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 ______________ 		12/16/2019
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)
L0547      
38993 Based on interview and record review, the facility failed to ensure the plan of care was implemented for two of four sampled patients (Patient 2 and Patient 3) when home visits were not done as indicated. This failure had the potential for the Patients to have unmet care needs. Findings: 1. During a review of Patient 2's "Hospice Plan of Care" (HPOC), dated 10/23/19, the "HPOC" indicated, HCA [Hospice Aide] 2x/wk x 14 wks [2 times a week for 14 weeks] . . .Clergy 2x/mo x4 mos [2x month for 4 months]". During a concurrent interview and record review, on 12/16/19, at 12:31 p.m., with the Director of Nursing (DON), the Hospice Activity Progress Note (HAPN) for Patient 2, dated 11/25/19 was reviewed. The HAPN indicated there was only one HCA visit for the week of 11/24/19-11/30/19. The Clergy Clinical Note dated 11/14/19, indicated there was only one clergy visit for the month of November. There was a missed HCA visit for the week of 11/24/19-11/30/19 and a missed clergy visit for the month of November. The DON confirmed the findings. During a review of the facility's policy and procedure (P & P) titled, "Hospice Aide Services" dated 10/15, the P & P indicated, "Hospice aide services may be included for routine care on an intermittent basis when personal care is needed. These activities, in accordance with the plan of care and physician's . . .orders, will be assigned and supervised by a hospice registered nurse." During a review of the facility's policy and procedure ( P & P) titled, "Spiritual Care Counseling Services" dated 10/15, the P & P indicated, "Hospice will provide spiritual care counseling in keeping with the patient's/family's/caregiver's belief system and practice, and in accordance with the plan of care." 31589 2. During a concurrent interview and record review, on 12/16/19, at 10:30 a.m., with the DON, Patient 3's "Quick Notes (QN)," dated 12/22/19, was reviewed. The QN indicated, "Appointment for Nov 28, 2019 cancelled on Nov 22, 2019 by RN, because Not Necessary." The DON stated the nurse should conduct home visits for Patient 3, two times a week. The clinical record indicated there was just one home visit on the week of 11/24/19-11/30/19, conducted on 11/25/19. The DON verified the findings and stated there was no physician's order to change the home visits.
L0553      
31589 Based on interview and record review, the facility failed to follow its policy and procedure for Plan of Care for one of four sampled patients (Patient 4). This had the potential for unmet care needs. Findings: During a review of Patient 4's "Care Plan" (CP), dated 10/16/19, the "CP" indicated, "Foley Cath [catheter]: Fill F/C 16F [French] balloon with 10 ml [milliliter] sterile water. F/C change frequency Q [every] 3 months or PRN [as needed] dislodged or clogged by OHS [facilty] nurse." There was no goals or other interventions indicated in the care plan. During a concurrent interview and record review, on 12/16/19, at 12:53 p.m., with Nurse Manager (NM), Patient 4's care plan was reviewed. The NM verified the findings and stated the care plan should have goals and other interventions. During a review of the facility's policy and procedure (P & P) titled, "Plan of Care" dated 6/11/19, the P & P indicated, "A written 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. . .This plan will focus on identified problems, goals, and interventions."