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
551548 A. BUILDING __________
B. WING ______________ 		01/29/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
INLAND VALLEY HOSPICE 3770 MYERS STREET, RIVERSIDE, CA, 92503
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)
L0650      
37626 Based on interview and record review, the agency failed to ensure the patient's responsible party (RP) was contacted when the patient had a change of condition (COC), for one of three patients reviewed (Patient 1). This failure had the potential to cause a delay of Patient 1's transfer to the general acute care hospital (GACH) for further treatment. Findings: On December 23, 2019, at 9: 58 a.m., an unannounced visit was conducted at the agency to investigate an agency reported incident. On December 23, 2019, the record of Patient 1 was reviewed. Patient 1 was admitted to the agency on December 2, 2019, with diagnoses which included acute kidney failure (when the kidneys lost the ability to eliminate excess salt, fluids, and waste materials from the blood). The facility document titled, "PATIENT FACE SHEET," dated December 2, 2019, was reviewed. The document indicated, "...Primary Contact...(Name of family member)..." The agency's document titled, "VISIT NOTES on call-Triage," dated December 6, 2019, was reviewed. The document indicated, "Received call from FSN (facility skilled nurse) requesting to reinstate for UTI (urinary tract infection). (Name of doctor) made aware. N/O (new order) Bactrim ds (sic; antibiotic) 1 (one) tab (tablet) by mouth BID (twice a day) x (times) 7 (seven) days. R/P (responsible party) (name of RP) did not answer..." The "VISIT NOTES Short Form," for Patient 1, indicated nursing visits were conducted at the patient's home on December 7 and 8, 2019. There was no documented evidence Patient 1's RP was notified of Patient 1's COC on December 7 and 8, 2019. On December 23, 2019, at 10:14 a.m., the Director of Patient Care Services (DPCS) was interviewed. The DPCS stated Patient 1 resided in the (name of assisted living facility). On December 23, 2019, at 10:40 a.m., the DPCS was interviewed. The DPCS stated Patient 1 was transferred to the GACH for further evaluation. The nursing visit notes on December 7 and 8, 2019, were concurrently reviewed with the DPCS. The DPCS stated the nurse who visited Patient 1 on December 7 and 8, 2019, should have called Patient 1's RP to notify of the COC. The agency's policy and procedure titled, "General Patient Care Policies," dated January 1, 2018, was reviewed. The policy indicated, "...It is the policy of (name of agency) to consider the family as the unit of care and to communicate with the family about the patient's condition...on a weekly basis whenever possible, and as necessary and reasonable to meet the patient's...needs...The licensed nurse...will document all communication, or attempted communication with family members/responsible parties..."