Every finding on record at Passages, LLC

Based on interview and record reviews, the Hospice agency’s IDG failed to ensure the completion of the Chaplain’s Initial Comprehensive Assessment within 5 days after the Election of Hospice Benefits for 1 (#13) of 18 (#6 through #23) live patients reviewed in the sample. --- Review of Patient #13’s Clinical Record revealed he was admitted to the agency and signed his Election of Hospice Benefits on 03/19/2025.  Further review revealed a current Certification Period of 03/19/2025 through 06/16/2025.  Review of Patient #13’s Physician Orders and Plan of Care for the Certification Period of 03/19/2025 through 06/16/2025 revealed, in part, an order written on 03/19/2025 for Chaplain Visits once a week and 10 as needed.  Review of Patient #13’s RN Admission Assessment, dated 03/19/2025, revealed, in part, Services Needed: Chaplain.  Review of Patient #13’s Chaplain Visit Calendar and Chaplain Service Notes, dated 03/19/2025 through 03/23/2025, revealed no documented evidence of the visit being attempted, refused or performed within the required timeframe.  An interview was conducted on 05/05/2025 at 5:12 p.m. with S2DON.  S2DON confirmed the Chaplain was a Core Service and was required to perform an Initial Visit/Assessment for newly admitted patients within 5 days of their admission to the Hospice agency.  S2DON reviewed Patient #13’s Clinical Record and confirmed he did not receive an initial Chaplain Visit for assessment within the required timeframe and should have.

Based on interview and record reviews, the Hospice agency’s IDG failed to ensure the completion of the Initial Spiritual Assessment within 5 days after the Election of Hospice Benefits for 1 (#13) of 18 (#6 through #23) live patients reviewed in the sample. --- Review of Patient #13’s Clinical Record revealed he was admitted to the agency and signed his Election of Hospice Benefits on 03/19/2025.  Further review revealed a current Certification Period of 03/19/2025 through 06/16/2025.  Review of Patient #13’s Physician Orders and Plan of Care for the Certification Period of 03/19/2025 through 06/16/2025 revealed an order written on 03/19/2025 for Chaplain Visits once a week and 10 as needed.  Review of Patient #13’s RN Admission Assessment, dated 03/19/2025, revealed, in part, the following: Services Needed: ChaplainHospice SN Mini Spiritual Assessment: Are you part of a faith based or Spiritual Community: No. Do you have any spiritual beliefs that need to be in the care we provide? Blank. What is important to you at end of life? Blank. Further review revealed no documented evidence of any additional Spiritual Assessment information.  Review of Patient #13’s MSW Admission Assessment, dated 03/20/2025, revealed, in part, no documented evidence of a Spiritual Assessment. Review of Patient #13’s Chaplain Visit Calendar and Chaplain Service Notes, dated 03/19/2025 through 03/23/2025, revealed no documented evidence of the visit being attempted and refused or performed within the required timeframe.  Further review revealed no documented evidence of the Spiritual Assessment within the required timeframe.  An interview was conducted on 05/05/2025 at 5:12 p.m. with S2DON.  S2DON confirmed she expected all required sections of a patient’s Initial Comprehensive Assessment to be completed within 5 days of admission to the Hospice agency.  S2DON reviewed Patient #13’s Clinical Record and confirmed his Initial Spiritual Assessment was not completed within the required timeframe and should have been.

Based on interview and record reviews, the Hospice agency failed to ensure the completion of the Initial Bereavement Assessment within 5 days after the Election of Hospice Benefits for 1 (#13) of 18 (#6 through #23) live patients reviewed in the sample. --- Review of the Hospice agency’s undated Bereavement Assessment Policy, as of 05/05/2025, revealed, in part, the following: Purpose: To provide guidance for the assessment and reassessment of the bereavement needs of family/caregivers. Procedure: 1.  On admission, the MSW or RN will complete a Bereavement Risk Assessment that will be given to the Bereavement Coordinator.  Review of Patient #13’s Clinical Record revealed he was admitted to the agency and signed his Election of Hospice Benefits on 03/19/2025.  Further review revealed a current Certification Period of 03/19/2025 through 06/16/2025.  Review of Patient #13’s Physician Orders and Plan of Care for the Certification Period of 03/19/2025 through 06/16/2025 revealed in part, the following:Care Need: Bereavement (added 03/20/2025 by the RN);Goal: Family/caregiver will grieve appropriately; and Intervention: Establish Bereavement Plan of Care.Review of Patient #13’s Assessments by the RN, MSW and Chaplain, dated 03/19/2025 through 03/23/2025, revealed, in part, no documented evidence of an Initial Bereavement Assessment.  An interview was conducted on 05/05/2025 at 5:12 p.m. with S2DON.  S2DON confirmed she expected all required sections of a patient’s Initial Comprehensive Assessment to be completed within 5 days of admission to the Hospice agency and per their policy, the Initial Comprehensive Assessment included an Initial Bereavement Assessment.  S2DON reviewed Patient #13’s Clinical Record and confirmed his Initial Bereavement Assessment was not completed within the timeframe and should have been.

Based on record reviews and interviews, the Hospice agency failed to ensure licensed professionals actively participated in all aspects of the patient’s hospice care in accordance with current professional standards.  The agency failed to ensure a patient’s medical pronouncement of death by a coroner was based on personal observation or information and statements obtained from a qualified professional for 2 (#3 and #4) of 3 (#3, #4 and #5) death records reviewed. --- Review of Louisiana Revised Statute (LA RS) 9:111 revealed, in part, the following: A. A person will be considered dead if in the announced opinion of a physician, duly licensed in the state of Louisiana based on ordinary standards of approved medical practice, the person has experienced an irreversible cessation of spontaneous respiratory and circulatory functions….B. The medical pronouncement of death by a coroner may also be based on personal observation, information, or statements obtained from coroner investigators, Registered Nurses, physician assistants, or emergency medical technicians at the scene who are reporting from firsthand observation of the physical condition of the deceased. …Review of the Hospice agency’s undated Death Policy, as of 05/05/2025, revealed, in part, the following: Procedure: 4.  The nurse will notify the attending physician of the patient’s death.  It will be the attending physician’s responsibility to pronounce death (depending on state regulations coroner).  5.  All deaths will be reported to the medical coroner or appropriate legal entity per state regulations.  11.  The nurse will document all of the above interventions and any other significant information regarding the death in the patient’s record.  Patient #3Review of Patient #3’s Clinical Record revealed a Start of Care Date of 08/20/2024 with a Certification Period of 08/20/2024 through 11/17/2024 and a date of death of 09/04/2024.  Review of Patient #3’s LPN Death Visit, dated 09/04/2024, revealed, in part, the following: Death Visit Performed by: S3LPNTime In: 3:25 p.m.Time Out: 4:25 p.m.Death Pronounced by: S3LPNNarrative: No signs of life on assessment.  Patient pronounced deceased at 3:30 p.m.  Phone call to the local Coroner with release number received.  Review of Patient #3’s Clinical Record, dated 08/20/2024, revealed no documentation indicating an RN or other qualified professional was present to perform the death assessment.Patient #4Review of Patient #4’s Clinical Record revealed a Start of Care Date of 05/13/2024 with a Certification Period of 05/13/2024 through 08/10/2024 and a date of death of 05/23/2024.  Review of Patient #4’s LPN Death Visit, dated 05/23/2024, revealed, in part, the following: Death Visit Performed by: S4LPNTime In: 8:55 p.m.Time Out: 9:45 p.m.Death Pronounced by: S4LPNNarrative: Physical Assessment Findings: Pupils fixed, respirations ceased, no palpable pulse, no palpable blood pressure.  Patient pronounced deceased at 3:30 p.m.  Phone call to the local Coroner.  Review of Patient #4’s Clinical Record, dated 05/23/2024, revealed no documentation indicating an RN or other qualified professional was present to perform the death assessment.An interview was conducted on 05/05/2025 at 5:12 p.m. with S2DON.  S2DON confirmed the agency’s process upon death was for a nurse, either LPN or RN, to perform a death assessment to ensure the absence of vital signs then contact the coroner or the patient’s physician by phone to receive pronouncement of death and release of the body.  S2DON confirmed she was not aware of LA RS 9:111 which prevented an LPN from performing a patient’s death visit assessment on behalf of the coroner or the patient’s physician.  S2DON reviewed Patient #3 and #4’s Clinical Records and confirmed an LPN performed their death assessments and should not have.

