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
551672 A. BUILDING __________
B. WING ______________ 		07/15/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
HIGH QUALITY HOSPICE CARE 21707 HAWTHORNE BLVD, SUITE 304, TORRANCE, CA, 90503
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)
L0500      
14065 Based on interview and record review, the hospice agency failed to meet the Condition of Participation for Patient's Rights by failing: 1. To process the grievances (the official statement of a complaint over something believed to be wrong or unfair) request, for one of six sampled patients (Patient 3), when Patient 3's family member (PCG) expressed to file a grievance regarding Patient 3 did not recieve his prescribed pain medication. (Refer to L505) 2. To include the patient and/or the patient's family member (PCG) in the care planning, for one of six sampled patients (Patient 3). (Refer to L513) The cumulative effect of these systemic practices resulted in the hospice agency's inability to ensure the patient's rights were protected and the provision of quality health care in a safe environment.
L0505      
14065 Based on interview and record review, the hospice agency failed, for one of six sampled patients (Patient 3), to process the grievances (the official statement of a complaint over something believed to be wrong or unfair) request when Patient 3's family member (PCG) expressed to file a grievance regarding Patient 3 did not recieve his prescribed pain medication. This deficient practice resulted in lacking of communication between Patient 3/PCG and the agency, that led to their questions and concerns were not being addressed. In addition, Patient 3 continued to experience pain, and was moaning in pain for three hours prior to passing away on 5/13/2021. Findings: Patient 3's record was reviewed. A review of the forms titled, "Plan of Care (POC)," for the certification period from 3/29/2021 to 6/26/2021, indicated that Patient 3 was admitted to the hospice agency on 3/29/2021, with diagnoses included malignant neoplasm (a cancerous tumor) of the prostate and terminal diagnosis of unspecified heart disease. The POC indicated an order for the skilled nurse (SN) visit two times a week for 90 days and one visit as needed per week for changes in condition. The POC indicated the SN to assess pain and assess response to pain medications. A review of the form titled, "Initial Physician's Orders and IDG Notification," dated 3/29/2021, indicated Methadone Hydrochloride (a medication that used to treat severe ongoing pain) 5 milligram (mg - unit of measurement) one tablet orally every 8 hours as needed for breakthrough pain was ordered for Patient 3. A review of the SN notes, dated from 3/29/2021 to 5/10/2021, with the director of patient care services/designee (DPCS/Designee) was conducted. The SN notes indicated Patient 3 continued to be in pain and was receiving pain medications. There was no documentation consistently indicated what pain medication Patient 3 received, the level of pain that Patient 3 was experiencing, and whether the pain medication was effective. During an interview with Licensed Vocational Nurse 3 (LVN 3) on 7/13/2021, at 3:05 p.m., she stated Patient 2 and his family were in emotional distress and were very anxious. LVN 3 stated they had many questions and concerns and had informed the agency on two occasions that Patient 3's family member (PCG) wanted to be involved in the patient's care and to meet with the agency via FaceTime or Zoom. LVN 3 stated she also informed the director of nursing (DON) that Patient 3's family member was saying they did not know what was going on with the patient's care and they wanted to be involved in his plan of care. LVN 3 further stated she informed the DON that the family had questions and concerns regarding his pain medications. During an interview with Patient 3's PCG on 7/13/2021, at 4:10 p.m., the PCG stated she reported to LVN 2 on two occasions that she wanted to file a grievance regarding Methadone not being available for the patient. During an interview with LVN 1 on 7/13/2021, at 4:20 p.m. , LVN 1 (Nursing Supervisor) stated she was made aware that Methadone was not being available to Patient 3, but she failed to follow up on the matter. LVN 1 stated they should have involved Patient 3's PCG in the plan of care and she should have filed of grievance when a family member requested one. During an interview with LVN 2 on 7/13/2021, at 5:20 p.m., LVN 2 stated she reported the Methadone not being available to LVN 1 but LVN 1 did not follow through on the grievance. During an interview with Patient 3's PCG on 7/14/2021, at 10 a.m., the PCG stated Patient 3 had to wait for close to three hours for his pain medication (Methadone) to arrive at the home, on 5/13/2021, the day he died. A review of the facility's policy titled, "Grievance Process," dated 5/2009, indicated the agency must take every complaint or allegation/grievance seriously and document the incident and implement a plan of correction. During an interview with the DON on 7/14/2021, at 4 p.m., the DON stated the grievance process for Patient 3 and his PCG was missed. The DON stated she takes full responsibility and she would make the correction.
