Every finding on record at Hospice Maui, Inc.

K-345 Fire Alarm System-Testing and Maintenance This STANDARD is not met as evidenced by: Based on record review with staff members, the facility failed to provide documentation for smoke detector sensitivity testing, in accordance with, NFPA 72 National Fire Alarm and Signaling Code, 2010 edition, section 14.4.5.3. This deficiency could affect all residents, staff, and visitors during the incipient stage of a fire due to delayed or no response from smoke detectors within the facility. Findings include: During record review on 3/8/22 at approximately 12:15 pm revealed that the facility failed to provide documentation for the smoke sensitivity testing of smoke detectors. These findings were verified at the exit conference with the Quality Assurance Officer and Business Agent on 3/8/22 at 2:00 pm.

K-351 Sprinkler System-Installation This standard is not met as evidenced by: Based on record review and observation of the facility's automatic sprinkler system, the facility failed to install a means to supervise the sprinkler system in accordance with NFPA 101, Life Safety Code, 2012 edition, section 9.7.2. This deficiency could affect all residents, staff, and visitors due to a lack of supervisory attachments for tamper and flow switches that would alert staff during a fire or accidental shut off of water supply to the fire sprinkler system. Findings include: During record review on 3/8/22 at approximately 1:15 pm revealed that the facility failed to provide documentation for the monthly and quarterly fire sprinkler inspection and testing. Upon observation of the fire sprinkler system, it was revealed that it lacked the proper means of electronic supervision by the fire alarm system. These findings were verified at the exit conference with the Quality Assurance Officer and Business Agent on 3/8/22 at 2:00 pm.

K-923 Gas Equipment-Other This STANDARD is not met as evidenced by: Based on observation and staff interview with maintenance staff, the facility failed to provide proper precautionary signage and the safeguards for oxygen cylinder storage greater than 300 cubic feet, in accordance with NFPA 99, Healthcare Facilities Code, 2012 edition, sections 11.3.2, 11.3.2.3 and 11.3.4. This deficiency could affect all residents, staff, and visitors due to the excessive amounts of oxidizing gases in a compartment not rated for this type of storage of compressed gases. Findings include: During facility survey on 3/8/22 at approximately 1:30 pm, revealed that the oxygen storage room lacked the proper precautionary signage and contained gases in excess of 300 cubic feet. These findings were verified at the exit conference with the Quality Assurance Officer and Business Agent on 3/8/22 at 2:00 pm.

Based on record review and interview with staff members, the facility did not meet the requirements of Subpart 489 of this chapter regarding advance directives for 2 (Patients 2 and 8) of 13 patients in the sample. The facility failed to assure documentation of whether the patient has executed an advance healthcare directive (AHCD) was included in their medical record. The lack of information has the potential to result in patients not exercising their right to execute an AHCD. Findings include: The facility's policy for Advance Directives includes the following procedures: "2. The hospice nurse of Social Worker documents that the patient has received written information related to advance directives and whether the patient has or has not executed an advance directive and 3. If available, a copy of any advance directive is placed in the patient's clinical record and the patient's wishes, including his/her DNR status, are communicated to members of the hospice IDG [interdisciplinary group] to be included in care planning for the patient." 1) Record review done on 03/01/22 at 01:40 PM found no documentation of an advance healthcare directive (AHCD) for Patient (P)2. A review of Social Worker (SW)4's assessment notes P2 is full code and patient chooses resuscitation if his/her heart or lungs stop working. Concurrent record review with the Education and Compliance Management Assistant (ECMA) on 03/02/22 at 10:16 AM found there is no documentation of whether P2 has executed an advance directive. The ECMA also confirmed there is no documentation of an (AHCD) in the chart. Inquired where would the facility document whether a patient has an AHCD. ECMA responded there are several places to check 2 ) Record review done on 03/03/22 at 08:08 AM found no documentation whether P8 has an advance directive. Review found of Initial Assessment by SW1, dated 07/22/21 notes P2 has a medical power of attorney and copy was provided to hospice. In the Advance Directives section of the electronic health record (EHR) patient is DNR (Do Not Resuscitate) , has completed a will, POLST (Provider Orders for Life-Sustaining Treatment) and POA (Power of Attorney). There was no documentation whether P2 has an AHCD. Also, the two entries in the electronic health record (EHR) are contradictory. One indicates the patient has a medical power of attorney and the other indicates the same person with Durable Power of Attorney (DPOA). Concurrent record review with the ECMA on 03/02/22 at 10:16 AM confirmed there is no documentation of an AHCD.

