Conemaugh Regional Hospice

“Based on review of agency policy, medical records (MR) and staff (EMP) interviews, the agency failed to review all the patient’s medications and update the medication profile and allergies for one (1) of nineteen (19) MR reviewed (CR8). Findings included: Review of the agencys policy was conducted on 12/18/2023 at approximately 9:43 AM which revealed, “;Monitoring Medications...PROCEDURE...1. Compare medication list to actual medications patient is taking. If the patient resides in a facility, compare medication list to the facilitys medication administration record (MAR) rather than reviewing actual medications. 2. Review over the counter (OTC) medications, vitamins, herbs and herbal products, and crems and topical ointments and medical marijuana (in states where legalized) to identify issues such as: a. potential adverse effects and drug reactions b. ineffective drug therapy c. significant side effects d. significant drug interactions e. duplicate drug therapy f. noncompliance with drug therapy g. dosage errors h. drug omissions...3. All nurses participating in the patients care are responsible to assist in maintenance of accurate patient medication information throughout the tenure of care. Through a collaborative process the care team will: a. Compare medication information patient is currently taking with medications ordered for the patient in order to identify and resolve discrepancies...” A review of CR8 on 12/15/2023 at approximately 1:14 PM with a start of care date of 11/10/2023 for a current certification period starting 11/23/2023 and ending 2/7/2024. The primary diagnosis was Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease. The hospital history and physical document was compared to the agency “Medication List “ (printed 12/12/2023). The following allergies were listed on the hospital history and physical as followed: “;ALLERGIES/HOME MEDICATIONS Allergies: Allergies Statins-HMG-CoA Reductase Inhibitor (Coded, 09/11/23), Sulfa (Sulfonamide Antibiotics) (Coded, DIARRHEA, 11/20/18), levofloxacin (Coded, 09/11/23), sulfamethoxazole (From BACTRIM) (Coded, 05/03/20), trimethoprim (From BACTRIM) (Coded, 05/03/20).” The agency medication list listed allergies as followed: Allergies: BACTRIM, STATINS, LEVOFLOXACIN...” An interview was conducted on 12/15/2023 at approximately 3:30 PM with the executive director, regional quality coordinator and regional vice president of operations which confirmed the above information.”

“Based on review of agency policy and procedure, observation (OBV), and staff (EMP) interviews, the agency failed to ensure an ongoing sharing of information between all disciplines providing care and services in all settings related to patient care for one (1) of four (4) patient observations that were conducted (OBV4). Findings included: Review of the agencys policy was conducted on 12/18/2023 at approximately 9:43 AM which revealed, “;Monitoring Medications...PURPOSE: To provide a process to ensure continuous monitoring of medications in patients home POLICY: A drug regimen review will be performed on all patients in conjunction with all comprehensive assessments. Additionally, all nurses will participate in medication review and reconciliation throughout the benefit period ...All nurses participating in the patients care are responsible to assist in maintenance of accurate patient medication information throughout the tenure of care...” (OBV4) MR4, patient home visit was conducted on 12/14/2023 at approximately 1:50 PM. Start of Care was 8/28/2022. Two folders were available with agency information in the home. The surveyor asked EMP8 to review the medication list and plan of care. The medication list and plan of care were both dated 8/11/2023. A current medication list and plan of care was not found within the agency information. An interview was conducted on 12/15/2023 at approximately 3:30 PM with the executive director, regional quality coordinator and regional vice president of operations which confirmed the above information.”

“Based on review of agency policy and procedure, observation visits (OBV), and staff (EMP) interviews, the agency failed to ensure one (1) of four (4) staff followed infection control policy and procedure for bag technique (OBV1). Findings included: Review of the agencys training document was conducted on 12/18/2023 at approximately 9:25 AM which revealed, “;Home Care Bag Protocol Job Aid...5...*One area of the bag shall be dedicated to clean, reusable items such as B/P cuff. * One area of the bag shall be dedicated to sterile, non-reusable items such as sterile dressings/items. Items removed from his section of the bag shall not be returned to this section...6. Personal items such as hand-held devices, cell phones, wallets and keys should not be carried in the clean section of the bag but may be carried in an outer pocket of the bag away from patient care supplies...” Observations (OBV1), during a visit to MR1 residence on 12/13/2023 at 2:00 PM revealed, EMP5 provided direct patient care. EMP5 placed the bag on a clean chuck/barrier on the bed side table. Then placed reusable items from the nursing bag on the chuck/barrier the bag was sitting on. Thermometer, blood pressure cuff, computer, container of wipes, hand cleanser and cell phone. An interview was conducted on 12/15/2023 at approximately 3:30 PM with the executive director, regional quality coordinator and regional vice president of operations which confirmed the above information.”