DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		 (X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER		 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED
101533 A. BUILDING __________
B. WING ______________ 		03/02/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
ADVENTHEALTH HOSPICE CARE CENTRAL FLORIDA 480 WEST CENTRAL PARKWAY, ALTAMONTE SPRINGS, FL, 32714
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation
LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE

 TITLE

 (X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
(X4) ID
PREFIX
TAG		 SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY SHOULD BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
L0671      
35086 Based on record review, interview and policy review the provider failed to ensure accuracy of documentation of clinical record for 1 of 12 sampled patients (#2). Findings: Patient #2 was originally admitted to Adventhealth Hospice Care on 11/12/21 and re-admitted on 1/4/22 with terminal diagnosis of malignant neoplasm of colon. She was being seen by the hospice staff in the home care setting and was receiving IV (intravenous) pain medication via PCA device. The patient-controlled analgesia (PCA) pump is a computerized machine that gives you medicine for pain when you press a button. In most cases, PCA pumps supply opioid pain-controlling medicines such as morphine, fentanyl, and hydromorphone. The pump is attached to a thin, flexible tube (intravenous or IV line) that is placed in your vein. This medicine is usually delivered only when you press the button (bolus), but a continuous rate may be added by your doctor if needed (basal rate) .... (https://my.clevelandclinic.org/health/drugs/12057). Record review of patient #2's physician orders revealed she had been getting hydromorphone ongoing infusion for pain since 12/17/21. The most recent physician order dated 1/2/22 read, "Hydromorphone PCA basal/continuous rate 1 milligrams (mg)/hour and bolus/PCA dose 0.5 mg every 10 minutes prn [as needed] breakthrough pain". Registered Nurse (RN) B conducted a home visit on 1/4/22 and obtained verbal SOC (start of care) orders for certification period 1/4/22 to 3/4/22 which included Hydromorphone 1 mg/ml (milliliter) in 0.9% sodium chloride intravenous for pain. Instructions: Hydromorphone PCA 1 mg/ml concentration 0.5 mg/hr. (hour) basal rate, 0.5 mg bolus with 10-minute lockout. RN B also documented on the "Start of Care with Consents" on page 3, "Validate current therapy therapy/pump programmed rate: Basal rate 1 mg per hour with 0.5 mg available every 10 minutes as needed for breakthrough pain". This contradicted the verbal SOC orders for certification period 1/4/22 to 3/4/22 for basal rate of 0.5 mg/hr. Record review of RN A's home visit note dated 1/5/22 read, "Validate current therapy/pump programmed rate: 2 mg/hr. Validated current therapy/pump programmed bolus rate: 1 mg with 10-minute lockout". The nurse's documentation was also contradictory to the most recent physician order dated 1/2/22. On 3/2/22 at 12:02 PM the Director of Compliance (DOC) said he called the pharmacy and spoke with the pharmacist who verified the patient had been on hydromorphone dose of 1 mg/hr. and 0.5 mg bolus every 10 minutes since 1/2/22. He added, that the DCS called RN A who said, he did not change the pump setting at home visit on 1/5/22. Further review of the medical record with the DOC revealed patient #2 had total amount infused of 38.2 mg of hydromorphone per nurses note dated 1/4/22. The nurses note on 1/5/22 indicated she had 43.7 mg of medication in the past 24 hours. Thus, she could not have been getting 2 mg per hour in addition to the bolus doses as that would have been greater than 48 mg in 24 hours. On 3/2/22 at 12:23 PM, the DCS provided the most recent physician orders dated 1/2/22 for the PCA pump which read, "hydromorphone 1 mg/hr. and 0.5 mg bolus every 10 minutes as needed". The DCS said the orders were not changed since patient #2's prior admission. The DCS acknowledged both RN B and A's documentation in the clinical record was inaccurate for 1/4/22 and 1/5/22. The DCS added, they must have 2 nurses when changing the pump settings and it was not changed since 1/2/22. Review of the policy #701.00 effective 9/16/16 read, " This policy applies to all staff who document in the patient clinical record. The purpose of this policy is to ensure accurate and timely documentation in the medical records ...Also to ensure complete and accurate record of hospice services provide ...The clinical record must contain correct clinical information that is available to patient's attending physician and Hospice ...staff..."