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
051708 A. BUILDING __________
B. WING ______________ 		08/17/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
COMMUNITY HOSPICE OF VICTOR VALLEY 16147 KAMANA ROAD, APPLE VALLEY, CA, 92307
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)
L0667      
44529 Based on interviews and record reviews, the agency failed to obtain written certification of terminal illness (anticipated six months or less life expectancy if the disease runs its normal course) from both the hospice medical director and the patient's attending physician for two of three sampled patients (Patient 1 and 2) when: 1.The certification of terminal illness for Patient 1 for the first 90-day benefit period (hospice services are provided in two 90-day periods and then an unlimited number of 60-day periods) did not include certification by Patient 1's attending physician. 2. The certification of terminal illness for Patient 2 for the first 90-day benefit period did not include certification by Patient 2's attending physician. This failure had the potential to give up curative treatments and opt for palliative (to make the effects of a disease less severe) care too soon due to not being properly evaluated as terminally ill for Patients 1 and 2. Findings: 1. A review of Patient 1's face sheet (a document that contains resident demographics and diagnoses) indicated a start of service date of June 14, 2022, with primary hospice diagnosis of malignant neoplasm of unspecified ovary. During a concurrent interview and record review with the Hospice Supervisor (HS), on July 20, 2022, at 10:25 AM, of Patient 1's medical record titled, "Hospice Certification of Terminal Illness," dated June 14, 2022, indicated a terminal diagnosis of malignant neoplasm of unspecified ovary. Section 6 of the same document, titled, "Benefit Period/Date Range," indicated Patient 1 was on Benefit Period 1 from June 14, 2022, to September 11, 2022. Section 15 of the same document, titled, "Attending Physician's Signature and Date." indicated it was signed by Physician 1 who was the agency's hospice physician and not the attending physician for Patient 1. During a concurrent interview and record review with the Administrator, on July 20, 2022, at 12:19 PM, the Administrator stated the Patient 1 came from the services of a home health agency before admission to their hospice care, and further stated Patient 1 has an attending physician under home health services. In a review of the agency's policy and procedure (P&P), titled, "Hospice Admission Criteria," revised September 2019, indicated, " ...Procedure ...4. The Hospice Medical Director and attending physician will jointly certify that the individual is terminally ill with a life expectancy of six months or less if the disease runs its normal course." The Administrator stated that Physician 1, whose signature appears as the attending physician certifying terminal illness for Patient 1 was not the attending physician prior to admission to hospice. The Administrator was unable to provide documentation that it tried to communicate with Patient 1's attending physician from home health. 2. A review of Patient 2's face sheet (a document that contains resident demographics and diagnoses) indicated a start of service date of June 8, 2022, with primary hospice diagnosis of breast cancer with metastatic disease to bone. During a concurrent interview and record review with the Hospice Supervisor (HS), on July 20, 2022, at 10:25 AM, of Patient 2's medical record titled, "Hospice Certification of Terminal Illness," dated June 8, 2022, indicated a terminal diagnosis of malignant neoplasm of unspecified site of unspecified female breast. Section 6 of the same document, titled, "Benefit Period/Date Range," indicated Patient 2 was on Benefit Period 1 from June 8, 2022, to September 5, 2022. Section 15 of the same document, titled, "Attending Physician's Signature and Date," indicated it was signed by Physician 2 who was the agency's hospice physician and not the attending physician for Patient 2. During a concurrent interview and record review with the Administrator, on July 20, 2022, at 12:19 PM, the Administrator stated the Patient 2 came from another hospice agency before admission to their hospice care, and further stated Patient 2 has an attending physician under previous hospice services. In a review of the agency's policy and procedure (P&P), titled, "Hospice Admission Criteria," revised September 2019, indicated, " ...Procedure ...4. The Hospice Medical Director and attending physician will jointly certify that the individual is terminally ill with a life expectancy of six months or less if the disease runs its normal course." The Administrator stated that Physician 2, whose signature appears as the attending physician certifying terminal illness for Patient 2 was not the attending physician prior to admission to their agency. The Administrator was unable to provide documentation that it tried to communicate with Patient 2's attending physician from the previous hospice agency..