VNA Hospice Home Care

“Upon patient record review, 6 of 21 (Patients #1,5,7,8,11,14) 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 #1: During SNF visit medication reconciliation this patient had Pepcid 20 mg on hand (ordered 10/6/25). This medication was not included on the hospice medication profile. Corrected on site-RN obtained order and updated hospice med profile. Patient #5: This patient is prescribed Acetaminophen ES 500mg. 2 tablets two times daily as needed. Acetaminophen 650mg Suppositories 1 suppository every 6 hours as needed, and Hydrocodone/ Acetaminophen 5/325 one tablet 3 times daily as needed. The medication profile did not specify a maximum dose of acetaminophen within 24 hours. Patient #7: This patient is prescribed Acetaminophen ES 500mg. 1 tablet at bedtime. Acetaminophen 650mg Suppositories 1 suppository every 4 hours as needed, and Hydrocodone/Acetaminophen 325 two tablets 4 times daily as needed. The medication profile did not specify a maximum dose of acetaminophen within 24 hours. Patient #8: This patient is prescribed Acetaminophen 325mg. 2 tablets four times daily as needed and Acetaminophen 650mg Suppositories 1 suppository every 4 hours as needed, The medication profile did not specify a maximum dose of acetaminophen within 24 hours. Patient #11: This patient is prescribed Acetaminophen 325mg. 2 tablets four times daily as needed and Acetaminophen 650mg Suppositories 1 suppository every 4 hours as needed, The medication profile did not specify a maximum dose of acetaminophen within 24 hours. Patient #14: This patient is prescribed Acetaminophen 325mg. 2 tablets six times daily as needed and Acetaminophen 650mg Suppositories 1 suppository every 4 hours as needed, The medication profile did not specify a maximum dose of acetaminophen within 24 hours.”

“Upon patient record review, 5 of 21 (Patients #5,7,8,11,14) did not have evidence the plan of care (POC) must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #5: This patient is prescribed Acetaminophen ES 500mg, 2 tablets two times daily as needed and Acetaminophen 650mg Suppositories 1 suppository every 6 hours as needed, and Hydrocodone/ Acetaminophen 5/325 one tablet 3 times daily as needed. The POC did not specify a maximum dose of acetaminophen within 24 hours. Patient #7: This patient is prescribed Acetaminophen ES 500mg, 1 tablet at bedtime. Acetaminophen 650mg Suppositories 1 suppository every 4 hours as needed, and Hydrocodone/ Acetaminophen 325 two tablets 4 times daily as needed. The POC did not specify a maximum dose of acetaminophen within 24 hours. Patient #8: This patient is prescribed Acetaminophen 325mg, 2 tablets four times daily as needed and Acetaminophen 650mg Suppositories 1 suppository every 4 hours as needed. The POC did not specify a maximum dose of acetaminophen within 24 hours. Patient #11: This patient is prescribed Acetaminophen 325mg, 2 tablets four times daily as needed and Acetaminophen 650mg Suppositories 1 suppository every 4 hours as needed. The POC did not specify a maximum dose of acetaminophen within 24 hours. Patient #14: This patient is prescribed Acetaminophen 325mg, 2 tablets six times daily as needed and Acetaminophen 650mg Suppositories 1 suppository every 4 hours as needed. The plan of care did not specify a maximum dose of acetaminophen within 24 hours.”

“Upon observation, there is no evidence the corridor walls and doors of a facility is provided consistent with the 2012 editions of the LSC of the National Fire Protection Association and NFPA 99. Hospices are exempt from chapter 19.3.6.3.5 “exception number 1 and 2 and 19.3.6.3.6 number 2”. If recommended by state survey agency, CMS may waive for periods deemed appropriate, specific provisions of the LSC which, if rigidly applied, would result in unreasonable hardship to the hospice, but only if the waiver would not adversely affect the health and safety of patients. 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. During the building tour, it was observed that the smoke compartment wall above the double doors contained two unsealed penetrations where electrical wires pass through the gypsum board. These unsealed penetrations compromise the integrity of the smoke barrier.”

“Upon observation, there is no evidence the smoke compartmentation and control 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. During the facility tour, kick-down door stops were identified in two Mechanical Rooms and two Medication Rooms located near the nursing station (s).”

“Upon observation, there was no evidence the automatic sprinkler system 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. During the building tour, it was observed that the Fire Department Connection (FDC) lacked the required identification signage. The FDC must be clearly marked and visible from the fire department’s normal point of approach to ensure prompt identification and connection during emergency operations.”

“Upon observation, there was no evidence the building service equipment 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. During the building tour, it was observed that the ceiling supply air register in the toy room showed evidence of a past or active water leak. The surrounding gypsum board exhibited water discoloration, indicating possible moisture intrusion or damage.”

“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 During the building tour, it was observed that two power strips at the nursing station were located directly on the floor. This placement makes them susceptible to water exposure during cleaning or mopping, creating a potential electrical shock and fire hazard.”

“Upon observation, there was no evidence the fire alarm systems of a facility are 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. During the building tour, it was observed that the manual fire alarm pull station located at the center exit was obstructed by a wheelchair. The obstruction could delay or prevent activation of the fire alarm system during an emergency.”

“Upon observation, there was no evidence the hazardous areas of a facility are 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. During the building tour, it was observed that three patient rooms has been converted to a storage rooms. The doors to these rooms is not equipped with an automatic self-closing device. Due to the change in room use from patient care to storage (which constitutes a higher fire load), the door is now required to be self-closing to maintain fire and smoke barrier integrity.”