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
191588 A. BUILDING __________
B. WING ______________ 		12/01/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
HEART OF HOSPICE 1001 HWY 190 EAST SERVICE RD, STE 202, COVINGTON, LA, 70433
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      
30984 Based on record review and interview, the hospice agency failed to ensure drugs and biologicals were disposed of properly, in accordance with all applicable laws and regulations, after patient death. This deficient practice was evidenced by failure to ensure the remaining counts of controlled drugs were documented in the patients' death notes for 2 (#3, #5) of 3 (#2, #3, #5) sampled patient death records reviewed from a total patient sample of 5 (#1- #5). Findings: Review of a memo issued by LDH-Health Standards Section, dated 06/25/2018, revealed the following: In accordance with Act 23 of the 2018 Regular Legislative Session, the LDH- Health Standards Section is issuing this notice to all licensed hospice providers. Effective 08/01/2018, Act 23 amends and reenacts LA RS 40:2191 relative to disposal of controlled substances by hospice providers; to provide for ownership; to provide for written procedures; to provide for patient records; to provide for disposal; to provide for patient notification; and to provide for related matters. Review of LA RS 40:2191 revealed the following: Disposal of deceased patient's unused controlled substances: A. Upon death of a patient receiving hospice services, ownership of the patient's unused Schedule II, III, IV, or V controlled substances under 21 CFR 1308 may transfer to the hospice for immediate disposal pursuant to the following provisions: 1. Each hospice shall establish a written procedure to ensure safe disposal of unused controlled substances by a hospice nurse at the time of death. 2. Upon death of a patient receiving hospice services, in the presence of a witness, the hospice nurse shall record in the medical record, the name and quantity of each unused controlled substance. Review of the hospice policy titled," Disposal of Medications in the Home", revealed the following, in part: Policy: The hospice nurse advises the destruction of all prescription medications when a medication is no longer needed by the patient or in the event of the patient's death at home. Disposal of controlled substances must be conducted in accordance with all applicable laws and regulations. Home hospice personnel may not dispose of controlled substances unless authorized by state law. Procedure: 1. When a patient no longer needs prescription medications or upon the death of the patient in the home, the nurse instructs the family/caregiver in the disposal of the medications. 2. The nurse obtains the consent to dispose of prescription medications from the patient or caregiver: a. medications are destroyed by the family with the nurse providing witness. b. the nurse documents the disposal of the medication in the clinical record. Patient #3 Review of Patient #3's medical record revealed a start of care date of 09/23/2021. Further review revealed the patient expired on 10/01/2021. Patient #3 was receiving routine hospice care in a SNF. Review of Patient #3's plan of care revealed the patient had current orders (prior to death) for the following medications: Morphine concentrate ( Schedule II Drug) 100 mg/5ml (20 mg/ml) oral solution: Dose: 0.5 ml; Route: Oral; Frequency: q 2 hours as needed for pain or SOB; Lorazepam ( Schedule IV Substance) 2 mg/ml oral concentrate: Dose: 0.5 ml q 4 hours as needed for restlessness. Review of Patient #3's death note documentation, dated 10/01/2021 10:05 a.m. revealed the following, in part: Medications: Agency staff did not dispose of medications; Reason: per facility protocol. Further review revealed there were no final counts documented in the death note, for the above referenced controlled medications, that had been destroyed by the SNF after the patient's death, Patient #5 Review of Patient #5's medical record revealed a start of care date of 09/20/2021. Further review revealed the patient expired at home on 09/29/2021. Review of Patient #5's plan of care revealed the patient had current orders (prior to death) for the following medications: Morphine concentrate 100 mg/5ml (20 mg/ml) oral solution: Dose: 0.5 ml; Route: Oral; Frequency: hourly as needed for pain or SOB. Lorazepam 0.5 mg tablet: Dose: 1 tablet by mouth every 4 hours as needed for anxiety. Review of Patient #5's death note documentation, dated 09/30/2021, revealed the following: 09/29/2021 - 11:55 p.m. Death note: patient expired at home. Summary of visit: Hospice nurse confirmed time of death at 11:55 p.m. Controlled medications counted and destroyed in deactivation kit with caregiver witnessing waste. Further review revealed there were no final counts, documented in the death note, for the above referenced controlled medications destroyed after the patient's death. In an interview on 12/01/2021 at 3:00 p.m. with S1PCM, she confirmed the hospice provided medications for patients who received hospice services in SNF's as well as for patients receiving in -home hospice services. S1PCM confirmed the death note documentaiton for Patients #3 and #5 failed to contain final counts of the patients' remaining controlled narcotics that were destroyed following the patients' deaths.