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
151614 A. BUILDING __________
B. WING ______________ 		06/14/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
DUNES HOSPICE LLC 4711 EVANS AVENUE, VALPARAISO, IN, 46383
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)
L0694      
41135 Based on record review and interview, the agency failed to follow agency policy for the disposal of controlled drugs in the patient's home in 2 of 4 clinical records reviewed. (#1, #2) The findings include: 1. Review of an agency policy on 6/14/2022, titled "Home Use and Disposal of Controlled Substances" dated October 2014, stated, "... After the patient dies or the drugs are discontinued, and therefore no longer needed, the qualified hospice personnel are responsible for the destruction, and should collect the drugs and dispose of them as determined by the procedures identified in the policy. Disposal of drugs will occur on site. Nurses must never transport drugs from the home. ... The hospice program must document in the clinical record the following information related to the disposed medications: The type of controlled substance, dosage, route of administration, and quantity, the time, date, and manner in which the disposal occurred. The drug disposal documentation should be maintained in the patient's medical record...." 2. Clinical record review on 6/14/2022, for patient #1, start of care 3/4/2021, evidenced an agency document titled "Pharmacy Uploads" which indicated the patient was provided 3 fentanyl (a narcotic pain medication) patches on 3/24/2021. Review of an agency document titled "Transfer/Discharge/Death Summary" electronically signed by registered nurse (RN) D and dated 3/30/2021, evidenced the patient requested a discharge from the agency due to dissatisfaction with the services. Review of agency documents titled "Medication Destruction Record" signed by RN D and dated 3/30/2021, indicated the method of disposal for all the patient medications except for fentanyl was disposal in coffee grounds. Review indicated 2 fentanyl patches were disposed of and the method of disposal for the fentanyl patch was not applicable and indicated the patches were cut up and destroyed in kitty litter. Review indicated the patient signed the form listing the patient's medications except for fentanyl. Review indicated the patient refused to sign the form listing the fentanyl. During an interview on 6/14/2022, at 10:00 AM, the family and patient care coordinator indicated all medications are the property of the patient and no medications are to be brought back to the office. During an interview on 6/14/2022, at 11:06 AM, RN D indicated narcotic medications are not to be removed from the patient's home. RN D indicated she has never brought back patient medications to the agency office. During an interview on 6/14/2022, at 1:15 PM, RN D indicated she disposed of the patient's medications in coffee grounds at the patient's home with the patient at time of discharge except for the fentanyl. When queried why the fentanyl was disposed of in kitty litter when the other medications were disposed of in coffee grounds, RN D indicated she took 2 fentanyl patches from the patient's home because the patient gave RN D the fentanyl patches after RN D had destroyed the other medications. RN D indicated the patient was upset regarding the lack of pain management, and RN D stated, "I was flustered." RN D indicated after she left the patient's home, the patient called her to inform her the nurse should not have taken the fentanyl patches from her home. RN D indicated she returned within 30 minutes to the patient's home with the fentanyl patches intact and indicated the patient refused to take the fentanyl patches back and refused to sign the medication disposal form. RN D indicated she marked "NA [not applicable]" on the disposal form because she did not destroy the fentanyl patches when she removed them from the patient's home. RN D indicated she brought the fentanyl patches to the agency's office and cut them up and placed them in kitty litter with another staff member as witness and then marked on the medication disposal form the patches were cut up and disposed of in kitty litter. 3. Clinical record review on 6/14/2022, for patient #2, start of care 1/13/2021, evidenced an agency document titled "Pharmacy Uploads" which indicated the patient was provided 30 pills of lorazepam (a narcotic medication to treat anxiety) on 9/3/2021, 3 fentanyl patches on 9/3/2021, and 20 milliliters (ml) of morphine (a narcotic pain medication) on 8/6/2021. Review of an agency document titled "Transfer/Discharge/Death Summary" electronically signed by registered RN E and dated 9/10/2021, evidenced the patient was discharged from hospice services due to increased functionality. Review indicated the RN destroyed the patient's medications. Review of a document titled "Controlled Drug Administration Record" indicated there was 7 ml of morphine remaining as of 8/17/2021, 14 pills of Lorazepam remaining as of 9/9/2021, and 2 fentanyl patches remaining on 9/8/2021. Review failed to evidence the date, time, and method of medication destruction per agency policy. During an interview on 6/14/2022, at 1:47 PM, the family and patient care coordinator indicated the lorazepam, morphine, and fentanyl were destroyed and indicated there was not record of the date, time, and method of medication destruction.