HospitalInspections.org

Based on interview the hospital failed to ensure services provided indirectly were in compliance with the Conditions of Participation. Specifically, staff from Certified Home Healthcare Agencies (CHHA) and infusion services were administering medications to the hospital's patients without a written agreement or defined process.

Findings:

On 10/19/16 at 11:35 am Staff D was interviewed regarding the care of patients receiving infusions in the hospital's outpatient clinics. Staff D stated that after finishing treatment in the clinic, some patients receive additional medication, which is infused at home. Those patients are sent home with medication and a medication pump provided by an infusion service.

CHHA and infusion services are arranged by hospital staff for patients who need additional infusions at home. Infusion service staff deliver the medication and pump to the patient, while the patient is in the hospital clinic. When the patient is ready to leave the clinic, hospital staff disconnect the patient from the hospital pump and medication. CHHA or infusion service staff then connect the patient to the pump with the medication dispensed by the infusion service, before the patient leaves the hospital clinic. Staff D said this process was defined in hospital policy. Staff D was not able to name the policy or provide a copy.

On 10/19/16 at noon Staff C was interviewed about the process for sending patients home with medication and a pump. Staff C reiterated that medications are dispensed by an infusion service and brought to the patient in the hospital's outpatient clinic. CHHA staff connect the patient to the infusion prior to the patient leaving the facility's outpatient clinic. Staff C also stated the process was defined by hospital policy, however was unable to provide a copy of the policy.

On 10/19/16 at 2:35 pm Staff G was interviewed regarding the care of an inpatient, discharged earlier in the day, who went home with continuation of a medication infusion. Staff G stated the patient was disconnected from the hospital infusion. Staff from the infusion service brought a pump and medication to the patient's bedside, and connected the patient to the medication infusion. Staff G stated it was hospital policy to have the CHHA or infusion service staff connect the patient to the pump and medication that would be going home with the patient. Staff G was not able to identify the hospital policy.

On 10/19/16 at 3:00 pm Staff I stated hospital policy prohibited staff from touching the home care pump or medication. A copy of the policy was requested. Staff I was not able to provide a copy of the policy.

On 10/20/16 at 8:45 am Staff J stated the hospital did not have written agreements for any services provided to hospital patients by CHHAs or infusion services.