Based on record review and interview with staff members, the facility failed to ensure the interdisciplinary group completed their comprehensive assessment no later than 5 calendar days after the election of hospice care for 3 of 13 patients sampled. Findings include: 1) Patient (P)9's election of hospice care was 10/05/21. A review of the patient's electronic health record (EHR) found the interdisciplinary group did not complete the comprehensive assessment no later than 5 (five) calendar days after the election of hospice care. The social work assessment was completed on 10/12/21 and the spiritual assessment was completed on 10/14/21. There was no documentation of refusals or cancellation by the patient. On 03/03/22 at 09:43 AM concurrent record review and interview was conducted with the Education and Compliance Nurse (ECN). The ECN confirmed the social worker and spiritual assessments were not done no later than five calendar days after the election of hospice care. The ECN was unable to find documentation to explain why the assessments were late. 2) P8's election of hospice care was 07/21/21. A review of the patient's EHR notes the interdisciplinary group did not complete the comprehensive assessment no later than 5 (five) calendar days after the election of hospice care. The spiritual assessment was completed on 07/27/21. On 03/03/22 at 09:50 AM concurrent record review and interview was conducted with the ECN. The ECN confirmed the spiritual assessment was not done not later than five calendar days after the patient's election of hospice care. There was no documentation of why the assessment was late. 3) P5's election of hospice care was 03/21/21. A review of P5's EHR found that the interdisciplinary group (IDG) did not complete the comprehensive assessment no later than 5 (five) calendar days after the election of hospice care. The social work assessment was completed on 03/23/21, with Social Worker (SW)2 documenting that P5 had answered "yes" when asked if she was interested in spiritual counseling. The spiritual counseling initial assessment was completed by the Spiritual Care Counselor (SCC) on 03/30/21. On 03/04/22 at 08:53 AM, during a concurrent record review and interview with the Education and Compliance Management Assistant (ECMA), the ECMA confirmed that there was no documentation of refusals or cancellation of spiritual services/appointments by P5, and that the spiritual assessment was not done until nine calendar days after the election of hospice care.

The facility failed to ensure care and services were provided in accordance with the plan of care for 3 (Patients 1, 4, and 13) of 13 patients sampled. Findings include: 1) Patient (P)13's election of hospice care is 12/22/21. Record review found plan of care dated 01/21/22 for skilled nursing services two times a week. A review of services provided found for the week of 02/13/22 to 02/19/22 and 02/20/22 to 02/25/22, skilled nursing services were provided three times a week without a change to the plan of care and/or physician's order. Concurrent record review and interview with Education and Compliance, Management Assistant (ECMA) was done on 03/04/22 at 10:00 AM. ECMA reviewed the patient's record and confirmed documentation of skilled nurse services twice a week for the following plan of care periods beginning: 12/27/21, 01/05/22, 01/12/22, and 01/21/22. The current plan of care dated 03/02/22 includes skilled nurse services twice a week. ECMA confirmed skilled nurse services were not provided in accordance with P13's plan of care. ECMA explained if there is a need for an update of visits, the physician will be consulted and a comprehensive review is completed. ECMA confirmed there is no documentation of a change to the patient's plan of care to increase the skilled nurse services from twice a week to three times a week. 2) Patient (P)1's election of hospice care was 12/21/21. Review of P1's electronic health record (EHR) found a plan of care dated 12/21/21 for social work services one to three times a month. A review of services provided noted that there were no social work services provided for the month of January 2022. On 03/04/22 at 08:59 AM, during a concurrent record review and interview with the Education and Compliance Management Assistant (ECMA), the ECMA confirmed that there was no documentation that social work services were provided, refused, or canceled for P1 during the month of January 2022. The ECMA also confirmed that this was not in accordance with the plan of care. 3) Patient (P)4's election of hospice care was 09/18/21. Review of P4's electronic health record (EHR) found a plan of care dated 09/22/21 for hospice aide services once a week. A review of services provided noted that there were no hospice aide services provided from 12/23/21 to 01/07/22, a period extending more than two weeks. On 03/04/22 at 09:08 AM, during a concurrent record review and interview with the ECMA, the ECMA confirmed that there was no documentation that hospice aide services were provided, refused, or canceled for P4 from 12/23/21 to 01/07/22. The ECMA could find no documentation to explain why the hospice aide services were not provided and confirmed that this was not in accordance with the plan of care.

