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
551550 A. BUILDING __________
B. WING ______________ 		12/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
ACCENTCARE HOSPICE & PALLIATICE CARE OF CALIFORNIA 16745 WEST BERNARDO DRIVE, SUITE 240, SAN DIEGO, CA, 92127
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)
L0694      
36708 Based on interview and record review, the hospice agency failed to ensure its policy and procedure related to the disposal of controlled medications was implemented for one of one sampled patient (1). This failure placed patients and family members at risk for the improper handling of controlled medications. Findings: Per the agency's Certification and Plan of Care, dated 6/1/21 to 8/29/21, Patient 1 was admitted to the agency on 6/1/21 with diagnoses which included malignant neoplasm of colon (a type of cancer that begins in the colon [final part of the digestive tract]). The Client Medication Report dated 6/1/21, indicated, Patient 1 had orders for: 1. Fentanyl patch (attaches to the skin and contains pain medication) 2. Hydrocodone (pain medication) 3. Morphine oral solution (pain medication) Per the Drug Enforcement Agency (DEA), Fentanyl, hydrocodone, and morphine were classified as a Schedule II drug/medication with a high potential for abuse or misuse. During a review of the record titled, Visit Note Report, dated 6/9/21, the record indicated this type of visit was a Skilled Nurse (SN) Hospice Death Visit. This visit was done by RN 1, however, there was no documentation to show what was completed during the death visit related to the medications of Patient 1. During an interview with the interim Director of Patient Care Services (DPCS) on 7/21/21 at 11:45 A.M., the DPCS stated a review of a patient's medications was completed upon admission; during a visit of discharge or death, and the agency protocol for medication disposal was completed by the visiting staff. The DPCS confirmed Patient 1 had three kinds of controlled drugs listed on the medication list. The DPCS also confirmed RN 1 did not write in detail on what was done with Patient 1's medication and did not follow the agency policy. During an interview with RN 1 on 8/3/21 at 4 P.M., RN 1 stated she was the on-call nurse on 6/9/21 and went to have death visit for Patient 1. RN 1 stated she was familiar with the agency policy on disposal of controlled drugs at the time of discharge/death of a patient. RN 1 confirmed she did not have any documentation to show a detailed report on the disposal of the controlled drugs of Patient 1. The agency's policy titled Disposal of Medications in the Home, dated 7/15, indicated,"...a. After the disposal of controlled substances, the name of the medication, the amount disposed and, if witnessed, the name/signature of [agency's name omitted] witness must be documented..."