Every finding on record at Abs Palliative and Hospice Care, LLC

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review and interview. In 1 of 23 (4%) clinical records reviewed, the agency did not ensure that medication profiles were updated with all over-the-counter medications. Clinical Record 15: The patient was admitted on 08/03/2024 with a diagnosis of Alzheimer's disease. The patient resided at home with the daughter as a caregiver. A skilled nursing note dated 09/09/2024 documented, "Pt. reports pain in her left ear. Pt. to try Claritin and, if not effective, Debrox." Claritin and Debrox were not included in the medication profile. During an interview and a joint record review on 09/18/2024, the Director of Clinical Services, Administrator, and Regional Vice President (VP) of Quality Control. The VP of Quality Control confirmed that Claritin and Debrox were not on the medication profile, and they should have been, even though they are over-the-counter medications.

It is required that the hospice has written policies and procedures for the management and disposal of controlled drugs in the patient’s home. The policies and procedures address the circumstances under which controlled drugs are disposed of (e.g., the patient’s death, a change in drug regimen, etc.) and the method to be used in accordance with the state and federal law and regulation. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #PC.140 “Disposal of Controlled Substances” (last reviewed 10/01/2021), read in part, “After disposal by the hospice staff and/or assistance with disposal, the hospice staff will document the occurrence in the clinical record. The documentation in the clinical record will include: 1. the type of controlled substance by name; 2. dosage; 3. route of administration; 4. quantity so disposed; and 5. the time, date, and the way the disposal occurred.” In 1 of 3 (33%) clinical records reviewed of deceased patients, the agency did not ensure that policies and procedures were followed related to the disposal of controlled substances. Clinical Record 21: The patient elected hospice care on 07/21/2024 with a diagnosis of end-stage heart failure. The patient’s medication record documented lorazepam 2mg/ml and morphine sulfate concentrate 20 mg/ml solution. The patient’s death was confirmed on 07/22/2024 by the Registered Nurse (RN). The RN’s death note dated 07/22/2024 documented, “Medications disposed of with daughter as witness.” The clinical record did not include the name, amount, or manner of disposal of the controlled substances, lorazepam and morphine sulfate. During an interview and a joint record review on 09/17/2024, the Director of Clinical Services stated, “Yes, she should have documented more than that.”

It is required that a hospice aide provides services: Ordered by the Interdisciplinary Group; Included in the plan of care; Permitted to be performed under state law and regulation; and Consistent with the hospice aide training. This standard was not met as evidenced by review of 3 of 10 (30%) clinical records with Hospice aide services that revealed the aide deviated from the ordered visit frequency for the following plans of care. Record #50673 with a 03/19/2021 start of care had visit orders for 2 x each week. The aide documentation indicates the aide visited 1 time in week #1 and 1 time in week #3. There was no documented rationale for the missed visits. Record #52882 with a 03/31/2021 start of care had visit orders for 5 x each week. The aide documentation indicates the aide visited 1 time in week #1 with no documented rationale for the missed visits. Record #40042 with a 09/28/2021 start of care had visit orders for 3 x each week. The aide documentation indicates the aide visited 1 time in week #1, had 1 documented missed visit but failed to document the 3rd ordered visit. Record #47454 with a 10/13/2021 start of care had visit orders for 3 x each week. The aide documentation indicates the aide visited 1 x in week #1 and week #2, had 1 justified missed visit both weeks but failed to document the 3rd ordered visit. These deficiencies result in a CMS L tag #626 or CFR 418.76(g)(2). Interview the Agency Director of Quality and Executor Director confirmed this finding.

It is required that the hospice has written policies and procedures for the management and disposal of controlled drugs in the patient’s home. The policies and procedures address the circumstances under which controlled drugs are disposed of (e.g., the patient’s death, a change in drug regimen, etc.) and the method to be used in accordance with the state and federal law and regulation. This standard was not met as evidenced by review of 2 of 3 (66%) discharged-through-death records when the skilled nurse failed to document disposal of controlled medications in accordance with agency policy. These records were reviewed on Site Visit day #2. Agency policy titled {Medication Disposal} state; "The Agency will not remove any medications from patient's home or dispose of patient's medications". "If Agency staff provides verbal assistance for proper disposal of medications, the staff will document in the patient's clinical record, the type of controlled substance, dosage, route of administration, quantity so disposed and the time, date and manner in which that disposal occurred". Policy deviation occurred for the following; Record #94335 with a death pronouncement visit on 11/18/2021 had a documented entry that the nurse "destroyed Morphine Sulfate 34 ml and Lorazepam 5 ml". This documented entry indicate the nurse disposed narcotics. Record #47454 with a death pronouncement visit on 11/13/2021 had a documented entry that state "the husband opted to keep the narcotics without disposal at this time". This record documentation entry failed to include the type of controlled substance, dosage, route of administration, quantity so disposed and the time in which narcotics were left in the possession of the husband". Of note is that agency provided a "Late Entry Addendum" on Site Visit day #3 for record #94335 that state; " Patient's husband witnessed this nurse dispose of medications Lorazepam and Morphine". "Medications were destroyed per denaturation with cleaning supplies".