Every finding on record at Hospice Care Corporation, Inc.

Based on document review and staff interview, it was determined the agency failed to develop and maintain a comprehensive emergency preparedness (EP) program that utilizes an all-hazards approach. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 1. --- Findings include: During document review of the facility's emergency preparedness plan (EPP) conducted on 05/09/23 between the hours of 2:56 p.m. and 3:27 p.m., the facility failed to complete the following emergency preparedness elements: The EPP was not based on or included a documented, facility-based and community-based risk assessment that utilized an all hazards approach. The EPP policies and procedures did not address the provision of subsistence needs for staff and patients whether they evacuate or shelter in place. The EPP policies and procedures did not address procedures to follow-up with on-duty staff and patients during a disruption of services. The EPP did not address procedures for a system to track the location of on-duty staff and sheltered patients in the agency's care during an emergency. The EPP did not address a means to shelter in place for patients, staff, and volunteers who remain in the agency. Policies and procedures for the use of volunteers during an emergency were not available for review. Policies and procedures for the development of arrangements with other hospices and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients were not available for review. Policies and procedures regarding the role of the hospice under a waiver declared by the Secretary, in accordance with 1135 of the Act, in the provision of care and treatment at an alternate care site were not available for review. The communication plan did not include contact information for entities providing services under arrangement or other Hospice's. The communication plan did not include contact information for Federal, State, Tribal, and Regional emergency management officials. The communication plan did not include primary and alternate means of communication for the Hospice staff and Federal, State, Tribal, Regional, and local emergency management agencies. The EPP did not include a method for sharing information and medical documentation for patients under the agency's care, as necessary, with other health providers to maintain the continuity of care. The EPP did not include a means of providing information about the agency's inpatient occupancy, needs, and its ability to provide assistance to the authority having jurisdiction, the Incident Command Center, or designee. The EP training program did not provide EP training at least annually. The hospice had not conducted exercises to the test the emergency plan at least annually, including a full-scale exercise and an additional exercise, as required by the EP testing requirements. Interview on 05/09/23 at approximately 3:29 p.m. with the Maintenance Director verified these findings. The findings were also acknowledged by the Director of Clinical Education at the exit interview on 05/09/23 at approximately 3:53 p.m.

Based on document review and staff interview, it was determined the agency did not train the employees annually on the emergency preparedness (EP) Program. This failure has the potential to impact all patients of the agency in the event of an emergency. --- Findings include: No documentation of annual EP training was present in all employee education files. An interview with the Director of Education on 05/09/23 at 1:30 p.m. revealed no annual training of the EP Program is in place for the agency.

Based on document review and staff interview, it was determined the facility failed to ensure that required emergency lighting systems were tested in accordance with NFPA (National Fire Protection Association) 101. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 1. --- Findings include: Document review on 05/09/23 at approximately 9:42 a.m. revealed no documentation for review that battery powered emergency exit lights throughout the facility had received monthly functional testing for a minimum of thirty (30) seconds since December 2022. Document review on 05/09/23 at approximately 9:45 a.m. revealed no documentation for review that battery powered emergency exit lights throughout the facility had received annual functional testing for a minimum of ninety (90) minutes. Interview on 05/09/23 at approximately 9:46 a.m. with the Maintenance Director verified these findings. These findings were also acknowledged by the Director of Clinical Education at the exit interview on 05/09/23 at approximately 3:53 p.m.

Based on document review and staff interview, it was determined the facility failed to ensure that the fire alarm system was tested and maintained in accordance with NFPA (National Fire Protection Association) 72. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 1. --- Findings include: Document review on 05/09/23 at approximately 10:07 a.m. revealed no documentation for review that smoke detector sensitivity testing had been completed in the previous two (2) years. Interview on 05/09/23 at approximately 10:08 a.m. with the Maintenance Director verified this finding. This finding was also acknowledged by the Director of Clinical Education at the exit interview on 05/09/23 at approximately 3:53 p.m.

