Initial Comments:Based on the findings of an unannounced, onsite Medicare recertification survey conducted on October 8 through October 10, 2024, All Care 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:
Initial Comments:Based on the findings of an unannounced, onsite Medicare recertification and state re-licensure survey conducted October 8 through October 10, 2024, All Care Hospice was found not to be in compliance with the following requirements of 42 CFR, Part 418, Subparts A, C and D: Conditions of Participation: Hospice Care.
Plan of Correction:
418.106(e)(2)(i) STANDARD
LABEL DISPOSE STORAGE DRUGS
Name - Component - 00
(2) Disposing. (i) Safe use and disposal of controlled drugs in the patient's home. The hospice must have written policies and procedures for the management and disposal of controlled drugs in the patient's home. At the time when controlled drugs are first ordered the hospice must:
Observations:
Based on review of hospice policy/procedure, documentation, clinical records and Pennsylvania (PA) controlled substance classification information, and based on interview with the hospice coordinator (Employee #2) and the administrator (Employee #7), the hospice failed to ensure that documentation of controlled substance/medication disposal was completed as per hospice policy/procedure for one (1) of three (3) hospice patients who expired in a private home. (Patient #13)
Findings Include:
On October 10, 2024 at approximately 3:29 PM, review of the hospice policy titled "Controlled Drug Disposal" revealed the following:
Purpose: To promote the proper disposal of hospice medications.
Objectives...To prevent use of a controlled drug by someone other than the patient.
On October 10, 2024 at approximately 3:20 PM, review of PA Code, Title 28, Chapter 25. Controlled Substances, Drugs, Devices and Cosmetics ( https://www.pacodeandbulletin.gov/Display/pacode?file=/secure/pacode/data/028/chapter25/s25.72.html ) revealed the following: Lorazepam (Ativan) is classified as a Schedule IV controlled substance.
On October 10, 2024 at approximately 3:22 PM, review of the PA Department of Health Questions and Answers under the Prescription Drug Monitoring Program (https://www.pa.gov/en/agencies/health/healthcare-and-public-health-professionals/pdmp/qa.html ) revealed the following: Schedule II - drugs with acceptable medical use, but with a high abuse potential that leads to dependence (morphine...).
Patient #13: On October 10, 2024 at approximately 3:07 PM, review of hospice medication delivery records revealed the following medications were delivered to the patient:
-Lorazepam: 30 tablets on 10/16/2023.
-Morphine Sulfate: 30 milliliter bottles on 10/16/2023 and 10/23/2023.
On October 10, 2024 at approximately 2:40 PM, review of the clinical record revealed the patient expired on 10/25/2023 as documented on the "Discharge-Death" skilled nursing note. "Discharge-Death" skilled nursing note documentation under "Comments/Summary" revealed the registered nurse/hospice administrator (Employee #7) documented that hospice medications were disposed as per hospice policy but there was no documentation under the section titled "Medication Disposal: Please indicate the name and quantity of all medications that were disposed" which provided evidence that Employee #7 had documented the name and quantity the remaining doses of lorazepam and morphine sulfate which were disposed on 10/25/2023.
During interview conducted on 10/10/2024 at approximately 3:26 PM, the hospice coordinator and administrator confirmed the name and remaining doses/volume of controlled substances/medications supplied by the hospice are to be documented at the time of disposal.
During interview on October 10, 2024 at approximately 4:00 PM, the hospice coordinator and the administrator confirmed that documentation of controlled substance/medication disposal was not completed as per hospice policy/procedure for Patient #13.
Plan of Correction:1. The Hospice Administrator and IDG reviewed the Controlled Drug Disposal Policy, Instruction for use of the Hospice Stat Medication Kit Policy, and Hospice Pain Medication and Safety Plan and Agreement. Revisions were made on the Controlled Drug Disposal Policy and Hospice Pain Medication and Safety Plan Agreement. All staff were educated on the Controlled Drug Disposal Policy, Instruction for use of the Hospice Stat Medication Kit Policy, Hospice Pain Medication and Safety Plan and Agreement and Hospice Controlled Drug Disposal Form on 10/16/24.
2. Hospice Nurse will provide a copy of Controlled Drug Disposal Policy, Instruction for use of the Hospice Stat Medication Kit and the Hospice Disposal Form to all active hospice patients. A new Hospice Pain Medication Safety Plan and Agreement form will be signed by each patient/responsible party that resides at home. This is currently in process and will be completed by 10/18/24.
3. Hospice admission folders were updated with copies of the Controlled Drug Disposal Policy, Instruction for use of the Hospice Stat Medication Kit Policy, updated Hospice Pain Medication and Safety Plan Agreement and Hospice Controlled Drug Disposal Form to be reviewed upon admission to hospice services.
4. Starting on 10/20/24, Hospice Administrator to perform chart audits on all discharges weekly x 4 ending on 11/17/24. The chart audit will continue monthly and results will be submitted to IDG for review and action planning.
The Administrator will be responsible for monitoring for continued implementation of all aspects of the Plan of Correction.
Initial Comments:Based on the findings of an unannounced, onsite state re-licensure survey conducted October 8 through October 10, 2024, All Care Hospice was found to be in compliance with the requirements of 28 Pa. Code, Health and Safety, Part IV, Health Facilities, Subpart A. Chapter 51.
Plan of Correction:
Initial Comments:Based on the findings of an unannounced, onsite state re-licensure survey conducted on October 8 through October 10, 2024, All Care Hospice was found to be in compliance with the requirements of 35 P.S. § 448.809 (b).
Plan of Correction:
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