Based on interviews and record reviews, the Hospice agency failed to ensure nursing services met the needs of the patients for 1 (#9) of 4 (#9, #15, #18, and #19) patients reviewed for pressure wounds. The Hospice agency failed to follow acceptable standards of practice for wound care specifically for complete wound assessments and weekly wound measurements by an RN, including the size and stage of the wounds for Patient #9. --- Review of the Louisiana State Board of Nursing Declaratory Statement Scope of Practice for Registered Nurses - Wound Care Management adapted 02/1999 revealed the following in part: Registered nurses render care that is directed towards the prevention and treatment of wounds. Wounds are a common health care challenge that often occur with or result from chronic disorders such as impaired circulation and malnutrition. Nursing care of skin/wound conditionsinvolves the identification, assessment, management, and ongoing evaluation of patients with alterations in skin/tissue integrity that includes but is not limited to draining wounds, pressure ulcers, and vascular ulcers, and conditions resulting from incontinence, surgical procedures, and/or trauma.Scope of Practice - The Louisiana State Board of Nursing recognizes that assessment, planning,intervention, teaching, evaluation, and supervision are the major responsibilities of the registered nurse in the practice setting. The registered nurse is responsible for performing a nursing assessment and physical examination for preventative and restorative nursing and for providing patient/family teaching. Recognizing that the physician must always prescribe wound care, the following roles are defined to delineate the scope of practice for each member of the nursing team members. The registered nurse initiates appropriate wound preventative measures, stages wounds and collaborates with the wound care team in the implementation and evaluation of nursing interventions as prescribed by an authorized prescriber.Review of the National Pressure Ulcer Advisory Panel Prevention and Treatment of Pressure Ulcers: Quick Reference Guide revealed, in part, the following:Pressure Ulcer Assessment 1. Assess the pressure ulcer initially and re-assess it at least weekly.1.1. Document the results of all wound assessments. Assess and document physical characteristics including: location, Category/Stage, size, tissue type(s), color, peri-wound condition, wound edges, sinus tracts, undermining, tunneling, exudate, and odor.Review of the Hospice agency’s undated Wound and Skin Care Management Policy, as of 05/05/2025, revealed, in part, the following: Documentation: Accurately document all wound assessments, interventions, and patient response to treatment in the medical record and weekly measurements.  Review of the Hospice agency’s Current Wound Log, as of 04/28/2025, revealed, in part, Patient #9 was receiving treatment for active wounds.  Review of Patient #9’s Clinical Record revealed she was admitted to the Hospice agency on 11/01/2024 with a current Certification Period of 01/30/2025 through 04/29/2025.  Further review revealed she was currently receiving treatment for a Stage 2 Pressure Wound to the Coccyx (identified on 01/03/2025) and an Unstageable Pressure Wound to the Left Calf (identified on 01/03/2025).  Review of Patient #9’s Physician’s Orders and Plan of Care for the current Certification Period revealed, in part, the following:01/30/2025 - SNV once weekly for one week;02/02/2025 - SNV twice weekly for twelve weeks; and 04/27/2025 – SNV once weekly for one week.   Review of Patient #9’s SNV Assessment and Coordination Notes for the current Certification Period revealed, in part, the following:Wound #1: Stage2 Pressure Wound to the Coccyx:02/03/2025 – No measurements and description documented by RN;02/17/2025 – No measurements and description documented by RN;03/03/2025 – No measurements and description documented by RN;03/10/2025 – No measurements and description documented by RN;03/17/2025 – No measurements and description documented by RN;03/31/2025 – No measurements and description documented by RN;04/14/2025 – No measurements and description documented by RN; and 04/22/2025 – No measurements and description documented by RN.Wound #2: Unstageable Pressure Wound to the Left Calf:02/03/2025 – No measurements and description documented by RN;02/17/2025 – No measurements and description documented by RN;03/03/2025 – No measurements and description documented by RN;03/10/2025 – No measurements and description documented by RN;03/17/2025 – No measurements and description documented by RN;03/31/2025 – No measurements and description documented by RN;04/14/2025 – No measurements and description documented by RN; and 04/22/2025 – No measurements and description documented by RN.An interview was conducted on 04/30/2025 at 9:45 a.m. with S5RN.  S5RN stated wounds should be measured and documented by an RN every week.  S5RN confirmed wound measurements and descriptions were only documented within the RN’s SNV Assessment and would not be located anywhere else within the Clinical Record.  An interview was conducted on 05/05/2025 at 5:12 p.m. with S2DON.  S2DON confirmed she expected wounds to be measured, assessed and documented by an RN every 7 days and it was not for Patient # 9.

Based on record review and interview, the Hospice agency failed to ensure the RN conducted an on-site HA Supervisory visit at least every 14 days to assess the quality of care and services provided by the HA for 1 (#12) of 18 (#6 through #23) live patients in the sample. --- Review of the Hospice agency’s undated HA Services Policy, as of 05/05/2025, revealed, in part, HA services will be supervised by the RN every 14 days to assess relationships and goals.  Review of Patient #12’s Clinical Record revealed he was admitted to the agency on 10/24/2023.  Review of Patient #12’s Physician’s Orders and Plan of Care revealed, in part, the following: Certification Period: 02/15/2025 through 04/15/2025 – HA Visits to be performed three times weekly for 8 weeks then once a week for one week; and Certification Period: 04/16/2025 through 06/14/2025 – HA Visits to be performed three times a week for 1 week then 5 times weekly for 8 weeks.  Review of Patient #12’s Visit Calendar and HA Service Notes, dated 02/15/2025 through 05/05/2025, revealed, in part, HA Visits were conducted from 02/15/2025 through 05/05/2025.  Further review revealed 54 HA Visits were conducted by S6HA on the following dates: 02/17/2025, 02/18/2025, 02/19/2025, 02/20/2025, 02/21/2025, 02/24/2025, 02/25/2025, 02/26/2025, 02/27/2025, 02/28/2025; 03/03/2025, 03/05/2025, 03/06/2025, 03/07/2025, 03/10/2025, 03/11/2025, 03/12/2025, 03/13/2025, 03/14/2025, 03/17/2025, 03/18/2025, 03/19/2025, 03/20/2025, 03/21/2025, 03/24/2025, 03/25/2025, 03/26/2025, 03/27/2025, 03/28/2025, 03/31/2025; 04/01/2025, 04/02/2025, 04/03/2025, 04/04/2025, 04/07/2025, 04/08/2025, 04/09/2025, 04/10/2025, 04/11/2025, 04/14/2025, 04/15/2025, 04/16/2025, 04/17/2025, 04/21/2025, 04/22/2025, 04/23/2025, 04/24/2025, 04/25/2025, 04/28/2025, 04/29/2025, 04/30/2025; and 05/01/2025, 05/02/2025, 05/05/2025.  Review of Patient #12’s RN Service Notes, dated 02/15/2025 through 05/05/2025, revealed, in part, no documented evidence of on-site HA Supervisory Visits performed by the RN from  02/19/2025 through 04/01/2025 and/or 04/03/2025 through 05/05/2025.   An interview was conducted on 05/05/2025 at 5:12 p.m. with S2DON.  S2DON confirmed she expected HA Supervisory Visits to be performed by an RN every 14 days.  S2DON reviewed Patient #12’s Clinical Record and confirmed there were no HA Supervisory Visits performed from 02/19/2025 through 04/01/2025 and/or 04/03/2025 through 05/05/2025 and should have been.