Based on observation and staff interview, it was determined the facility failed to ensure that automatic sprinkler and standpipe systems were tested and maintained in accordance with NFPA (National Fire Protection Association) 25. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 1. --- Findings include: Observation on 05/09/23 at approximately 10:46 a.m. revealed no documentation for review that the applicable (pendent or horizontal) dry sprinkler system heads had been replaced or that a sample of these sprinkler heads had been tested for the previous ten (10) years. Interview on 05/09/23 at approximately 10:47 a.m. with the Maintenance Director verified this finding. This finding was also acknowledged by the Director of Clinical Education at the exit interview on 05/09/23 at approximately 3:53 p.m.

Based on observation and staff interview, it was determined the facility failed to ensure that portable fire extinguishers were installed and maintained in accordance with NFPA (National Fire Protection Association) 10. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 1. --- Findings include: Observation on 05/09/23 at approximately 11:55 a.m. revealed fire extinguishers throughout the inpatient unit, which had not been inspected monthly since March 2023. Interview on 05/09/23 at approximately 11:56 a.m. with the Maintenance Director verified this finding. This finding was also acknowledged by the Director of Clinical Education at the exit interview on 05/09/23 at approximately 3:53 p.m.

Based on observation and staff interview, it was determined the facility failed to ensure that electrical wiring and equipment shall be in accordance with NFPA (National Fire Protection Association) 70. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 1. --- Findings include: Observation on 05/09/23 at approximately 11:57 a.m. revealed a junction box missing a cover on the ceiling of the Inpatient Dining Room Area. Interview on 05/09/23 at approximately 11:58 a.m. with the Maintenance Director verified this finding. This finding was also acknowledged by the Director of Clinical Education at the exit interview on 05/09/23 at approximately 3:53 p.m.

Based on document review and staff interview, it was determined the facility failed to ensure that fire-rated door assemblies in the means of egress were inspected, tested, and maintained in accordance with NFPA (National Fire Protection Association) 101. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 1. --- Findings include: Document review on 05/09/23 at approximately 10:30 a.m. revealed no documentation was available for review to show that fire doors located throughout the facility had been inspected and tested during the previous twelve (12) months. Interview on 05/09/23 at approximately 10:31 a.m. with the Maintenance Director verified this finding. This finding was also acknowledged by the Director of Clinical Education at the exit interview on 05/09/23 at approximately 3:53 p.m.

Based on document review and staff interview, it was determined the facility failed to maintain and test electrical receptacles at patient bed locations in accordance with NFPA (National Fire Protection Association) 101. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 1. --- Findings include: Document review on 05/09/23 at approximately 9:21 a.m. revealed the testing for patient bed location receptacles did not contain documentation for testing of the physical integrity, continuity of the grounding circuit, correct polarity of the hot and neutral connections, or the retention force of the grounding blade for each electrical receptacle at the patient bed locations in the facility for the previous twelve (12) months. Interview on 05/09/23 at approximately 9:22 a.m. with the Maintenance Director verified this finding. The finding was also acknowledged by the Director of Clinical Education at the exit interview on 05/09/23 at approximately 3:53 p.m.

Based on document review and staff interview, it was determined the facility failed to ensure that maintenance and testing of the generator and transfer switches was performed in accordance with NFPA (National Fire Protection Association) 110. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 1. --- Findings include: Document review on 05/09/23 at approximately 8:41 a.m. revealed no documentation for review that the emergency generator had met the required monthly load rating of 30% of the rated KW for the generator for the months of October, November, and December of 2022 and April 2023. Document review on 05/09/23 at approximately 8:45 a.m. revealed no documentation for review that the emergency generator had received an annual load bank test for the previous twelve (12) months. Document review on 05/09/23 at approximately 8:48 a.m. revealed no documentation for review that the emergency generator had received an annual fuel quality test in the previous twelve (12) months. Document review on 05/09/23 at approximately 8:54 a.m. revealed the documentation for weekly battery voltage measurement for the generator, which had sealed batteries, was only recorded for one (1) week each month for the previous twelve (12) months. Document review on 05/09/23 at approximately 9:03 a.m. revealed no documentation for review that the generator, which had sealed batteries, had received monthly conductance testing for the previous twelve (12) months. Interview on 05/09/23 at approximately 9:04 a.m. with the Maintenance Director verified these findings. These findings were also acknowledged by the Director of Clinical Education at the exit interview on 05/09/23 at approximately 3:53 p.m.

