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
051716 A. BUILDING __________
B. WING ______________ 		09/15/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
KINDRED HOSPICE 36947 COOK STREET, BUILDING 10, SUITE 102, PALM DESERT, CA, 92211
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)
L0555      
41348 Based on interview and record review, the agency failed to ensure care services were provided in accordance with the plan of care, for one of three patients reviewed (Patient 2). This failure had the potential for an unrecognized decline in Patient 2's condition and for Patient 2 to not receive the necessary care and treatment timely. Findings: On July 29, 2020, at 9:35 a.m., an unannounced visit was conducted at the agency for the investigation of a complaint. On July 29, 2020, the record of Patient 2 was reviewed. Patient 2 was admitted to the agency on August 23, 2019, with diagnoses which included hemiplegia (paralysis on one side of the body) of the right side, dementia (memory loss), and history of falling. The untitled document dated, June 3, 2020, indicated, "...SN (skilled nurse) Effective 06/16/2020 1WK9 (once a week for nine weeks)..." The document titled, "Hospice IDG Comprehensive Assessment and Plan of Care Update Report," dated June 24, 2020, indicated "...routine home care..." The document titled, "Visit Note Report," dated June 27, 2020, indicated a SN visit was performed for Patient 2 on that date. The document titled, "Visit Note Report," dated July 17, 2020, indicated a SN visit was performed for Patient 2 on that date. There was no documented evidence a SN visit was conducted during the weeks of June 28 to July 4, 2020, and July 5 to 11, 2020. On July 29, 2020, at 10:23 a.m., an interview was conducted with the Administrator (Adm). The Adm stated if a nurse missed a visit or if the patient refused a visit there should be documentation in the notes by the nurse on the reason for the missed visit. On July 30, 2020, at 11:35 a.m., a telephone interview and concurrent review of Patient 2's record were conducted with the Adm. She stated Patient 2's physician order indicated SN visit once a week for nine weeks starting on June 16, 2020. She stated Patient 2's plan of care was for routine home care. She stated there was no documentation of a SN visit for the weeks of June 28, 2020, to July 5, 2020, and July 6, 2020, to July 11, 2020. She stated there was no documentation why the visits were missed. She stated the next documented SN visit was July 17, 2020 (19 days between SN visits for Patient 2). She stated patients need a visit at a minimum of every 15 days by the agency. She stated there was no excuse for the missed visits. On August 3, 2020, at 11:10 a.m., a telephone interview was conducted with SN 1. He stated he was the nurse assigned to Patient 2. He stated there were times he did not conduct a visit to Patient 2. He stated he did not communicate the missed visits to the agency or document the missed visits in his notes. He stated at a minimum the patient should have been seen every 14 days. He further stated he did not attempt a phone visit to check on Patient 2 when he missed the home visits. The agency document titled, "Provision of Care and Record Management," dated April 2020, was reviewed. The document indicated, "...An individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care. The plan of care will meet the documentation requirements of the physician directed medical orders and the care planning process...care provided to the patient will be in accordance with the plan of care...Every effort should be made to adhere to the ordered visit frequency. Attempts should be made to reschedule a visit within the ordered time frame to avoid a missed visit. In the event the ordered frequency is not met, the following should occur: A. If unable to reschedule within the ordered time frame, complete a missed visit coordination note... C. During the IDG meeting all missed visits must be reported to the Medical Director/Hospice Physician and documented in the patient-specific IDG note..."