Every finding on record at Hospice of Marshall County Inc

Based on review of agency policy and procedure, medical records (MR) and interview, it was determined the agency staff failed to ensure an initial bereavement (BV) assessment was done completed on 4 of 13 patient records reviewed. This affected MR # 7, MR # 2, MR # 3, MR # 6, and had the potential to negatively affect all patients served by the hospice agency. Findings include: Agency Policy: PC- 18 Revised Date: 5/5/2021 Bereavement Support Services Policy It is the policy of Shepherd's Cove Hospice (SCH) to provide an organized bereavement support services for children and adults, regardless of participation in SCH services, to assist them in coping with loss and grief. Patient Related Bereavement Support 1. The primary caregiver is assessed for bereavement risk and documented by the Social Worker or member of the IDT (Interdisciplinary Team), the Electronic Medical Record (EMR) upon the patient's admission to the SCH program and as needed throughout their enrollment, and after the death of the patient. 1. MR # 7 was admitted to hospice on 11/5/2021 with the diagnosis including Malignant Neoplasm of Prostate and Essential (primary) Hypertension. Review of the Hospice Inpatient Unit (IPU) documentation from 11/5/2021 to 11/11/2021 revealed no documentation a bereavement initial assessment was performed by the hospice team. An interview was conducted on 12/9/2021 at 1:30 PM with Employee Identifier (EI) # 4, Compliance Director, who confirmed the agency failed to complete the initial bereavement assessment. 2. MR # 2 was admitted to the inpatient hospice unit (IPU) on 11/14/21 at GIP (General Inpatient) Level of Care for symptom management with the focus on observation. Review of the Bereavement Assessment dated 11/15/21 revealed the following assessment questions: - Preparation for Death was blank and not answered. - Description of Significant stressors - "unable to assess" was documented. The clinician failed to complete the tool to obtain a total score for the Bereavement Assessment. In an interview conducted on 12/9/21 at 3:30 PM, EI # 8, Chief Clinical Officer, confirmed the staff failed to complete the Bereavement Assessment. 3. MR # 3 was admitted to the agency on 10/14/21 with diagnoses including Malignant Neoplasm of Rectum, Hepatomegalay, Chronic Pain, Major Depressive Disorder, Single Episode, Unspecified. Review of the medical record revealed no documentation a bereavement assessment was completed. The facility failed to ensure a bereavenent assessment was completed. In an interview conducted on 12/9/21 at 2:35 PM, EI # 4, confirmed a bereavement assessment had not been completed. 4. MR # 6 was admitted to hospice on 10/6/21 with a hospice diagnosis of Malignant Neoplasm of the Colon. Review of the SN Assessment dated 10/6/21 revealed no documentation of a Bereavement Risk Assessment. Review of the Medical Social Worker Comprehensive Assessment dated 10/8/21 revealed, "SW (Social Worker) unable to complete initial bereavement assessment due to (spouse),...not being home, and working full time. SW was unable to contact (spouse) at work due to (her/his) cell phone not being turned on." In an interview conducted on 12/9/21 at 2:45 PM, EI # 4, confirmed the staff failed to complete the Bereavement Assessment.