L0513      
14065 Based on interview and record review, the hospice agency failed, for one of six sampled patients (Patient 3), to include the patient and/or Patient 3's family member (PCG) in the care planning for Patient 3. This deficient practice resulted in lacking of communication between Patient 3/PCG and the agency, that led to their questions and concerns were not being addressed. In addition, Patient 3 continued to experience pain, and was moaning in pain for three hours prior to passing away on 5/13/2021. Findings: Patient 3's record was reviewed. A review of the forms titled, "Plan of Care (POC)," for the certification period from 3/29/2021 to 6/26/2021, indicated that Patient 3 was admitted to the hospice agency on 3/29/2021, with diagnoses included malignant neoplasm (a cancerous tumor) of the prostate and terminal diagnosis of unspecified heart disease. The POC indicated an order for the skilled nurse (SN) visit two times a week for 90 days and one visit as needed per week for changes in condition. The POC indicated the SN to assess pain and assess response to pain medications. A review of the form titled, "Initial Physician's Orders and IDG Notification," dated 3/29/2021, indicated Methadone Hydrochloride (a medication that used to treat severe ongoing pain) 5 milligram (mg - unit of measurement) one tablet orally every 8 hours as needed for breakthrough pain was ordered for Patient 3. A review of the SN notes, dated from 3/29/2021 to 5/10/2021, with the director of patient care services/designee (DPCS/Designee) was conducted. The SN notes indicated Patient 3 continued to be in pain and was receiving pain medications. There was no documentation consistently indicated what pain medication Patient 3 received, the level of pain that Patient 3 was experiencing, and whether the pain medication was effective. During an interview with Licensed Vocational Nurse 3 (LVN 3) on 7/13/2021, at 3:05 p.m., she stated Patient 2 and his family were in emotional distress and were very anxious. LVN 3 stated they had many questions and concerns and had informed the agency on two occasions that Patient 3's family member (PCG) wanted to be involved in the patient's care and to meet with the agency via FaceTime or Zoom. LVN 3 stated she also informed the director of nursing (DON) that Patient 3's family member was saying they did not know what was going on with the patient's care and they wanted to be involved in his plan of care. LVN 3 further stated she informed the DON that the family had questions and concerns regarding his pain medications. During an interview on 7/13/2021, at 3:15 p.m., the DON stated she was in the process of meeting with the family to discuss the care for the patient in more detail and to gather input from the PCG. The DON stated, however, due to staffing issues, she failed to follow through and it was missed. During an interview with the PCG on 7/13/2021, at 4:10 p.m., the PCG stated she reported to the DON that Patient 3 did not have Methadone (pain medication) available as ordered. The PCG stated she was so anxious about the medication not being available for the patient when he needs it. The PCG stated she reported to LVN 2 on two occasions that she wanted to file a grievance regarding Methadone not being available for the patient. During an interview with LVN 1 on 7/13/2021, at 4:20 p.m. , LVN 1 (Nursing Supervisor) stated she was made aware that Methadone was not being available to Patient 3, but she failed to follow up on the matter. LVN 1 stated they should have involved Patient 3's PCG in the plan of care and she should have filed of grievance when a family member requested one. During an interview with LVN 2 on 7/13/2021, at 5:20 p.m., LVN 2 stated she reported the Methadone not being available to LVN 1 but LVN 1 did not follow through on the grievance. During an interview with Patient 3's PCG on 7/14/2021, at 10 a.m., the PCG stated she requested the agency to involve her and allowed her to participate in the care planning, so she could remind them the patient did not have Methadone (pain medication) available at home. The PCG stated she was upset the lack of care planning that led to Patient 3 not receiving pain medication in a timely manner on 5/13/2021, the day he died. The PCG stated Patient 3 had to wait for close to three hours for his pain medication to arrive at the home. During an interview with the DON on 7/14/2021, at 4:10 p.m., the DON stated she felt terrible that the agency failed to include Patient 3's family in the care planning process. A review of the facility policy titled, "Care Planning," dated 5/2009, indicated care planning is an interdisciplinary team effort which involves patient/family participation and should be encouraged to benefit the patient.
