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
051725 A. BUILDING __________
B. WING ______________ 		02/25/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
BRISTOL HOSPICE - BAKERSFIELD 4900 CALIFORNIA AVE, SUITE 110A, BAKERSFIELD, CA, 93309
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)
L0523      
32234 Based on interview and record review, the agency failed to ensure the interdisciplinary group (IDG) completed the comprehensive patient assessment no later than five calendar days after the start of care (SOC) for one of 16 sampled patients (Patient 4). This failure had the potential for not timely addressing the care needs of Patient 4 during the end of life plan of care (POC). Findings: During a review of Patient 4's "Revision to Plan Of Care" (RPOC), certification period dated 11/27/19 to 2/24/20, the "RPOC" indicated, Patient 4's SOC was on 11/27/19. During a concurrent interview and record review, on 2/25/20, at 3:30 PM, with Licensed Vocational Nurse (LVN) 1, Patient 4's IDG (members include the physician, Registered Nurse [RN], Spiritual Counselor [SC], and Medical Social Worker [MSW]) comprehensive patient assessments were reviewed. LVN 1 stated SC's comprehensive assessment for Patient 4 was completed on 12/11/19 (14 calendar days after the SOC). LVN 1 stated Patient 4 was not available on 11/29/20 for SC to assess the patient. LVN 1 was unable to find additional information within the five calendar days (from 11/30/19 to 12/2/19 from the SOC) the reason SC's comprehensive assessment was not done. LVN 1 verified the findings. LVN 1 stated, "It [SC's comprehensive assessment] didn't fall within five calendar days." During a review of the agency's policy and procedure (P&P) titled, "Comprehensive Assessment," dated 10/15, the P&P indicated, "A comprehensive patient assessment will be performed by the interdisciplinary group no later than 5 calendar days after the election of hospice care in consultation with attending physician."
L0541      
42167 Based on interview and record review, the agency failed to ensure all core team members (physician, registered nurse, social worker, pastoral service) of the Interdisciplinary Group (IDG) attended the Interdisciplinary Team Meeting (IDTM) and contributed to the overall care planning for three of 16 sampled patients (Patient 4, Patient 6 and Patient 11). This failure had the potential for the plan of care (POC) not developed appropriately to ensure all the care needs of the patient and family/caregivers were met. Findings: During a concurrent interview and record review, on 2/26/2020, at 1:28 PM, with Licensed Vocational Nurse (LVN 1), Patient 4, Patient 6 and Patient 11's "Interdisciplinary Team Note (IDTN)," were reviewed. a. LVN 1 was unable to provide any supporting documents that a social worker was in attendance or assessment was completed during the IDTM on 1/2/20 for Patient 6. b. LVN 1 was unable to provide any supporting documents that a pastoral service and a social worker were in attendance or assessments were completed during the IDTM on 12/18/19, for Patient 4 and 12/24/19, for Patient 11. During an interview on 2/26/20, at 2:31 PM, with Director of Patient Care Services (DPCS), DPCS stated that the core team members should attend the IDTM and document their findings in the clinical record. During an interview on 2/26/20, at 3:46 PM, with Registered Nurse Case Manager (RNCM), RNCM stated that each disciplines who attends the IDTM are given an area in the clinical record to document their assessment. RNCM stated, "We're supposed to document what we talked about during the meeting". During a review of the facility's policy procedure (P&P) titled, "Interdisciplinary Group Plan Of Care," dated 10/15, the P&P indicated, "4 ... Documentation of all communications will be included in the clinical record ... Documentation will include the date and time of the communication, individuals involved with the communication, information discussed, and the outcome of the communication." During a review of the facility's P&P titled, "Psychosocial Services", dated 10/15, the P&P indicated, "The social worker will be a member of the IDG and will participate in the development, implementation and revision of the plan of care ... 5. Social worker personnel will participate in IDT meetings and quality assessment performance improvement teams, as indicated." During a review of the facility's P&P titled, "Spiritual Care Counseling Services", dated 10/15, the P&P indicated, "The Chaplain will be a member of the IDG and will participate in the development, implementation and revision of the plan of care ... 12. The Hospice Chaplain will attend IDG meetings, and will work in a team approach with members ... to evaluate patient and family/caregiver response to care and resolution of ethical issues."
