Every finding on record at Vitas Healthcare Corporation Midwest

Based on observation, staff interviews, and review of maintenance records on July 26, 2022 the facility did NOT construct, install and maintain the building systems to ensure physical environment to inpatients. 42 CFR 418.110(c) Condition of Participation: Life Safety Physical Environment was NOT MET Findings include: The facility was found to contain the following deficiencies: K 0345 Fire Alarm Systems - Testing and Maintenance K 0711 Evacuation and Relocation Plan K 0712 Fire Drills K 0761 Maintenance, Inspectioon & Testing - Doors K 0918 Electrical systems - Essential Electric System K 0919 Electrical Equipment - Other K 0920 Electrical Equipment - Power Cords And Extensions Refer to the full description at the cited K tags. The cumulative effect of the environmental deficiencies results in the Hospice's inability to ensure a safe environment for the inpatients.

Based on observation, staff interviews, and review of maintenance records on July 26, 2022 the facility did NOT construct, install and maintain the building systems to ensure physical environment to inpatients. 42 CFR 418.110(d) Fire Protection was NOT MET Findings include: The facility was found to contain the following deficiencies: K 0345 Fire Alarm Systems - Testing and Maintenance K 0711 Evacuation and Relocation Plan K 0712 Fire Drills K 0761 Maintenance, Inspectioon & Testing - Doors K 0918 Electrical systems - Essential Electric System K 0919 Electrical Equipment - Other K 0920 Electrical Equipment - Power Cords And Extensions Refer to the full description at the cited K tags. The cumulative effect of the environmental deficiencies results in the Hospice's inability to ensure a safe environment for the inpatients.

Based on record review and interview, the facility policy did not include use of volunteer(s) in accordance with the Emergency Preparedness requirements outlined in 42 CFR 483.73 This deficient practice could affect all residents and an undetermined number of staff and visitors. Findings include: On 07/26/2022 at 11:20 am, review of the document titled "Emergency Preparedness Plan" dated 02/10/2022 revealed that the facility's Emergency Preparedness plan did not include policies and procedures for the use of volunteers and other staffing strategies during an emergency. This deficient practice was confirmed by Staff A & Staff B at the time of discovery.

Based on record review and interview, the facility failed to prepare and maintain an emergency preparedness plan in accordance with the requirements of CFR 483.73. This deficient practice could affect all residents, as well as an undetermined number of staff and visitors. Findings include: On 07/26/2022 at 11:21 am, review of the document titled "Emergency Preparedness Plan" dated 02/10/2022 revealed that the facility's Emergency Preparedness plan did not include transfer agreements with other providers. This deficient practice was confirmed at the time of discovery by a concurrent interview with Staff A & Staff B

Based on record review and interview the facility staff failed have a documented plan for patient to share patient medical records in the case of emergency in accordance with the requirements of 42 CFR 483.73 in 1 of 1 Emergency Preparedness program reviewed (Emergency Preparedness Plan). Findings include: On 07/26/2022 at 11:15 am, review of the facilities Emergency Preparedness Plan dated 02/10/2022 revealed that there was no documented plan to share patient records with other health providers to maintain the continuity of care in the communication plan to make them readily available in the event of an emergency. This deficient practice was confirmed by Staff A and Staff B at the time of discovery.

Based on record review and interview, the facility did not perform the semi-annual testing and inspections of the fire alarm system in accordance with the requirements of NFPA 101 (2012 edition) Sections 19.3.4 and 9.6.1.3 and NFPA 72 (2010 edition) Sections 14.3.1 and 14.4.5. This deficient practice could affect residents, as well as an undetermined number of staff and visitors. Findings include: On 07/26/2022 at 12:10 pm, review of fire alarm inspection and testing documents over the past 24 months revealed that sensitivity testing of the fire alarm system was not conducted. On 02/16/2022 JCI provided an annual fire alarm test report that listed smoke detectors as pass/fail rather than providing an actual sensitivity reading. This deficient condition was confirmed at the time of discovery by a concurrent interview with Staff A.

Based on record review and interview the facility failed to have a written fire safety plan that addressed the items required by NFPA 101 (2012 edition) Section 19.7.2.2. This deficient practice could affect all residents, as well as an undetermined number of staff and visitors. Findings include: On 07/26/2022 at 12:01 pm, review of the undated document titled "Fire Plan" revealed that the facility's written fire safety plan did not address use of transmission of the fire alarm signal to the fire department, emergency call to fire department, evacuation of the smoke compartment, or preparation of the floors and building for evacuation. The plan did however include a description of RACE. This deficient practice was confirmed at the time of discovery by a concurrent interview with Staff A.

