Every finding on record at Tri-Cities Chaplaincy Hospice House

Based upon observations and staff interviews on May 29, 2024, during the physical tour of the facility between approximately 0915 and 1100 hours, the facility has failed to test and maintain carbon monoxide within the building. This could result in the spread of carbon monoxide throughout the build, which would endanger the patients, staff, and/or visitors within the facility. --- Findings include: Facility was unable to provide documentation of monthly testing of carbon monoxide alarms. The above was discussed and acknowledged by facility staff.

Based upon observation and staff interviews on May 29, 2024, during approximately 0915 and 1100 hours the facility has failed to maintain their automatic and manual fire alarm system in accordance with NFPA 72. This could result a failure of the fire alarm system to properly operate in the event of a fire, which would endanger the patients, staff, and/or visitors within the facility. --- Findings include: Facility was unable to provide documentation of smoke detector sensitivity report. Facility provided documentation of service on September 7 and 21, 2022 but documentation did not include complete results of testing. Panel C circuit 15 was not locked allowing access to the fire alarm system circuit disconnect. The above was discussed and acknowledged by facility staff.

Based on observation and staff interview on May 29, 2024, between approximately 0915 and 1100 hours the facility has failed to have a written procedure for instituting an approved fire watch in the event of a failure of the fire alarm system. This could result in an inadequate fire watch which may result in a delay of fire detection and suppression, potentially endangering patients, staff, and/or visitors within the facility. --- Findings include: Facility was unable to provide a fire watch procedure if the fire alarm system is out of service for greater than 4 hours. The above was discussed and acknowledged by facility staff.

Based on documentation review, observation and staff interview on May 29, 2024, during the physical tour of the facility between approximately 0915 and 1100 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. --- Findings include: Facility was unable to provide documentation of second quarter 2023 fire sprinkler system inspection. Facility was unable to provide documentation of sample testing on quick response fire sprinkler heads greater than 20 years old. Facility was unable to provide documentation of annual forward flow testing of the fire system backflow within the past twelve months. Facility was unable to provide documentation of fire sprinkler system internal pipe inspection within the past five years. Fire sprinkler head escutcheon rings were missing in the following locations: Soiled Utility across from Room 8 Corridor outside Room 8 Storage across from Room 104 Kitchen - fire sprinkler heads had excessive particulate on them. Room 9 - fire sprinkler head had paint on it. The above was discussed and acknowledged by facility staff.

Based on documentation review, observation and staff interview on May 29, 2024, during document review between approximately 0915 and 1100 hours the facility has failed to have a written procedure for instituting an approved fire watch in the event of a failure of the fire sprinkler system. This could result in an inadequate fire watch which may result in a delay of suppression, potentially endangering patients, staff, and/or visitors within the facility. --- Findings include: Facility was unable to provide procedure if fire sprinkler system is out of service for greater than 10 hours. The above was discussed and acknowledged by facility staff.

Based on observation and staff interview on May 29, 2024, during approximately 0915 and 1100 hours, the facility has failed to maintain electric equipment in a safe manner and in accordance with NFPA 70. This could endanger patients, staff, and visitors in the building by risk of fire, electrocution, or other harm. --- Findings include: Medication Room - access to electrical panel was obstructed by medication cart. Breakroom - appliances were plugged into multiplug adapters in two locations. Maintenance Office/Riser Room - open junction box behind the fire sprinkler riser. The above was discussed and acknowledged by facility staff.

Based upon documentation review and staff interviews on May 29, 2024, between approximately 0915 and 1100 hours, the facility has failed to maintain and test fire and smoke dampers in accordance with NFPA 80 and NFPA 105. This could result in failure of the dampers to operate and close in the event of a fire, allowing the spread of the products of combustion from one compartment to another, endangering the patients, staff, and/or visitors. --- Findings include: Facility was unable to provide documentation of fire/smoke damper testing within the past four years. The above was discussed and acknowledged by facility staff.

Based on observation and staff interview on 05/29/2024 the facility has failed to maintain a written plan for the protection of all patients, staff and visitors and for their evacuation in the event of an emergency. At a minimum a written care occupancy fire safety plan shall provide for the following: (1) Use of alarms (2) Transmission of alarms to fire department (3) Emergency phone call to fire department (4) Response to alarms (5) Isolation of fire (6) Evacuation of immediate area (7) Evacuation of smoke compartment (8) Preparation of floors and building for evacuation (9) Extinguishment of fire --- Findings include: Facility was unable to provide an evacuation plan that includes both full and partial evacuation. The above was discussed and acknowledged by facility staff.

Based upon documentation review and staff interviews on May 29, 2024, between approximately 0915 and 1100 hours, the facility has failed to fully maintain and test 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 egress and work lighting in the event of a power failure which in turn would endanger the patients, staff, and/or visitors within the facility. --- Findings include: Facility was unable to provide documentation of the emergency generator diesel fuel testing within the past twelve months. Facility was unable to provide documentation of four hour continuous load test of the emergency generator within the past three years. The above was discussed and acknowledged by facility staff.

