Every finding on record at Partners in Care, Inc.

Based on observation, interview, and document review, it was determined the agency failed to ensure direct patient care staff followed accepted standards of practice for the prevention of infection transmission for 1 of 6 home visits. --- Findings: Home Visit #1: Observation of a home visit on 8/15/2024 at 8:00 AM revealed Employee #14 provided bed bath to Patient #22. Review of Patient #22's record titled "HOSPICE PLAN OF CARE" revealed start of care date of 02/09/2024 with "Principal Diagnosis" of "Degenerative disease of basal ganglia, unspecified" and "Pertinent Diagnoses" of "Personal history of urinary (tract) infections." Observation of a home visit revealed, during bed bath after washing Patient #22's face with a washcloth, Employee #14 washed Patient #22's left arm and left leg using a soapy washcloth. Employee #14 then dried left arm and axillae with a towel then applied lotion without rinsing or changing gloves. Similar technique was used by Employee #14 to clean Patient #22's right arm and right leg. Observation also revealed, Employee #14 took a clean wipe and soaked it in the same dirty soapy water used to clean Patient #22's upper and lower extremities and wiped Patient #22's perineum. Employee #14 failed to use clean water for the perineum area. Review of the undated hospice policy titled "HAND HYGIENE," revealed under "Procedure" the following statement: "Hand decontamination using an alcohol-based hand rub should be performed: ...C. After contact with a patient's intact skin... D. After contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings, if hands are not visibly contaminated. E. When moving from a contaminated body site to a clean body site during patient care. F. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. G. After removing gloves." During an interview via telephone call with Employee #15 on 8/19/2024, beginning at 8:40 AM, the above findings were presented. Employee #15 acknowledged the findings.

Based on document review and interview during the survey, it was determined through on-going dialog with the Hospice House Manager, Quality Manager and Support Services Manager that the facility failed to comply with Federal, State and local EP requirements to establish and maintain a comprehensive EP program (CFR 42 Part 418.113(a)(3)). Findings include: On 8/22/2024, during record review between 9:25 am and 11:00 am, the facility failed to provide documentation within their written EP Plan that addressed patient/client population, including patients at risk and the types of services the facility has the ability to provide in an emergency. Surveyor was accompanied by the Hospice House Manager, Quality Manager and Support Services Manager who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Hospice House Manager and Support Services Manager that the facility failed to install proper hold-open devices that will release on the actuation of the fire alarm system, fire sprinkler system or power loss for the entire building. This resulted in the potential for smoke and fire to spread to other areas of the facility (LSC 7.2.1.8.2, 19.2.2.2.7, 19.2.2.2.8). Findings include: On 8/22/2024 at 12:41 pm, the door closer on the Soiled Utility Door was missing which did not allow the door to automatically close and latch as required. Surveyor was accompanied by the Hospice House Manager and Support Services Manager who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Hospice House Manager and Support Services Director that the facility failed to maintain/construct at least a 1-hour fire resistance rated smoke barrier for 1 of 3 sampled smoke compartments of the building. This resulted in the potential for the spread of fire/smoke to other smoke compartments (LSC 19.3.7.3, 19.3.7.4, 19.3.7.5 8.3, and 8.5). Findings include: On 8/22/2024 at 12:34 pm, there were multiple openings/penetrations in the ceiling of the mechanical room greater than 1/4 inch that would allow for the spread of smoke or fire to other areas of the facility. Surveyor was accompanied by the Hospice House Manager and Support Services Manager who acknowledged the existence of these conditions.

