Survey Report for 141582

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
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION	141582	A. BUILDING __________ B. WING ______________	02/10/2022
NAME OF PROVIDER OR SUPPLIER	STREET ADDRESS, CITY, STATE, ZIP
ACCENTCARE HOSPICE & PALLIATIVE CARE OF ILLINOIS	606 POTTER RD, FL 6, DES PLAINES, IL, 60016
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)
L0693
L0693	44221 A. Based on clinical record reviews, staff interviews and policy review it was determined the Hospice failed to ensure patient medication was properly labeled. This was found in 1 out of 3 (Pt. #1) clinical records reviewed. Findings Include: 1. Pt. #1 SOC 11/09/2021 Dx: Multiple Myeloma The clinical record was reviewed on 02/10/2022 at 11:00 AM. The clinical record included a SN visit note dated 11/09/2021. The note documented " ...medication reconciliation, medication review complete, yes ..." During an interview with the Senior Director of Clinical Operations at 1:30 PM, she stated the medication was delivered to the patient on 11/08/2021. A coordination note dated 11/09/2021 documented, " ...after SNV, received message from daughter that medication ordered was mislabeled ..." 2. A policy titled, Medication Error effective 02/18/1997, and last reviewed on 04/24/2020 was reviewed on 02/10/2022 at 2:00 PM. The policy documented, "All medication errors will be promptly reported to the physician and documented in the clinical record ... 1. A medication error is due to an error in prescribing, transcribing, dispensing, administering, or monitoring ... examples include ... labeling error ... 2. A medication error may occur on the part of the patient, the caregiver, Seasons Hospice Staff, contracted staff, and/or the prescriber ... 6. The incident, actions taken, and patient response will be documented in the clinical record and on an Adverse Event Report ..." 3. During an interview with the Senior Director of Clinical Operations on 02/10/2022 at 2:30 PM, she confirmed the medication error. She also confirmed the clinical record lacked documentation of physician notification, and documentation of an adverse event report or incident report per Hospice policy.