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
141595 A. BUILDING __________
B. WING ______________ 		07/08/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
ST MARGARETS HOSPICE 600 E 1ST STREET, SPRING VALLEY, IL, 61362
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)
L0549      
32189 Based on document review and interview, it was determined for 1 of 2 (Pt#1) patients records reviewed that resided in a Skilled Nurse Facility, the Hospice failed to ensure the medications were available to meet the needs of the patient. This has the potential to affect all patients who receive care by the Hospice with a current census of 13 patients. Findings include: 1. The policy titled "Identification, Prevention and Treatment of Secondary Symptoms" (issued 12/10/20) was reviewed on 7/9/22. The policy noted "3. The primary nurse will follow the Plan of Care and physician standing orders for secondary symptoms, including placement of comfort care kit." 2. Pt #1 Start of Care: 9/20/21 Diagnosis: Metastatic Prostate Cancer. The record was reviewed on 6/7/22 at approximately 10:00 AM. The Physician Phone/Verbal Order dated 6/4/22 noted "... Standing Order to initiate Comfort Medication As Needed from Facility Emergency Box 1) Roxanol concentrated liquid 20 mg (milligrams)= 1 ml (milliliter) start with 5 mg p.o. every 30 minutes, may increase to 10 mg p.o. every 30 minutes for pain". The Nursing Regular Visit note dated 6/4/22 at 8:45 AM noted "Respiratory Overview Assessment... labored at times, morphine (Roxanol) will be started today." A new order for Roxanol with the same dose was obtained on 6/4/22 (written order is not timed/electronic record noted order was entered at 12:10 PM). The record noted E#3 arrived at the Skilled Nurse Facility with the Roxanol although Pt #1 had passed away prior to administration. E#3 3. During an interview on 6/8/22 at approximately 1:45 PM, the Director of Hospice (E#2) reviewed Pt #1's record and verbally agreed E#3 was unaware of the existing standing order and should have asked the Skilled Nurse Facility for the Roxanol from their emergency box. E#2 verbally agreed this resulted in a delay of care.
L0555      
32189 Based on document review and interview, it was determined for 1 of 3 (Pt#1) patients records reviewed, the Hospice failed to ensure medications were administered as ordered. This has the potential to affect all patients who receive care by the Hospice with a current census of 13 patients. Findings include: 1. The policy titled " 2. Pt #1 Start of Care (SOC): 9/20/21 Diagnosis: Metastatic Prostate Cancer. The record was reviewed on 6/7/22 at approximately 10:00 AM. The Physician Phone/Verbal Order dated 6/4/22 noted Roxanol (20 mg/ml) (milligrams/milliliter) 0.25 ml (5 mg) po (orally) q (every 30 min (minutes) PRN (as needed), may increase to 0.5 ml (10 mg) po q 30 min PRN. The Destruction/Return of Unused Medications for Hospice Patients dated 6/4/22 noted Roxanol 29.5 ml from a 30 ml vial was returned to the pharmacy. The record lacked documentation Roxanol was administered or wasted. 3. During an interview on 6/7/22 at approximately 3:00 PM, the Vice President of Quality and Community Services (E#1) reviewed Pt #1's record and stated the Hospice Nurse (E#3) drew up 0.5 ml (10 mg) of Roxanol to administer to Pt #1, although the order noted to initiate at the 0.25 ml (5 mg) dose. E#1 verbally agreed 5 mg should have been administered initially.
L0696      
32189 Based on document review and interview, it was determined for 1 of 2 (Pt#1) discharged patients records reviewed, the Hospice failed to ensure controlled drugs were accurately wasted per policy. This has the potential to affect all patients who receive care by the Hospice with a current census of 13 patients. Findings include: 1. The Destruction/Return of Unused Medications for Hospice Patients form (updated 5/16/22) was reviewed on 7/7/22. The form noted " Note any medications/dosage/quantities provided by... Hospice that were destroyed by facility staff:" 2. Pt #1 Start of Care: 9/20/21 Diagnosis: Metastatic Prostate Cancer. The record was reviewed on 6/7/22 at approximately 10:00 AM. The "Destruction/Return of Unused Medications for Hospice Patients" dated 6/4/22 noted Roxanol 29.5 ml (mililiters) from the 30 ml vial was returned to the pharmacy. The record lacked documentation Pt #1 received Roxanol. 3. During an interview on 6/7/22 at approximately 2:30 PM, the Vice President of Quality and Community Services (E#1) reviewed Pt #1's record and verbally agreed the record lacked documentation Pt #1 received Roxanol. At approximately 3:00 PM, E#1 stated the Hospice Nurse (E#3) drew up 0.5 ml of Roxanol to adminster to Pt #1, although Pt #1 had passed away prior to administration therefore the Roxanol 0.5 ml was wasted without witness and should not have been.