Retreat Health Care Services Inc.

“It is required the hospice have a written agreement with another organization or individual to furnish hospice care or services includes the scope of services to be provide, how Interdisciplinary Group (IDG) management oversight and coordination is provided, how communication with the IDG and hospice administration occurs, and the hospice retains financial management responsibility. This standard was not met as evidenced by interview and personnel record review. In 3 of 3 (100%) applicable contracted nursing and social worker personnel records revealed that the hospice did not ensure that contract services provided had a written agreement. Personnel Record 5: A review of the social worker personnel record on 11/6/23 identified the contracted date of hire as 9/30/22 with a signed W-9 on the date of hire. A review of the personnel record on 11/9/23 confirmed a signed W-4 dated 11/8/23. The review of the contract list and personnel record did not identify a contract to provide social work services. Personnel Record 11: A review of the social worker personnel record on 11/6/23 identified the contracted date of hire as 5/19/21 with a signed W-9 on the date of hire. A review of the personnel record on 11/9/23 confirmed a signed W-4 dated 11/8/23. The review of the contract list and personnel record did not identify a contract to provide social work services. Personnel Record 12: A review of the nurse practitioner personnel record on 11/6/23 identified the contracted date of hire as 10/27/21 with a signed W-9 on the date of hire. A review of the personnel record on 11/9/23 confirmed a signed W-4 dated 11/7/23. The review of the contract list and personnel record did not identify a contract to provide nursing services. During the interview on 11/6/23, the Administrator stated the nurse practitioner, and the two social workers were under contract (W-9) with the hospice. Additionally, during the interview on 11/9/23, the Administrator stated the nurse practitioner and both social workers were no longer under contract and were directly hired employees of the hospice with a completed W-4.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: Physician orders. This standard was not met as evidenced by clinical record review and interview. In 1 of 10 (10%) applicable clinical records of patients who received Hospice inpatient facility (IPU) services, the hospice did not ensure orders and/or a plan of care was completed for the level of care to be provided to the patient. Clinical Record 16: A review clinical record revealed the patient was admitted to the Hospice IPU on general inpatient (GIP) level of care on 6/15/23-6/19/23, then changed to routine home care (RHC) level of care at the IPU on 6/20/23, respite level of care at IPU 6/21/23, RHC level of care at the IPU on 6/26/23 and expired at the IPU on 7/9/23. There was no documented evidence for a physician order and/or plan of care which identified the level of care for the GIP on 6/15/23-6/19/23, RHC on 6/20/23, and Respite level of care 6/21/23 that was provided on the Hospice IPU. The clinical record did include a plan of care for the RHC which started on 6/26/23. During the interview on 11/7/23, the Director of Professional Services/IPU Manager confirmed the missing orders and/or plans of care.”

“It is required that hospice inpatient facilities dispose of controlled medications in compliance with hospice policy and in accordance with state and federal law and regulation. The hospice maintains current and accurate records of the receipt and disposition of all controlled medications. This standard was not met as evidenced by document review, interview and observation. Federal Controlled Substance Act: Ordering and Dispensing: “Count all ‘Countable’ Controlled Substances any time the control of the medication key is passed (ex. at the beginning and end of the assignment/shift). If there is a witness (another Certified staff) available, the count should be done with the witness (two Certified staff)”. 26 (State) Admin. Code, Statute 558.862: (f) A hospice that provides inpatient care directly in its own inpatient unit must dispose of controlled drugs in compliance with the hospice’s policy and in accordance with State and federal requirements, including (State) Health and Safety Code Chapter 481. The hospice must maintain current and accurate records of the receipt and disposition of all controlled drugs. 26 (State) Admin. Code § 558.862”. A review of the Hospice IPU policies and procedures revealed missing established policies, procedures, and/or protocols for storage, double locks requirements, access, accountability and sign-out procedures, and disposal of controlled substances at the Hospice IPU. A tour of the hospice IPU was completed on 11/7/23 along with the IPU Registered Nurse (RN), Administrator, and Director of Professional Services/IPU Manager. The Hospice IPU is located on a wing of an assisted living facility (ALF) building and both the Hospice IPU and the ALF have the same owner. Observation of the controlled medication locked compartment on the locked medication cart revealed a controlled substance medication (Norco) which was taped up, dated, and signed on the bottle by two nurses on the date the patient was admitted to the IPU. During an interview on 11/7/23, the IPU RN stated, “The patient brought the Norco to the IPU, and two nurses counted the medication on admission to the IPU and then taped the bottle, and two nurses did not count the medication at the end of each shift”. During the tour of the locked medication room at the hospice inpatient unit (IPU) with the IPU RN, Administrator, and Director of Professional Services/IPU Manager, observation of the controlled medication disposition and disposal was completed. Additionally, a tour of the IPU and disposition and disposal of controlled substance process on 11/7/23 revealed that the Hospice IPU did not store and destroy expired controlled substance medications in the IPU and that a non-licensed employee (employee of both the Hospice IPU and ALF) transported and stored the expired patients’-controlled substance medications at the ALF in a locked cabinet and not the Hospice IPU, as required by standards of practice and the Federal Controlled Substance Act. There was no documented evidence that controlled medications at the inpatient facility are destroyed by the contracted pharmacist and a registered nurse and no evidence that an account of all controlled medications was maintained and reconciled, as required by inpatient facility policy and procedure. During an interview on 11/7/23, the Clinical Coordinator, who is an unlicensed/non-certified employee of the Hospice IPU and the ALF, stated, “I pick up the expired controlled substances at the Hospice IPU and store the medications in this ALF cabinet, I do count the medications with the IPU RN when I pick up the medications then record the medications on a tracking form that I type up, I am the only one that has a key to this cabinet, and do not count again until the pharmacist comes to count and destroy once every quarter”. There was no documented evidence that the