Survey Report for 551702

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
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION	551702	A. BUILDING __________ B. WING ______________	01/10/2020
NAME OF PROVIDER OR SUPPLIER	STREET ADDRESS, CITY, STATE, ZIP
DELTA HOSPICE OF INLAND VALLEY, INC	41715 WINCHESTER RD SUITE 106, TEMECULA, CA, 92590
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)
L0523
L0523	32192 Based on interview and record review, the agency failed to ensure the interdisciplinary group (IDG) completed the comprehensive assessment no later than five calendar days after the start of care (SOC), for two of 14 patients reviewed (Patients 1 and 2). These failures had the potential for the agency to not identify and address Patients 1 and 2's physical, psychosocial, emotional, and spiritual needs. In addition, these failures had the potential for Patients 1 and 2's plans of care (POC) to not be developed. Findings: 1. On January 6, 2020, Patient 1's record was reviewed. Patient 1 was admitted to the agency with the SOC date of December 13, 2019, with diagnoses including hypertensive heart disease with heart failure (the inability of the heart to pump blood effectively due to high blood pressure). The plan of care (POC) for the certification period from December 13, 2019, to March 11, 2020, was reviewed. The document titled, "POC/IDG Review," dated December 23, 2019, indicated the SOC was begun on December 13, 2019. The document indicated the IDG review was conducted on December 23, 2019 (10 calendar days from SOC). There was no documented evidence the medical social worker participated in the POC/IDG review . 2. On January 6, 2020, Patient 2's record was reviewed. Patient 2 was admitted to the agency with the SOC date of December 13, 2019, with diagnoses including Alzheimer's disease (memory loss) and atherosclerosis (hardening of the blood vessels). The POC for the certification period from December 13, 2019, to March 11, 2020, was reviewed. The document titled, "POC/IDG Review," dated December 23, 2019, indicated the SOC was begun on December 13, 2019. The document indicated the IDG review was conducted on December 23, 2019 (10 calendar days from SOC). There was no documented evidence the physician, medical social worker, and chaplain, attended the IDG meeting. On January 8, 2020, at 3:52 p.m., the AD was interviewed. The AD stated the POC/IDG review should be conducted by the IDG team members within five calendar days after the SOC. The agency's policy and procedure titled, "Interdisciplinary Group Membership and Responsibilities," revised April 2011, was reviewed. The policy indicated, "...The interdisciplinary group will...Participate in the establishment of the plan of care for each patient admitted to the hospice service...Provide and/or supervise and coordinate hospice care services...Review utilization criteria for each discipline including: Appropriateness of the level of care to protect the health and safety of patients...Timeliness of care...Adequacy of care to meet patients' needs...Appropriateness of specific services provided..."
L0530
L0530	32192 Based on observation, interview, and record review, the agency failed to ensure the medications listed on the patient's plan of care (POC) and on the medication profile were updated and accurate, for one of 14 patients reviewed (Patient 6). This failure had the potential for the agency to not identify any potential adverse effects and drug reactions, ineffective drug therapy, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy for Patient 6. Findings: On January 6, 2020, Patient 6's record was reviewed. Patient 6 was admitted to the agency with the start of care (SOC) date of October 24, 2019, and with diagnoses including kidney failure (when the kidneys lose the ability to filter waste from the blood sufficiently), hypertension (high blood pressure), congestive heart failure (the inability of the heart to pump blood effectively), and diabetes mellitus (abnormal blood sugar). The POC for the certification periods from October 24, 2019, to December 22, 2019, and December 22, 2019, to February 20, 2020, were reviewed. On January 8, 2020, at 10:05 a.m., a home visit for Patient 6 was conducted with the Registered Nurse/Director of Patient Care Services (RN/DPCS). Patient 6 was observed sitting in her recliner chair in her living room. Patient 6 was observed to be alert, oriented to time, person, place, and was able to verbalize her needs. A concurrent interview was conducted with Patient 6. Patient 6 stated she could administer her own medications daily including as needed medications. Patient 6 stated she was taking all the medications which were in her room. On January 8, 2020, at 10:33 a.m., a concurrent interview and medication review was conducted with the RN/DPCS. During the medication review the following medication prescription bottles were observed to be in Patient 6's room, but were not listed on Patient 6's current POC and medication profile which were concurrently reviewed: - "Calcitriol (vitamin D3) 0.25 mg (milligrams - a unit of measurement) 1 (one) capsule by mouth three times a week;" - "Pantoprazole (medication for hyperacidity) 20 mg 1 tablet by mouth daily;" - "Allopurinol (medication for gout [disorder with increased uric acid levels]) 100 mg 1 tablet by mouth daily;" and - "Metolazone (a "water pill" for high blood pressure) 5 (five) mg 1 tablet by mouth daily." On January 9, 2020, at 4:29 p.m., the RN/DPCS was interviewed and stated the agency did not have a policy regarding updating Patient 6's POC and the medication profile in the patient's home.
