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 ______________ 		03/06/2020
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)
L0508      
41348 Based on interview and record review, the agency failed to ensure an injury of unknown source was reported by the hospice aide (HA) to the hospice agency, for one of three patients reviewed (Patient 1). This failure had the potential to delay the necessary care and treatment for Patient 1. Findings: On February 20, 2020, at 1:10 p.m., an unannounced visit was conducted at the agency for the investigation of an agency reported incident. On February 20, 2020, at 1:20 p.m., an interview was conducted with the Director of Patient Care Services (DPCS). She stated on February 12, 2020, around 2:15 p.m., the agency received a call from the facility were Patient 1 resided. She stated the facility informed her Patient 1 had two skin tears on her right hand. She stated the HA assigned to Patient 1 was called in and asked about Patient 1's skin tears. She stated the HA saw the skin tears while bathing Patient 1 on February 12, 2020, around 9 a.m., and did not report the skin tears to the agency's case manager (CM). She stated the HA should have immediately reported Patient 1's skin tears to the CM. On February 20. 2020, the record of Patient 1 was reviewed. Patient 1 was admitted to the agency on February 8, 2020, with diagnoses which included Alzheimer's disease (a progressive disease affecting memory and other mental functions). The "Plan Of Care," dated February 8, 2020, indicated, "...Level of Care...HA: -HHA (home health aide) 3-5x (three to five times) weekly for personal hygiene/assist ADL's (activities of daily living)/safety x 90 days..." The "Plan Of Care," also indicated, "...Pt (patient) will remain free of injury...Report any change of condition..." The "HA Visit Note," dated February 12, 2020, at 9 a.m., indicated, "...visualize condition of skin and report to the RN (Registered Nurse)..." The "Job Description-CHHA (certified home health aide)," dated January 28, 2013, indicated "...Observe for and report to the hospice licensed nurse, the presence of skin redness, breakdown, open areas...or any other sign of symptom of skin problems...Observe for changes in patients during visits. Report changes to Hospice Nurse...Report all accidents/incidents, regardless of how minor, to the Hospice nurse as soon as possible..." The "Hospice In-Service Education Attendance Record...Topic: What to Report to the RNCM...," dated January 18, 2018, and January 30, 2019, indicated, "...What to report IMMEDIATELY...Any new discolorations, skin tears, or redness..." The document indicated the HA received the in-services. There was no documented evidence of the skin tears on Patient 1's right hand. There was no documented evidence Patient 1's right hand skin tears were reported to the agency's administrator. The policy and procedure titled, "Incident Report-Non-employee," effective January 1, 2020, was reviewed. The policy indicated, "...It is the policy of (agency name) to require completion of an Incident Report whenever any type of incident occurs in a nursing facility...When an incident occurs, it must be reported to the Director of Patient Care Services..."