Every finding on record at VNA Home Care of Mercer County Inc

Based on medical record review, staff interview, and review of facility documents, the facility failed to ensure that members of the interdisciplinary group (IDG) maintained a plan of care specific to the patients' individual needs by failing to: 1) accurately update the plan of care for patients and appropriately communicate important patient information that could impact patient care (L-0546); and 2) ensure that the medical record contained communications regarding the patient's condition (L-0554). --- Cross Reference: 418.56(c)(1) - Interventions to manage pain and symptoms 418.56(e) - Coordination of services

Based on medical record review, and review of facility policy and procedure, it was determined that the facility failed to communicate the patient's needs and update the plan of care in two of ten medical records reviewed (Patient (P) 1 and P5) for the management of pain. --- Findings include: P5's medical record was reviewed on 4/11/24. The nursing visit notes for P5 were reviewed, and the following was identified: On 11/17/23: The medication order sheet noted that P5 was prescribed Tramadol 50 mg (milligrams) for pain. P5 "denied pain" and the nursing visit note did not contain documentation that P5 had taken anything for pain on that day and did not identify how and with what frequency the prescribed pain medication was being utilized. On 11/22/23: Documentation stated, "patient [was] received in hospital bed awake with confusion [he/she] denied any pain ..." The nursing visit note did not contain documentation that P5 had taken anything for pain on that day and did not identify how and with what frequency the prescribed pain medication was being utilized. On 11/24/23: Documentation stated, "... Medicated x1 for bilateral leg pain. Rates pain at 3/10 ..." The facility policy, titled, ";Pain Assessment", identifies pain intensity as, ";... pain intensity using a rating scale (on a scale of 0-10: 0 = no pain; 10 = unbearable pain ..." On 11/24/23, the medical record revealed that the patient was then prescribed the additional pain medications Dilaudid 2 mg and Methadone 5 mg despite the patient's report of 0-3 pain intensity. An Interdisciplinary Group (IDG) meeting was conducted on 12/5/23. Staff (S) 8, Nurse, stated that the patient denied pain, but that Methadone was ordered "for pain to bilateral lower extremities with tramadol for breakthrough pain". The IDG notes lacked documentation of the reason for prescribing the additional pain medications Dilaudid and Methadone in light of the patient's minimal reports of pain as per the nurse and visit notes. On 12/11/23, the nurse visit note documented the patient's pain as a "0" out of "10", but lacked documentation of the utilization of the prescribed pain medications. On 12/13/23, the nurse visit note documented the patient's pain as a "0" out of "10", but lacked documentation of the utilization of the prescribed pain medications. On 12/14/23, the nurse visit note lacked documentation of a pain assessment and additionally lacked documentation of the utilization of the prescribed pain medications. On 12/15/23, P5's methadone dosage was increased from 5mg to 10mg. The medical record lacks documentation of the reason for the increased dosage of pain medication. On 1/2/24, in the IDG meeting notes, S10, the physician, stated the patient "denies pain or discomfort". The IDG notes lacked documentation of the discussion of the need to maintain the current pain regimen of all three pain medications to best suit the patient's needs. The policy, titled, "Interdisciplinary Group Meeting", states, "... The Interdisciplinary Group will meet on a regular basis to discuss: patient and family/caregiver changes and progress; updates to the care plan... An Interdisciplinary Group meeting plan of care update will be done for the patient and family/caregiver and the attending physician. It will note changes, response to treatment and progress toward targeted outcomes, which may include: A. Pharmacotherapeutic effectiveness of symptom