L0536      
14065 Based on observation, interview, and record review, the hospice agency failed to meet the Condition of Participation for Interdisciplinary Group, Care Planning, and Coordination of Services for three of six sampled patients (Patient 3, Patient 4 and Patient 5). The hospice agency failed to: 1. Ensure the skilled nurse (SN), Licensed Vocational Nurse 3 (LVN 3) conducted an in-depth pain assessment for Patient 3 and notify the physician that the pain medication was ineffective. (Refer to L549) 2. Ensure LVN 3 administered Methadone Hydrochloride (a medication that used to treat severe ongoing pain) to Patient 3 as ordered by the physician. (Refer to L549) 3. Ensure Methadone Hydrochloride was available and given as ordered as indicated in the agency's policy on pain assessment. (Refer to L549) 4. Ensure that coordination of care occurred between the pharmacy and the agency by not sharing the patients' allergy information for two of six sampled patients (Patient 4 and Patient 5). (Refer to L 558) The cumulative effect of these systemic practices resulted in the hospice agency's inability to provide the services that met the patient's needs and the agency failed to ensure the provision of quality and safe health care to the patients.
L0549      
14065 Based on interview and record review, the hospice agency failed to follow the individualized written plan of care established by the hospice interdisciplinary group (the team responsible for the holistic care of the hospice beneficiary), for one of six sampled patients (Patients 3). The hospice agency failed to: 1. Ensure the skilled nurse (SN), Licensed Vocational Nurse 3 (LVN 3) conducted an in-depth pain assessment for Patient 3 and notify the physician that the pain medication was ineffective. 2. Ensure LVN 3 administered Methadone Hydrochloride (a medication that used to treat severe ongoing pain) to Patient 3 as ordered by the physician. 3. Ensure Methadone Hydrochloride (a medication that used to treat severe ongoing pain) was available and given as ordered as indicated in the agency's policy on pain assessment. These deficient practices resulted in Patient 3 continued to experience pain, and was moaning in pain for three hours prior to passing away on 5/13/2021. Findings: On 7/13/2021, at 1 p.m., Patient 3's record was reviewed. A review of the forms titled, "Plan of Care (POC)," for the certification period from 3/29/2021 to 6/26/2021, indicated that Patient 3 was admitted to the hospice agency on 3/29/2021, with diagnoses included malignant neoplasm (a cancerous tumor) of the prostate and terminal diagnosis of unspecified heart disease. The POC indicated an order for the skilled nurse (SN) visit two times a week for 90 days and one visit as needed per week for changes in condition. The POC indicated the SN to perform skilled body systems assessment and pain management. SN to provide patient care giver (PCG) with instructions regarding pain medication effectiveness, adverse/side effects of medications and assess for compliance. SN to provide PCG with pain assessment forms and teach PCG to document and assess for effectiveness of pain medications. SN to provide a medication profile at the home for the PCG, with a focus on pain medications and to notify the physician if pain management is ineffective. SN also to provide palliative care (medical care that relieves pain, symptoms and stress caused by serious illnesses) and comfort measures to Patient 3. A review of the form titled, "Initial Physician's Orders and IDG Notification," dated 3/29/2021, indicated several pain medications were ordered for Patient 3: Methadone Hydrochloride (a medication that used to treat severe ongoing pain) 5 milligram (mg - unit of measurement) one tablet orally every 8 hours as needed for breakthrough pain; Norco 5/325 mg, half to one tablet every six hours as needed for moderate pain; and Tylenol 650 mg one tablet orally every six hours as needed for mild pain. A review of the Patient/PCG folder left at the home with the PCG on 7/13/2021, at 2:45 p.m., indicated the folder lacked any documentation of teachings regarding pain management for Patient 3. The folder did not contain a medication profile nor did it contain the current list of medications Patient 3 was taking. There was no documented ongoing pain medication assessment or log book at the home. During a concurrent interview and the record review with the director of nursing (DON) on 7/13/2021 at 2:45 p.m., the DON stated she was disappointed that the pain assessment or the log book was not completed by the agency's staff. During an interview with LVN 3 on 7/13/2021, at 3 p.m., she stated Patient 3 was still in pain after she gave Tylenol to him. LVN 3 stated Norco 5/325 mg was not working well as it used to and she would have to give additional Methadone to help Patient 3 with his increasing pain. During an interview on 7/13/2021, at 3:10 p.m, Patient 3's family member (PCG) stated Patient 3 woke up around 1 a.m. and 5 a.m. for the last two months, requesting for his pain pills. The PCG stated the SN was aware that Patient 3 was still experiencing pain not relieved with the current pain medication regime. The PCG stated they ran out of Methadone and LVN 3 stated she told the agency to order Methadone but they had a miscommunication and Methadone was not ordered. The PCG stated