Based on record review and interview, the Hospice Agency failed to ensure volunteers provided day-to-day administrative and/or direct patient care services in an amount that, at a minimum, equaled 5% of the total patient care hours of all paid hospice employees. --- Review of the Hospice agency’s Volunteer Services Cost Savings Report, dated 01/01/2024 through 05/05/2025, revealed they did not meet the annual volunteer requirements of 5% of the total patient care hours of all paid hospice employees.  An interview was conducted on 05/06/2025 at 3:45 p.m. with S1ADM.  S1ADM provided documentation for the Hospice agency’s volunteer service hours performed from 01/01/2024 through 05/05/2025 and confirmed the hours did not meet the 5% requirement and should have.

Based on interviews and record review, the Hospice agency failed to ensure Discharge Orders were obtained from the Medical Director prior to the discharge of a patient for 2 of 2 (#1 and #2) patients reviewed for discharge. --- Patient #1Review of Patient #1’s Clinical Record revealed he was admitted to the Hospice agency on 12/13/2024 and discharged for cause on 01/17/2025.  Review of Patient #1’s Physician Orders and Plan of Care, dated 12/13/2024 through 01/17/2025, revealed no order written by the Medical Director to discharge the patient.    Patient #2Review of Patient #2’s Clinical Record revealed he was admitted to the Hospice agency on 01/09/2025 and discharged for cause on 03/28/2025.  Review of Patient #2’s Physician Orders and Plan of Care, dated 01/09/2025 through 03/28/2025, revealed no order written by the Medical Director to discharge the patient.    An interview was conducted on 04/29/2025 at 3:23 p.m. with S2DON.  S2DON confirmed prior to a patient’s discharge, she expected the patient’s nurse to obtain an order from their Medical Director to discharge the patient then add the order to the patient’s EHR.  S2DON reviewed Patient #1 and #2’s Clinical Record and confirmed neither contained written discharge orders by the Medical Director to discharge the patients from the Hospice agency and should have.

Based on record review and interview the facility failed to ensure medication was administered as ordered for 1 of 5 sampled patients (Patient #1) reviewed for pharmaceutical services. Findings: Review of Patient #1's Physician Progress Notes dated 06/09/2022 revealed Patient #1 with senile degeneration of brain and cervical (spinal cord) fractures. Further revealed titrate medications as needed; increase Fentanyl (narcotic/pain patch) patch today. Review of Patient #1's Physician Orders dated 06/09/2022 revealed Fentanyl patch 25mcg (micrograms) apply one patch transdermal (patch to the skin) every 72 hours. Review of Patient #1's Nurses Notes dated 06/09/2022 at 12:25pm revealed the nurse applied Patient #1's increased Fentanyl 25mcg patch. Review of Patient #1's MAR (Medication Administration Record) for June 2022 revealed Patient #1's Fentanyl 25mcg patch was to change every 3 days with administration time ordered for 12:30pm. Further review revealed the Fentanyl patch was changed on 06/09/2022 and then changed on 06/12/2022 by SRN (a night shift nurse). Review of Patient #1's Nurses Notes dated 06/12/2022 at 8:00pm revealed Patient #1's Fentanyl 25mcg patch was applied. In an interview on 08/10/2022 at 3:38pm, S2ADON (Assistant Director of Nursing) stated with the review of Patient #1's MAR and the facility's Controlled Substance Sheets the facility was able to confirm Patient #1 did not have her Fentanyl patch replaced during the day shift as ordered.

Based on record review and interview the facility failed to have evidence of staff competencies for staff providing direct patient care for 5 of 5 sampled direct care staff (S4RN (Registered Nurse), S5RNAuditor, S6CNA (Certified Nursing Assistant), S7RN, and S8RN) reviewed for staff competency. Findings: Review of S4RN's Personnel File revealed a date of hire of 08/22/2017. Further review revealed no documented evidence and, the facility presented no documented evidence of S4RN had professional skills competency assessed. Review of S5RN/Auditor's Personnel File revealed a date of hire of 04/16/2021. Further review revealed no documented evidence and, the facility presented no documented evidence of S5RN/Auditor had professional skills competency assessed. Review of S6CNA's Personnel File revealed a date of hire of 04/06/2022. Further review revealed no documented evidence and, the facility presented no documented evidence of S6CNA had professional skills competency assessed. Review of S7RN's Personnel File revealed a date of hire of 05/24/2022. Further review revealed no documented evidence and, the facility presented no documented evidence of S7RN had professional skills competency assessed. Review of S8RN's Personnel File revealed a date of hire of 11/19/2021. Further review revealed no documented evidence and, the facility presented no documented evidence of S8RN had professional skills competency assessed. In an interview on 08/10/2022 at 3:06pm, S3Assistant Administrator stated the facility had no documented evidence of staff competencies having been assessed.

Based on record review and interview the facility failed to ensure the facility had documented clinical notes for care and services provided by the nursing staff for 1 of 5 sampled patients (Patient #1) reviewed for care and services provided as ordered. Findings: Review of Patient #1's record revealed no documented evidence and the facility presented no documented evidence of documentation of the care and services provided to Patient #1 by nursing staff on 06/12/2022 from 7:00am to 7:00pm. In an interview on 08/10/2022 at 3:38pm, S1Administrator stated the facility had no documented evidence of the care and services provided on 06/12/2022 from 7:00am to 7:00pm.