management outcomes ..." Findings include: P5's medical record was reviewed on 4/11/24. The nursing visit notes for P5 were reviewed, and the following was identified: On 11/17/23: The medication order sheet noted that P5 was prescribed Tramadol 50 mg (milligrams) for pain. P5 "denied pain" and the nursing visit note did not contain documentation that P5 had taken anything for pain on that day and did not identify how and with what frequency the prescribed pain medication was being utilized. On 11/22/23: Documentation stated, "patient [was] received in hospital bed awake with confusion [he/she] denied any pain ..." The nursing visit note did not contain documentation that P5 had taken anything for pain on that day and did not identify how and with what frequency the prescribed pain medication was being utilized. On 11/24/23: Documentation stated, "... Medicated x1 for bilateral leg pain. Rates pain at 3/10 ..." The facility policy, titled, ";Pain Assessment", identifies pain intensity as, ";... pain intensity using a rating scale (on a scale of 0-10: 0 = no pain; 10 = unbearable pain ..." On 11/24/23, the medical record revealed that the patient was then prescribed the additional pain medications Dilaudid 2 mg and Methadone 5 mg despite the patient's report of 0-3 pain intensity. An Interdisciplinary Group (IDG) meeting was conducted on 12/5/23. Staff (S) 8, Nurse, stated that the patient denied pain, but that Methadone was ordered "for pain to bilateral lower extremities with tramadol for breakthrough pain". The IDG notes lacked documentation of the reason for prescribing the additional pain medications Dilaudid and Methadone in light of the patient's minimal reports of pain as per the nurse and visit notes. On 12/11/23, the nurse visit note documented the patient's pain as a "0" out of "10", but lacked documentation of the utilization of the prescribed pain medications. On 12/13/23, the nurse visit note documented the patient's pain as a "0" out of "10", but lacked documentation of the utilization of the prescribed pain medications. On 12/14/23, the nurse visit note lacked documentation of a pain assessment and additionally lacked documentation of the utilization of the prescribed pain medications. On 12/15/23, P5's methadone dosage was increased from 5mg to 10mg. The medical record lacks documentation of the reason for the increased dosage of pain medication. On 1/2/24, in the IDG meeting notes, S10, the physician, stated the patient "denies pain or discomfort". The IDG notes lacked documentation of the discussion of the need to maintain the current pain regimen of all three pain medications to best suit the patient's needs. The policy, titled, "Interdisciplinary Group Meeting", states, "... The Interdisciplinary Group will meet on a regular basis to discuss: patient and family/caregiver changes and progress; updates to the care plan... An Interdisciplinary Group meeting plan of care update will be done for the patient and family/caregiver and the attending physician. It will note changes, response to treatment and progress toward targeted outcomes, which may include: A. Pharmacotherapeutic effectiveness of symptom management outcomes ..." 2. The medical record of P1 was reviewed. The coordination note entered by S8 on 1/24/24 at 9:48 PM indicates that P1 revealed to nurse that he/she is taking CBD (Cannabidiol). S8 indicated that he/she would inform the physician and pharmacy to determine if CBD would interfere with P1s medications. The medical record lacked documentation of communication from S8 to the patient's physician regarding the CBD, and the IDG meeting notes from 1/30/24 lacked documentation of communication of this medication from S8 to the rest of the IDG. The medical record of Patient (P) 1 was reviewed. From the period of 12/21/23 to 4/11/24, there were 38 pain assessments documented in P1s medical record. The pain assessments were noted as followed: P1 had rated his/her pain was a three out of 10 on two visits, two out of 10 on seven visits, and one out of 10 on two visits. On the 17 remainder of the visits, P1 denied pain.

