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
361573 A. BUILDING __________
B. WING ______________ 		02/13/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
KINDRED HOSPICE II 540 OFFICENTER PLACE, SUITE 100, GAHANNA, OH, 43230
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)
L0543      
35036 Based on medical record review and staff interview the agency failed to coordinate care with another agency upon a patient's discharge. This finding affected one of three patients reviewed (Patient #1). Findings include: The medical record review revealed Patient #1 was admitted to the agency on 08/23/19. Patient #1 was discharged from the agency on 12/31/19. The reason listed for discharge was the patient was noncompliant with the plan of care. Review of the Interdisciplinary Group Note dated 12/11/19 under the Skilled Nursing (SN) section it was noted the hospice would coordinate with the passport agency and discuss findings and plan. Review of the Interdisciplinary Group Note dated 12/11/19 under the Skilled Nursing (SN) section also noted the hospice would coordinate with the passport aide two to three times per month to discuss assessment. On 02/13/20 at10:30 AM interview was conducted with Staff A who stated Patient #1 refused to call the agency back after they tried to contact him multiple times for discharge. Staff A stated Patient #1 never allowed the hospice back into his home to complete the discharge. Patient #1 was discharged to passport services which he had been receiving concurrently with hospice care. The Administrator stated the agency did call passport to notify them of Patient #1's discharge. On 02/13/20 at 12:20 PM Staff B confirmed there is no documented evidence the hospice contacted passport or the patient regarding the discharge or need for treatment elsewhere.
L0700      
35036 Based on record review and staff interview the agency failed to investigate suspected drug discrepancies and where required report to appropriate authority. This affected three of three records reviewed for drug diversion (Patient #1, Patient #2 and Patient #3). Findings include: 1. The medical record review revealed Patient #1 was admitted to the agency on 08/23/19. Patient #1 was discharged from the agency on 12/31/19 with the reason listed as noncompliant with plan of care. A communication note dated 12/30/19 revealed Patient #1 had 15 less Oxycodone pills than should have had since the last refill and a small bag of marijuana was found in an empty medication bottle. The physician was notified, and Patient #1 was informed the agency would no longer prescribe narcotics and he/she might be discharged. There were no logs of medication kept. The medical record revealed a signed agreement dated 12/16/19 with the hospice and Patient #1 which stated, "Patient agree to obtain narcotics only from Kindred Hospice and their Medical Director. I (Patient #1) agree to have my (Patient #1) case manager count my narcotics upon each visit. Narcotics will always be kept in a lock box. I (Patient #1) agree to random drug screens at any time per the discretion of the Hospice Medical Directors. In the event that the narcotic counts are incorrect and/or positive drug screen or refused drug screens occur, patient listed (Patient #1) will be discharged and assisted to a Skilled Nursing Facility (SNF). Review of occurrence report revealed on 12/09/19 Patient #1 had 17 more tablets of Oxycodone taken per the maximum the prescription allowed. Patient #1 stated he only took them two or three times per day. The prescription could be for up to nine per day. Patient #1 was unwilling or unable to explain the missing tablets other than, "you know I drop pills sometimes." Teaching was provided regarding the necessity to exceed the prescription maximums. On 12/19/19 the report revealed a medication agreement was signed by Patient #1 and was read aloud to him and discussed. On 12/26/20 the report revealed the medication count was correct if Patient #1 was taking Oxycodone (a narcotic) every four hours. Patient #1 continued to insist he took his medication two times per day and occasionally three times a day. The pharmacy delivered 45 tablets. On 12/30/19 the report revealed Patient #1 stated "we have a problem" and informed the nurse someone stole his Oxycodone from him. Patient #1 was reminded he was supposed to lock them up and he stated the key to the safe broke. There were two of 45 tablets left. Patient #1 continued to insist he only took two to three per day. On 12/31/19 the occurrence report revealed the agency determined Patient #1 would be discharged from hospice and local law enforcement was notified. On 02/13/20 at10:30 AM an interview was conducted with Staff A who stated they did not call law enforcement the first-time diversion was suspected but we did the second time after he did not follow the agreement. 