Every finding on record at Seasons Hospice

Based on interview and document review the facility failed to provide emergency preparedness training to their employees that was individualized and based on their risk assessment and emergency preparedness plan. --- During review of the facility's emergency preparedness plan, the plan lacked evidence of a training program for employees on the entity's individualized emergency preparedness plan. During an interview on 1/11/23 at 8:47 A.M., the director of clinical services (DCS) stated they use Relias to provide an overview on emergency preparedness to new employees upon hire, but that it is not specific to their risk assessment or emergency preparedness plan. The DCS stated they will discuss their tabletop and community exercises at staff meetings but had not had a staff meeting in the past year. During interview on 1/11/24 at 2:15 p.m., the executive director (ED) also confirmed that their training on emergency preparedness was not individualized to their risk assessment or emergency preparedness plan. A policy on emergency preparedness training was requested but not received.

Based on document review and staff interview the facility failed to inspect and test doors per NFPA 101 (2012 edition), Life Safety Code, sections 7.2.1.15, and NFPA 80 (2010 edition), sections 5.2.1. This deficient condition could have a widespread impact on the residents within the facility. Findings include: On 01/11/2024 between 9:00 AM and 12:00 PM, it was revealed by review of available documentation that there was no documentation presented to confirm that the facility has conducted annual maintenance, inspection and testing of doors since 05/04/2022. An interview with Administrator verified this deficient finding at the time of discovery.

Based on a review of available documentation and staff interview, the facility failed to conduct electrical receptacle testing in resident rooms per NFPA 99 (2012 edition), Health Care Facilities Code, section(s) 6.3.3.2, 6.3.4, 6.3.4.2. This deficient condition could have a widespread impact on the residents within the facility. Findings include: On 01/11/2024 between 9:00 AM and 12:00 PM, it was revealed by review of available documentation that there was no documentation presented to confirm that the facility has conducted annual inspection and testing of electrical outlets located in resident rooms since 05/05/2021. An interview with Administrator verified this deficient finding at the time of discovery.

Based on interview and document review, the agency failed to ensure hospice visits were conducted in accordance with the plan of care for 2 of 14 patients (P10 and P12) reviewed for coordination of services. --- P10's Face Sheet form indicated P10 was admitted to the facility on 11/9/23 with a primary diagnosis of chronic obstruction pulmonary disease. P10's Assignment Details form, dated 11/19/23, indicated P10 had orders for 1 registered nurse (RN) visit weekly and 1 skilled nursing visit weekly on Wednesday. P10's visit sets indicated a skilled nurse visit was missed the week of 11/19/23 - 11/25/23. P12's Face Sheet form indicated P12 was admitted to hospice on 11/25/23 with a primary diagnosis of senile degeneration of the brain. P12's Assignment Details form, dated 10/29/23, indicated P12 had orders for 1 RN visit weekly and 3 as needed visits every 7 days. P12's visit sets indicated a RN visit was missed the week of 11/19/23 - 11/25/23. During interview on 1/11/24 at 2:15 p.m., the executive director (ED), the director of clinical services (DCS), and licensed practical nurse (LPN)-A verified the missed visits above. The DCS further stated the expectation was for the visit order frequency to be followed each week.