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
551530 A. BUILDING __________
B. WING ______________ 		03/18/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
EVERGREEN HOSPICE CARE, INC 17215 STUDEBAKER ROAD, SUITE 100, CERRITOS, CA, 90703
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)
L0577      
22303 Based on observation, interview and record review, the hospice agency failed to ensure the Condition of Participation (COP) in Infection Control was met as follows: a. The hospice agency failed to follow the standards of practice to prevent spread of COVID-19 (Coronavirus 19 disease, a highly, contagious respiratory illness caused by virus that spread from person to person) by failing to: 1. Have procedures for symptoms screening for COVID-19 for the staff and visitor who enter in the hospice agency as indicated in the Centers for Disease Control and Prevention (CDC). (Refer to L 579) 2. Have procedures for fit-testing for N95 masks (a respiratory protective device designed to achieve a very close facial fit to form a seal around the nose and mouth to efficiently filter airborne particles) the agency staff, composed of 18 licensed nurses and 12 certified home health aide (CHHA). (Refer to L 579) These deficient practices placed the patients, staff, and/or visitors at risk for COVID-19 and further spread of infection that could lead to severe respiratory illness, hospitalization and/or death. b. The hospice agency failed to develop and implement its policy and procedures on vaccination for COVID-19 (Coronavirus 19 disease, a highly, contagious respiratory illness caused by virus that spread from person to person) for 38 staff and 116 patients by failing to: 1. Have a process for ensuring all required staff (who provide any care, treatment or other services for hospice patients) have received, at a minimum, the first dose of a multi-dose COVID-19 vaccine, or a one-dose COVID-19 vaccine, before staff provide any care, treatment, or other services for the hospice and/or its patients; 2. Have a process for ensuring that all required staff are fully vaccinated; 3. Have a process for ensuring that the hospice continues to follow all standards of infection prevention and control practice, for reducing the transmission and spread of COVID-19 in the hospice, especially by those staff who are unvaccinated or who are not yet fully vaccinated; 4. Have a process for tracking and securely documenting the COVID-19 vaccination status for all required staff; 5. Have a process for ensuring all staff obtain any recommended booster doses, and any recommended additional doses for individuals who are immunocompromised, in accordance with the recommended timing of such doses; 6. Have a process by which staff may request a vaccine exemption from the COVID-19 vaccination requirements based on recognized clinical contraindications or applicable Federal laws, such as religious beliefs or other accommodations; 7. Have a process for tracking and securely documenting information confirming recognized clinical contraindications to COVID-19 vaccines provided by those staff who have requested and have been granted a medical exemption to vaccination; 8. Have a process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination: 9. Have a process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; 10. Have contingency plans for staff that are not yet vaccinated for COVID-19 (and without an exemption for medical contraindications or without a temporary delay in vaccination due to clinical considerations). (Refer to L 900) The cumulative effect of these systemic problems resulted in the agency's inability to ensure the provision of quality health care in a safe environment.
L0579      
22303 Based on observation, interview, and record review, the hospice agency failed to follow the standards of practice to prevent spread of COVID-19 (Coronavirus 19 disease, a highly, contagious respiratory illness caused by virus that spread from person to person) by failing to: 1. Have procedures for symptoms screening for COVID-19 for the staff and visitor who enter in the hospice agency as indicated in the Centers for Disease Control and Prevention (CDC). 2. Have procedures for fit-testing for N95 masks (a respiratory protective device designed to achieve a very close facial fit to form a seal around the nose and mouth to efficiently filter airborne particles) for the agency staff, composed of 18 licensed nurses and 12 certified home health aide (CHHA). These deficient practices placed the patients, staff, and/or visitors at risk for COVID-19 and further spread of infection that could lead to severe respiratory illness, hospitalization and/or death. Findings: 1. During an observation on 3/16/22 at 10 a.m., upon entrance to the hospice agency, there was no procedures to screen for COVID-19 symptoms. An interview was conducted with the Director of Patient Care Services (DPCS) on 3/16/22 at 11:30 a.m., she stated that there was no screening done for the visitors and staff, but she would start to implement the screening of the visitors for COVID-19 symptoms. 2. During an interview with the DPCS on 3/18/22, at 12 p.m., she stated she did not know if all staff were fitted for N 95 masks and did not have documented evidence of fit testing. In an interview on 3/16/22 at 12:30 p.m., the DPCS stated the agency has 12 Registered Nurses, 6 licensed vocational nurses, and 18 CHHA. In another interview on 3/17/22 at 2 p.m., the DPCS stated that there was one staff member (CHHA) who was positive for COVID-19 on 12/27/21. DPCS stated the staff member (CHHA) did not work and was quarantined at home. DPCS stated there was no COVID-19 positive patient. A review of the agency's policy and procedure titled, "Infection Control Plan" dated April 2019 indicated the organization will address surveillance, prevention, identification, control and reporting of infections, utilizing current scientific methods and epidemiologic principles. The policy and procedure did not include procedures for COVID-19 symptoms screening for the staff and visitors. A review of the agency's policy and procedures titled, Pandemic Infectious Disease revised April 2019 indicated the purpose was to reduce the risk of further spreading the COVID-19 virus. COVID-19 is transmitted mostly through airborne droplets (sneezing or coughing). Symptoms of COVID-19 ranges from mild disease to non-specific signs and symptoms of acute respiratory illness to severe pneumonia with respiratory failure and septic shock. The policy and procedure did not address procedures for symptoms screening for COVID-19 for the staff and visitor who enter the workplace. The policy and procedure also did not address fit testing for N-95 respirator. A review of the Centers for Disease Control and Prevention (CDC)'s Interim Infection Control Recommendation for Healthcare Personnel during COVID-19 Pandemic updated 2/2/22 indicated to establish a process to identify and manage individuals with suspected or confirmed COVID-19 regardless of vaccination status including options that could include individual screening on arrival at the facility or implementing electronic monitoring system in which the individual can self-report before entering the facility. A review of the CDC's Interim Infection Control Recommendation for Healthcare Personnel during COVID-19 Pandemic updated 2/2/22 indicated to implement Source Control Measures that addressed the use of respirators or well-fitting facemasks or cloth masks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing. NIOSH-approved N95 or equivalent or higher-level respirators should be used for aerosol-generating procedures or by healthcare personnel (HCP) working in other situations where risk factors for transmission are present such as the patient is not up to date with all recommended COVID-19 vaccine doses or may also be considered if healthcare-associated COVID-19 transmission is identified and universal respirator use by HCP working in affected areas is not already in place. A review of the Centers for Disease Control and Prevention (CDC) regarding the need of Fit Testing during emerging infectious disease outbreaks indicated proper respirator use is essential for healthcare worker who are expected to interact with patients with infectious respiratory disease. Fit testing confirms the fit of any respirator that creates a tight seal on the user's face before it used in the workplace.