Based on staff interview, medical record review, and review of facility documents, it was determined that the facility failed to ensure the medical record contained communications regarding the patient's condition in one of 10 medical records reviewed (Patient (P) 1). --- Findings include: The medical record of Patient (P) 1 was reviewed. From the period of 12/21/23 to 4/11/24, there were 38 pain assessments documented for P1. The pain assessments were documented as follows: P1 had rated his/her pain as a 3/10 on two visits, 2/10 on seven visits, and one 1/10 on two visits. On the 17 remaining visits, the medical record contained documentation that P1 denied pain. The facility policy titled, ";Pain Assessment" identifies pain intensity as, ";... pain intensity using a rating scale (on a scale of 0-10: 0 = no pain; 10 = unbearable pain) ..." On 4/10/24 at 3:21 PM, an interview was conducted with Staff (S) 6, Nurse Practitioner. S6 explained that the nurses put requests for medication refills into the Enclara electronic ordering system. According to S6, he/she will not be able to sign an order if the request for a medication is too soon. S6 also reports that he/she always has a conversation with the patient's nurse regarding the patients condition before increasing a patients dosage of a medication, but he/she does not document the conversation in the medical record. On 4/11/24 at 1:12 PM, an interview was conducted with S10, Medical Director. S10 reports that when a nurse requests a medication dosage increase or reorder, S10 has a discussion with the nurse regarding the patients condition. S10 relies on the nurses assessment and description of the patients needs when approving medication orders. S10 also reports that he/she does not read previous notes from the medical record or look at the last time medications were ordered when approving medication orders from the nurse. S10 stated that he/she does not document the conversation in the medical record. Upon request, on 4/11/24 at 2:50 PM, S1 provided the Enclara Pharmacy Report for P1. This report indicates that S8, Hospice Nurse, requested medications to be ordered for P1, and the orders were signed and approved by a hospice provider for the following medications: Hydromorphone (controlled medication used to treat pain) 2mg (milligrams) - 60 tablets on 1/18/24 Methadone (controlled medication used to treat pain or detoxification of opiates) 5 mg - 30 tablets on 1/18/24 Hydromorphone 2mg – 60 tablets on 1/23/24 Methadone 5mg – 15 tablets on 1/31/24 Morphine Sulfate Solution (controlled medication used to treat pain) 100 mg/5ml – 30 ml on 2/19/24 Lorazepam (controlled medication used to treat anxiety) 0.5 mg – 7 tablets on 2/19/24 Lorazepam 0.5 mg – 7 tablets on 2/19/24 Hydromorphone 2mg – 60 tablets on 3/9/24 Hydromorphone 2mg – 60 tablets on 3/25/24 An interview with the family of P1 on 4/10/24 at 1:23 PM, revealed that it had been "months since the patient had taken the pain medication Dilaudid." The patient's family stated that P1 had not taken Dilaudid ever since the pain medication, Methadone had been ordered for the patient, and that a controlled substance log was not maintained because the patient had not taken anything that needed to be logged. Review of P1's medication orders revealed that Methadone was initially ordered for the patient to start on 1/19/24. The IDG meeting notes for P1 from the period of 1/1/24 to 4/11/24 were reviewed, and the following was identified: IDG meeting notes dated 1/16/24 indicated that P1 refused to take Percocet for pain since it irritated his/her stomach. Methadone 5mg twice daily and Dilaudid 2mg every three hours as needed for breakthrough pain were prescribed by the Medical Director for the patient at that time. IDG meeting notes dated 1/30/24 indicated per the nurse's note that P1's family felt that the dose of Methadone was too much because P1 would awake confused. After re-evaluation by the nurse and the family, the methadone was switched to be taken at night and a supportive back brace was ordered to assist with the patient's pain. The IDG notes lacked documentation of the Dilaudid's frequency and use for breakthrough pain. IDG meeting notes dated 2/13/24 indicated that P1's family decreased the dose of Methadone to 2.5mg at bedtime. The IDG notes lacked documentation of the Dilaudid's frequency and use for breakthrough pain. IDG meeting notes dated 3/10/24 and 3/26/24 stated that P1 has "... no more complaints of back pain after first week of starting Methadone and Dilaudid ..."The IDG notes lacked documentation by the physician for the management of pain with the decrease in pain medication and use of a back brace. The IDG notes lacked documentation the Dilaudid's frequency and use for breakthrough pain. IDG meeting notes dated 4/9/24 indicated that P1 had no complaints of back pain and "take meds only when [he/she] wants to ..." The IDG notes lacked documentation the Dilaudid's frequency and use for breakthrough pain. The medical record lacked evidence of communications between S8 and either S6 or S10 of P1's use of Dilaudid for breakthrough pain at the time of the IDG meetings and at the time of the nursing visits. The medical record lacked a provider's note acknowledging the decreased dose of the pain medication, methadone for effective pain management. The medical record contains evidence that the orders for pain medication were not changed per the patient's needs, and were continued to be ordered despite the lack of documentation in the medical record of how these medications were or were not being used. Facility policy titled, "Hospice Care/Service Coordination," effective 9/19/13, stated, "... Procedure: ... 3. ... Documentation of all communications will be included in the clinical record on a communication note, case conference summary, or clinical note. Documentation will include: the date and time of the communication, individuals involved with the communication, information discussed, and the outcome of the communication ..."

