.1 Maintenance and Testing of Alternate Power Source and Transfer Switches. 6.5.4.1.1.2 Inspection and Testing. Generator sets shall be inspected and tested in accordance with 6.4.4.1.1.3. NFPA 99, 6.4.4.1.1.3 Maintenance shall be performed in accordance with NFPA110, Standard for Emergency and Standby Power Systems, Chapter 8. NFPA 110, Standard for Emergency and Standby Power Systems, 2010 Edition Chapter 8 Routine Maintenance and Operational Testing 8.4 Operational Inspection and Testing. 8.4.1 EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly. Based on observation, record review, and interview, the facility failed to ensure that generator set was tested and maintained according to NFPA 110, 8.4.1 as referred to by NFPA 99, . The facility failed to ensure that the onsite generator was tested at least monthly for a minimum of 30 minutes for the months of November 2020, December 2020, March 2021, May 2021, July 2021 and September 2021. This deficient practice could affect the safety and health of patients, if the emergency generator isn't maintained and tested on a monthly basis to ensure that it can operate and provide power to all necessary circuits in the event of a utility power failure. Findings included: Observation on 10/14/21 at 10:50 a.m. revealed an emergency electrical system was installed throughout the facility to provide emergency power to critical/emergency systems for the entire facility. Record review on 10/14/21 at 10:50 a.m. of the generator logs revealed that there was no documentation of the generator being tested at least monthly for a minimum of 30 minutes for the months of November 2020, December 2020, March 2021, May 2021, July 2021 and September 2021. In an interview on 10/14/21 with Maintenance at the time of record review, he stated that he was responsible for the overall maintenance of the generator at the facility. He further stated that he knew that the monthly testing of the generator under load for the aforementioned months was overlooked but was overwhelmed with other tasks that were occurring at these times that these monthly tests were supposed to be done.