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
551644 A. BUILDING __________
B. WING ______________ 		07/21/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
GRACEFUL PALMS HOSPICE AND PALLIATIVE CARE CORP. 38700 5TH ST W STE G, PALMDALE, CA, 93551
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)
L0538      
44916 Based on interview and record review, the Hospice Agency (HA) failed to specify the hospice care and services necessary to meet the patient and family specific need identified in the comprehensive assessment as such needs relate to the terminal illness and related conditions for 2 of 3 sampled patients Patient 1 and Patient 2. This deficient practice had the potential to negatively affect the delivery of necessary care and services for Patient 1 and Patient 2. Findings: a. A review of Patient 1's Plan of Care (POC) dated 5/20/22, indicated Patient 1 was admitted to the HA on 5/13/22, with the diagnoses of malignant neoplasm of the bronchus or lung(also known as bronchogenic carcinoma or lung cancer, is a malignant cancer that originates in the bronchi, bronchioles, or other parts of the lung), and hypertension (A condition in which the force of the blood against the artery walls is too high causing high blood pressure). A review of Patient 1's POC indicated hospice aide to visit 3 times a week, licensed vocational nurse (LVN) visits 3 times per week, social worker (SW) visits once a month and as needed, Registered nurse (RN) once every other 2 weeks and as needed, Chaplain visits once a month and one as needed. A review of Patient 1's psychosocial assessment dated 5/20/2022, indicated Patient 1's living condition was found to be unsafe and unhealthy, piles of things everywhere around the patient and throughout the home. Patient 1 presented high risk of falling and smokes cigarettes inside the home. Patient 1's couch smelled of urine. Patient 1 presented as oriented to place and time, frail, slim, pale color, weak , irritable, poorly groomed, non-ambulatory, poor memory, uncooperative and confused. Patient 1 reported to feeling pain and was unable to reach medications. Patient 1 was reported to stay alone from 6:00 a.m. to 4:00 p.m., is not eating well and is unable to go to the restroom. During the LCSW (licensed clinical social worker) visit, Patient 1 stated she had not eaten for 2 days. The patient and daughter had a strained relationship, negative, argumentative relationship. Patient 1's daughter declined suggestions by the LCSW and refused volunteers to help. A review of Patient 1's hospice staff's visit note dated 5/16/22 between 5:00 p.m. to 5:45 p.m., indicated Patient 1's chief complaint was fire hazard/fall precautions. Patient 1's visit note indicated no narrative notes, no vital signs were recorded, head to toe assessment was incomplete, no COVID 19 infection screening done, questions for fall/incidence occurrence,safety issues and care provided was left blank and was not electronically signed by visiting nurse. A review of Patient 1's skilled nurse (SN) visit note dated 5/17/22 between 4:00 p.m., and 4:25 p.m., SN indicated no answer on door, SN waited 20 minutes and no one was at Patient 1's home. SN informed supervisor and staffing department. A review of Patient 1's visit note dated 5/19/22 between 1;15 p.m. to 1:25 p.m., indicated SN contacted Patient 1's daughter prior to arrival for supervisory visit. Patient 1's daughter verbalized that all staff visits needed to be after 4 p.m.. SN asked if there was a way to visit without the daughter and daughter stated " No there is not, all visits after 4 p.m.". A review of Patient 1's clinical record indicated no documented evidence a care plan was developed identifying the family's request for specific time the hospice staff are able to visit the patient to provide the care services. b. A review of Patient 2's Plan of care dated 5/20/22 for the certification period of 5/20/22 to 8/17/22, indicated Patient 2's diagnosis included non-Hodgkin's lymphoma (Cancer that starts in the lymphatic system. The condition occurs when the body produces too many abnormal lymphocytes, a type of white blood cell. Symptoms include swollen lymph nodes, fever, belly pain, or chest pain. Treatments may include chemotherapy, radiation therapy, stem-cell transplant, or medications.) A review of Patient 2's POC/IDG discussion indicated Patient 2 was in denial regarding end of life signs and symptoms. Patient 2 has a long history of drug use with meth as his drug of choice. Patient was homeless, currently living with friend and smokes cigarettes inside the home. Patient 2 was weak, KPS ( karnofsky performance status-an assessment tool for predicting of length of survival in terminally ill patients. A KPS of 40 percent means disabled and requires special care and assistance and PPS(Palliative performance scale-a reliable and valid tool and correlates well with actual survival and median survival time for cancer patients in outpatient and ambulatory settings is 40 means mainly in bed unable to do any activity due to extensive disease. A review of the Patient 2's POC indicated no care plan for home safety and smoking. On 5/24/22 at 11:20 a.m., during an interview with Registered Nurse Case manager( RNCM) stated that she asks patient for any special needs/ instructions, spiritual need, any concerns regarding their care/ status, dietary, wound care, falls, emergency protocols. RNCM stated that she calls the care team and develops and assigns staff for the plan of care. A review of the HA's document titled " Changes in Care, Treatment and Services-Patient notification" indicated to define the requirements for patient notification of changes in care, treatment and services. plan of care notification documentation includes the date and time, specific changes in the plan of care and the patient, family or caregiver response. A review of the HA's document titled " Notice of Hospice Patient Rights and Responsibilities" indicated patients to receive considerate and respectful care, provided a safe environment. Have your cultural, psychosocial, spiritual and personal values , beliefs and preferences respected. To assure these preferences are identified and communicated to staff, a discussion of these issues, including the availability of spiritual and counseling services will be included during the initial nursing admission assessment. Be informed by knowledgeable staff about your medical condition, to the extent known and be given an opportunity to participate in designing a care plan that addresses your needs and preferences and updating it as your condition changes.