Based on the findings of an onsite unannounced Medicare recertification and State relicensure survey completed on 12/23/2020, Conemaugh Regional Hospice was found to be in compliance with the requirements of 42 CFR, Part 418.113, Subpart D, Conditions of Participation: Hospice Care - Emergency Preparedness.
Plan of Correction:
Based on the findings of an onsite unannounced Medicare recertification and state relicensure survey completed on 12/23/2020, Conemaugh Regional Hospice was found not to be in compliance with the following requirement of 42 CFR, Part 418, Subparts A, C, and D, Conditions of Participation: Hospice Care.
Plan of Correction:
CONTENT OF COMPREHENSIVE ASSESSMENT
Name - Component - 00
[The comprehensive assessment must take into consideration the following factors:]
(6) Drug profile. A review of all of the patient's prescription and over-the-counter drugs, herbal remedies and other alternative treatments that could affect drug therapy. This includes, but is not limited to, identification of the following:
(i) Effectiveness of drug therapy
(ii) Drug side effects
(iii) Actual or potential drug interactions
(iv) Duplicate drug therapy
(v) Drug therapy currently associated with laboratory monitoring.
Based on review of agency policy, medical records (MR), observation, and staff (EMP) interviews, the agency failed to review all the patient's medications and update the medication profile and allergies for one (1) of thirteen (13) MR reviewed (MR7).
A review of agency policy and procedure on 12/23/2020 at approximately 1:30 PM which revealed, Policy " Initial & Comprehensive Admission Assessment & Plan of Care ...Policy Number:2.00 ...Procedure: The registered nurse (RN) will conduct an initial assessment to determine the patient ' s immediate care and support needs within 48 hours of referral, as ordered by the physician, or requested by the patient/caregiver. This initial assessment will be documented in the patient ' s medical record ...7. A qualified Pharmacist or Hospice Medical Director will review all of the patient ' s prescription and over-the-counter drugs, herbal remedies and other alternative treatments that could affect drug therapy upon admit. This review will be documented in the patient ' s medical record and will include identification or effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy and drug therapy currently associated with laboratory monitoring. "
A review of agency policy and procedure on 12/23/2020 at approximately 1:30 PM which revealed, Policy " Monitoring Medications ...Policy Number: 12.008 ...Policy: A drug regimen review will be performed on all patients in conjunction with all comprehensive assessments. Additionally, all nurses will participate in medication review and reconciliation throughout the benefit period. All clinicians will have immediate access to current drug books and/or current web based programs. The physician is contacted immediately if any discrepancies between agency information and patient medications are found. Procedure: 1. A Comprehensive Medication Review will be completed on admit and at every Interdisciplinary Group (IDG), in conjunction will all comprehensive assessments 1. Compare medication list to actual medication patient is taking. If the patient resides in a facility, compare medication list to the facility ' s medication administration record (MAR) rather that reviewing actual medications. 2. Review over the counter (OTC) medications, vitamins, herbs and herbal products, and creams and topical ointments and medical marijuana (in states where legalized) to identify issues such as: a. potential adverse effects and drug reactions b. Ineffective drug therapy c. significant side effects d. significant drug interactions e. duplicate drug therapy f. noncompliance with drug therapy g. dosage errors h. drug omissions 2. Notify physician of any of the above identified issues/discrepancies. 3. All nurses participation in the patient ' s care are responsible to assist in maintenance of accurate patient medication information throughout the tenure of care. Through a collaborative process the care team will: a. Compare medication information patient is currently taking with medications ordered for the patient in order to identify and resolve discrepancies. b. Collaborate with Executive Director, Patient Care Manager and or physician as needed. c. Have access to information about each patient in order to facilitate continuity of care. At a minimum, this information includes: age, sex, current medications, diagnoses, co-morbidities, laboratory values, allergies, past sensitivities and as appropriate weight, height, or any other information for safe medication management ... "
A review of CR7 on 12/23/2020 at approximately 11:37 AM revealed, the agency document " Episode detail Report ...Allergies Description ERYTHROMYCIN ... " patients start of care date 7/14/2020 for a current certification period starting 10/12/2020 and ending 10/17/2020. The primary diagnosis was hypertensive heart disease with heart failure. The agency episode detail report was compared to a " Summary of Care Document " located in the electronic medical record dated 7/10/2020. The summary of care document listed " Allergies Cephalexin ...Gabapentin ...Pregabalin ...Tramadol ... " No additional documentation was provided by the agnecy to confirm all allergies listed within the medical record were addressed.
An exit interview was conducted on 12/23/2020 at approximately 1:45 PM with the quality regional representative, administrator and patient care coordinator which confirmed the above information.
Plan of Correction:
All Nurses were educated on 12/24/2020 regarding Hospice Policy #12.009 Medication Administration - which states; "The clinician will check all medications a patient is taking to identify possible ineffective drug therapy or adverse reactions, significant side effects, drug allergies, contraindicated medication(s), and known drug to drug interactions and shall report any problems to the physician". All Nurses were instructed on the requirement and process to assess for drug allergies and to document any findings in the patient electronic medical record. The RN will review any history and physical documentation with patient or caregiver, including a focus on any medication allergies. All allergies will be documented in the patient's electronic medical record. In the event that there are any discrepancies regarding the patients reported allergies and the allergies identified in the patient medical record, the RN will update the patient electronic medical record and will contact the patient's Attending Physician and/or the Medical Director if there is a need for further orders, such as medication adjustments. A sign in sheet was used to document attendance and understanding of information provided.
The Executive Director and Patient Care Manager completed a 100% review of all active patients to ensure that any allergies listed in the patient's history and physical were recorded in the patient's electronic medical record. Any discrepancies were reviewed with patient or caregiver to verify that the allergy information in the history and physical documentation was accurate. The Hospice Nurse updated the allergy information in the electronic medical record and informed the Medical Director and Pharmacy provider. The Hospice patient identified during the survey died on 10/17/2020 from her terminal condition and therefore was not included in the 100% review of current patient charts.
To ensure ongoing compliance the Executive Director or designee will review all admissions to ensure that any allergies identified in the patient history and physical documentation are identified in the patient hospice electronic medical record, or a note is present identifying that the allergy information in the history and physical documentation is incorrect. The audit will occur for at least three months, or until 100% compliance is achieved for three consecutive months.
Based on the findings of an onsite unannounced State relicensure survey completed 12/23/2020, Conemaugh Regional Hospice was found to be in compliance with the requirements of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart A, Chapter 51.
Plan of Correction:
Based on the findings of an onsite unannounced State relicensure survey completed 12/23/2020, Conemaugh Regional Hospice was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction: