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
231665 A. BUILDING __________
B. WING ______________ 		11/05/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
INTELICARE HOSPICE 604 W MAIN ST, GAYLORD, MI, 49735
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      
17040 Based on record review and interview, it was determined the hospice failed to ensure the plan of care included all drugs and treatments necessary to meet the patient's needs in 1 of 3 records reviewed (MR #1), resulting in the potential for unmanaged symptoms. Findings include: ** Hospice policy 9.12.1, revised dated June 2018, stated, "The care of plan [sic] specifies the care and services necessary to meet the patient and family-specific needs identified in the comprehensive assessment as such needs related to the terminal illness and related conditions... The plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions, including: Interventions to manage pain and other symptoms... Drugs and treatments necessary to meet the needs of the patient. Medical supplies and appliances necessary to meet the needs of the patient..." MR #1: During the review of the nursing visit note dated 9-25-20, it was noted that the hospice nurse documented, "Pt has not had a BM (bowel movement) in a week so this nurse suggested use of milk of Magnesia per (doctor) ... This nurse observed that this patient calls out in pain when he's touched or moved so this nurse contacted (Doctor) who ordered Norco 5-325mg q6h PRN (every 6 hours as needed) and if that does not bring relief Morphine 0.5 ml (milliliters) q4-6 PRN (every 4-6 hours as needed) for severe pain ..." On the nursing visit note dated 9-28-20 the nurse documented, "Mepilex (dressing) applied to wound on L (left) heel. Pressure ulcer opened and dark in color." On the nursing visit note dated 9-30-20 the nurse documented, "...this nurse placed Mepilex on pressure sore on patient's L buttock ..." The hospice plan of care did not include orders for the nurse to use the Milk of Magnesia, Norco, and Mepilex dressings.
L0555      
17040 Based on record review and interview, it was determined that the hospice failed to ensure that all ordered medications were provided to the patient in a timely manner in 1 of 3 records reviewed (MR #1), resulting in the potential for untreated symptoms and poor patient outcomes. Findings include: ** Hospice Policy 8.4.1 Medication Dispensing, revised date June 2018, stated, "Hospice will provide drugs and biologicals related to the palliation and management of the terminal illness and related conditions as identified in the Hospice plan of care. includes prescription and over-the-counter drugs...Hospice staff will order medications from contracted pharmacy in advance of patient's need to assure timely delivery of medications.. Hospice provides medications 24 hours/day, 7 days/week through contracted pharmacy providers." During the review of the record on 11-4-20, it was noted that the hospice provided and instructed the patient to use Milk of Magnesia for bowels, Norco for pain and used Mepliex dressings on heel wound and coccyx wound, however, there were no orders on the plan of care for the hospice to provide these treatments. MR #1: The complaint intake dated 10-19-20 stated, "The family was left with no medications ... (Caregiver) called again about medication that was supposed to be delivered by mail ... The comfort pack of medications showed up 5 days later with (patient's) name but had the wrong address. The nurse said it got lost in the mail ... [sic]" The plan of care included orders for the following medications (Comfort Pak) to be used as needed for symptom control: Acetaminophen (pain or fever; Bisacodyl (constipation); Haloperidol (agitation); Hycosamine (excessive secretions); Lorazepam (anxiety); Morphine (pain); and Prochlorperazine (nausea/vomiting). During the 11-4-20 review of the start of care assessment, dated 9-23-20, it was noted that the nurse documented, "Comfort pak ordered through Enclara but will not be delivered until 9/25." During an interview on 11-5-20 at 2:00 pm the Administrator produced a document from Enclara that stated the "Comfort Pak" was not shipped until 9-25-20 which would have been delivered on 9-27-20. During an interview on 11-5-20 at 2:10:pm the Administrator stated, "the Comfort Pak was first delivered to the neighbors house due to a wrong address, then the UPS driver came back and picked the package up and re-delivered it to the patient's home the same day. I thought that was the 25th." There was no evidence in the record that the Comfort Pak was delivered to the patient prior to 9-27-20, the fifth day of hospice services. The complaint intake also stated, "(Caregiver) called ... about (the patient) having a sore throat ... His mouth was full of thrush which I'm assuming was the cause of his sore throat. The medication for this finally showed up the day the patient died ... [sic]" During the 11-5-20 review of the record it was noted that there was no documentation of a phone call placed to the hospice regarding the patient having a sore throat. On the SN visit note dated 10-5-20 the nurse documented, "Thrush noted in pt's mouth. Nystatin to be ordered per (physician)." Per the complaint, the Nystatin arrived on the patient's day of death, 10-7-20, thus the Nystatin arrived at the patient's home 48 hours after the need was identified.