Based on observations, interviews and record review during the survey, it was determined through on-going dialog with the Hospice House Manage and the Support Services Manager that the facility failed to provide fire drills for all staff affecting the entire building. This resulted in the potential for inadequate staff knowledge during fire emergencies, potentially exposing residents to smoke and fire in the facility (LSC 19.7.1.4 - 19.7.1.7). Findings include: On 8/22/2024, during record review between 11:00 am and 12:00 pm, facility documentation presented to the surveyor by the facility showed that fire drills for day and night shifts in 2023 and 2024 were not completed at random time throughout the shifts. Fire drills for day shift were conducted at 11:30 am, 1:30 pm, 11:20 am and 11:00 am; fire drills for night shift were conducted at 9:01 pm, 9:13 pm, 9:10 pm, and 9:02 pm which demonstrates that fire drills were conducted in a manner that created a pattern, instead of at different times throughout the shifts. Surveyor was accompanied by the Hospice House Manager and Support Services Manager who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Hospice House Manager and Support Services Director that the facility failed to ensure that that electrical wiring & equipment was used/maintained and in accordance with NFPA 70 for 1 of 3 sampled smoke compartments of the building. This resulted in the potential for injury to patients and staff (LSC 9.1.2, NFPA 99 10.2.3.6, 10.2.4, NFPA 70, TIA 12-5). Findings include: On 8/22/2024, at 12:36 pm, there was a washer and dryer in the Laundry Room plugged into a multiplex outlet extender and not directly into the wall which could overload and short the circuit. Surveyor was accompanied by the Hospice House Manager and Support Services Manager who acknowledged the existence of these conditions.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Acting Facility Administrator, Director of Nursing Services, Support Services Director, and Maintenance Director that the facility failed to comply with Federal, State and local EP requirements to establish and maintain a comprehensive EP program (CFR 42 Part 483.73(a)(1)-(2)). Findings include: On 01/04/2022, during documentation review between the hours of 11:35 am and 12:30 pm, the facility failed to provide to this surveyor the necessary documentation sufficiently outlining both a facility-based and community-based risk assessment, utilizing an all-hazards approach. Surveyor was accompanied by the Facility Administrator, Director of Nursing Services, Support Services Director, and Maintenance Director who acknowledged the existence of these findings.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Facility Administrator, Director of Nursing Services, Support Services Director, and Maintenance Director that the facility failed to comply with Federal, State and local EP requirements to establish and maintain a comprehensive EP program (CFR 42 Part 483.73(b)). Findings include: On 01/04/2022, during documentation review between the hours of 11:35 am and 12:30 pm, the facility failed to develop and implement EP policies and procedures, based on their reported all-hazards and vulnerability assessment within their established and communicated plan. Surveyor was accompanied by the Facility Administrator, Director of Nursing Services, Support Services Director, and Maintenance Director who acknowledged the existence of these findings.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Facility Administrator, Director of Nursing Services, Support Services Director, and Maintenance Director that the facility failed to comply with Federal, State and local EP requirements to establish and maintain a comprehensive EP program (CFR 42 Part 483.73(b)(1)). Findings include: On 01/04/2022, during documentation review between the hours of 11:35 am and 12:30 pm, the facility failed to provide to this surveyor evidence of a secure and stable patient environment in the event of an elongated emergency, to include: (1)(i) defined policies and/or protocols for medical, and pharmaceutical supplies of staff, and (D) sewage and/or waste disposal capable of supporting the length of time the facility has chosen to shelter-in-place, as identified within the facility's EP plan. Surveyor was accompanied by the Facility Administrator, Director of Nursing Services, Support Services Director, and Maintenance Director who acknowledged the existence of these findings.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Facility Administrator, Director of Nursing Services, Support Services Director, and Maintenance Director that the facility failed to comply with Federal, State and local EP requirements to establish and maintain a comprehensive EP program (CFR 42 Part 483.73(b)(6)). Findings include: On 01/04/2022, during documentation review between the hours of 11:35 am and 12:30 pm, the facility failed to define the roles of volunteers in the event of an emergency including, but not limited to, a process for integration of State and federally designated health care professionals to address surge needs during an emergency. Surveyor was accompanied by the Facility Administrator, Director of Nursing Services, Support Services Director, and Maintenance Director who acknowledged the existence of these findings.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Facility Administrator, Director of Nursing Services, Support Services Director, and Maintenance Director that the facility failed to comply with Federal, State and local EP requirements to establish and maintain a comprehensive EP program (CFR 42 Part 483.73(b)(8)). Findings include: On 01/04/2022, during documentation review between the hours of 11:35 am and 12:30 pm, the facility failed to provide evidence of its defined role under a waiver declared by the Secretary of State, in accordance with section 1135 of the Stafford Act, in the provision of care and treatment at its facility, or an alternate care site, as identified by emergency management officials. Surveyor was accompanied by the Facility Administrator, Director of Nursing Services, Support Services Director, and Maintenance Director r who acknowledged the existence of these findings.