Based on record review and interview, the facility failed to conduct fire drills in accordance with the requirements of NFPA 101 (2012 edition) Sections 4.7.1, 4.7.2, 4.7.6, 19.7.1, 19.7.1.4, 19.7.1.6, & 19.7.1.7. This deficient practice could affect all residents, as well as an undetermined number of staff and visitors. Findings include: 1.On 07/26/2022 at 12:13 pm, review of the facility fire drills for the last twelve months revealed that fire drills did not include the record of transmission of the alarm signal to the monitoring company. 2.On 07/26/2022 at 12:14 pm, review of the facility fire drills for the last twelve months revealed that fire drills were not conducted at varied times. With the exception of 12/22/2021, drills were held during the last week of the month: 01/31/22, 02/23/22, 03/29/22, 04/29/22, 05/31/22, 06/30/22, 07/30/21, 08/27/21, 09/28/21, 10/28/21, and 11/29/21. These deficient practices were confirmed at the time of discovery by a concurrent interview with Staff A.

Based on record review and interview, the facility failed to inspect fire/smoke door assemblies at least annually, with written records of inspection and testing in accordance with NFPA 101(2012 edition), sections 19.7.6, 4.6.12, 7.2.1.15, 8.3.3. This deficient practice could affect all residents and an undetermined number of staff and visitors. Findings include: On 07/26/2022 at 10:00 am, it was noted during record review that the facility had no documentation that fire/smoke door assemblies had been inspected or tested in the last year. This deficient practice was confirmed by Staff A at the time of discovery.

Based on record review and interview, the facility did not perform testing of the emergency generator in accordance with the requirements of NFPA 101 (2012 edition) Sections 19.5.1 and 9.1.3; and NFPA 110 (2010 edition) Sections 8.4.9 This deficient practice could affect all residents, as well as an undetermined number of staff and visitors. Findings include: 1. On 07/26/2022 at 11:49 am, review of the generator documentation revealed that the 36- month test for a duration of 4 hours was not performed. 2. On 07/26/2022 at 11:50 am, review of the generator documentation revealed no record that a monthly test had been performed over the past 12 month. 3. On 07/26/2022 at 11:51 am, review of the generator documentation revealed no record that a weekly test had been performed over the past 12 month. 4. On 07/26/2022 at 11:52 am, review of the generator documentation revealed no record of a yearly natural gas reliability from the gas utility. Latest reliability letter was dated 2017. These deficient practices were confirmed at the time of discovery by a concurrent interview with Staff A.

Based on observations and staff interview, the facility failed to properly maintain electrical devices in accordance with 2012 NFPA 101 s. 19.5.1.1 and 9.1.2 and 2011 NFPA 70 s. 300.4. This deficient practice could affect all residents and an undetermined number of staff and visitors. Findings include On 07/26/2022 at 01:59 pm. observation outside the south fire exit door revealed that an exterior exit path light was hanging by its exposed electrical supply wiring. This deficient practice was confirmed at the time of discovery by a concurrent interview with Staff A.

Based on observations and staff interview, the facility failed to properly maintain electrical devices in accordance with NFPA 101 (2012 edition), Sections 19.5.1.1 and 9.1.2, and NFPA 70 (2011 edition) Sections 400.8, 590.2(B) and 300.4. This deficient practice could affect all residents, as well as an undetermined number of staff and visitors. Findings include: 1. On 07/26/2022 at 2:18 pm, observation in the sprinkler riser room in the basement revealed that the fire sprinkler air compressor's electric supply was unprotected. The supply was provided by plugging the appliance cord into a duplex outlet in a 4x4 inch electric box leaving the supply unprotected. 2. On 07/26/2022 at 2:19 pm, observation in the sprinkler riser room in the basement revealed that the fire sprinkler air compressor's automatic drain valve's power supply was unprotected. The drain valve was supplied with power by plugging the appliance cord into a duplex outlet in a 4x 4 inch electric box leaving the automatic drain's power supply unprotected. These deficient conditions were confirmed at the time of discovery by a concurrent interview with Staff A.