Based on staff interview and document review, it was determined that the facility failed to maintain the quality assurance and performance improvement (QAPI) program for the accountability and oversight of controlled medications. --- Findings include: On 4/10/24, Staff (S)1, Clinical Manager, provided the QAPI (Quality Assurance Performance Improvement) meeting minutes for the last two quarters. The meeting minutes from the "FY [fiscal year] 2024 Quarter One" dated November 21, 2023, stated, "... TOPICS/FINDINGS ... Narc [narcotic] counts ... Q1 [quarter one] ... 90% ... ACTIONS ... Great strides were made to address areas that were previously below target areas 15 charts reviewed ... FOLLOW UP/EVAL [evaluation] ... QI [quality improvement] Coordinator will update chart audit findings at next QI Meeting ..." The meeting minutes for the next meeting held on February 27, 2024, for FY 2024 Quarter two, were reviewed. The minutes stated, "... TOPICS/FINDINGS ... Narc counts ... Q2 [quarter two] ... 90% ... ACTIONS ... Great strides were made to address areas that were previously below target areas 15 charts reviewed ... FOLLOW UP/EVAL ... QI Coordinator will update chart audit findings at next QI Meeting ..." Both the Q1 and Q2 meeting minutes lacked documentation of what action plans were in place and which indicators were below target areas. S1 stated that the Quality Coordinator was S11. An interview was conducted with S11 on 4/11/24 at 2:00 PM. S11 stated that when he/she reviews for the narc counts, he/she looks at 5 random charts in a month and reviews them to see if weekly narcotic counts are being completed per facility policy, and if the amount of narcotics in the weekly count made sense to have in the patient's home. If the amount in the count does not make sense compared to usage and patient indications for the medication, then the discrepancy would be reported to the clinical manager for review. S1 stated that currently he/she is behind in the audits as he/she is the only one doing this. S11 stated that there used to be two people to assist with the QAPI program, but the other staff member left a few months ago, and he/she has fallen behind on the monthly audits. S1 confirmed that there was only one person left to do the audits at this time. When asked if S1 maintained any oversight in the management and accountability of controlled substances, S1 stated that he/she gets the orders for the medications for review. The medications are ordered to have an adequate amount for a two-week supply for the patient. S1 stated that he/she does not compare previous orders to each other and does not compare the orders to the weekly medication count in a patient's medical record. An interview was conducted with S10, Medical Director, on 4/11/24 at 1:13 PM. S10 stated that he/she does not provide the oversight for the Nurse Practitioner (NP) for the hospice agency. S10 stated that the NP is independent and can sign orders on his/her own. S10 was asked how he/she is involved with the interdisciplinary group (IDG). S10 stated that the IDG meets every two weeks, if there were concerns before then, then S10 would rely on the nursing staff to contact him /her. S10 stated that two days prior to each IDG meeting, he/she would review all emails from the hospice agency staff, current patient medications, and would review any updates. S10 stated that he/she would not look in the patients' medical records at the nurse's notes and does not review the controlled substance usage and effectiveness. S10 stated that this would just be a routine discussion in IDG and that he/she would rely on the hospice nurse to provide information.