Based on observation and staff interviews on May 29, 2024, during approximately 0915 and 1100 hours, the facility has failed to ensure all electrical wiring is in accordance with NFPA 70 and that extension cords are not used as a substitute for fixed wiring of a structure. This could result in an electrical hazard due to misuse or prolonged use of an extension cord, endangering the patients, staff, and/or visitors within the facility. --- Findings include: Room 104 - multiplug adapter was plugged into another multiplug adapter. Room 4 - a non-medical grade multiplug adapter was in use by patient bed. The above was discussed and acknowledged by facility staff.

Based on documentation review, observation and staff interviews on May 29, 2024, between approximately 0915 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. --- Finding include: Facility was unable to provide inventory log with testing dates on all patient care related electrical equipment. Facility was unable to provide training of staff responsible for testing and maintenance of patient care related electrical equipment. Facility was unable to provide a policy for testing, repairs and maintenance of patient care related electrical equipment. The above was discuss with and acknowledged by facility staff.

Based on documentation review and staff interview on May 29, 2024, between approximately 0915 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. --- Findings include: The facility was unable to provide documentation of guidelines and training of staff on medical gas risks and safety. The above was discussed and acknowledged by the facility staff.

Based on document review and interview, the hospice failed to develop and implement a process for routine and preventive maintenance of medical equipment used in their hospice care center. Failure to have a system to track scheduled and preventive maintenance of bio-medical equipment, puts patients at risk of harm from unsafe or unusable devices. Findings included: 1. On 03/30/22, during a tour of the Hospice House, Surveyor #7 asked to see documentation of their routine and preventive maintenance for biomedical equipment. Hospice staff were unable to produce documentation demonstrating a process for ensuring preventive and ongoing maintenance for patient care equipment. 2. On 03/30/22 at 10:15 AM, Surveyor #7 interviewed the Facilities Director (Staff #701) about maintenance of equipment, including biomedical equipment. Staff #701 stated that they were unable to locate any current documents to demonstrate completion of preventive maintenance, and also stated they would develop a tracking system moving forward. .

Based on record review and interview, the agency failed to implement policies and procedures consistent with state licensing requirments through failure to provide patients and their families information on the provision of back-up care and abuse reporting as part of their patients' Bill of Rights. Reference: Washington Administrative Code (WAC) 246-335-635 (16) (17) and (20). 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: (16) Be informed of the agency's policies and procedures regarding the circumstances that may cause the agency to discharge a patient. (17) Be informed of the agency's policies and procedures for providing back-up care when services cannot be provided as scheduled. (20) Be informed of the DSHS end harm hotline number to report suspected abuse of children and vulnerable adults. Findings included: 1. Document review of the agency's Patient Bill of Rights showed the agency's document failed to include the following state-required elements: a. The patient's right to be informed of the agency's policies and procedures regarding the circumstances that may cause the agency to discharge a patient. b. The patient's right to be informed of the agency's policies and procedures for providing back-up care when services cannot be provided as scheduled. c. The patient's right to be informed of the Department of Social and Health Services (DSHS) End Harm hotline number to report suspected abuse of children and vulnerable adults. 2. Surveyor #4 interviewed the Clinical Director (Staff #401) on 03/29/22 at 12:00 PM about the missing information. Staff #401 verified the Bill of Rights did not include a statement about the patients' right to the back-up plan , circumstances that could cause the agency to discharge a patient, or the end harm hotline number. Staff #401 acknowledged these findings and said the Bill of Rights would be updated to include the information. .

Based on document review and interview, the hospice failed to develop policies to ensure that contracted staff with access to patients have documented evidence of their vaccination status or an approved exemption. Failure to develop policies that ensure all staff who provide care, treatment or other services to patients and their families have a documented completion of vaccination or approved exemption puts patients, families and staff at risk of harm from infection. Findings included: 1. Document review of the hospice policy titled, "Covid-19 Vaccination", approved 08/11/21, showed the policy applied to all employees. The policy failed to describe provisions for contractors and volunteers providing care, treatment or services to patients. 2. On 03/30/22 between 12:00 and 12:30 PM, Surveyor #7 interviewed the Clinical Director (Staff #702) and the Infection Preventionist (Staff #703) about the missing elements in the hospice policies and procedures developed to ensure compliance with "Medicare and Medicaid Programs; Omnibus COVID–19 Health Care Staff Vaccination". Staff #702 stated that volunteers were considered unpaid employees under their definition, but also acknowledged that the policy did not include contracted staff, such as those working in environmental services at the hospice care center.

Based upon observations and staff interviews on 03/31/2022 between approximately 1030 to 1130 hours the facility has failed to maintain the ability of doors to be held open only by devices arranged to automatically close upon activation of the fire alarm. This could result in the passage of smoke or fire from one compartment into another compartment thereby exposing patients, staff and/or visitors to the toxic products of combustion. The findings include: Clean and Soiled Room doors failed to close and latch when tested. The above was discussed and acknowledged by the maintenance director who stated that he was unaware of this problem. NFPA 101 (2012) 19.3.6.3.5

Based on observation and staff interview on 03/31/2022 between approximately 1030 to 1130 hours the facility failed to restrict the use of extension cords and non-approved power strips in their facility. This could endanger people in the facility due to the increased fire risk. The findings include: Non-UL1363A power strips were discovered in patient rooms 2, 4 and 8. The above was discussed and acknowledged by the facility staff. NFPA 70 (2011) 400.8