Based on visual observation the facility failed to assure the construction of fire barriers walls. The walls are required to be continuous and properly protected from penetrations and gaps. Unprotected penetrations would permit the movement of smoke/fire rapidly from one compartment to the other within the facility. The deficient practice has the potential to affect seven of seven patients. Findings: During the facility tour on June 9, 2022 between the hours of 10:00 a.m. to 12:45 p.m. and June 10, 2022 between the hours of 6:30 a.m. to 8:00 a.m. the two hour fire barrier separation between the business occupancy and the healthcare occupancy had several penetrations in the attic area and the HVAC refrigerant pipe was lacking the proper two hour rated fire stopping material. Additionally, the ninety minute hinged single leaf door located in the two hour fire barrier providing access to the sprinkler riser room did not self close properly. NFPA 101:8.3.1.1 Fire barriers used to provide enclosure, subdivision, or protection under this Code shall be classified in accordance with one of the following fire resistance ratings: (1) 3-hour fire resistance rating (2) 2-hour fire resistance rating (3) 1-hour fire resistance rating (4)*1/2-hour fire resistance rating NFPA 101:8.3.1.2* Fire barriers shall comply with one of the following: (1) The fire barriers are continuous from outside wall to outside wall or from one fire barrier to another, or a combination thereof, including continuity through all concealed spaces, such as those found above a ceiling, including interstitial spaces. (2) The fire barriers are continuous from outside wall to outside wall or from one fire barrier to another, and from the floor to the bottom of the interstitial space, provided that the construction assembly forming the bottom of the interstitial space has a fire NFPA 101:8.3.5 Penetrations. The provisions of 8.3.5 shall govern the materials and methods of construction used to protect through-penetrations and membrane penetrations in fire walls, fire barrier walls, and fire resistance-rated horizontal assemblies. The provisions of 8.3.5 shall not apply to approved existing materials and methods of construction used to protect existing through-penetrations and existing membrane penetrations in fire walls, fire barrier walls, or fire resistance-rated horizontal assemblies, unless otherwise required by Chapters 11 through 43. NFPA 101: 8.3.5.1 Firestop Systems and Devices Required. Penetrations for cables, cable trays, conduits, pipes, tubes, combustion vents and exhaust vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a firestop system or device. The firestop system or device shall be tested in accordance with ASTM E 814, Standard Test Method for Fire Tests of Through Penetration Fire Stops, or ANSI/UL 1479, Standard for Fire Tests of Through- Penetration Firestops, at a minimum positive pressure differential of 0.01 in. water column (2.5 N/m2) between the exposed and the unexposed surface of the test assembly. The interview with the maintenance director revealed the facility was not aware of the penetrations in the fire barrier nor the ninety minute fire door was not working properly..

Based on visual observation the facility failed to assure that the fire alarm system was inspected and tested in accordance with the approved maintenance and testing program in NFPA 72. The fire alarm system gives a sense of security to offer an advance warning in fire and/or smoke emergency. This deficient practice could potentially affect seven of seven patients. Findings: During the facility tour on June 9, 2022 between the hours of 10:00 a.m. to 12:45 p.m. and June 10, 2022 between the hours of 6:30 a.m. to 8:00 a.m. the fire alarm lacked a annual certification from a licensed fire alarm company. NFPA 72: 10.3.2 System components shall be installed, tested, and maintained in accordance with the manufacturer's published instructions and this Code. NFPA 72:10.4.1.2 State or local licensure regulations shall be followed to determine qualified personnel. Depending on state or local licensure regulations, qualified personnel shall include, but not be limited to, one or more of the following: (1) Personnel who are registered, licensed, or certified by a state or local authority. LAC 55:V:3033. Fixed Fire Suppression and Fire Detection and Alarm Systems and Equipment... B. All existing required fixed fire suppression systems including kitchen, pre-engineered and engineered systems, and fire detection and alarm systems shall be certified, hydrostatically tested, inspected, integrated, maintained and serviced in an operational condition in accordance with the manufacturer's installation manuals, specifications, and per the inspection, testing and maintenance chapters of the applicable codes and standards adopted in L.A.C.55:V.103 or noted in these rules. LRS 40:1646 (A)(B)(C) The fire marshal is authorized to cause the inspection and testing of all life safety systems and equipment in the state, whether in public or private buildings, during installation or immediately after installation to determine compliance with applicable standards. The owner of any building containing a life safety system and equipment shall cause at a minimum an annual inspection to be made of the life safety system and equipment in that building to assure compliance with applicable safety standards and to determine whether structural changes in the building or in the contents of the building mandate alteration of a system. Life safety systems and equipment includes but is not limited to fire sprinkler, fire alarm, fire suppression, special locking systems and equipment, and portable fire extinguishers. NFPA 72: 14.4.4.3* In other than one- and two-family dwellings, sensitivity of smoke detectors shall be tested in accordance with 14.4.4.3.1 through 14.4.4.3.7. NFPA 72: 14.4.4.3.1 Sensitivity shall be checked within 1 year after installation. NFPA 72: 14.4.4.3.2 Sensitivity shall be checked every alternate year thereafter unless otherwise permitted by compliance with 14.4.4.3.3. NFPA 72: 14.4.4.3.3 After the second required calibration test, if sensitivity tests indicate that the device has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. The interview with the facility director revealed the facility was not aware that the required inspections had not been conducted on the fire alarm system and was acknowledged by the Administrator.