Based on medical record review, staff interview and review of facility documents, it was determined that the medical director failed to assume the responsibility and obligations of the role. --- Cross Reference: 418.102(d): Medical director responsibility

Based on medical record review, staff interview, and review of facility documents, it was determined that the medical director failed to assume responsibility for the oversight of hospice providers and nursing staff, in ensuring that the needs of the patients are met. --- Findings include: An interview was conducted with S10, Medical Director, on 4/11/24 at 1:13 PM. S10 is a member of the QAPI committee. S10 was asked how he/she is involved with the interdisciplinary group (IDG). S10 stated that the IDG meets every two weeks, if there were concerns before then, then S10 would rely on the nursing staff to contact him /her. S10 stated that two days prior to each IDG meeting, he/she would review all emails from the hospice agency staff, current patient medications, and would review any updates. S10 stated that he/she would not look in the patients' medical records at the nurse's notes and does not review the controlled substance usage and effectiveness. S10 stated that this would just be a routine discussion in IDG and that he/she would rely on the hospice nurse to provide information. S10 also stated that he/she does not provide the oversight for the Nurse Practitioner (NP) for the hospice agency. S10 stated that the NP is independent and can sign orders on his/her own. Facility policy titled, "Attending Physician Responsibility in Managing Hospice Patients," stated, "... Physician Responsibilities The physician has a responsibility to: A. Be an active participant in the development, revision, and approval of the hospice Interdisciplinary Team plan of care/hospice orders. B. Provide the hospice with timely information regarding managing his/her patient. Notification and contact will occur when there are changes ... 6. Changes needed regarding diagnoses, treatments, medications, precautions, limitations ..." Cross Refer: 418.56: Condition of Participation: Interdisciplinary Group, Care, Planning, and coordination of services

Based on medical record review, staff interview, and review of facility documents, it was determined that the facility failed to ensure the management of controlled substances prescribed to hospice patients by failing to: 1.) to maintain accurate records of controlled substances (L-0691); 2.) ensure compliance with policy regarding the destruction of controlled drugs in the home (L-0694); and 3) to provide education to the patient and family regarding the safe use and disposal of controlled drugs (L-0696). --- Cross Reference: 418.100(c)- Dispensing of drugs and biologicals 418.100(e)(2)- Safe use and disposal of controlled drugs in the patient's home 418.100(e)(2)(B)- Discuss policies and procedures for managing the safe use and disposal of controlled drugs

Based on medical record review, staff interviews, and review of facility documents, it was determined that the facility failed to maintain accurate records of controlled substances in four of 10 medical records (Patients (P) 1, 3, 4, and 5) reviewed. --- Findings include: The facility policy, titled, "Prevention Drug Diversion in Hospice Home Patient Procedure" effective 4/4/18 last revised 12/22, states, "... The nurse will perform a medication count of all controlled substances prescribed for the patient each week, while maintaining clean technique ... The counts will be documented in the clinical record narrative at the end of the visit, and a reminder to perform a medication count will be added to the hospice revisit plan ..." An interview was conducted on 4/10/24 at 12:17 PM with Staff (S)4, Vice President, which discussed the process of counting controlled substances. S4 confirmed controlled substances should be counted weekly by the nurse and if the patient had a comfort kit the nurse "would still be counting it and if it was sealed they (the nurse) would document weekly that the kit is closed." A medical record review of Patient (P)3's chart was conducted on 4/10/24. P3 is currently on hospice service with a start of care of 11/17/23. During