Based on review of medical records (MR), policy and practices and interview it was determined the hospice staff failed to ensure: 1. The Interdisciplinary Team (IDT) addressed patient's constipation from 11/22/21 to 12/1/21 2. The Social Worker (SW) notified the IDT of patient's level of pain greater than acceptable level. 3. The plan of care was updated to include oxygen. 4. The plan of care was updated to include care of the chest tube site. This affected 2 of 2 inpatient records and 1 of 11 records of home care patients reviewed including MR # 2, MR # 3, and MR # 1. This deficient practice had the potential to negatively affect all patients served by the hospice. Findings include: Agency Facility policy: Plan of Care PC-4 Reviewed date:5/25/21 Policy It is the policy of Shepard's Cove Hospice that each patient has an individualized written plan of care. Practices 1. Coordination of all care and services furnished to patients and their families follow an individualized written plan of care established by the interdisciplinary group... C. Measurable outcomes anticipated from implementing and coordinating the plan of care. D. Drugs and treatment necessary to meet the needs of the patient... 5. The plan of care is reviewed no less frequently than every fifteen (15) days.... D. Provide for and ensure the ongoing sharing of information between all disciplines providing care and services in all settings. 1. MR # 2 was admitted on 11/14/21 to the Inpatient Unit (IPU) at GIP (General Inpatient) LOC (Level of Care) for observation. Review of SN (Skilled Nurse) Assessment and Aide IPU FlowSheet notes dated 11/22/21 to 12/1/21 revealed the date of MR # 2's last bowel movement (BM) was 11/22/21. Review of the 12/1/21 IDT Meeting note revealed no documentation the RN (Registered Nurse) discussed the patient's constipation with the IDT/ physician. In an interview conducted on 12/9/21 at 3:30 PM, Employee Identifier (EI) # 8, Chief Clinical Officer (CCO), confirmed the RN failed to document the constipation in the 12/1/21 IDT meeting. 2. MR # 3 was admitted to the agency on 10/14/21 with diagnoses including Malignant Neoplasm of Rectum, Hepatomegalay, Chronic Pain, Major Depressive Disorder, Single Episode, Unspecified. Review of the Hospice Plan of Care (HPOC) dated 10/14/21 revealed the patient's pain goal of 4 or less, and no order for oxygen. Review of the SW visit note dated 11/2/21 revealed the patient's pain level was 5. There was no documentation the SW notified the IDT of patient pain greater than acceptable level of 4. Review of the 11/11/21 SN visit note revealed patient was educated on oxygen safety. During an observation of care on 12/7/21 at 11:29 AM, the surveyor observed the patient wearing oxgyen. Review of the MAR (Medication Administration Record) printed on 12/7/21 revealed no documentation oxygen was ordered. In an interview conducted on 12/9/21 at 2:35 PM, EI # 4, Compliance Director, confirmed the SW failed to notify the IDT of patient's pain level of 5 and the IDT failed to ensure oxygen was ordered on the plan of care. 3. MR # 1 was admitted on 11/2/21 with a terminal diagnosis of Malignant Neoplasm of Bronchus or Lung. Review of the Plan of Care (POC) dated 11/2/21 revealed SN frequency 2 x wk x 9 wks. Plueral drain in place for draining fluid from right lung. Drain pleural drain 1 to 2 times per week or PRN (as needed) for shortness of breath. There was no documentation in the Plan of Care for dressing changes at the Plueral drain site. Review of the SN Assessment dated 11/2/21 revealed the nurse documented "Peri skin around drain site is normal in appearance with sutures to keep drain tubing in place." There was no documentation of care of the site. Review of the IDT meeting dated 11/3/21 revealed no documentation of orders for the care of the plueral drain site. Review of the SN Visit dated 11/4/21 revealed the nurse documented "Pt. has a pleural drain present to right side...drained 500 ml (milliliters)...sterile dressing applied." Review of the SN visit note dated 11/8/21 revealed the nurse documented "...drained 600 ml...via plueral drain and applied sterile dressing..." Review of the SN Visit note dated 11/15/21 revealed the nurse documented "...drained 400 ml...sterile dressing applied..." Review of the IDT Meeting dated 11/17/21 revealed no updates to the Plan of Care or orders to include the care to the plueral drainage site. Review of the SN Visit note dated 11/23/21 revealed the nurse documented "...drained 600 ml...sterile dressing applied..." Review of the SN Visit note dated 12/3/21 revealed "...drained 500 ml...sterile dressing applied..." In an interview on 12/9/21 at 1:50 PM, EI # 4, Compliance Director, confirmed there was no order documented for the care of the plueral drainage site.

