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
261646 A. BUILDING __________
B. WING ______________ 		08/11/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
INTEGRITY HOME CARE + HOSPICE 2960 N EASTGATE AVE, SPRINGFIELD, MO, 65803
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)
L0530      
29559 Based on policy review, record review, and interview, the hospice provider failed to ensure the ongoing comprehensive assessments had an effective clinical review of all of a patient's prescription medications. A hospice patient was taking an undetermined amount of liquid morphine for a unknown length of time without knowledge or review from the hospice team (Patient/Record #1). The deficient practice has the potential to affect all patients on service with the hospice provider. Findings included: Review of the agency drug regimen review policies "H:2-055.2.1 and H:2-055.2" showed in part the following: - Hospice patients will have a current and accurate medication profile in the medical record - Medication profile will be used as a teaching guide to caregivers; - A medication review will include effectiveness of drug therapy, drug side effects, drug interactions, noncompliance with drug therapy regimen, and duplicate drug therapy. - Based on review of the medication profile as well as the written material, changes in the plan of care may be required. - Any conclusions and findings of patient medication use or monitoring should be communicated to the pharmacist, when appropriate, and other clinicians. - Deviations from taking medications as ordered will be documented in clinical notes, and the physician (or other authorized independent practitioner) will be notified upon the hospice staff becoming aware of such deviation. Review of the agency policy titled "ONGOING COMPREHENSIVE ASSESSMENTS Policy No. H:2-047.1" showed in part the following: - The policy purpose is to "provide guidelines for assessments of patients during ongoing care" - The scope and intensity of ongoing hospice patient assessments will be determined by the patient's prognosis, diagnoses, condition, desire for care, response to previous care, and the care setting. - The hospice nurse to assess pain, secondary symptoms, current treatment related to the identified symptoms, the patient's response to treatment, vital signs, breath sounds, skin integrity, functional status, safety/home environment, patient and family/caregiver support, compliance with treatments and medication regimen, and the need for an alternative setting or level of care. - Based on the assessments, the plan of care including problems, needs, goals, and outcomes will be reviewed and updated by the interdisciplinary group members responsible for the case. - Based upon the findings of the assessment, change/verbal orders will be generated and forwarded to the physician (or other authorized independent practitioner) as needed. - The physician will be notified to verify any changes in medications, including over-the-counter medications, and treatment/interventions. PATIENT/RECORD #1: Review of the patient's care plan showed that he/she was admitted on 05/09/2020 with a terminal hospice diagnosis of lung cancer. Review of the patient's admission orders and medication profile, dated 05/09/2020, showed no orders for liquid Morphine (Roxanol: a liquid opioid narcotic). The plan of care showed pain management as a problem, with interventions listed for medication regimen compliance of the caregiver. Review of the initial comprehensive assessment, completed on 05/09/2020 by RN-A, showed no education on use of Roxanol, or a drug regimen review that included Roxanol. The ongoing nursing assessments on 05/10/2020, 05/11/2020, 05/14/2020, 05/19/2020, 05/28/2020, 06/01/2020, 06/04/2020, 06/08/2020, 06/11/2020, 06/15/2020, 06/18/2020, 06/22/2020, 06/29/2020 and 07/02/2020 were reviewed. The assessments showed no use of Roxanol to control pain, education to caregiver on Roxanol use, drug regimen review including Roxanol, or counting of any Roxanol. The patient's primary nurse switched from RN-A to RN-B on 06/08/2020. Review of the hospice call log showed that on 07/05/2020 (a Sunday) at 11:41 AM the on-call service received a call from the patient's primary caregiver. The "Reason" was described as "emergency". The message from the caregiver was "PT needs liquid Morphine today running out". Review of the on-call nurse narrative on 07/05/2020 at 11:55 AM showed "call place to (caregiver) who states patient needs a refill on liquid morphine. This nurse does not see liquid morphine in the patient's medication profile". The on-call nurse contacted a hospice physician for liquid morphine orders. Review of the interdisciplinary care group (IDG) meeting summary, dated 07/01/2020, showed that RN-A was in attendance. The meeting had no review or comment for the use of Roxanol for the patient. The medication profile attached to the summary showed no order for liquid morphine. Review of the plan of care showed an interim order on 07/05/2020 at 1:52 PM to start liquid Morphine every two hours for pain and shortness of breath. The medication profile showed that liquid Morphine (Roxanol) was not started/ordered until 07/05/2020. During an interview with patient's primary nurse/case manager, RN-B, on 08/05/2020 at 9:12 AM, he/she stated the following: - He/she was case manager for the patient and had took the patient over from another case manager approximately 06/08/2020; - He/she had saw the patient prior to 07/05/2020 and was the case manager during this time; - He/she does not know what happened with the Roxanol not being on the patient's drug profile, physician orders, or regimen review before 07/05/2020; - He/she did not complete a drug regimen review when taking over as case manager for the patient; - He/she normally does a drug regimen review when taking over a patient from another case manager, but the previous case manager had just completed a review; - He/she tries to do the medication reconciliations once a week or once every two weeks, but sometimes it is missed due to an emergency with another patient; - He/she doesn't count narcotics every visit, but usually once a week and usually documents them in the narrative and the count sheet in the home; and - He/she thinks the agency policy is to complete a drug regimen review once a week.