Based on document review and staff interview, it was determined the facility failed to maintain the testing and maintenance requirements for fixed and portable patient-care equipment in accordance with NFPA (National Fire Protection Association) 101. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 1. --- Findings include: Document review on 05/09/23 at approximately 10:18 a.m. revealed no documentation available for review of testing of the physical integrity of the power cord assembly, electrical resistance, or touch/leakage current testing for rental beds and concentrators used throughout the inpatient unit. Interview on 05/09/23 at approximately 10:19 a.m. with the Maintenance Director verified this finding. This finding was also acknowledged by the Administrator at the exit interview on 05/09/23 at approximately 3:53 p.m.

Based on record review and staff interview, it was determined the agency failed to include the frequency of nursing services provided in the plan of care for three (3) of fourteen (14) active patients, patients #5, 8, and 13. This failure has the potential to impact the delivery of care to all hospice patients. --- Findings include: A review was conducted of the medical record for Patient #5, start of care date 05/05/23. No frequency of skilled nursing (SN) visits was documented in the patients plan of care. A review was conducted of the medical record for Patient #8, start of care date 11/18/22. No frequency of SN visits was documented in the patients plan of care. A review was conducted of the medical record for Patient #13, start of care date 10/07/22. No frequency of SN visits was documented in the patients plan of care. The Director of the Inpatient Unit on 05/10/23 at 2:12 p.m., confirmed there were no nursing visit frequencies in patients #5, 8, and 13s plan of care.

Based on record review and staff interview, it was determined the agency failed to ensure care and services are provided in accordance with the plan of care for two (2) of fourteen (14) patients, patients #1 and 8, by missing scheduled visits with no documentation. This failure has the potential to negatively impact all patients receiving hospice care by the agency. --- Findings include: A review of the medical record for Patient #1, start of care date 02/28/23, revealed the hospice services that were ordered included skilled nursing (SN) two (2) times a week and home health aide (HHA) two (2) times a week. A review of notes revealed there was only one (1) SN visit the weeks of 03/05, 03/12, 03/19, and 04/02/23. There were no HHA visits documented the week of 03/12/23, and only one (1) HHA visit the week of 03/19/23. A review of the medical record for Patient #8, start of care date 11/18/22, revealed the hospice services that were ordered included HHA three (3) times a week. A review of notes revealed there were only two (2) HHA visits the weeks of 02/12, 02/19, and 02/26/23. An interview was conducted on 05/10/23 at 11:45 a.m. with the Director of the Inpatient Unit (DIU) regarding the missed SN and HHA visits for Patient #1. The DIU confirmed that SN and HHA visits were both ordered two (2) times a week, and that there were missed visits with no documented evidence within the medical record of the reasons why the ordered visits were missed. Later the same day at 1:05 p.m., the DIU confirmed that Patient #8 had HHA services ordered three (3) times a week, and that there were missed visits with no documented evidence within the medical record of the reasons why the ordered visits were missed.