that time, P3 was prescribed a comfort kit which included morphine (a controlled drug used to treat pain) and lorazepam (a controlled drug used to treat anxiety). Staff (S) 8, registered nurse, was identified by S4 as the primary nurse for P3. S8's nursing visit documentation lacked evidence of a weekly narcotic count or mention of a sealed comfort kit. A medical record review of P4's chart was conducted on 4/10/24. P4 is currently on hospice service with a start of care of 3/15/23. During that time, P4 was prescribed a comfort kit which included morphine and lorazepam. S8 was identified by S4 as the primary nurse for P4. S8's nursing visit documentation lacked evidence of a weekly narcotic count or mention of a sealed comfort kit. A medical record review of P5's chart was conducted on 4/11/24. P5 was on hospice service from 10/14/23 until 1/9/24. During that time, P5 was prescribed lorazepam, morphine, tramadol (a controlled drug used to treat pain), and methadone (a controlled drug used to treat pain). S8 was identified by S4 as the primary nurse for P4. Nursing documentation revealed a documented narcotic count by S8 on 10/23/23, 10/30/23, 11/20/23 and 12/19/23. The facility was unable to provide additional documentation of weekly narcotic counts. The medical record of P1 was reviewed. P1 entered hospice services at the facility with a start of care on 12/21/23 for Stage 4 Kidney Disease. The first medication count in P1s medical record was found in the coordination note entered by S8, Hospice Nurse on 2/5/24 at 9:05 PM. The medication count on this date: ";Methadone [controlled substance used to treat pain or detoxification of opiates] 5mg tablets = 24 Tablets" ";Dilaudid [controlled substance for pain] 2mg tablets = 58 Tablets" The coordination note entered by S8 on 2/20/24 at 9:37 PM included a medication count. ";Morphine [controlled substance for pain] 100mg/5mL = 30 mL" ";Lorazepam [controlled substance for anxiety] 0.5mg = 7 tablets" ";Hydromorphone [Dilaudid] 2 mg = 59 tablets" ";Methadone 5mg = 16 ½ tablets" The coordination note entered by S8 on 2/28/24 at 1:02 AM included a medication count. ";Hydromorphone 2mg = 48 tablets" ";Methadone 5mg = 17 tablets" ";Morphine 20mg/ml = 30ml" The coordination note entered by S8 on 3/13/24 at 11:42 PM included a medication count. "Morphine Sulfate 20mg/ml= 30 ml" ";Hydromorphone 2mg tablets = 100 tablets" ";Ativan [Lorazepam] .5 mg tablets = 7 tablets" ";Methadone 5 mg tablets = 9 tablets" On 4/11/24 at 2:50 PM, S1 provided the Enclara Pharmacy Report for P1. This report indicates that S8 ordered the following medications for P1: Hydromorphone 2mg – 60 tablets on January 18, 2024 Methadone 5 mg - 30 tablets on January 18, 2024 Hydromorphone 2mg – 60 tablets on January 23, 2024 Methadone 5mg – 15 tablets on January 31, 2024 Morphine Sulfate Solution 100 mg/5ml – 30 ml on February 19, 2024 Lorazepam 0.5 mg – 7 tablets on February 19, 2024 Lorazepam 0.5 mg – 7 tablets on February 29, 2024 Hydromorphone 2mg – 60 tablets on March 9, 2024 Hydromorphone 2mg – 60 tablets on March 25, 2024 On 4/10/24 at 11:11 AM, an interview was conducted with S1, Clinical Manager. S1 explained that nurses complete a medication count on the first visit of the week, review the patients medication log, compare it to the order and document the count in the narrative. On 4/10/24 at 12:17 PM, an interview was conducted with S4, Vice President. S4 confirmed controlled substances should be counted weekly by the nurse and if the patient had a comfort kit the nurse, "would still be counting it and if sealed closed they would document weekly that the kit is closed." The above findings were shared with S1 and S4 at the time of discovery. S1 and S4 confirmed that the weekly narcotic counts were not completed and documented according to facility policy. Findings include: The facility policy titled, "Prevention Drug Diversion in Hospice Home Patient Procedure" effective 4/4/18 last revised 12/22, stated, "... The nurse will perform a medication count of all controlled substances prescribed for the patient each week, while maintaining clean technique ... The counts will be documented in the clinical record narrative at the end of the visit, and a reminder to