Survey Report for 391707

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
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION	391707	A. BUILDING __________ B. WING ______________	10/30/2020
NAME OF PROVIDER OR SUPPLIER	STREET ADDRESS, CITY, STATE, ZIP
VIAQUEST HOSPICE, LLC	610 PARK AVENUE, MONONGAHELA, PA, 15063
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
L0694	37775 Based on review of facility policy, clinical records (CR), and interview with facility staff, the hospice failed to ensure written policies and procedures for the management and disposal of controlled drugs in the patient's home were followed for one (1) clinical record reviewed for a discharged patient that received services in the home (CR1). Findings included: Facility policy/procedure review on 10/30/2020 at approximately 1:30 PM reveled: "...Policy #: C-745...Medication Management...PURPOSE...To ensure safe disposal of controlled drugs in the patient's home...PROCEDURE...II...C. Controlled Substances...2. Discontinuation...When a patient no longer requires the controlled drug, the nurse will inform the family of the need to destroy the remaining medication...a. It will be the responsibility of...licensed staff (i.e.: RN, LPN) to document disposal of controlled substance(s) in the presence of another person, such as a family member. This documention shalt be maintained in the patient's record..." Review of CR1 on 10/29/2020 at approximately 11:00 AM revealed Start of care on 5/18/2020. Certification period 5/18/2020 to 8/15/2020. CR1 documented discharge summary 8/3/2020 and "Freedom of Choice" form signed by facility staff and patient family representative for transfer to an inpatient hospice facility on 8/3/2020. CR1 discharge summary did not contain documentation of the disposition of the following controlled drugs listed on the patient medication profile: "...fentanyl 25mcg/hr (micrograms/hour) transdermal film, extended release...morphine 30 mg tablet..." An exit interview was conducted off site via telephone with facility administrator (EMP1) on 10/30/2020 at approximately 2:45 PM. EMP1 confirmed above finding. EMP1 stated "...drug disposal...should have been documented..."