Every finding on record at Hospice of Spokane

.Based on document review and interview, the agency failed to provide a patient Bill of Rights that is in compliance with the Washington Administrative Code 246-335-635, Hospice Bill of Rights. Failure of the agency to update the patient’s Bill of Rights places the patient at risk of being unaware of their rights pertaining to their care. Reference:WAC 246-335-635 Bill of rights.A hospice agency at the time of admission must provide each patient, designated family member, or legal representative with a written bill of rights affirming each patient's right to:(8) The name of the individual within the hospice agency responsible for supervising the patient's care and the manner in which that individual may be contacted. --- Findings included: 1. Document review of the agency's Hospice admission booklet in Client’s Patient Rights showed that the agency failed to include the name of the individual within the hospice agency responsible for supervising the patient's care and the manner in which that individual may be contacted.  2. On 09/25/25 at 9:30 AM, Surveyor #1 interviewed the agency’s Chief Executive Office (Staff #113) regarding the missing patients’ Bill of Rights.  Staff #113 acknowledged the findings and stated that the agency’s contact phone number is listed for complaints but no name of the agency who supervises the patient’s care.

.Based on document review, record reviews, and interview, the agency failed to notify the patient’s physician of missed hospice services resulting in changes to the patient’s plan of care for 9 of 20 active patients (Patient #101, Patient #103, Patient #106, Patient #108, Patient #109, Patient #112, Patient #115, Patient #116, and Patient #119).Failure to communicate with the patient’s physician of changes to the plan of care may potentially have a clinical impact on the patient’s medical needs. --- Findings included:1.    Document review of the agency’s policy titled, “Plan of Care,” (Revised: 01/25) showed that the plan of care contains hospice services available to meet the patient and family needs. 2.  Record review of patient records of Patient #101, Patient #103, Patient #106, Patient #108, Patient #109, Patient #112, Patient #115, Patient #116, and Patient #119 showed:a.   Patient #101 was admitted on 06/12/25. Registered Nurse (RN) Services were ordered with frequencies of 1 time a week starting 06/12/25.  There was no documentation as to why there were no RN visits made during the Medicare week of 07/20/25 to 07/26/25, and no physician notification of the missed RN visit. b.  Patient #103 was admitted on 06/26/25. Hospice Aide (HA) services were ordered with frequencies of 3 times a week starting 06/30/25. There was no documentation as to why only 1 of 3 HA visits were made during the Medicare week of 08/31/25 to 09/06/25, and no physician notification of the HA missed visit. c.   Patient #106 was admitted on 08/07/25. RN Services were ordered with frequencies of 1 time a week starting 08/07/25.  There was no documentation as to why there were no RN visits made during the Medicare week of 08/31/25 to 09/06/25, and no physician notification of the missed RN visit. d.     Patient #108 was admitted on 08/13/25. HA services were ordered with frequencies of 2 times a week starting 08/17/25. There was no documentation as to why only 1 of 2 HA visits were made during the Medicare week of 08/31/25 to 09/06/25, and no physician notification of the HA missed visit. e.   Patient #109 was admitted on 05/21/25. HA services were ordered with frequencies of 2 times a week starting 05/27/25. There was no documentation as to why only 1 of 2 HA visits were made during the Medicare week of 06/29/25 to 07/05/25, and no physician notification of the HA missed visit.f.    Patient #112 was admitted on 06/04/25. HA services were ordered with frequencies of 1 time a week starting 06/11/25. There was no documentation as to why there was no HA visits made during the Medicare week of 07/27/25 to 08/02/25, and no physician notification of the HA missed visit.g.   Patient #115 was admitted on 08/01/25. HA services were ordered with frequencies of 2 times a week starting 08/03/25. There was no documentation as to why only 1 of 2 HA visits were made during the Medicare week of 08/31/25 to 09/06/25, and no physician notification of the HA missed visit.h.  Patient #116 was admitted on 06/05/25. HA services were ordered with frequencies of 2 times a week starting 06/10/25. There was no documentation as to why only 1 of 2 HA visits were made during the Medicare week of 06/29/25 to 07/05/25, and no physician notification of the HA missed visit.i.    Patient #119 was admitted on 05/05/25. HA services were ordered with frequencies of 2 times a week starting 05/09/25. There was no documentation as to why only 1 of 2 HA visits were made during the Medicare week of 06/29/25 to 07/05/25, and no physician notification of the HA missed visit.3.   On 09/24/25 at 3:30 PM, Surveyor #1 interviewed the agency’s Chief Executive Office (Staff #113) regarding the lack of documentation and physician notification of the missed hospice services. Staff #113 acknowledged the findings and stated that most of the missed services occurred during a holiday.  In addition, Staff #113 stated that they were unable to provide documentation of why the missed services occurred and why the patient’s physician was not notified.