Based on document review and staff interview, it was determined the agency failed to maintain documentation that demonstrates the requirements of hospice aide training are met in four (4) out of four (4) hospice aides hired after the last survey was completed on 07/15/20. This failure has the potential to negatively impact all patients with Hospice Aide care. --- Findings include: A review was conducted of Hospice Aide (HA) #1's training/personnel file. HA #1 was hired on 07/02/21. HA #1 is a Certified Nursing Aide (CNA). No documentation of previous training, including the requirement of seventy-five (75) training hours and the documentation in which the training addresses all subjects listed at §418.76 (b)(3), are in the HAs education record. A review was conducted of HA #2's training/personnel file. HA #2 was hired on 04/12/21. HA #2 is a CNA. No documentation of previous training, including the requirement of seventy-five (75) training hours and the documentation in which the training addresses all subjects listed at §418.76 (b)(3), are in the HAs education record. A review was conducted of HA #3's training/personnel file. HA #3 was hired on 06/01/21. HA #3 is a CNA. No documentation of previous training, including the requirement of seventy-five (75) training hours and the documentation in which the training addresses all subjects listed at §418.76 (b)(3), are in the HAs education record. A review was conducted of HA #4's training/personnel file. HA #4 was hired on 05/03/21. HA #4 is a CNA. No documentation of previous training, including the requirement of seventy-five (75) training hours and the documentation in which the training addresses all subjects listed at §418.76 (b)(3), are in the HAs education record. An interview was conducted with the Director of Education on 05/09/23 at 1:00 p.m. The Director confirmed the hospice does not currently have a Hospice Aide Training program. All HAs have a CNA license, but no one documents the program elements required.

Based on document review, observation, and staff interview, it was determined the agency failed to develop procedures for controlling ventilation/air changes throughout the hospice. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 1. --- Findings include: Document review on 05/09/23 at approximately 9:35 a.m. revealed no documentation for review of developed procedures for managing ventilation and air exchanges for clean/dirty areas throughout the hospice. Observation on 05/09/23 at approximately 9:38 a.m. revealed the Clean Supply Room near the Laundry Room had a negative air relationship to the adjacent Laundry Room. Interview on 05/09/23 at approximately 9:39 a.m. with the Maintenance Director verified these findings. These findings were also acknowledged by the Director of Clinical Education at the exit interview on 05/09/23 at approximately 3:53 p.m.

Based on document review and staff interview, it was determined the agency failed to meet the provisions applicable to the 2012 edition of the Life Safety Code of the National Fire Protection Association (NFPA) 101. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 1. --- Findings include: In reference to Federal Life Safety Code (FLSC) citation K 291 the facility failed to ensure the appropriate testing of emergency lighting. In reference to FLSC citation K 345 the facility failed to ensure the appropriate testing of the fire alarm system. In reference to FLSC citation K 353 the facility failed to ensure the appropriate testing of the sprinkler system. In reference to FLSC citation K 355 the facility failed to ensure the appropriate testing of portable fire extinguishers. In reference to FLSC citation K 511 the facility failed to maintain electrical wiring and equipment. In reference to FLSC citation K 761 the facility failed to ensure the appropriate testing of fire doors. In reference to FLSC citation K 914 the facility failed to ensure appropriate documentation of testing of patient bed location receptacles. In reference to FLSC citation K 918 the facility failed to ensure appropriate documentation of testing of the emergency generator. In reference to FLSC citation K 921 the facility failed to maintain documentation of testing of patient-care related electrical equipment. Interview on 05/09/23 at approximately 12:01 p.m. with the Maintenance Director verified these findings. The findings were also acknowledged by the Director of Clinical Education at the exit interview on 05/09/23 at approximately 3:53 p.m.

Based on observation and staff interview, it was determined the facility failed to have plumbing fixtures that regulated the temperature of the hot water. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 1. --- Findings include: Observation on 05/09/23 at approximately 11:46 a.m. revealed the hot water temperature at the hand sink in the bathroom of Patient Room 9 measured approximately 142.8 degrees Fahrenheit. Corrections were implemented immediately by adjusting the hot water tank temperature. Interview on 05/09/23 at approximately 11:47 a.m. with the Maintenance Director verified this finding. This finding was also acknowledged by the Director of Clinical Education at the exit interview on 05/09/23 at approximately 3:53 p.m.