Based on agency policy, CDC (Centers for Disease Control) Injection Safety Information Guidelines, observation and interviews with staff, it was determined the facility staff failed to follow infection control practices for: 1. Location of sharps containers. 2. Sharps containers were not over-filled. 2. Performing hand hygiene between glove changes. 3. Using a sterile unused needle to draw medication from vials. This affected 3 of 3 observations of medication administration and 1 of 1 observations of wound care in the hospice inpatient unit (HIPU), and did affect MR (Medical Record) # 3,MR # 2, and MR # 7. These deficient practices had the potential to affect all patients served by the agency. Findings include: Agency Policy: Standard Precautions Reviewed: 5/25/21 General Precautions Hand Washing Hand washing will be performed to prevent cross-contamination between patients and personnel. Hands should be thoroughly washed with soap and water: 3. Before and after gloves are worn;... Needles, Syringes, and Sharps ... After use, non self-sheathing needles and other sharps will be placed directly into a puncture-proof container located at the patient's bedside... CDC Injection Safety Information for Providers FAQs (Frequently Asked Questions) Regarding Safe Practices for Medical Injections FAQs Regarding Safe Practices for Medical Injections Medication Preparation Questions 1. How should I draw up medications? Parenteral medications should be accessed in an aseptic manner. This includes using a new sterile syringe and sterile needle to draw up medications while preventing contact between the injection materials and the non-sterile environment. Proper hand hygiene should be performed before handling medications and the rubber septum should be disinfected with alcohol prior to piercing it. Medication Administration Questions ...4. Is it acceptable to reuse a syringe and/or needle to enter a medication vial for the same patient if the medication vial and the syringe will be discarded at the end of the procedure and not used for subsequent patients? The safest practice is to always enter a medication vial with a sterile needle and sterile syringe, even when obtaining additional doses of medication for the same patient. This adds an extra layer of safety in case, for some reason, the medication vial is not discarded at the end of the procedure as it should be and is inadvertently used on a subsequent patient. OSHA (Occupational Safety and Health Administration) Protecting Yourself When Handling Contaminated Sharps Date of issue: 1/2011 ...Sharps Containers: ...The containers must be replace routinely and not be overfilled, which can increase the risk of needlesticks or cuts... 1. During observations of care conducted on 12/7/21 at the HIPU by Employee Identifier (EI) # 10, Registered Nurse (RN) the following observations were made: At 11:29 AM, EI # 10, administered 2 milligram (mg) of Haldol subcutaneous (SubQ) in the upper right arm of MR # 3. After administering the medication, EI # 10 walked to the patient's bathroom and disposed of the dirty needle into a red biohazard (sharps) container, on the bottom shelf of the built in cabinets. At 12:15 PM the surveyor observed EI # 10 administer Morphine 6 mg SubQ to MR # 3's upper left arm. After administering the medication, EI # 10, walked to the patient's bathroom and disposed of the dirty needle into a sharps container on the bottom shelf of the built in cabinet. The facility failed to ensure a sharps container was located at the bedside per policy. In an interview conducted on 12/9/21 at 3:15 PM, EI # 7, Chief Nursing Officer, confirmed the sharps containers were in the patient bathrooms and not at the bedside. 2. During an observation of medication administration for MR # 2 conducted on 12/7/21 at 2:10 PM. EI # 10 removed 1 mg of Haldol from 1 vial and 1 mg from another vial of Haldol using the same syringe. EI # 10 administered Haldol 2 mg via a SubQ line in upper left arm. Then EI # 10 walked to the patient's bathroom and discarded the syringe in an overfilled sharps container on the bottom shelf of the built in cabinet. EI # 10 confirmed at the time one syringe was used and the sharps container was overfilled. 3. An observation of wound care for MR # 7 was conducted on 12/8/21 at 8:55 AM. EI # 10 removed a dirty dressing from Stage 2 wound on buttocks and removed and reapplied gloves. Then EI # 10 applied Aloe Vista protective cream to gloved finger and then applied the cream directly to the open wound bed and covered with an OptiFoam dressing. EI # 10 failed to perform hand hygiene after removing dirty gloves and prior to reapplying clean gloves for wound care. In an interview conducted on 12/9/21 at 3:15 PM, EI # 7 confirmed staff failed to follow standard precaution policy for sharps disposal, safe practice for withdrawing medications and hand hygiene.

