Initial Comments:Based on the findings of an onsite, unannounced state re-licensure and Medicare recertification survey completed on 2/28/24, Paramount Hospice and Palliative Care was found to be in compliance with the following requirements of 42 CFR, Part 418.113, Subpart B, Conditions of Participation: Hospices - Emergency Preparedness.
Plan of Correction:
Initial Comments:Based on the findings of an onsite, unannounced state re-licensure and Medicare recertification survey completed on 2/28/24, Paramount Hospice and Palliative Care was found not to be in compliance with the following requirements of 42 CFR, Part 418, Subpart C, Conditions for Participation: Hospices.
Plan of Correction:
418.106(e)(2)(i)(A) STANDARD
LABEL DISPOSE STORAGE DRUGS
Name - Component - 00
[At the time when controlled drugs are first ordered the hospice must:]
(A) Provide a copy of the hospice written policies and procedures on the management and disposal of controlled drugs to the patient or patient representative and family;
Observations:
Based on employee interviews (EMP) and reviews of agency policy, patient admission packets, and clinical records (CR) the agency failed to provide patients and patient representative/families with a copy of the hospice's written policies and procedures on the management and disposal of controlled drugs for one (1) of ten (10) CRs reviewed. (CR 5)
Findings included:
A review of the agency document Patient Admission Handbook on 2/26/24 at approximately 10:00 am revealed patient teaching..."...How to Manage Medications at Home...Do...Non-Controlled Substances: dispose of all medications by dissolving agent...Consult the FDA-approved list of medicines that are considered safe to flush... Contact ...for the location of take back events or pharmacy drop boxes. ..."
A review of agency clinical policies on 2/26/24 at approximately 1:00 pm revealed:
Agency policy titled Safe Drug Disposal Procedure, effective 11/14/17, read: "2. In a long-term care facility setting, hospice employees will dispose of controlled substances with the facilities nursing staff by... 3. In the home, the hospice staff will encourage the patient and/or designated caregiver to dispose of medications (including controlled substances) that are no longer ordered, due to discontinued use or death of the patient. ... 4. Hospice staff are responsible for the education of patients and families regarding the proper medication disposal methods. ..."
Agency policy titled Narcotic Destruction, effective 5/1/08, read: "Standard: It is the hospice nurse's ethical responsibility to inform/assist the patient/caregiver of their responsibility in disposing of narcotics. Procedure: ...2. If the patient resides in a facility, the medications are to be disposed of in accordance with the facility's policies and procedures. 3. If a hospice nurse, with patient's/caregiver's approval, participates in the disposal of medication, the method of disposal and amount disposed is documented and cosigned with a witness on the Narcotic Destruction Form and placed in the hospice medical record. Only licensed hospice staff will participate in medication destruction."
A Clinical record (CR) review was conducted on 2/28/24 between approximately 10:00 to 1:00 pm:
CR5: Start of Care (SOC): 12/28/23, Certification Period Reviewed (Cert): 12/28/23 - 3/26/24. CR contained a Plan of Care dated 12/28/23 which contained orders for controlled substances with a start date of 12/28/23. CR contained no evidence that a written policy/procedure on the management and disposal of controlled drugs was provided to the patient or patient family/representative at the time that controlled substances were ordered on 12/28/23.
During an interview with EMP1 (Administrator) on 2/28/24 at approximately 2:00 pm it was determined that the hospice agency did not provide copies of the hospice's written policies and procedures on the management and disposal of controlled drugs to patients or patient representative/families. EMP1 verified that the information within the Patient Admission Handbook was the only document provided to all patients and patient family/representatives to review the management and disposal of controlled drugs.
The above finding was reviewed during an exit conference on 2/28/24 at approximately 2:45 pm with EMP1 (Administrator), EMP2 (Project Manager), and EMP3 (Alternate Administrator).
Plan of Correction:Patients and/or their designee, as well as facility staff caring for the patient, will receive a copy of the Safe Drug Disposal Clinical Procedure policy at the time of admission and it will be reviewed with them at that time and throughout the length of stay. A copy of the policy will be signed by the patient and/or designee at the time of admission and placed on the chart with the informed consents for hospice services.
Additionally, a letter regarding the policy and 2 copies of the policy, one to keep and one for signature, will be mailed to each current patient or designee along with a self addressed stamped envelope for returned of the signed copy. The hospice RN, administrator and MSW will coordinate phone calls to notify patient/designees that the information is being dispersed via mail and provide additional education to patients and/or designees regarding the policy.
418.108(c)(6) STANDARD
INPATIENT CARE PROVIDED UNDER ARRANGEMENTS
Name - Component - 00
[If the hospice has an arrangement with a facility to provide for short-term inpatient care, the arrangement is described in a written agreement, coordinated by the hospice and at a minimum specifies-]
(6) A method for verifying that the requirements in paragraphs(c)(1) through (c)(5) of this section are met.
Observations:
Based on a review of inpatient agreements (AG) and interviews with staff (EMP) it was determined that the hospice agency failed to maintain training materials and verification of training for personnel within contracted inpatient facilities for one (1) of one (1) inpatient agreements reviewed. (AG1)
Findings included:
A review on 2/28/24 at approximately 2:00 pm of agency agreements revealed:
AG1: Entry date: 5/6/21. Titled Inpatient and Respite Care Service Agreement revealed: "3. Services and Responsibilities of Hospice...3.5 Nursing Facility Orientation. Hospice personnel must assure orientation of Nursing facility staff furnishing care to Hospice Patients in the hospice philosophy, including Hospice policies and procedures regarding methods of comfort, pain control, symptom management, as well as principles about death and dying, individual responses to death, patient rights, appropriate forms, and record keeping requirements. ..."
During an interview on 2/28/24 at approximately 2:00 pm with EMP1 (Administrator) it was determined that a roster of trained individuals and the training program/materials for AG1 were not available for review.
The above finding was reviewed during an exit conference on 2/28/24 at approximately 2:45 pm with EMP1 (Administrator), EMP2 (Project Manager), and EMP3 (Alternate Administrator).
Plan of Correction:Paramount Hospice is developing a training packet for contracted Inpatient Hospice Facilities including Paramount Hospice policies on the following:
Patient Rights and Responsibilities
Pain Management
Documentation/Record Keeping (Policies entitled Transfer to Inpatient Hospice; Transfer From Inpatient Hospice)
Care of Dying Patient
Inservice and Booklet entitled "Life Beyond Loss"
Also included will be educational resource materials from the HPNA regarding Care of the Patient Nearing End of Life and additional Symptom Management Guides from HPNA.
Due to the volume of information to be distributed, Paramount Hospice aims to provide inservices on a bi-monthly or quarterly basis to meet education needs without overwhelming the staff of the contracted facility. A sign in sheet with the names and titles of Inpatient Facility Staff in attendance will be completed at the time of inservice and maintained in an education binder in the Paramount Hospice Office.
Initial Comments:Based on the findings of an unannounced onsite state re-licensure and Medicare recertification survey completed 2/28/24, Paramount Hospice and Palliative Care 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:
Initial Comments:Based on the findings of an unannounced onsite state re-licensure and Medicare recertification survey completed 2/28/24, Paramount Hospice and Palliative Care was found to be in compliance with the requirements of 35 P.S. § 448.809 (b).
Plan of Correction:
|