perform a medication count will be added to the hospice revisit plan ..." An interview was conducted on 4/10/24 at 12:17 PM, with Staff (S) 4, Vice President, which discussed the process of counting controlled substances. S4 confirmed that controlled substances should be counted weekly by the nurse and if the patient had a comfort kit the nurse "would still be counting it and if it was sealed they [the nurse] would document weekly that the kit is closed." P3's medical record was reviewed on 4/10/24. P3 is currently on hospice service with a start of care of 11/17/23. During that time, P3 was prescribed a comfort kit which included Morphine (a controlled drug used to treat pain) and lorazepam (a controlled drug used to treat anxiety). Staff (S) 8, hospice nurse, was identified by S4 as the primary nurse for P3. S8's nursing visit documentation lacked evidence of a weekly narcotic count or mention of a sealed comfort kit. P4's medical record was reviewed on 4/10/24. P4 is currently on hospice service with a start of care of 3/15/23. During that time, P4 was prescribed a comfort kit which included Morphine and lorazepam. S8 was identified by S4 as the primary nurse for P4. S8's nursing visit documentation lacked evidence of a weekly narcotic count or mention of a sealed comfort kit. P5's medical record was reviewed on 4/11/24. P5 was on hospice service from 10/14/23 until 1/9/24. During that time, P5 was prescribed lorazepam, Morphine, tramadol (a controlled drug used to treat pain), and methadone (a controlled drug used to treat pain). S8 was identified by S4 as the primary nurse for P5. Nursing documentation revealed a documented narcotic count by S8 on 10/23/23, 10/30/23, 11/20/23 and 12/19/23. The facility was unable to provide additional documentation of weekly narcotic counts. The medical record of P1 was reviewed. P1 entered hospice services at the facility with a start of care on 12/21/23 for Stage 4 kidney disease. The first medication count in P1s medical record was found in the coordination note entered by S8, on 2/5/24 at 9:05 PM. The medication count on this date was as follows: Methadone 5mg [milligram] tablets = 24 Tablets Dilaudid [controlled substance for pain] 2mg tablets = 58 Tablets The coordination note entered by S8 on 2/20/24 at 9:37 PM, included the following medication count: Morphine100mg/5mL [milliliter] = 30 mL Lorazepam 0.5mg = 7 tablets Hydromorphone [Dilaudid] 2 mg = 59 tablets Methadone 5mg = 16 ½ tablets The coordination note entered by S8 on 2/28/24 at 1:02 AM, included the following medication count: Hydromorphone 2mg = 48 tablets Methadone 5mg = 17 tablets Morphine 20mg/ml = 30ml The coordination note entered by S8 on 3/13/24 at 11:42 PM, included the following medication count: Morphine Sulfate 20mg/ml= 30 ml Hydromorphone 2mg tablets = 100 tablets Ativan [lorazepam] .5 mg tablets = 7 tablets Methadone 5 mg tablets = 9 tablets On 4/11/24 at 2:50 PM, S1 provided the Enclara Pharmacy Report for P1. This report indicated that S8 ordered the following medications for P1: Hydromorphone 2mg – 60 tablets on January 18, 2024 Methadone 5 mg - 30 tablets on January 18, 2024 Hydromorphone 2mg – 60 tablets on January 23, 2024 Methadone 5mg – 15 tablets on January 31, 2024 Morphine Sulfate Solution 100 mg/5ml – 30 ml on February 19, 2024 Lorazepam 0.5 mg – 7 tablets on February 19, 2024 Lorazepam 0.5 mg – 7 tablets on February 29, 2024 Hydromorphone 2mg – 60 tablets on March 9, 2024 Hydromorphone 2mg – 60 tablets on March 25, 2024 On 4/10/24 at 11:11 AM, an interview was conducted with S1, Clinical Manager. S1 explained that nurses complete a medication count on the first visit of the week, review the patients medication log, compare it to the order and document the count in the narrative. On 4/10/24 at 12:17 PM, an interview was conducted with S4. S4 confirmed controlled substances should be counted weekly by the nurse and if the patient had a comfort kit the nurse, "would still be counting it and if sealed closed they would document weekly that the kit is closed." The above findings were shared with S1 and S4 at the time of discovery. S1 and S4 confirmed that the weekly narcotic counts were not completed and documented according to facility policy.