Based on review of medical records (MR), policy and interview it was determined the facility failed to ensure Physician orders were obtained for medications administered. This affected 1 of 13 records reviewed and did affect MR # 9. This deficient practice had the potential to negatively affect all patients served by the hospice. Finding include: Agency Policy: Drugs and Biological's Revised date: 2/23/21 It is the policy of (Shepherd's Cove Hospice), that all necessary drugs and biological's... identified in the plan of care are necessary ... 5. Verbal orders are recorded on a Physician's Orders Form or in the EMR (Electronic Medical Record) by the individual receiving the the order, signed and returned to the prescribing person. Verbal Orders 2. All medications and treatments are ordered by a licensed physician, Nurse Practitioner or Physician's Assistant and will include: a. Date medication/treatment was ordered; b. Ordering physician; c. Specifics of treatment to be provided; d. Name, strength and dose of medication, e. Frequency of administration; f. Routes of administration... 1. MR # 9 was admitted to the agency on 1/14/21 with a hospice diagnosis of Cerebral Infarct. Review of the SN Assessment dated 1/14/21 revealed documentation by the nurse, "The patient did have s/s (signs and symptoms) of pain during assessment. The RN (Registered Nurse) started the patient on roxanol 0.25 ml (milliliters) - 0.5 ml via peg (Percutaneous Endoscopic Gastrostomy) tube Q (every) 1 - 2 hrs (hours) prn (as needed) for pain. The patient was given 0.25 ml during visit...The RN started the patient on compazine 10 mg (milligrams) via peg tube Q 4-6 hrs prn". Further review of the SN Assessment dated 1/14/21 revealed documentation by the nurse, "During admission, the patient was noted to have nonverbal s/s of pain. Seems aching/stabbing. RN left to go sign out roxanol from aipu (inpatient unit) and brought it back to patient home" An interview was conducted on 12/9/21 at 2:26 PM with EI # 4, Compliance Director. The surveyor requested the verbal order for the Roxanol and Compazine and none could be provided. EI # 4 confirmed there was no verbal order for the Roxanol and Compazine.

Based on observation, review of agency policy, Controlled Medication Logs, and interviews, it was determined the inpatient hospice failed to ensure both the off-going and the on- coming nurse verified the number of controlled medications each shift. This had the potential to affect all patients served by the hospice. Findings include: Agency Policy: Drugs and Biological's Revised date: 2/23/21 Practices: It is the policy of (Shepherd's Cove Hospice), that all necessary drugs and biological's...identified in the plan of care... are provided by the agency... and that all drugs and biological's are handled in compliance with appropriate state and federal regulations... Inpatient Drugs and Biological's Administration of controlled medications 1. Controlled medications are kept double locked in the medication room... 4. The oncoming nurse unlocks the controlled medication cabinet/refrigerator and counts narcotics present. The off-going nurse verifies the number of narcotics present according to the controlled substance sign-out log... A tour of the Hospice Inpatient Unit (HIPU) medication room was conducted on 12/7/21 at 10:35 AM to 12:15 PM and 1:00 PM to 3:30 PM with Employee Identifier (EI) # 10, Registered Nurse (RN). The surveyor observed the following: At 10:35 AM review of the Controlled Medication log (CML) dated 12/6/21 and 12/7/21 revealed only one signature. The surveyor asked, "Who was the off-going nurse for 12/6/21 and the on-coming nurse for 12/7/21?" Employee Identifier (EI) #, 10 RN, stated, "Oh, I forgot to sign that yesterday and today." EI # 10 proceeded to sign the CML for 12/6/21 and 12/7/21 as the surveyor watched. The hospice failed to ensure both the off-going and the on-coming nurses verified the number of controlled medications each shift. In an interview conducted on 3:40 PM, EI # 7 confirmed the log should have been signed by both nurses when the medications were counted.

Based on observation, review of policies and procedures and interview, it was determined the hospice inpatient unit staff failed to: 1. Dispose of controlled medications for expired and discharged patients. 2. Follow their policy for disposal of controlled substances. 3. Ensure medications were kept secure. 4. Maintain pharmacy records and monthly reports as directed per policy. This deficient practice had the potential to affect all patients served by the hospice. Findings include: Agency Policy: Hospice Comfort Kit Revised date: 2/23/21 When appropriate, (Shepherd's Cove Hospice) will provide a Comfort Kit to hospice patients. The Comfort Kit will contain medications for the management of pain and symptoms that may arise during a crisis. Procedure: 1. Upon receipt of a signed physician's order, the appropriate designee will order the kit from the appropriate pharmacy. 2. The family will be instructed to pick up the sealed kit from the pharmacy once the order has been faxed and filled... 7. After initiating the use of any medication from the Comfort Kit, ... Use of the medication will be documented ... and each medication will be listed on the MAR (Medication Administration Record) with other medications currently in use... 9. At the time of the patient's death or discharge, the remaining contents of the Comfort Kit will be destroyed as per agency policy. Each individual medication destroyed will be listed on the Medication Disposal/Refusal form. Agency policy: Drugs and Biological's Revised date: 2/23/21 Practices: It is the policy of (Shepherd's Cove Hospice), that all necessary drugs and biological's...identified in the plan of care... are provided by the agency... and that all drugs and biological's are handled in compliance with appropriate state and federal regulations... Inpatient Drugs and Biological's Administration of controlled medications 1. Controlled medications are kept double locked in the medication room... "Stat" Medication Cabinet... 5. The consulting pharmacist: a. Inspects the cabinet at least each calendar month;... c. Reviews inventory forms for accuracy;... d. Reports all discrepancies noted immediately to the clinical manager; and e. Documents same in the monthly pharmacy report. Inpatient Unit Destruction of Medications 1. Controlled substances and other medications unused because the medication is discontinued or because the patient is discharged, deceased, or transferred are destroyed with a reasonable period of time not to exceed 30 days... 5. The registered pharmacist verifies accuracy of the list of medications to be destroyed. 6. The registered pharmacist and the clinical director carry out medication destruction. 7. A third party (licensed nurse, member of management) witnesses the destruction of all controlled medications... 12. Copies of destruction records are maintained by the pharmacist and the clinical manager for a period of not less than two years... A tour of the Hospice Inpatient Unit (HIPU) medication room was conducted on 12/7/21 at 10:35 AM to 12:15 PM and 1:00 PM to 3:30 PM with Employee Identifier (EI) # 10, Registered Nurse (RN). The surveyor observed the following: At 10:45 AM inspection of the second locked cabinet revealed 14 Comfort Kits (CK). Each of the CK's was labeled with 13 different patient names, 2 of the CK's were labeled with the same patient's name. The surveyor asked EI # 10, "Why are there so many CK's here? And why does 1 patient have 2 CK's in this cabinet?" EI # 10 explained, "When a patient is admitted to Shepard's Cove Hospice, the doctor orders a Comfort Kit, the pharmacy delivers the Comfort Kit to the HIPU and then the home care nurse picks it up and takes it to the patient's home." EI # 10 added, "If there's a problem in the home like abusing medications, the home nurse will leave it here and get it when needed. And some nursing homes won't let you keep the CK at their facility." "I think (unsampled patient) has been discharged and re-admitted and discharged a couple of times, that's why he/she has 2 CK's in here." The surveyor compared the names written on the CK's with the current patient and discharged patient list which revealed 7 current patients (1 patient had 2 CK's) and 6 patients had been discharged or expired. The discharge/expired dates ranged from 6/10/21 to 10/29/21. (All dates were greater than 30 days.) At 2:10 PM the surveyor observed EI # 10 prepare medication for administration and observed the locked medication cabinets in the medication room were unlocked. On 12/7/21 at 3:30 PM, in the medication room, the surveyor asked EI # 7, Chief Nursing Officer, "Are you aware there are 14 CK's housed in the HIPU? Why are the CK's at the HIPU for home care patients?" EI # 7 replied, "No, I didn't know they were there. If the patient doesn't want the CK's in the home, we keep them here. Then when needed, the home care nurse delivers it to the home." EI # 7 further confirmed CK's are ordered on admission to hospice and not "when appropriate" as directed in agency policy; there were 14 CK's (for home care patients and discharged /expired greater than 30 days) currently in the cabinet; and confirmed the doors for the controlled medications were not locked but should be locked at all times. A telephone interview was conducted on 12/9/21 at 10:55 AM with EI # 12, Contract Pharmacist. EI # 12 was asked, "Are you aware the Inpatient Unit (IPU) has 14 CK's in the cabinet beside the STAT medication cabinet?" EI # 12 response was, "No ma'am, I did not." EI # 12 went on to say, "We do medication destruction every 3 weeks to a month. I leave it up to the them (the staff) to put medications in the box." The surveyor asked "Who is we?" EI # 12 referred to EI # 3, IPU Clinical Director and said, "She (EI # 3) keeps up with all of the documentation of what I destroy. And I destroy it, which I disagree with, but that's the regulation. I make sure they have enough controlled medications in the STAT cabinet." The surveyor asked EI # 12, "Do you keep copies of what is destroyed at the HIPU? Present monthly reports for quality assurance?" EI # 12 answered, "I don't keep the records. She (EI # 3) keeps up with the destruction log for medications. I do not submit any monthly reports." In an interview conducted on 12/9/21 at 2:45 PM, EI # 7 confirmed the above findings. The HIPU / pharmacist failed to secure, destroy, inventory all controlled medications, prepare monthly reports and maintain records as stated per policy.