the folder did not have any information regarding pain medications and she did not use the folder as a guide because there was nothing in the folder regarding pain medications. The PCG stated she went by what was on the medication bottles. The PCG stated she told the SN many times during her visits at the home and she did not understand why LVN 3 did not notify the physician. A review of the SN notes, dated from 3/29/2021 to 5/10/2021, with the director of patient care services/designee (DPCS/Designee) was conducted. The SN notes indicated Patient 3 continued to be in pain and was receiving pain medications. There was no documentation consistently indicated what pain medication Patient 3 received, the level of pain that Patient 3 was experiencing, and whether the pain medication was effective. During an interview with the DPCS/Designee on 7/13/2021, at 3:15 p.m., the DPCS/Designee stated they had staffing issues and she could not explain why the physician was not notified regarding Patient 3's condition. The DPCS/Designee stated she was disappointed that a medication profile and pain assessment log for Patient 3 was not at the home or in the patient's clincal record. The DPCS/Designee stated on 5/13/2021, at 5 a.m., she received a call from the PCG that Patient 3 was in pain and they did not have Methadone available to give him. The DPCS/Designee immediately ordered through the pharmacist, "Methadone STAT (now)." The DPCS/Designee stated the medication (Methadone) arrived three hours later at 8:10 a.m. During an interview with the PCG on 7/13/2021, at 3:20 p.m., the PCG stated she was so upset because Patient 3 was moaning in pain for three hours on 5/13/2021. The PCG stated Patient 3 then passed away later that afternoon. A review of the skilled nurse home visit note, dated 5/13/2021, at 8:15 a.m., indicated Patient 3 was lying in bed with a blanket over his head. Patient 3 stated he was in pain, and he did not want to remove the blanket from his face.The note indicated that throughout the skilled nurse visit from 8 a.m. to 10 a.m., Patient 3 was observed moaning in pain. A review of the interdisciplinary team meeting (IDT), dated 4/12/2021, indicated Patient 3 was experiencing increased pain and as a result, increased agitation. The plan of care included giving the patient Methadone (breakthrough pain medication ) when the Tylenol or Norco was ineffective. During an interview with LVN 3 and the PCG on 7/13/2021, at 3:45 p.m., they stated they wanted to give Patient 3 his Methadone but it was not available. A review of the agency's policy and procedure, dated 1995 titled, " Pain Assessment," indicated an in-depth pain assessment should be conducted when a patient continues to experience pain. Pain assessment must be updated if significant changes occur and if current pain regime is not available or ineffective, the physician will be contacted for a more effective regime. Pain medication ordered must be available and given as ordered.
L0558      
25046 Based on observation, interview, and record review, the hospice agency failed to ensure that coordination of care occurred between the pharmacy and agency by not sharing the patients' allergy information for two of six sampled patients (Patient 4 and Patient 5). This deficient practice placed the patients at risk for taking the medications that they were allergic to which could result in adverse reactions. Findings: a. A review of Patient 4's record indicated the start of care (SOC), dated 3/24/2020, with diagnoses including heart disease and malignant neoplasm (a cancerous tumor) of breast. A review of Patient 4's Plan of Care (POC) for the certification period, dated from 5/18/2021 to 7/16/2021, indicated the skilled nurse (SN) visit once a week, the aide visit twice a week, the medical social worker visit once a month, and chaplain visit was declined. The POC indicated the hospice nurse to assess/monitor pain and severity every visit, and administer appropriate doses of pain medications. A review of Patient 4's physician's order, dated 3/24/2020, indicated the physician prescribed Methadone (a medication that used to treat severe ongoing pain) 5 milligram (mg - unit of measurement) one tablet by mouth every eight hours as needed for moderate to severe pain. On 7/13/2021, at 1 p.m., during the home visit at the board and care facility, Patient 4 was observed lying in her bed, alert and oriented. Caregiver 1 and Caregiver 2 were at the facility. On 7/13/2021, at 1:35 p.m., Patient 4's medications and the medication profile were reviewed. There was a comfort kit observed containing a vial of Morphine Sulfate (a drug used to treat moderate to severe pain) 100 mg/5 milliliter (ml - unit of measurement). A review of Patient 4's medication profile indicated Morphine Sulfate was not included on the medication profile; however, Methadone was included on the medication profile for moderate to severe pain/shortness of breath. During an interview with Caregiver 1, she stated Patient 4 never had Methadone at the facility, but the Morphine Sulfate medication was in the comfort kit. A review of Patient 4's record indicated there was no documented evidence that the physician had ordered Morphine Sulfate (pain medication) to Patient 4. A review of the Medication profile indicated Patient 4 was allergic to Codeine (codeine is very similar chemically