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)
L0558      
25046 Based on observation, interview, and record review, the hospice agency failed to ensure that there were communication and coordination between the staff of ordering supplies, for one of four sampled patients (Patient 10). This deficient practice resulted in the shortage of supplies for Patient 10 that prevent Patient 10 from receiving optimal comfort care that met his needs. Findings: A review of Patient 10's record was conducted. The "Patient Intake" form indicated that Patient 10 was admitted to the agency on 4/10/2021, with diagnoses that inlcuded Alzheimer's disease (a progressive decrease in the ability to think and remember great enough to affect a person's daily functioning) and hypertension (high blood pressure). A review of the Plan of Care (POC) for the certification period, dated from 8/8/2021 to 10/6/2021, indicated that skilled nurse (SN) to visit Patient 10 twice a week for 60 days and as needed three visits per week as needed. The POC indicated that Patient 10 had problems of difficulty swallowing and potential for altered bowel elimination related to diagnosis and co-morbidities. The interventions included implementing measures to improve nutritional status and restore fluid balance, instructing nutritional supplements, and changing incontinent pads/adult diapers in a timely manner. During a home visit conducted at Patient 10's residence on 9/10/2021, at 10 a.m., Patient 10 was observed lying in a hospital bed. During a concurrent interview with Patient 10's family member (Family Member 2 [FM 2]), FM 2 stated that there was a problem with supplies running out among the agency's services. FM 2 stated the supplies for Patient 10; such as diaper, gloves, wipes, and Ensure (dietary supplement), always run out and she often has to buy them. FM 2 stated she informed Licensed Vocational Nurse 1 (LVN 1), LVN 3, and called the agency last week about the needs of Patient 10's supplies but did not get any responses from them. During a telephone interview with FM 2 on 9/10/2021, at 2 p.m., FM 2 stated when the supplies for Patient 10 ran out, she called the agency but they did not send the supplies. During a telephone interview with LVN 3 on 9/10/2021, at 2:20 p.m., LVN 3 stated that Family member 2 has to call the agency if the supplies are not provided in the next visit. LVN 3 also stated she would call the agency to follow up on the supplies for Patient 10. During an interview with LVN 1 on 9/13/2021, at 10:50 a.m., LVN 1 stated that FM 2 had called to notify her that Patient 10 had ran out of supplies and she had provided the information to the intake personnel who is in charge of ordering supplies. During an interview with Intake Personnel on 9/13/2021, at 11 a.m., she stated that there was no documentation indicated when the agency received phone call from FM 2 and the delivery of the supplies for Patient 10. During an interview with the Director of Patient Care Services (DPCS) on 9/13/2021, at 11:50 a.m., the DPCS stated that there was no documentation of a phone call received from Patient 10's caregivers or the supplies were delivered to Patient 10. The DPCS also stated that staff should have communicated to the office regarding any supplies shortage for the patient. A review of the agency's policy and procedure (P&P), revised in April 2018, titled, "Durable Medical Equipment and Supplies," indicated the equipment and supplies are provided for hospice patients based on assessed health care needs. Those supplies required for optimal comfort, care, and management of the hospice patient will be obtained from the hospice stock supplies or approved company. A review of the agency's P&P, revised in April 2011, titled, "Interdisciplinary Group Coordination of Care," indicated the agency's personnel will communicate changes in a timely manner via telephone, one-to-one meeting, interdisciplinary group meetings, and home visits. Documentation of all communications will be included in the clinical record on a communication note, interdisciplinary group meeting form, and/or clinical note.