Based on observations, interviews, facility policy, Equipment Maintenance Contract, and Preventive Maintenance records, it was determined the facility failed to ensure all equipment used for patient care was inspected for safe operation regularly. This deficient practice had the potential to affect all patient in the Inpatient Hospice Unit (IPU). Findings include: Agency policy: Standard of Practice Patient Electrical Equipment Preventive maintenance of patient care equipment is the responsibility of the maintenance staff person and will be done at least annually. For fixed and portable patient care equipment that requires testing and maintenance, the appropriate vendor will be secured... SCH (Shepherds Cove Hospice) maintenance staff will maintain a log that records the following: 1. When the equipment is sent out to MMC (Modern Medical Home Care) 2. The particular piece of equipment being serviced 3. The issue being addressed and 4. The disposition of the equipment. Contract: Patient Equipment Maintenance Agreement Between Shepherd's Cove Hospice and Modern Medical Home Care, Inc.(Incorporated) Date: 9/30/2021 Shepherd's Cove Hospice (SCH) periodically will need assistance with testing and/or maintenance of patient equipment used in SCH's inpatient unit. Such equipment may include, but is not limited to, nebulizers, suction machines, oxygen concentrators, lifts. Modern Medical Home Care, Inc. (MMC Home Care) agrees to provide testing and maintenance services for such patient equipment... 1. An interview was conducted on 12/8/21 at 11:50 AM with Employee Identifier (EI) # 11, Inventory Maintenance Clerk. EI # 11 was asked how he/she ensures the electrical safety of the equipment. EI # 11 responded, "I check the cords and the prongs. I don't have anyway to check if there are any shorts in the wiring." A tour if the IPU was conducted on 12/8/21 at 1:50 PM with EI # 11. The following electrical items were observed on the unit and in the storage room for patient use with no preventive maintenace sticker: 4 Oxygen Concentrator Units located in the storage room. 2 Oxygen Concentrator Units located in patient rooms. 8 Nebulizer units located in the storage room. 6 portable suction units located in the storage room. 10 adjustable electric beds. 1 portable electric hair dryer in the storage room. A review of the PM logs was conducted on 12/8/21. No documentation was provided of electrical safety checks on any of the 31 electrical patient care items observed. An interview was conducted on 12/11/21 at 1:30 PM with EI # 1, Chief Executive Officer, who confirmed the Preventive Maintenance had not been completed per policy.

Based on observations and interviews, it was determined the Inpatient Hospice Unit (IPU) failed to ensure the water temperature was maintained at a safe level. This deficient practice had the potential to negatively affect all patients in the IPU. Findings include: On 12/7/21 at 10:30 AM a tour of the facility was conducted with Employee Identifier (EI) # 1, Chief Executive Officer. During the tour an observation was conducted in one of the mechanical rooms. A hot water heater was observed with a water temperature on the indicator of 160 degrees. The temperature was verified by EI # 1. EI # 1 confirmed the water heater was the only on in the building and supplied the water to the patient rooms. On 12/7/21 at 11:15 AM a tour of Guest Room # 2 was conducted with EI # 8, Chief Compliance Officer. The surveyors themometer was calibrated by imersing in iced water. The temperature of the running water in the sink was measured at 140 degrees. The temperature of the water from the patient's shower was 130 degrees. EI # 8 verified the temperature readings during the observation and verified 110 degrees or below would be the safe temperature. In an interview on 12/9/21 at 1:30 PM, EI # 1, Chief Executive Officer, confirmed the water temperature in the IPU rooms was not regulated. EI # 1 voiced plans for installing a water temperature regulating valve to ensure the water in the patient rooms was at a safe level.