L0536
L0536	35056 Based on interview and record review, the facility failed to ensure the interdisciplinary group (IDG) provided and supervised the care and services needed by the patients, when the agency failed to: 1. Ensure the IDG and the physician developed a plan of care for one patient (Patient 2) (Refer L537); 2. Develop a plan of care for a patient's risk for fall and skin breakdown (Patient 5) (Refer L538); 3. Ensure the IDG included a physician, social worker, and a chaplain, for eight of 14 patients reviewed (Patients 1, 2, 5, 7, 8, 9, 10, and 11) (Refer L541); and 4. Ensure the frequency of visits by the skilled nurse, hospice aide, social worker, and chaplain were completed as ordered and indicated in the plan of care, for eight of 14 patients reviewed (Patients 3, 4, 6, 7, 8, 9, 10, and 11) (Refer L543). The cumulative effect of these systemic problems had the potential for the patients' needed care and services to not be provided timely and/or supervised.
L0537
L0537	32192 Based on interview and record review, the agency failed to ensure the interdisciplinary group (IDG) and the attending physician developed a written plan of care (POC) after the start of care (SOC), for one of 14 patients reviewed (Patient 2). This failure had the potential for the agency to not identify the care and services needed by Patient 2 and for the attending physician to not develop an appropriate POC. Findings: On January 6, 2020, Patient 2's record was reviewed. Patient 2 was admitted to the agency with the SOC date of December 13, 2019, with diagnoses including Alzheimer's disease (memory loss) and atherosclerosis (hardening of the blood vessels). The POC for the certification period from December 13, 2019, to March 11, 2020, was reviewed. The document titled, "POC/IDG Review," dated December 23, 2019, indicated the SOC was begun on December 13, 2019. There was no documented evidence the physician, medical social worker, and chaplain, participated in the POC/IDG review on December 23, 2019. There was no documented evidence a POC was developed in consultation with the patient's attending physician for Patient 2. On January 8, 2020, at 3:52 p.m., the Administrator Designee (AD) was interviewed. The AD stated the POC/IDG should be signed by the IDG team members within five calendar days after the SOC. The agency's policy and procedure titled, "Interdisciplinary Group Membership and Responsibilities," revised April 2011, was reviewed. The policy indicated, "...The interdisciplinary team/group will collaborate with the patient's attending physician to develop a patient-directed plan of care..."
L0538
L0538	37626 Based on interview and record review, the agency failed to develop a plan of care for the risks of falls and skin breakdown to meet the patient and family's needs as identified in the initial comprehensive assessment, for one of 14 patients reviewed (Patient 5). This failure had the potential for Patient 5 to not receive the care and services to prevent further falls and skin breakdown. Findings: On January 8, 2020, the record of Patient 5 was reviewed. Patient 5 was admitted to the agency on December 3, 2019, with admitting diagnoses including Alzheimer's disease (memory loss). The certification period reviewed was December 3, 2019, to January 31, 2020. The agency document titled, "Comprehensive Nursing Assessment," dated December 3, 2019, was reviewed. The comprehensive assessment indicated, "...Narrative & (and) Disease Trajectory...Patient able to ambulate (walk) with one person assistance, unstable balance, has history of multiple falls...urinary incontinence..." The agency documents titled, "POC/IDG (Plan of Care/Interdisciplinary Group) Review," dated December 10 and 23, 2019, was reviewed. There was no documented evidence the POC for Patient 5 addressed Patient 5's risks for falls and possible skin breakdown due to urinary incontinence. On January 9, 2020, at 4:30 p.m., an interview and record review was conducted with the Administrator Designee (AD). The AD confirmed there was no documentation the POC was updated to include Patient 5's risk for falls and skin breakdown. The AD stated the POC should been updated by the IDG. The agency policy and procedure titled,"INTERDISCIPLINARY GROUP MEETING," revised April 2011, was reviewed. The policy indicated, "...The interdisciplinary group will meet on a regular basis to discuss patient and family/caregiver changes...and updates to the plan of care...Each patient's plan of care will be updated utilizing the results from the ongoing comprehensive assessments..."