Based on medical record review, staff interview, and review of facility policies and procedures, it was determined that the facility failed to implement their policy regarding the destruction of controlled drugs in the home in five of 10 (Patient (P) 1, P2, P5, P8, and P9) sampled patients. --- Findings include: The policy titled, "Safe Drug Disposal", states that "...The Hospice Nurse will document all medication name and amounts destructed on Medication Destruction Form and have patient representative witness and sign form. If patient representative declines medication destruction, the medication name and amounts left in the home will be documented on medication destruction form and signed by patient representative that destruction was refused." An interview was conducted on 4/10/24 at 1:33 PM with Staff (S)4, Vice President, regarding the processes of medication destruction. S4 stated, "our process is the waste log and it should be filled out. The family signs off and it's scanned into the chart." When asked the timeframe for uploading the scan, S4 stated, "24 hours for documentation, that's what I would hold someone accountable to." The facility policy, titled, "Clinical/Services Data Collection", confirms the timeframe stating, "...Staff are expected to complete all documentation related to care and communication of delivery of such care. At a minimum, and as an exception, documentation must be completed and submitted within 24 hours of care delivery...". The clinical record for P1 indicated that the patient received hospice services in the home setting from 12/21/23 to current. P1 was prescribed Percocet (a controlled pain medication) that was discontinued on 1/30/24. The clinical record lacked documentation that a waste log was completed and signed per the hospices policy. The clinical record for P5 indicated that the patient received hospice services in the home setting from 10/14/23 to 1/9/24. P5 was prescribed Dilaudid (a controlled pain medication), Lorazepam (a controlled anti-anxiety medication), Methadone (a controlled pain medication), and Morphine. A nursing note dated 1/9/24 stated ";...client breathless and pulseless. Apical pulse auscultated for two minutes. Pronounced at 8:30 AM...Narcotics disposed of per policy..." The clinical record lacked documentation that a waste log was completed and signed per the hospices policy. S1, Clinical Manager, confirmed this finding on 4/11/24 at 2:16 PM. The clinical record for P8 indicated the patient received hospice services in the home setting. P8 was prescribed a comfort pack (a kit of controlled drugs to help with pain and anxiety). A nursing note dated 2/9/24 stated, ";...received client breathless and pulseless. Apical pulse auscultated x2 minutes. Pronounced at 3:00 PM....Narcotics disposed of as per policy..." The clinical record lacked documentation tat a waste log was completed and signed per the hospices policy. S4 confirmed this finding on 4/11/24 at 3:09 PM. The clinical record for P9 indicated the patient received hospice services in the home setting from 3/14/24 to 3/27/24. P9 was prescribed Lorazepam and Morphine. A nursing note dated 3/27/24 stated, ";... Client expired on 3/27/24 at 8:20 AM....Drugs left at home as family requested..."The clinical record lacked documentation that a waste log was completed and signed per the hospices policy. The clinical record for P2 indicated the patient received hospice services in the home setting from 9/21/23 to current. A comfort pack was re-ordered for P2 on 3/28/24 as his/her was about to expire. The facility was unable to provide documentation of a waste log that was completed and signed per the hospices policy. Danielle needs to add that the MRR was completed that showed a note by S8 saying that the one comfort pack was removed for expiration On 4/11/24 at 9:47 AM, a home visit was conducted for P2. During the home visit, two comfort packs were located in P2's refrigerator. Comfort Pack one was dispensed on 9/21/23 with an expiration date of 7/23/24. Comfort Pack two was dispensed on 3/28/24 with an expiration date of 1/22/25. S7, Hospice Nurse, performed a medication count during the visit. Both comfort packs were open but the medications inside contained the original amount of medication. S7 was unsure why two unexpired unused comfort packs were present in the home. He/she explained the medication destruction process and planned to remove one of the comfort packs during the visit. S7 explained that once the destruction form is completed, it is uploaded immediately to the electronic medical record (EMR).

Based on medical record review, review of facility policy and procedures and staff interview, it was determined that the facility failed to provide education to the patient and family regarding the safe use and disposal of controlled drugs in one of 10 (Patient (P) 4) sampled patients. --- Findings include: On 4/11/24, the medical record for P4 was reviewed and indicated P4 was prescribed a comfort kit which contained Morphine (a controlled pain medication) and lorazepam (a controlled anti-anxiety medication) on 3/15/23. A nursing note written on 3/15/23 indicated that the comfort kit education would be given at the next appointment. The medical record lacked documented evidence that the comfort kit medication handout was provided, in accordance with facility policy. The medical record for P4 lacked documented evidence that the hospice provided education on the safe use and disposal of controlled drugs to the patient or the patient's representative. During an interview on 4/11/24 at 12:50 PM, Staff (S) 4, Vice President, acknowledged that education for the safe management and disposal of controlled drugs had not been given to the patient or caregivers. Facility policy titled, "Hospice Patient Self-Administration of Medications," revised date 12/22, stated, "... (name of facility) will encourage patient and family/caregiver participation in his/her own care and will provide teaching about the correct administration of medications by patient and family/caregiver as ordered by the attending physician ..." Facility policy titled, "Prevention Drug Diversion in Hospice Home Patients Procedure," revised date 12/22, stated, "... When the Comfort Kit is initially provided to the patient/family, the nurse will review the "Comfort Pack Medications" Handout ..."