Based on record review, policy review, and interview with staff members, the facility failed to follow accepted standards of practice to prevent the transmission of COVID-19 and other communicable diseases and infections. This is evidenced by the facility failing to ensure that each staff member had been medically evaluated, cleared, and fit-tested for N95 respirator use. As a result of this deficient practice, the facility placed the staff at risk of being unable to safely wear a respirator if required for their protection and placed both staff and patients at risk for the transmission of COVID-19. This deficient practice has the potential to affect all healthcare personnel and patients of the facility. Findings include: On 03/03/22 at 09:25 AM, during a review of the facility's documentation of staff who had been exempted from receiving the COVID-19 vaccination, it was noted that one direct-care staff member, Registered Nurse (RN)2, had been approved for a religious exemption. During a concurrent interview with the Interim Chief Executive Officer (CEO) at the same time, it was revealed that although RN2's contingency plan for continuing to provide direct care to patients while being unvaccinated included "Be fit-tested for an N95...and wear a fitted/approved mask at all times in a work setting...," RN2 had not been fit-tested for an N95 respirator. Upon further questioning, the CEO explained that when required, all staff wear a "universal" N95 respirator provided by the facility, and perform a "user seal check," in accordance with the Occupational Safety and Health Administration (OSHA) Mini Respiratory Protection Program (29 CFR 1910.504), in lieu of being fit-tested for a respirator. A review of an OSHA Fact Sheet about the Mini Respiratory Protection Program (RPP) provided by the facility revealed that "for Standard and Transmission-Based Precautions," the OSHA Normal RPP (29 CFR 1910.134) should be utilized, as the Mini RPP would not be applicable. A review of the facility's COVID-19 Plan, effective August 8, 2021, noted the following: "For employees with exposure to people with suspected or confirmed COVID-19 ...will provide respirators ...will ensure respirators are used in accordance with the OSHA Respiratory Protection standard (29 CFR 1910.134) ..." A review of the OSHA 29 CFR 1910.134(c)(1) standard revealed the following: "In any workplace where respirators are necessary to protect the health of the employee or whenever respirators are required by the employer, the employer shall establish and implement a written respiratory protection program ...the employer shall include in the program the following provisions ... (ii) Medical evaluations of employees required to use respirators; (iii) Fit testing procedures for tight-fitting respirators ..." During an interview with the CEO on 03/04/22 at 09:35 AM, the CEO confirmed that throughout the COVID-19 Public Health Emergency (PHE), none of their staff had been medically evaluated, cleared, or fit-tested for N95 respirator use. The CEO also confirmed that over the course of the COVID-19 PHE, staff had been required at various times to use a respirator as part of their personal protective equipment (PPE) due to potential exposure to patients (or family members) with suspected or confirmed COVID-19.

Based on observation and interview with staff members, the facility did not assure expired food and supplements were discarded to prevent serving items to the patients. This deficient practice has the potential to result in foodborne illnesses to the patients. Findings include: 1) On 03/01/22 at 10:50 AM concurrent observation of the inpatient unit refrigerator was done with the Chief Executive Office (CEO). The refrigerator contained a bowl of uncooked sliced Portuguese sausage that was not dated, an opened can of chicken broth covered with a Ziploc bag labeled with a date of 02/24/22, an opened can of evaporated milk covered with foil that was not labeled with a date, an opened jar of mayonnaise with the manufacturer's label removed and no label when it was opened, and a bottle of Ensure with expiration date of 11/2021. The refrigerator also contained staff members' food items, for example, tartar sauce with expiration date of 08/19/21, and opened Mexican hot sauce labeled with staff member's name and expiration date of 03/21/21. The CEO and Hospice Aide (HA)1 reported that the Portuguese sausage was cut this morning and the can of evaporated milk was for a patient. Inquired how long are opened food items kept in the refrigerator, the CEO responded food items should be discarded after three days. The CEO disposed of the Ensure and other expired food items. 2) On 03/01/22 at 10:40 AM during a concurrent observation of the inpatient unit dry goods storage cabinet and interview with the Interim Chief Executive Officer (CEO), four (4) serving size containers of vanilla-flavored liquid nutritional supplements were found on the bottom shelf of the cabinet with labeled manufacturer expiration dates of 01/01/22. The CEO confirmed that the expired supplements should have been pulled and discarded during a routine check.