Based on observations, review of temperature logs, facility policy and procedures, 2017 U.S.(United States) Food and Drug Administration (FDA) Food Code, and interviews, it was determined the Inpatient Unit (IPU) failed to ensure: 1. Staff stored and labeled food correctly. 2. Outdated/expired foods were not available for patient consumption. 3. Refrigerator temperatures were checked to maintain temperature at or below 40 degrees. This had the potential to affect all patients admitted to the IPU. Findings include: Agency Policy: Infection Control Plan/Universal Precautions Policy Number: None Policy Review Date: 5/25/21 Kitchen/Food Preparation: Refrigerator: ...In the inpatient facility, all refrigerated food shall be covered, labeled, and dated. 2017 U.S. FDA Food Code: Commercially Processed Food: Open and Hold Cold: (B) ...refrigerated, ready to eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked at the time the original container is opened in a food establishment, and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises... Facility policy: Standard Precautions Reviewed: 5/25/21 Kitchen/ Food Preparation Food Freshness Observe expiration dates and general freshness of food..., cold food should be maintained below 40 degrees Fahrenheit... Food Storage Inpatient Facility 2. All purchased ice cream and other frozen desserts shall be from an approved source... 1. A tour of the Hospice Inpatient Unit (HIPU) was conducted on 12/7/21 at 10:05 AM with Employee Identifier (EI) # 1, Chief Executive Officer (CEO), the surveyor observed the following: The patient nourishment refrigerator contained 7 Vanilla Boost supplements with the expiration date of 12/4/21. The patient nourishment freezer contained 3 large Styrofoam cups labeled: a. Patient's name, Room #, 4:50 PM and no date documented on the cup. b. Vanilla Milkshake and labeled with the date of 11/4/21 (which was 33 days.) c. Room # and 11/25/21 was documented on the cup (which was 13 days ago.) Observation of 6 of 6 Temperature Logs on the IPU revealed the date of 12/6/21 the refrigerators /freezers temperature were checked. This was the only date documented on the Temperature Logs. During the tour on 12/7/21 at 10:30 AM, EI # 1 confirmed the staff failed to label food correctly, dispose of outdated /expired foods and check the refrigerator/freezer temperatures. 2. A tour of the dietary department was conducted on 12/8/21 at 10:45 AM with Employee Identifier (EI) # 13, registered dietician. Inside the refrigerator there was an opened carton of liquid pasteurized eggs, whole milk, and buttermilk. There was no opened date noted on either of the containers. In an interview conducted 12/8/21 at 10:55 AM, EI # 13, confirmed the opened containers should have been labeled with an opened date.

Based on review of documentation, the facility failed to maintain the kitchen hood's automatic fire-extinguishing system per the requirements of: 2012 NFPA 101, 19.3.2.5.1, and 9.2.3 2011 NFPA 96, 10.2.6 (4), and 11.2.1 This deficiency affects 1 of 2 smoke compartments. Findings include: On 12/07/2021, during the review of documentation from 11:15 am to 3:30 pm, the facility failed to conduct semi-annual (6 month) inspections for the kitchen hood's automatic fire-extinguishing system. Per documentation provided by the facility, the kitchen hood's automatic fire-extinguishing system was inspected on 07/11/2020 and on 07/06/2021. A member of maintenance staff was present when this deficiency was identified. .

Based on review of documentation, the facility failed to maintain the smoke detectors per the requirements of: 2012 NFPA 101, 19.3.4.1, and 9.6.1.3 2010 NFPA 72, 14.4.5.3.2 This deficiency affects 2 of 2 smoke compartments. Findings include: On 12/08/2021, during a tour of the facility from 8:30 am to 11:30 am, the facility failed to provide a smoke detector sensitivity test report completed within the past two years. The last documented sensitivity test was dated 02/06/2018. A member of the maintenance staff was present when this deficiency was identified.