Based on visual observation the facility failed to assure that the sprinkler system system was inspected and tested in accordance with the approved maintenance and testing program in NFPA 25. The fire alarm system gives a sense of security to offer an advance warning in fire and/or smoke emergency. This deficient practice could potentially affect seven of seven patients. Findings: During the facility tour on June 9, 2022 between the hours of 10:00 a.m. to 12:45 p.m. and June 10, 2022 between the hours of 6:30 a.m. to 8:00 a.m. the sprinkler system was lacking a annual certification from a licensed sprinkler company and the quarterly inspection documentation was lacking for the last year. NFPA 25:4.3.1* Records shall be made for all inspections, tests, and maintenance of the system and its components and shall be made available to the authority having jurisdiction upon request. NFPA 25:4.3.2 Records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date. NFPA 25:4.3.3* Records shall be maintained by the property owner. LAC 55:V:3033. Fixed Fire Suppression and Fire Detection and Alarm Systems and Equipment... B. All existing required fixed fire suppression systems including kitchen, pre-engineered and engineered systems, and fire detection and alarm systems shall be certified, hydrostatically tested, inspected, integrated, maintained and serviced in an operational condition in accordance with the manufacturer's installation manuals, specifications, and per the inspection, testing and maintenance chapters of the applicable codes and standards adopted in L.A.C.55:V.103 or noted in these rules. LRS 40:1646 (A)(B)(C) The fire marshal is authorized to cause the inspection and testing of all life safety systems and equipment in the state, whether in public or private buildings, during installation or immediately after installation to determine compliance with applicable standards. The owner of any building containing a life safety system and equipment shall cause at a minimum an annual inspection to be made of the life safety system and equipment in that building to assure compliance with applicable safety standards and to determine whether structural changes in the building or in the contents of the building mandate alteration of a system. Life safety systems and equipment includes but is not limited to fire sprinkler, fire alarm, fire suppression, special locking systems and equipment, and portable fire extinguishers. Actual NFPA Standard: NFPA 25 (2011) Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection System NFPA 25:5.1.1.2 Table 5.1.1.2 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance. (Quarterly inspections) The sprinkler system was lacking a annual certification from a licensed sprinkler company and the quarterly inspection documentation was lacking for the last year.

Based on visual observation and record review the facility failed to maintain documentation for fire drills conducted during each quarter on each shift. Fire drills provide training in procedures in cases of emergency. The deficient practice had the potential to affect seven of seven residents. There were four of the four quarters in the year 2021 thru 2022 were that deficient. This deficient practice could potentially affect seven of seven patients. Findings: During the facility tour on June 9, 2022 between the hours of 10:00 a.m. to 12:45 p.m. and June 10, 2022 between the hours of 6:30 a.m. to 8:00 a.m. the fire drills were lacking for the 7:00 a.m. to 7:00 p.m. shift and the 7:00 p.m. to 7:00 a.m. shift of the first quarter of 2022, the 7:00 p.m. to 7:00 a.m. shift for the second quarter of the year 2022, the third quarter of the year 2021 and the fourth quarter of the year 2021. NFPA 101:19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. The interview with the Facility Director revealed the facility was not aware fire drills were not being held for each work shift of each quarter.

Based on record review the facility failed to provide annual fire door testing documentation. Written annual records demonstrate all fire doors are properly being maintained to ensure protection for life and property. The deficiency has the potential to affect seven of seven patients. Findings: During the facility tour on June 9, 2022 between the hours of 10:00 a.m. to 12:45 p.m. and June 10, 2022 between the hours of 6:30 a.m. to 8:00 a.m. the annual fire door inspection documentation were lacking. NFPA 80: 5.2.4.1* Periodic inspections and testing shall be performed not less than annually. A.5.2.4.1 Doors subject to high-volume use and abuse might warrant an increased frequency of inspection. Components including, but not limited to, hinges, catches, closers, latches, and stay rollers are especially subject to wear. The interview with the Facility Director revealed the facility was not aware annual fire door inspections were required to be conducted annually.

Based on visual observation the facility is lacking a generator remote annunciator that is storage battery powered to operate outside of the generating room in a location readily observed by operating personnel. The annunciator is hard wired to indicate alarm conditions of the emergency power source. A centralized compute system (e. g., building information system) is not to be substituted for the alarm annunciator. The deficiency has the potential to affect seven of seven patients. Findings: During the facility tour on June 9, 2022 between the hours of 10:00 a.m. to 12:45 p.m. and June 10, 2022 between the hours of 6:30 a.m. to 8:00 a.m. the nurses station remote annunciator that communicates to the life safety generator was not energized at time of survey. NFPA 110:5.6.5.2 (4) A individual alarm indicator to annunciate any of the conditions listed in Table 5.6.5.2. NFPA 99:6.4.1.1.17 Alarm Annunciator. A remote annunciator that is storage battery powered shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see 700.12 of NFPA 70, National Electrical Code). The annunciator shall be hard-wired to indicate alarm conditions of the emergency or auxiliary power source as follows: (1) Individual visual signals shall indicate the following: (a) When the emergency or auxiliary power source is operating to supply power to load (b) When the battery charger is malfunctioning (2) Individual visual signals plus a common audible signal to warn of an engine?generator alarm condition shall indicate the following: (a) Low lubricating oil pressure (b) Low water temperature (below that required in 6.4.1.1.11) (c) Excessive water temperature (d) Low fuel when the main fuel storage tank contains less than a 4-hour operating supply (e) Overcrank (failed to start) (f) Overspeed NFPA 99:6.4.1.1.17.5 A centralized computer system (e.g., building automation system) shall not be permitted to be substituted for the alarm annunciator in 6.4.1.1.17 but shall be permitted to be used to supplement the alarm annunciator. NFPA 99:6.4.1.1.17.1* A remote, common audible alarm shall be provided as specified in 6.4.1.1.17.4 that is powered by the storage battery and located outside of the EPS service room at a work site observable by personnel. [110:5.6.6] The interview with the Facility Director revealed the facility is in the process of installing a generator remotely located annunciator.