to drugs such as morphine). b. A review of Patient 5's record indicated the start of care (SOC), dated 6/3/2020, with diagnoses including heart disease. A review of Patient 5's Plan of Care (POC) for the certification period, dated from 5/29/2021 to 7/27/2021, indicated the skilled nurse (SN) visits two times a week, the aide visits twice a week, the medical social worker visit once a month, and chaplain visit was declined. The POC indicated the hospice nurse to assess/monitor pain and severity every visit, and administer appropriate doses of pain medications. On 7/13/2021, at 1:10 p.m., during the home visit at the board and care facility, Patient 5 was observed lying in her bed with both eyes closed. Caregiver 1 and Caregiver 2 were at the facility. On 7/13/2021, at 1:55 p.m., Patient 5's medications and the medication profile were reviewed. There was a comfort kit observed containing a vial of Morphine Sulfate 100 mg/5 ml while the medication profile did not include Morphine Sulfate. During a concurrent interview with Caregiver 1, she stated she heard from Patient 5's family member that Patient 5 was allergic to Morphine Sulfate. A review of Patient 5's record indicated there was no documented evidence the physician ordered Morphine Sulfate to Patient 5. A review of the Medication profile indicated that Patient 5 was allergic to Morphine Sulfate. On 7/13/2021, at 2:15 p.m., during a telephone interview with the Director of Patient Care Service (DPCS), she stated she was not sure whether or not Patient 4 and Patient 5 were allergic to Morphine Sulfate. On 7/14/2021, at 12:10 p.m., during an interview with Licensed Vocational Nurse 1 (LVN 1), she stated both Patient 4 and Patient 5 were allergic to Morphine Sulfate, and Morphine Sulfate should not have been included in the patients' comfort kits. On 7/14/2021, at 2:20 p.m., during an interview with the DPCS, the DPCS stated she had ordered by telephone the comfort kits for Patient 4 and Patient 5. The DPCS stated she did not tell the pharmacist that Patient 4 and Patient 5 were allergic to Morphine Sulfate when she ordered the comfort kits from the pharmacy because she assumed the pharmacy had an allergy list of the agency's patients. A review of the pharmacy's "Incident and Discrepancy Form," dated 7/14/2021, indicated the agency's staff placed an order for Patient 4 for comfort kit which included Morphine Sulfate. Patient 4's allergy profile did not include Morphine Sulfate so the medication was delivered to the patient. A review of the pharmacy's "Incident and Discrepancy Form," dated 7/14/2021, indicated the agency's staff placed an order for Patient 5 for comfort kit which included Morphine Sulfate. Patient 5's allergy profile did not include Morphine Sulfate so the medication was delivered to the patient. A review of the agency's undated policy titled, "Policy of Hospice Agency on ordering Medication from Contracted Pharmacy," indicated the followings: 1. Orders for the administration of medications must be given by a physician. 2. The intake form along with the updated medication profile will be faxed to the pharmacy. 3. The Medication profile must include lists of allergies. 4. The agency staff must call confirmation of the receipt of the intake form and the updated Medication Profile. 5. Only medications ordered by the attending physician (or other authorized independent practitioner) is/are in the patient's home and are written in the Medication Profile.
L0671      
25046 Based on interview and record review, the hospice agency failed to ensure the "Medical Guidelines for Determining Prognosis" (the guidelines to determine the eligibility of patient for hospice services) was completed for two of six sampled patients (Patient 4 and Patient 5). This deficient practice resulted in lacking of information to determine the eligibility of patients to receive hospice services. Findings: a. A review of Patient 4's record indicated the start of care (SOC), dated 3/24/2020, with diagnoses including heart disease and malignant neoplasm (a cancerous tumor) of breast. A review of Patient 4's "Medical Guidelines for Determining Prognosis," dated 5/16/2021, for the period from 5/18/2021 to 7/16/2021, indicated the section for "Functional assessment Staging" and "New York Heart Association" were blank. b. A review of Patient 5's record indicated the start of care (SOC), dated 6/3/2020, with current episode from 5/29/201 to 7/27/2021, with diagnoses including heart disease. A review of Patient 5's previous episode "Medical Guidelines for Determining Prognosis," dated 1/24/2021, indicated the section for "Functional assessment Staging" and "New York Heart Association" were blank. A review of Patient 5's previous episode "Medical Guidelines for Determining Prognosis," dated 5/24/2021, indicated the section for "New York Heart Association" were blank. During an interview with the Director of Patient Care Service (DPCS) on 7/15/2021, at 11:15 a.m., she stated the licensed nurse should have completed the "Medical Guidelines for Determining Prognosis" after assessing the patients completely. A review of the agency's policy titled, "Admission Criteria and Process" revised on April 2018 indicated the Registered Nurse Evaluator must complete the initial assessment of Medical Guidelines for Determining Prognosis and Diagnosis Specific Criteria.