hospice counted the disposition of all controlled substance medications at the end of each shift, as required by standards of practice and the Federal Controlled Substance Act. Additionally, when reviewing the controlled substance count sheets on 11/7/23, it was revealed the Hospice IPU did not record and have two nurses sign the controlled substance count sheet when a patient expired and had leftover controlled substance medications. Expired patients’-controlled medications were stored in the locked medication box in the locked medication cart attached to a controlled substance count sheet. The count sheet revealed a missing final count signed by two nurses. During an interview on 11/7/23, the Hospice IPU RN stated, “We do have two nurses do the final count, but we do not always record it and have two nurses sign on the expired patients’-controlled substance medications” and “We always have two nurses count and record it when the patients go home”. During an interview on 11/10/23, the Hospice Administrator stated, “We have corrected the controlled substance medication process at the IPU”, “Immediately on 11/7/23, the taped-up Norco bottle was counted and recorded by two nurses and the nurses will always count all controlled substances at the change of shift”, “Two nurses are now counting and recording the expired patients’ controlled substance medications, and the non-clinical Clinical Coordinator no longer has access to the IPU controlled substance medications and no longer stores controlled substances in the assisted living facility”, “The expired patients’ controlled substances are now stored only at the IPU until the pharmacist comes and destroys the medications”, and “All controlled substances that the patients bring into the IPU are now counted and recorded every shift change”. A review of the Hospice IPU policies and procedures revealed missing established policies, procedures, and/or protocols for storage, double locks requirements, access, accountability and sign-out procedures, and disposal of controlled substances at the Hospice IPU. During an interview on 11/7/23, the Director of Professional Services/IPU Manager stated she is in the process of updating the IPU policies and procedures to include the requirements for controlled substances at the Hospice IPU. A tour of the hospice IPU was completed on 11/7/23 along with the IPU RN, Administrator, and Director of Professional Services/IPU Manager. The Hospice IPU is located on a wing of an assisted living facility (ALF) building and both the Hospice IPU and the ALF have the same owner. During the tour of the locked medication room at the hospice inpatient unit (IPU) with the IPU RN, Administrator, and Director of Professional Services/IPU Manager, observation of the controlled medication disposition and disposal was completed. There was no evidence the hospice counted the disposition of all controlled substance medications at the end of each shift, as required by standards of practice and the Federal Controlled Substance Act. The IPU RN reviewed the process of the controlled substance and count sheets. Observation of the controlled medication locked compartment on the locked medication cart identified a controlled substance medication (Norco) which was taped up, dated, and signed on the bottle by two nurses on the date the patient was admitted to the IPU. During an interview on 11/7/23, the IPU RN stated, “The patient brought the Norco to the IPU and two nurses counted the medication on admission to the IPU and then taped the bottle, and two nurses did not count the medication at the end of each shift”. Additionally, a tour of the IPU and disposition and disposal of controlled substance process on 11/7/23 revealed the Hospice IPU did not store and destroy expired controlled substance medications on the IPU and that a non-licensed employee (employee of both the Hospice IPU and ALF) transported and stored the expired patients’ controlled substance medications at the ALF and not the Hospice IPU, as required by standards of practice and the Federal Controlled Substance Act. During observation on 11/7/23, expired Hospice IPU patients’ controlled substance medications were stored in a locked cabinet at the ALF. During an interview on 11/7/23, the Clinical Coordinator, who is an unlicensed/non-certified employee of the Hospice IPU and the ALF, stated, “I pick up the expired controlled substances at the Hospice IPU and store the medications in this ALF cabinet, I do count the medications with the IPU RN when I pick up the medications then record the medications on a tracking form that I type up, I am the only one that has a key to this cabinet, and do not count again until the pharmacist comes to count and destroy once every quarter”. Additionally, when reviewing the controlled substance count sheets on 11/7/23, it was revealed the Hospice IPU did not record and have two nurses sign the controlled substance count sheet when a patient expired and had leftover controlled substance medications. Expired patients’ controlled medications were stored in the locked medication box in the locked medication cart attached to a controlled substance count sheet. The count sheet revealed a missing final count signed by two nurses. During an interview on 11/7/23, the Hospice IPU RN stated, “We do have two nurses do the final count but we do not always record it and have two nurses sign on the expired patients’ controlled substance medications” and “We always have two nurses count and record it when the patients go home”. During an interview on 11/10/23, the Hospice Administrator stated, “We have corrected the controlled substance medication process at the IPU”, “Immediately on 11/7/23, the taped-up Norco bottle was counted and recorded by two nurses and the nurses will always count all controlled substances at the change of shift”, “Two nurses are now counting and recording the expired patients’ controlled substance medications, and the non-clinical Clinical Coordinator no longer has access to the IPU controlled substance medications and no longer stores controlled substances in the assisted living facility”, “The expired patients’ controlled substances are now stored only at the IPU until the pharmacist comes and destroys the medications”, and “All controlled substances that the patients bring into the IPU are now counted and recorded every shift change”. Federal Controlled Substance Act: Ordering and Dispensing: “Count all ‘Countable’ Controlled Substances any time the control of the medication key is passed (ex. at the beginning and end of the assignment/shift). If there is a witness (another Certified staff) available, the count should be done with the witness (two Certified staff)”. 26 (State) Admin. Code, Statute 558.862: (f) A hospice that provides inpatient care directly in its own inpatient unit must dispose of controlled drugs in compliance with the hospice’s policy and in accordance with State and federal requirements, including (State) Health and Safety Code Chapter 481. The hospice must maintain current and accurate records of the receipt and disposition of all controlled drugs. 26 (State) Admin. Code § 558.862”.”