Based on visual observation the facility failed to assure records of the monthly load test for the diesel generator did not include percentage of nameplate kilowatt rating achieved during load test, the column for "AMPS" had not be filled out on the logs. Further record review revealed the facility had not conducted the annual load bank test due to not meeting the kilowatt requirement during monthly load tests required by NFPA 110 8.4.2. and 8.4.2.3. The deficiency has the potential to affect seven of seven patients. Findings: During the facility tour on June 9, 2022 between the hours of 10:00 a.m. to 12:45 p.m. and June 10, 2022 between the hours of 6:30 a.m. to 8:00 a.m. the generator weekly, monthly and load bank documentation was lacking at time of survey. NFPA 110:8.3.7* Storage batteries, including electrolyte levels or battery voltage, used in connection with systems shall be inspected weekly and maintained in full compliance with manufacturer's specifications. NFPA 110:A.8.3.7 A battery load test should be performed quarterly. NFPA 110:8.4.1* EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly. NFPA 101:A.8.4.1 Weekly inspection does not require running of the EPS. Running unloaded generators as part of this weekly inspection can result in long-term problems such as wet stacking. See Figure A.8.4.1(a) and Figure A.8.4.1(b). (2) The weekly generator inspection logs lacking from the previous year of service. NFPA 110:8.3.7* Storage batteries, including electrolyte levels or battery voltage, used in connection with systems shall be inspected weekly and maintained in full compliance with manufacturer's specifications. NFPA 110:8.4.1* EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly. (3) The monthly load generator inspection logs were lacking from the previous year of service. NFPA 110:A.8.4.1 Weekly inspection does not require running of the EPS. Running unloaded generators as part of this weekly inspection can result in long-term problems such as wet stacking. See Figure A.8.4.1(a) and Figure A.8.4.1(b). NFPA 110:8.4.2* Diesel generator sets in service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods: (1) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer (2) Under operating temperature conditions and at not less than 30 percent of the EPS standby nameplate kW rating NFPA 110:A.8.4.2 Light loading creates a condition termed wet stacking, indicating the presence of unburned fuel or carbon, or both, in the exhaust system. Its presence is readily indicated by the presence of continuous black smoke during engine-run operation. The testing requirements of 8.4.2 are intended to reduce the possibility of wet stacking. If equivalent loads are used for exercising, it is suggested that all essential loads be energized first, with the equivalent load used only to supplement the test. If the normal power were to fail during the exercise period, it would negate the urgency to automatically remove the equivalent load as described in 8.4.2.2. The generator set manufacturer should be consulted where the nameplate data do not indicate rating type. There is a difference between prime and standby ratings. For example, there are usually two kW nameplate ratings found on most engine-driven generators: "standby" and "prime." There can be a significant difference between the resulting kW figures when calculating 30 percent of nameplate-for example, a 100 kW standby generator is normally considered an 80 kW set for prime power: 100 kW × 30% = 30 kW, but 80 kW × 30% = 24 kW. A permanent record of the rating should be maintained and readily available. NFPA 110:8.4.2.1 The date and time of day for required testing shall be decided by the owner, based on facility operations. NFPA 110:8.4.2.2 Equivalent loads used for testing shall be automatically replaced with the emergency loads in case of failure of the primary source. NFPA 110:8.4.2.3* Diesel-powered EPS installations that do not meet the requirements of 8.4.2 shall be exercised monthly with the available EPSS load and shall be exercised annually with supplemental loads at not less than 50 percent of the EPS nameplate kW rating for 30 continuous minutes and at not less than 75 percent of the EPS nameplate kW rating for 1 continuous hour for a total test duration of not less than 1.5 continuous hours. NFPA 110:A.8.4.2.3 The generator set manufacturer should be consulted where the nameplate data do not indicate rating type. There is a difference between prime and standby ratings. For example, there are usually two kW nameplate ratings found on most engine-driven generators: "standby" and "prime." There can be a significant difference between the resulting kW figures when calculating 30 percent of nameplate - for example, a 100 kW standby generator is normally considered an 80 kW set for prime power: 100 kW × 30% = 30 kW, but 80 kW × 30% = 24 kW. A permanent record of the rating should be maintained and readily available. The interview with the Facility Director revealed the facility was not aware that all documentation was not complete regarding the inspection/testing of the emergency generator.

