Survey Report for 051690

DEPARTMENT OF HEALTH AND HUMAN SERVICES		FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES		OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION	(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER	(X2) MULTIPLE CONSTRUCTION	(X3) DATE SURVEY COMPLETED
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION	051690	A. BUILDING __________ B. WING ______________	02/07/2020
NAME OF PROVIDER OR SUPPLIER	STREET ADDRESS, CITY, STATE, ZIP
HEARTLAND HOSPICE SERVICES	2005 DE LA CRUZ BOULEVARD, SUITE 271, SANTA CLARA, CA, 95050
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation
LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE		TITLE	(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
(X4) ID PREFIX TAG	SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY SHOULD BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)
L0628
L0628	42149 Based on record review, and interview the agency failed to ensure hospice aide staff documented a patient's condition and interventions in the clinical record for one (Patient 2) out of 2 sampled patients. This failure resulted in an incomplete clinical record and had the potential to result in less than optimal care. Findings: During a review of the clinical record on 2/4-5/2020, indicated Patient 2 had diagnoses that included right sided hemiplegia (paralysis) from a stroke, dysphagia (difficulty swallowing), aphasia (difficulty speaking), seizures, hypertension (high blood pressure) and dementia. Further review indicated Patient 2 was on hospice care. During a review of a complaint investigation, indicated Patient 2 had a seizure on 1/29/2020. A home health/hospice aide (HHA D) was providing care at the time and telephoned a Patient Care Manager (PCM - a registered nurse) at the agency for assistance. During a review of the hospice aide "Visit Note Report" dated 1/29/2020. Indicated no documentation regarding the seizure was on the aide's visit note. During an interview on 2/5/2020 at 2:40 p.m., HHA D stated on 1/29/2020, she had just finished assisting Patient 2 with a shower and had transferred her to the wheelchair, when Patient 2 had a seizure. HHA D stated she called the office and spoke to a newly hired PCM to report the seizure because the Patient's husband was concerned. The PCM stated she would call the case manager and gave a recommendation to the HHA to have the family give the patient an as needed medication for seizures. HHA D stated she should have documented in Patient 2's medical record the seizure and communication with the PCM. During an interview on 2/5/2020 at 3:00 p.m., the Director of Professional Services (DPS), stated both the hospice aide and the PCM should have documented the episode with the seizure in the clinical record and confirmed they had not. During a review of the agency's job description for "Hospice Aide" last updated 6/2018, indicated "Essential Job Functions ...Delivery of Care Responsibilities ...Provides accurate, timely and appropriate documentation of patients visit on the clinical record per agency policies". During a review of the agency's policy and procedure, "DOCUMENTS MAINTAINED IN THE CLINICAL RECORD", dated 2/2019, indicated "The clinical record contains a representation of the actual experience of the patient in the agency. Information is documented to demonstrate status of the patient plan of care and the effects of the care provided. Progress notes provide a picture of the patient's condition ...and collaboration with ...other team members."