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
551671 A. BUILDING __________
B. WING ______________ 		04/07/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
HAGA HOSPICE, INC 5627 SEPULVEDA BLVD SUITE 230, VAN NUYS, CA, 91411
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)
L0513      
25997 Based on observation, interview and record review, the agency failed to implement a home visit scheduling system that ensured two of 11 sampled patient's (Patient 4 and Patient 6) were allowed to participate in their home visit schedules. As a result of this deficient practice patients and caregivers stated they were unable to make plans because they did not know from week to week when the hospice staff were coming. In addition, this deficient practice resulted in one of 11 sampled patients (Patient 1) not being placed on the requested home visit schedule for the week of 4/5/21 to 4/10/21 which could have resulted in missed visits for Patient 1. Findings: On 4/5/21, at 9:30 AM, upon entrance for an unannounced complaint validation survey, the survey team requested a copy of the scheduled home visits for the week of 4/5/21 to 4/10/21. The Patient Care Coordinator Licensed Vocational Nurse (LVN 1) stated she did not have a calendar listing the visits. After forty five minutes LVN 1 provided a copy of the individual patient's face sheets attached to a handwritten piece of paper with the individual staff members names. LVN 1 explained once the staff member told her what date he or she would be seeing the patient, she attached the face sheets to the staff member's name. The lists did not indicate what time the staff member would be seeing the patient. LVN 1 stated she would write in the time once the staff members told her what time they would be going. The lists did not indicate the time the patients scheduled for visits that same day were going to be seen. On 4/5/21, at 2:45 PM, Patient 6's care giver stated, "It would be nice to have a schedule for the nurse visits. They just show up." The care giver stated she would be better able to plan her schedule if the RN (Registered Nurse) and LVN came on a regular schedule. The care giver further stated she never knew if the LVN or the RN were coming, and sometimes the hospice Patient Care Coordinators (LVN 1 and LVN 2) came instead of the RN or LVN. A review of Patient 6's Plan of Care, dated 4/1/21, indicated he was to have weekly skilled nurse visits. On 4/6/21, at 10:15 AM., during a home visit, Patient 4 stated he did not have any say about when the hospice staff came to see him. Patient 6 stated he would like to know when they are coming so he can be ready. A review of Patient 4's Assessment dated 3/19/21, indicated he was to have skilled nurse visits once each week and HHA (home health agency) visits once a week. The HHA visit order was discontinued at the patient's request. On 4/7/21, at 11:10 AM, LVN 1 stated she was aware the hospice policy indicated the staff would contact the office daily to confirm their schedule for the day, and to confirm all planned visits for the day were made. The LVN stated the nurses sometimes forgot to call the office. LVN 1 stated every Friday the hospice volunteer called all of the patients and if a patient stated a nurse had not been out that week to visit, either she or LVN 2 would go out to see the patient, or the Assistant Director of Patient Care Services would do a televisit with the patient, if appropriate. On 4/7/21, at 11:45 AM, the Administrator stated she was aware sometimes the nurses did not call the agency to alert them they would not be able to do a scheduled home visit. The Administrator stated LVN 1 or LVN 2 would then go out to see the patient. The Administrator stated she was aware this caused inconsistency for the patients. When asked the reason, the Administrator stated some of the staff worked at other facilities and if they had to do an extra shift they could not come see the hospice patients. A review of the agency's undated "Staffing and Scheduling" policy number 2.155.1, indicated: The purpose of the policy was to ensure continuity of care for all patients. Continuity of care is fostered by assigning consistent personnel to the patients whenever possible. Hospice staff would contact the office daily to confirm their schedule and caseload with the Nursing Supervisor. Hospice clinicians would communicate with the office to verify that all planned visits for the day were made and hospice clinicians cannot alter the schedule for assignment of cases without the prior approval of the Nursing Supervisor.