L0552      
42167 Based on interview and record review, the agency failed to ensure the Interdisciplinary Group (IDG) reviewed the plan of care no less frequently than every 15 days for one of 16 sampled patients (Patient 11). This failure had the potential for agency unable to provide the appropriate care and services needed for the patient and family/caregivers. Findings: During a concurrent interview and record review, on 2/26/20, at 1:39 PM, with Licensed Vocational Nurse (LVN) 1, Patient 11's "Interdisciplinary Team Note (IDTN)," dated 12/10/19 was reviewed. The IDTN indicated, no IDG were present during the Interdisciplinary Meeting (IDTM). LVN 1 was unable to provide signatures of all the attendees of the IDTM. LVN 1 stated, "I'm not sure what happened on this day, it looks like it wasn't done." During an interview on 2/26/20, at 1:42 PM, with Director of Patient Care Services (DPCS), DPCS stated, "The IDG is a team collaboration with the physician, registered nurse, a social worker, and the clergy. We do our IDG meetings every 14 days." During a review of the agency's policy and procedure (P&P) titled, "Interdisciplinary Group Plan Of Care," dated 10/15, the P&P indicated, "The IDG (in collaboration with the attending physician, if any) will conduct assessments, develop and update the plan of care, and review the effectiveness of a care minimum of every 15 calendar days."
L0555      
32234 Based on interview and record review, the agency failed to ensure the care and services were provided in accordance with the plan of care ordered by the physician for two 16 sampled patients (Patient 13 and Patient 4). This failure had the potential for unmet care needs. Findings: 1. During a concurrent interview and record review, on 2/25/20, at 2:10 PM, with Licensed Vocational Nurse (LVN) 1, Patient 13's "Revision To Plan Of Care (RTPOC)" dated 1/11/20 to 3/10/20 was reviewed. The RTPOC indicated, Clergy (Spiritual Counselor [SC]) home visits two times a month. The clinical record indicated Patient 13 had a missed SC scheduled home visit on 1/31/20. LVN 1 stated SC called Patient 13 to confirm the home visit. Patient 13 did not answer the phone call. LVN 1 stated, the physician or members of IDG (interdisciplinary group - members include the physician, Registered Nurse [RN], Medical Social Worker [MSW] and Spiritual Counselor [SC]) had to be notified on missed home visits. LVN 1 was unable to find documentation the physician or IDG were notified. LVN 1 stated, "She [SC] did not write it in her notes. It's not there." She stated there was no documentation for an IDG discussion of Patient 13's refusal for a home visit with SC. 2. During a concurrent interview and record review, on 2/25/20, at 3:30 PM, with LVN 1, Patient 4's RTPOC was reviewed. The RTPOC indicated, SN (Skilled Nurse) home visits two times a week (for the weeks starting on Mondays on 1/6/20, 1/13/20, and 1/20/20). The clinical record indicated Patient 13 had one home visit on 1/17/20 for the week of 1/13/20 and one home visit on 1/21/20 for the week of 1/20/20. LVN 1 stated Patient 4 canceled the home visit on 1/24/19. LVN 1 was unable to find documentation the physician was notified or there was an IDG discussion of Patient 4's SN missed home visits and refusal of the SN home visits. During a concurrent interview and record review, on 2/25/20, at 3:40 PM, with LVN 1, Patient 4's RTPOC, dated 11/27/19 to 2/24/20 was reviewed. The RTPOC indicated, MSW home visits two times a month for two months. The clinical record indicated Patient 4 had a missed scheduled home visit by MSW on 1/15/20 and was rescheduled on 1/21/20. Patient 4 refused MSW home visit on 1/21/20. LVN 1 was unable to find documentation the physician or IDG were notified. LVN 1 stated, there should have been documentation the physician or IDG were notified of the MSW home visit refusal by Patient 4. During a review of the agency's policy and procedure (P&P) titled, "The Plan Of Care," dated 10/15, the P&P indicated, "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."