2. The medical record review revealed Patient #2 was admitted to the hospice on 05/21/19 and was discharged from the hospice on 12/10/19 for noncompliance with the plan of care. The record revealed a signed agreement dated 11/27/19 with the hospice and Patient #2 which stated, "Patient agree to obtain narcotics only from Kindred Hospice and their Medical Director. I agree to have my case manager count my narcotics upon each visit. Narcotics will always be kept in a lock box. I agree to random drug screens at any time per the discretion of the Hospice Medical Directors. In the event that the narcotic counts are incorrect and/or positive drug screen or refused drug screens occur, patient listed will be discharged and assisted to a Skilled Nursing Facility (SNF). Further review of Patient #2's medical record revealed a coordination note dated 12/06/19 that revealed the SN had documented upon her arrival the pharmacy did visit by counting Patient #2's medication per agreement. Patient #2 had not logged his/her medications on a medication count sheet. The SN had timed and dated the last visit on each sheet and was able to calculate how many doses per 24 hours up to time of current visit. The Morphine Sulfate (narcotic)15 milligrams (mg) count was 29, off by 6. The Soma (muscle relaxer count was 16 1/2 and was off by 3 1/2 tablets. The SN reminded the patient of the medication agreement and she should write down her medication count every time she took a pill. The SN stated the patient would have to be discharged for medication diversion. The patient stated she forgot to log her medications. The patient was reminded the Fentanyl patch had been ordered and she had not picked it up and she was not to double the current dose of medications. The patient denied taking more than she should have and then stated, "Oh I remember I took some with me in my pocketbook" when she went out with her friend the previous day. The SN documented the patient then went to the bedroom and the SN could hear banging around and the patient mumbling to herself. The patient returned with a bottle with three Somas inside, the bottle was labeled Xanax (antianxiety). The SN told the patient she was still off by 1/2 a pill which the patient stated was in her room and she would get it. The SN changed the subject to the missing Morphine and the patient began arguing about medication not working and was again reminded of the Fentanyl that was ordered and had not been picked up and she was not to take more of other medications than prescribed. The SN also again reminded the patient to write down each time she took a pill. The patient began to argue about the drugs not working and she would have to be discharge due to medication agreement. The patient then said she knew where the medications were and left the room and returned with a bottle with 10 tablets of Morphine 15 mg, the SN made up new medications sheets and instructed patient to log medications. The SN called her supervisor after the visit to report the incident and was advised to call the physician. The SN called the physician and he preferred to discharge the patient due to non-compliance and he told the nurse anytime a medication comes from a bottle that is not labeled correctly diversion of medication occurs. The physician felt that the patient should be discharged for cause. On 02/13/20 at 12:51 PM Staff A confirmed no documented evidence of investigation or notification of law enforcement of the suspected drug diversion. 3. The medical record review revealed Patient #3 was admitted to the agency on 09/24/19 and discharged on 11/06/19 for noncompliance with plan of care. The record revealed a signed agreement dated 09/24/19 with the hospice and Patient #3 which stated, "Patient agree to obtain narcotics only from Kindred Hospice and their Medical Director. I agree to have my case manager count my narcotics upon each visit. Narcotics will always be kept in a lock box. I agree to random drug screens at any time per the discretion of the Hospice Medical Directors. In the event that the narcotic counts are incorrect and/or positive drug screen or refused drug screens occur, patient listed will be discharged and assisted to a Skilled Nursing Facility (SNF)." Review of a patient coordination note dated 09/25/19 revealed Patient #3 reported her son had been involved in taking her medications in the past and she was aware she needed to keep medications in a lock box. Review of a coordination note dated 10/04/19 revealed the SN counted the medications and noted the Ativan (antianxiety) was not in a lock box. The SN explained to Patient #3 again medications should be kept in a lock box. Review of coordination note dated 10/21/19, Patient #3 reported her friend picked up Oxycodone (narcotic) and one tablet was missing. Review of coordination note dated 11/05/19 revealed Patient #3 was seen and she refused to use the Oxygen. The agency began discharge due to noncompliance and count being off the previous week. The note also revealed Patient #3 had multiple Ativan (antianxiety) bottles and it was unknown when they were prescribed. On 02/13/20 at 12:51 PM Staff A confirmed no documented evidence of investigation or notification of law enforcement of the suspected drug diversion.