Based on interview and record review, the hospice agency failed to ensure a patient's comprehensive assessment included psychosocial needs for 2 (#2, #8) of 16 patient records reviewed. Findings: Review of the clinical record for Patient #2 revealed the patient elected to receive hospice benefits from the agency on 05/20/2022. The patient had an admitting diagnosis of Parkinson's Disease. Further review of the clinical record revealed no documentation a psychosocial assessment was included in the patient's comprehensive initial assessment. Review of the clinical record for Patient #8 revealed the patient elected to receive hospice services from the agency on 04/22/2022. The patient had an admitting diagnosis of Alzheimer's Disease. Further review of the clinical record revealed no documentation a psychosocial assessment was included in the patient's comprehensive initial assessment. An interview was conducted with S2DON on 06/10/2022 at 12:30 p.m. She reviewed the records for Patient #2 and Patient #8. She confirmed there was no documentation in either record indicating an initial psychosocial assessment was completed.

Based on record review and interview, the agency failed to ensure patient wounds were assessed weekly to evaluate for wound healing per professional standards for 1 (Patient #4) of 2 patients reviewed for wounds in a total sample of 16 patients. Findings: Review of the Wound Ostomy and Continence Nurses Society's Guidelines Assessment and Documentation of Wound Status, revealed assessment should include comprehensive clinical data demonstrating evidence of progress in healing or failure to heal. Comprehensive wound assessment includes: dimensions and depth; presence, location and depth of any sinus tracts or undermining areas; status and characteristics of the wound bed; volume, color, and odor of exudates; evidence of infection in surrounding tissues. Further review revealed when recorded over time this information can be used to track the progress of wound healing. Review of Patient #4's Plan of Care for benefit period of 04/04/2022 thru 06/02/2022 revealed in part a problem of impaired skin integrity with a problem onset date of 02/22/2022. Review of Patient #4's Registered Nurse Skilled Nursing Visit dated 04/27/2022 revealed in part Patient #1 was assessed as having a stage 2 (open wound) pressure injury to the sacrum measuring 1.6cm (centimeters) by 1cm with no depth. Review of Patient #4's Record revealed no documented evidence and the agency presented no documented evidence that Patient #4 had sacral wound assessments on the following weeks: Week of 04/03/2022 thru 04/09/2022; Week of 04/10/2022 thru 04/16/2022; Week of 04/17/2022 thru 04/23/2022; Week of 05/01/2022 thru 05/07/2022; Week of 05/15/2022 thru 05/21/2022; and Week of 05/29/2022 thru 06/04/2022. In an interview on 06/09/2022 at 3:41pm, S2DON (Director of Nursing) stated the nurses were not consistent with documenting the wound care assessment weekly per agency protocol. S2DON confirmed the nurses should be assessing the wound weekly and documenting the assessment in the patient's nurse's notes.

Based on record review and interview, the agency failed to ensure: 1.) all employees were fully vaccinated for COVID-19 or had a medical or religious exemption per agency policy for 4 (S7RN and S8LPN, S12CNA, S13CNA) of 10 employees reviewed for COVID-19 vaccination status; 2.) policies and procedures included a process for tracking and securely documenting the COVID-19 vaccination status of all staff. Findings: Review of the agency's COVID-19 Vaccination Policy: Mandatory revealed, in part, that all employees are required to receive COVID-19 vaccination(s) by 02/20/2022. Further review revealed employees not in compliance with this policy will be placed on unpaid leave until their employment status was determined by the human resources department. Review revealed an employee who did not get vaccinated due to a disability covered by the ADA or a sincerely held religious belief, practice, or observance covered by Title VII may be entitled to reasonable accommodations. Further review revealed all requests must be submitted on the required form and given to the human resources department as soon as possible and before the 01/31/2022 deadline. A review was made of the vaccination status for all employees that currently worked for the agency. The following information was provided: -S7RN (Registered Nurse) had one dose of the Pfizer COVID-19 Vaccine (Pfizer vaccine requires at minimum 2 doses of the vaccine to be considered vaccinated) administered on 01/26/2022; and -S8LPN (Licensed Practical Nurse) had one dose of the Pfizer COVID-19 Vaccine administered on 10/11/2021. -S12CNA (Certified Nursing Assistant) was hired on 05/19/2022, first day worked was 06/03/2022 and last worked on 06/07/2022. S12CNA submitted a religious exemption on 06/09/2022. -S13CNA was hired on 12/22/2021 and her last day worked was on 06/07/2022. S13CNA had no documentation in their employee record they had received a COVID-19 vaccination or submitted a religious or medical exemption. In an interview on 06/08/2022 at 2:51pm, S5Director of Human Resources stated the agency was trying to reach the staff members which had only one dose of the vaccine documented, to see if they received their second dose of the vaccine. S5Director of Human Resources stated the first dose was months ago so they should have received the second dose of the vaccine, but the agency did not ensure this information was received or documented. S5Director of Human Resources stated the agency had no one other than herself tracking COVID-19 vaccinations and/or exemptions, to ensure the staff was fully vaccinated and/or had requested an exemption. Review of the Agency's May 2022 Schedule revealed both S7RN and S8LPN had worked at the inpatient unit in the month of May 2022. In an interview on 06/09/2022 at 4:13pm, S4Director of Patient Navigation stated the human resources department was having issues, and the agency should have had the status of either the exemption or vaccination status for all employees. A request was made for the agency to provide their COVID-19 Staff Vaccination Policies and Procedures. On 06/10/2022 at 1:00 p.m., S5Director of Human Resources provided all components of the agencies COVID-19 Staff Vaccination Policy. Review of the policy revealed no process was included how the agency would track and securely document the vaccination status of all current employees. An interview was held with S5Director of Human Resources at that time. She verified the COVID-19 policy that was provided for review did not include those required components.