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
141666 A. BUILDING __________
B. WING ______________ 		03/24/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
KINDRED HOSPICE 2815 OLD JACKSONVILLE ROAD, SUITE 202, SPRINGFIELD, IL, 62704
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)
L0687      
32822 A. Based on document review and staff interview, it was it was determined in 1 of 10 (Pt #1) Hospice patients records reviewed, the Hospice failed to ensure that palliative medication was available for patient use. This has the potential to affect all patients receiving care at the Hospice in a Nursing Home. Findings include: 1. Pt #1 SOC 2/10/2022 Diagnosis: Pneumonia due to COVID The clinical record was reviewed on 3/23/2022 at approximately 3:00 PM. Pt #1 was admitted to the Hospice Program on 2/10/2022 with a diagnosis of pneumonia due to COVID. The record contained an admission "Visit Note" written by Hospice Nurse (E #2) that indicated Pt #1 did not have pain and that the palliative pain medication would be ordered on 2/11/2022. Hospice failed to have palliative medication available at the Nursing Home for patient comfort from 2/11/22 to 2/15/22. Palliative medication was ordered 2/11/2022. 2. On 3/22/2022 at approximately 4:00 PM, the "Nursing Facility Hospice Services Agreement (effective 11/04/2020) was reviewed. It required, on page 5, "section 2.10 Provision of Hospice Services; Hospice Responsibilities. Hospice is responsible for providing, (c) furnishing medical supplies, durable medical equipment, and drugs necessary for the palliation of pain and symptoms associated a Resident Patient's terminal illness and related conditions ..." 3. On 3/22/2022 at approximately 3:00 PM an interview was conducted with E #2. E #2 stated "the patient did not have any pain or symptoms requiring palliative medication like morphine or lorazepam. I just entered the medications on the medication profile, and we have till 9:00 AM the next day to obtain a physician orders/prescription for the medication." 4. The "Client Coordination Notes" Report dated 2/12/2022 indicated the Hospice Nurse (E #3) called the Hospice Physician (MD #1) on 2/11/2022 requesting the palliative medication to be ordered : A. Morphine Concentrate 100 mg/5 ml (20 mg/ml) (milligrams/milliliters) oral solution 0.25 ml every hour as needed for moderate pain and shortness of breath B. Morphine Concentrate 100 mg/5 ml (20 mg/ml) oral solution 0.5 ml every hour as needed for severe pain and shortness of breath. C. Lorazepam 1 mg tablet every 2 hours as needed for anxiety, shortness of breath or nausea. 5. On 3/23/2022 at approximately 9:00 AM, an interview was conducted with E #3. E #3 stated, "MD #1 sent an electronic prescription for the palliative medications listed above to the Nursing Home Pharmacy and notified E #3 by text on 2/11/2022 that the prescription was sent to the Pharmacy." 6. On 3/23/2022 at approximately 10:00 AM, an interview was conducted with E #1. E #1 stated, "we do not have a policy regarding electronic prescriptions or a system in place to verify if the electronic prescription actually went to the pharmacy. We do not keep a copy of the electronic prescription/order in the patients chart. The electronic prescription was sent from MD#1's cell phone and goes directly to the pharmacy, therefore there is no paper documentation that verifies the prescription was sent to the pharmacy. MD #1 is currently on vacation therefore unable to confirm the 2/11/2022 prescriptions were sent to pharmacy. E #1 verbally confirmed Pt #1 did not have palliative medication available from 2/11/22 to 2/15/2022.