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
551652 A. BUILDING __________
B. WING ______________ 		06/29/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
MISSION HOSPICE SERVICES OF SAN DIEGO LLC 2385 NORTHSIDE DRIVE, SUITE 200, SAN DIEGO, CA, 92108
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)
L0701      
39448 Based on interview and record review, the facility failed to provide a functional BIPAP (a medical device to help a patient breath) to one of two patients (1). As a result, Patient 1 was sent to an acute care hospital. Findings: Per the agency's visit note report, there was a hospice initiation visit for Patient 1 on 6/12/19, and Patient 1 was oxygen dependent. On 6/25/19 at 9:57 A.M., an interview was conducted with SN 1 (Skilled Nurse). SN 1 stated, she was present when Resident 1 was transported home from the hospital for admission to hospice services. SN 1 further stated, once they switched Resident 1 from the transport's BIPAP to the hospice's BIPAP, Patient 1 could not feel air-flow coming from the BIPAP. SN 1 stated, they had to call the paramedics to take Patient 1 back to the hospital because Patient 1's oxygen saturation (a measure of oxygen levels) dropped immediately upon use of the hospice's BIPAP. Per the agency's Non-Admit Details, dated 6/15/19, Patient 1 was required continuous BIPAP to maintain her oxygen saturation. Patient 1's oxygen saturation was 85% when she arrived on the transport's BIPAP. Transport removed their DME, and SN 1 attached the hospice's DME. Patient 1 reported that she could not feel air coming in through the mask. Patient 1 reported respiratory distress, oxygen saturation dropped to 80%, and they called the paramedics to take Patient 1 back to the hospital. Oxygen saturation progressively declined to 71%. SN 1 confirmed there was no air return coming from the DME, and had to use a bag-valve-mask (a hand-held device to manually ventilate a patient) to maintain 87% oxygen saturation until the paramedics arrived. On 12/31/20 at 2:45 P.M., a telephone interview was conducted with the DMES (Durable Medical Equipment Supervisor). The DMES stated, when they picked up the BIPAP, it was missing the water chamber used to humidify the air, which was required for the device to function. The DMES further stated, whoever setup the BIPAP might have forgotten to put the chamber in the device. On 6/17/21 at 10:30 A.M., a telephone interview was conducted with the DPCS (Director of Patient Care Services). The DPCS stated, a respiratory therapist from the company who delivered the BIPAP should be present when the hospice agency admitted a patient dependent on a BIPAP onto hospice services. On 6/22/21 at 10 A.M., a telephone interview was conducted with the DPCS. The DPCS stated, at the time of Patient 1's admission, the respiratory therapist had not yet arrived.