.Based on document review, record review, and interview the agency failed to provide bereavement services to the family and other individuals in the bereavement plan of care up to one year following the death of the patient for 1 of 4 bereavement patients (Patient #127) .Failure to provide bereavement services to the bereaved family or individuals puts them at risk of not being able to deal with their grief. --- Findings included:1. Document review of the agency’s policy titled, “Home Care Bereavement Services,” (Revised: 12/23) showed that bereavement services are provided up to 13 months following the death of the patient, and that the agency offers an organized program for the provisions of these bereavement services.2. Record review of Patient #127’s medical records showed that the patient’s date of death was 11/26/24. In addition, documentation showed that the agency attempted to contact the patient’s family member on 11/27/24, but there were no other documentation to show that the agency provided bereavement services up to the thirteen months following the date of death.3. On 09/25/25 at 10:00 AM, Surveyor #1 interviewed the agency’s Chief Executive Office (Staff #113) regarding the missed bereavement services for Patient#127’s family. Staff #113 acknowledged the findings and stated that they were unable to provide documentation as to why there were no bereavement services for 13 months for Patient #127’s bereaved family.

Based upon observations and staff interviews on September 23, 2025 between approximately 0930 and 1400 hours the facility failed to notify Department of Health, Construction Review Services regarding any construction, replacement, alterations, additions, expansions, conversion, change of approved use, improvements, remodeling, renovating and upgrading for Hospice Care Centers, licensed under chapters RCW 70.127 and WAC 246.335. --- Findings: The facility is in the process of upgrading their flooring in their resident wings. The above was discussed and acknowledged by the facility staff.

Based upon observations and staff interviews on September 23, 2025 between approximately 0930 to 1400 hours the facility has failed to maintain all means of egress continuously free of obstructions. This could inhibit the orderly exit of patients, staff, and visitors out of the building during an emergency and may prevent emergency responders from entering. --- The findings include:During the inspection it is noted that the flooring is being replaced and in the west hall wing that is currently closed off from staff and residents, the exit is obstructed by flooring material. The above was discussed and acknowledged by the facility staff.

Based upon observations and staff interviews on September 23, 2025 between approximately 0930 to 1400 hours the facility has failed to maintain doors and walls to hazardous areas. This could result in the spreading of the toxic products of combustion into the corridor in the event of a fire which would endanger patients, staff and/or visitors. --- The findings include:During the physical inspection it is noted that the fire door to the supply room was being propped open by a wedge, not allowing it to automatically close and latch. The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on September 23, 2025 between approximately 0930 to 1400 hours the facility has failed to have appropriate testing of the fire alarm system which result in the failure to notify staff of a problem with the fire alarm system. This could lead to the system not functioning as intended and lead residents, staff, and visitors within the building not being notified of a fire. --- The findings include:The facility was unable to provide documentation showing the Fire Alarm system has had the semi-annual battery discharge and visual inspection completed within the past 12 months.The facility was unable to provide documentation showing the Fire Alarm system has had a sensitivity test completed, last report on file is from October 3, 2019.The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on September 23, 2025 between approximately 0930 to 1400 hours the facility has failed to maintain the fire sprinkler system as required. This could result in the failure of the fire sprinkler system to operate properly in the event of a fire and allow the fire to increase in size and intensity which would endanger the patients, staff, and/or visitors within the facility. --- The findings include:     a. On the Western States Fire Protection annual report from 9/30/24 a dry UL test was completed on the 155 degree dry pendants, but facility was unable to provide the UL results report.     b. Facility was unable to provide documentation on the 5-year FDC hydro.      c. In the small supply closed there is fire rated caulk adhered to the fire sprinkler escutcheon. The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on September 23, 2025 between approximately 0930 to 1400 hours the facility has failed to provide fire drill records reflecting drills being conducted on all shifts for each quarter for the past 12 months. This could potentially result in the staff not responding in a coordinated manner in the event of a fire or other emergency and endangering patients, staff, and/or visitors. --- The findings include:The facility is not providing all the information on the completed fire drill documents, the time the fire drill was started and completed was missing.May 31, 2025 (day shift)--2nd quarterMarch 31, 2025 (day shift) --1st quarterThe above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on September 23, 2025 between approximately 0930 to 1400 hours the facility has failed to provide policies for the testing, repairs, and modifications of patient care related electrical equipment as required. This could result in the failure of the patient care related electrical equipment to operate properly which would endanger the patients, staff, and/or visitors within the facility. --- The findings include:The facility was unable to provide a policy/procedure for the testing, repairs and modifications of patient care related electrical equipment. The above was discussed and acknowledged by the facility staff.

