Every finding on record at Homereach

Observed in Record Review. The surveyor observed that while all volunteers received EM training on hire, they had not received EM training every year as all the paid staff had been required to do. The volunteer coordinator stated that volunteers only received EM training during orientation and not again throughout the time they volunteered. This issue was discussed and confirmed with hospice leadership.

Observed in Record Review. The surveyor observed on 1/18 records reviewed that the chaplain had not completed the inital assessment until day 7 missing the required 5 day required time frame. The surveyor , along with hospice leadership could find no communication note or missed visit note. This issue was discussed and confirmed with leadership.

Observed in Record Review. In 12 of 18 patient records reviewed, The surveyor observed that IDG , nor staff notes had documentation of the patients progress toward goals. The issue was observed with hospice leadership, discussed and confirmed with hospice leadership.

Observed in Record Review. In 14 of 18 patient records reviewed, The surveyor , along with hospice leadership found that documented goals had not been measurable and time frames stated on multiple goals throughout care. This was an issue organization stated that they had self identified and had begun work on. The issue was discussed with hospice leadership and confirmed.

Observed in Record Review. In 8 of 18 , The surveyor observed that when multiple medication for pain medication had been ordered that the POC had not directed as to when to take which drug. This issue was specifically related to oxycodone when ordered along with Tylenol and morphine. This issue was discussed and confirmed with hospice leadership.

Observed in Record Review. In 2 of 18 patient records reviewed, The surveyor observed that care had not been provided according to the aide plan of care. The frequency on 1 record ordered that aide visit patient twice a week X 4 weeks and the surveyor noted on 2 of the four weeks the aide had only visit once per week. On a second record the surveyor observed that the aide care plan ordered visits 2x per week times 4 weeks and one of the 4 weeks only one visit had been completed. The organization leadership along with surveyor could find no evidence of missed visit note or communication note to physician or any staff member. The issue was observed ,discussed and confirmed with organization leadership.

Observed in Document Review. The surveyor observed that the organization had not been collecting data or analyzing said data on hand hygiene in 2023,2024 or 2025. This issue was discussed and confirmed with organization leadership.

Observed in Building Tour. There was an escutcheon plate that was not properly installed. This was located in the corridor between rooms 28 and 29. This was observed by the Manager of Clinical Excellence and Accreditation for Home Reach Hospice, Senior Consultant Safety Environment, Plumber, Facility Manager, and the Senior Director of Facilities. 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. In 1 of 6 above ceiling checks, There was a bundle of wire that was supported by the sprinkler pipe. This was located above the ceiling at the entrance of wing 26-33. This was observed by the Manager of Clinical Excellence and Accreditation for Home Reach Hospice, Senior Consultant Safety Environment, Plumber, Facility Manager, and the Senior Director of Facilities. 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 Document Review. There was no evidence that the monthly elevator firefighters’ emergency recall was tested in the month of December 2025. This was observed by the Manager of Clinical Excellence and Accreditation for Home Reach Hospice, Senior Consultant Safety Environment, Plumber, Facility Manager, and the Senior Director of Facilities.

Based on record review, observation, and staff interview, the facility failed to ensure Fire Alarm system components were maintained in accordance with NFPA 101 - 2012 Edition Section: 19.3.4, 9.6.1.3 and NFPA 72 - 2010 Edition Section 14.4.5.3 through 14.6.2.4. This had the potential to affect all 16 patients of the facility. Findings include: --- Record review on 11/21/24 between 10:51 A.M. and 1:45 P.M. noted the annual inspection of the fire alarm system by the contractor dated 07/29/24. Further review of the documentation revealed that there was no sensitivity testing within the past twenty-four months available for review. Record review on 11/21/24 between 10:51 A.M. and 1:45 P.M. noted the annual inspection of the fire alarm system by the contractor dated 07/29/24. Further review of the documentation revealed that there were no electric smoke/fire dampers listed as being inspected during the fire alarm inspection, or within the past twelve months. Observation on 11/21/24 between 1:45 P.M. and 2:45 P.M. revealed electric smoke/fire dampers located in some of the HVAC ductwork in the interstitial spaces. Interview with Facilities Director at time of discovery verified the above findings.

Based on record review, and staff interview the facility failed to ensure fire and smoke dampers were maintained in accordance with NFPA 101 2012 Edition 19.5.2, NFPA 90 A-2012 Edition, Section 5.4.8, NFPA 80-2010 Edition, Section 19.4.1. This had the potential to affect all 16 patients residing in the facility. Findings include: --- Record review on 11/21/24 between 10:55 A.M. and 1:45 P.M. noted the record of fire and smoke dampers from the contractor. The report dated 11/16/18 was the last inspection of the dampers. This is past the four year requirement. Interview with Facilities Director at the time of discovery during tour verified the above findings.

Based on record review, observation, and staff interview the facility failed to ensure fire door assemblies were annually inspected and tested in accordance with NFPA 101 – 2012 edition Chapter 19 sections 19.7.6, 7.2.1.15, 8.5.4, NFPA 80 5.2.4, and NFPA 105 – 2010 Edition Section 4.1.1 and 5.2.1. This had the potential to affect all 16 patients of the facility. Findings include: --- Record review on 11/21/24 between 10:51 A.M. and 1:45 P.M. noted no record of the fire doors being inspected and tested within the past 12 months. Observation on 11/21/24 during tour of the facility between 1:45 P.M. and 2:45 P.M. revealed there were several 90-minute fire rated doors in the facility. Interview with Facilities Director at the time of discovery during tour verified the above findings.

The facility must meet the applicable provisions of the 2012 Existing Edition of the Life Safety Code (LSC) of the National Fire Protection Association. An initial Life Safety Code Survey was completed on 11/21/24 by the Ohio Department of Health. At this survey, OhioHealth Hospice was found to NOT be in substantial compliance with the requirements for participation in Medicare/Medicaid at 42 CFR Subpart 418.110 (d), Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code, Chapter 19 Existing Health Care Occupancies Chapter The facility is an inpatient Hospice Center. See Life Safety Code Report

See K345, K521, and K761 of the life safety code report.