Unitypoint Hospice

“Upon patient record review, 3 of 26 (Patient #5, 12, 20 ) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 05: The medication profile includes menthol-methyl muscle rub apply topically to affected area twice daily for pain, it does not include an application site. (Profile corrected and updated on site.) Patient 12: The medication profile includes Nystatin powder, apply topically 2 times daily, it does not include an application site. (Profile corrected and updated on site.) Patient 20: The medication profile includes polyethylene glycol 17g by mouth daily for constipation, it does not include a diluent. (Profile corrected and updated on site.)”

“Upon patient record review, 3 of 26 (Patient #5, 12, 20) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 05: Medication orders on 2/7/25 for menthol-methyl muscle rub, apply topically to affected area twice daily for pain, it does not include an application site. (Order corrected and updated on site.) Patient 12: The medication order entered on 3/7/25 for Nystatin powder, apply topically 2 times daily, does not include an application site. (Order corrected and updated on site.) Patient 20: The medication order on 3/10/25 for polyethylene glycol 17g by mouth daily for constipation, does not include a diluent. (Order corrected and updated on site.)”

“Upon patient record review, 2 of 26 (Patient #5, 7) did not have evidence that a revised plan of care includes information from the patient’s updated comprehensive assessment and must note the patient’s progress towards outcome/goals from the plan of care. Patient 05: The patient record includes new onset of anxiety and agitation documented on 3/11/25 with new orders for lorazepam 0.5mg by mouth every 2 hours as needed for anxiety, the plan of care was not updated to include a problem statement for anxiety/agitation with interventions and goals. Patient 07: The patient is prescribed Coumadin 2.5mg with routine lab monitoring every month, for a diagnosis of paroxysmal atrial fibrillation, related to the hospice diagnosis. The plan of care does not include a problem statement with interventions and goals for the cardiovascular/hematology issues.”

“Upon patient record review, 1 of 26 (Patient #11) the agency did not have evidence that the hospice has offered and/or provided spiritual counseling in accordance with the patient/family’s desires which include: •Providing spiritual counseling to meet these needs in accordance with the patient’s and family’s acceptance of this service and in a manner consistent with their beliefs and desires Patient 11: Spiritual Care visits are ordered for 2 x per month effective 1/30/25 - 4/24/25. The patient record indicates missed visits x 2 for the month of February and no visits currently in March for Spiritual Care, noted as “unable to contact son.” The RN documentation for 2/10/25, 2/13/25, 2/25/25 and 2/26/25 indicated needs for spiritual and emotional support and referral to chaplain. (Patient died on 3/13/25 during the survey window with no spiritual visit made.)”

“Upon observation, there was no evidence the electrical of a facility is provided consistent with the 2012 editions of the LSC of the National Fire Protection Association and NFPA 99. The provisions of the adopted edition of the Life Safety Code do not apply in a State if CMS finds that a fire and safety code imposed by State law adequately protects patients in hospices. New and existing Construction NFPA 110: Standard for Emergency and Standby Power Systems, in conjunction with NFPA 70: National Electrical Code. NFPA 110, 5.6.5.6 states: “All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building.” An appendix item at A-5.6.5.6 suggests: “For systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified.” Upon inspection it is identified that the location does not include an appropriately identified manual stop station for the outdoor generator.”

“Upon observation, there was no evidence the furnishing and decorations of a facility is provided consistent with the 2012 editions of the LSC of the National Fire Protection Association and NFPA 99. The provisions of the adopted edition of the Life Safety Code do not apply in a State if CMS finds that a fire and safety code imposed by State law adequately protects patients in hospices. Existing Construction A.7.1.10.1 A proper means of egress allows unobstructed travel at all times. An example of an obstruction or impediment to full instant use of means of egress is any security device or system that emits any medium that could obscure a means of egress. It is, however, recognized that obstructions occur on a short-duration basis. In these instances, awareness training should be provided to ensure that blockages are kept to a minimum and procedures are established for the control and monitoring of the area affected. It was identified during the life safety inspection that the means of egress located in the south hallway (a protected area) and identified as door set #31 do have latching hardware contained within the fire rated doors. It was identified that the latching hardware is faulty and does not allow for a means of egress when attempting to disengage the latching mechanism. The door requires an excessive amount of force to disengage the latching mechanism and can substantially delay the exit time of any person who attempts to exit through the corridor doors.”