Based on documentation review and staff interviews on October 5, 2022 the facility has failed to carbon monoxide detection. This could result in toxic fumes not being contained to the area of origin andcould endanger patients, staff and/or visitors. --- The findings include: The facility was unable to provide documentation of carbon monoxide alarm testing and maintenance.NFPA 101 (2012) 19.1.1.1.3, NFPA 101 4.6.1.2, NFPA 720 (2012) 9.8.1, 8.7.1. The above was discussed and acknowledged by the facility staff.

Based upon observation and staff interviews on October 5, 2022 between approximately 0800 and 1100 hours the facility has failed to maintain all means of egress continuously free of obstructions. This could inhibit the orderly exit of patients, staff, and visitors out of the building during an emergency and may prevent emergency responders from entering. --- The findings include: Emergency Exit across from Room 6 - the force required to open the door exceeded the allowable pound-force. NFPA 19.2.2.2.1, 7.2, 7.2.1.4.5. The above was discussed and acknowledged by facility staff.

Based on documentation review and staff interview on October 5, 2022 between approximately 0800 and 1100 hours the facility failed to properly maintain their gas systems. This could lead to harm of the patient if they do not receive the proper amount of gases and oxygen. --- The findings include: The facility's documentation of inspection on November 11, 2021 reflects that the oxygen manifold will bleed through from the left bank to the right bank preventing proper changeover. The system will not alarm at the master panel when switching from the left bank to the right bank. NFPA 99 5.1.9.2.4 The facility's documentation of inspection on November 11, 2021 reflects that the left header shutoff valve on the oxygen manifold leaks when being turned off. NFPA 99 5.1.12.2.3.6 The above was discussed and acknowledged by the facility staff.

Based on documentation review, observation and staff interview on October 5, 2022 between approximately 0800 and 1100 hours the facility has failed to maintain the emergency generator in accordance with NFPA 110. This could result in a failure of the emergency power system which would leave the facility without generator power in the event of a power failure which would endanger the patients, staff and/or visitors within the facility. --- The findings include: The facility was unable to provide documentation of a secondary fuel on site for the generator powered by City of Spokane natural gas utility. NFPA 110 5.1.2 The above was discussed with facility staff.

Based on documentation review and staff interviews on October 5, 2022 between approximately 0800 and 1100 hours the facility has failed to provide policies for the testing, repairs, and modifications of patient care related electrical equipment as required. This could result in the failure of the patient care related electrical equipment to operate properly which would endanger the patients, staff, and/or visitors within the facility. --- The findings include: The facility was unable to provide a complete inventory of patient care related electrical equipment, including testing dates. NFPA 99 1.1.1, 10.5.6.2.1 The facility was unable to provide documentation of qualifications and continued training for facility personnel performing testing and maintenance on patient care related electrical equipment.NFPA 99 1.1.1, 10.5.8.1.1, 10.5.8.3. The facility was unable to provide a policy for testing and repairs of patient care related electrical equipment. NFPA 99 1.1.1, 10.5.2.1.2 The above was discussed and acknowledged by facility staff.

Based on documentation review, observation and staff interview on October 5, 2022 between approximately 0800 and 1100 hours the facility has failed to provide documentation of personnel concerned with the application, maintenance, and handling of medical gases and cylinders that are trained on the risk and provide continuing education. Failure to provide training and continuing education on the safe handling and use of gases and cylinders could place patients, visitors and staff at risk of oxygen malfunctions. --- The findings include: The facility was unable to provide documentation of training for medical gas equipment use. The above was discussed and acknowledged by facility staff.