L0541
L0541	32192 Based on interview and record review, the agency failed to ensure the interdisciplinary group's (IDG) composition included a physician (MD), medical social worker (MSW), and chaplain, for eight of 14 patients reviewed (Patient 1, 2, 5, 7, 8, 9, 10, and 11). This failure had the potential for the plan of care (POC) for Patients 1, 2, 5, 7, 8, 9, 10, and 11, to not be appropriately developed which may result in the patients to not receive the necessary care and treatment timely. Findings: 1. On January 6, 2020, Patient 1's record was reviewed. Patient 1 was admitted to the agency with the start of care (SOC) date of December 13, 2019, with diagnoses including hypertensive heart disease with heart failure (the inability of the heart to pump blood effectively due to high blood pressure). The POC for the certification period from December 13, 2019, to March 11, 2020, was reviewed. The agency document titled, "POC/IDG Review," dated December 23, 2019, indicated the SOC was begun on December 13, 2019. There was no documented evidence the MSW participated in the POC/IDG review for Patient 1 on December 23, 2019. 2. On January 6, 2020, Patient 2's record was reviewed. Patient 2 was admitted to the agency with the SOC date of December 13, 2019, with diagnoses including Alzheimer's disease (memory loss) and atherosclerosis (hardening of the blood vessels). The POC for the certification period from December 13, 2019, to March 11, 2020, was reviewed. The document titled, "POC/IDG Review," dated December 23, 2019, indicated the SOC was begun on December 13, 2019. There was no documented evidence a physician, MSW, and chaplain, participated in the POC/IDG review for Patient 2 on December 23, 2019. On January 8, 2020, at 3:52 p.m., the Administrator Designee (AD) was interviewed. The AD stated the POC/IDG should be signed by the IDG team members within five calendar days after the SOC. 37626 3. On January 8, 2020, the record of Patient 5 was reviewed. Patient 5 was admitted to the agency on December 3, 2019, with admitting diagnoses including Alzheimer's disease. The certification period reviewed was December 3, 2019, to January 31, 2020. The agency document titled, "POC/IDG Review," dated December 10, 2019, was reviewed. There was no documented evidence the MSW participated in the POC/IDG review for Patient 5 on December 10, 2019. The agency document titled, "POC/IDG Review," dated December 23, 2019, was reviewed. There was no documented evidence the IDG members participated in the POC/IDG review for Patient 5 on December 23, 2019. On January 9, 2020, at 4:30 p.m., the record of Patient 5 was reviewed with the Administrator Designee (AD). During a concurrent interview with the AD, the AD confirmed the MSW did not participate in the POC/IDG meeting on December 10, 2019, for Patient 5. The AD did not know why the POC/IDG, dated December 23, 2019, was not signed by the POC/IDG members. 4. On January 9, 2020, the record of Patient 7 was reviewed. Patient 7 was admitted to the agency on May 3, 2019, with admitting diagnoses of Alzheimer's disease. The certification period reviewed was for October 30, 2019 to December 28, 2019. The agency documents titled, "POC/IDG Review," dated November 12 and 26, 2019, and December 23, 2019, were reviewed. There was no documented evidence the MSW participated in the POC/IDG review for Patient 7 on November 12, and 26, 2019. On January 9, 2020, at 3:45 p.m., an interview and record review was conducted with the AD. The AD confirmed there was no documentation the MSW participated in the POC/IDG review for Patient 7 on November 12 and 26, 2019. 5. On January 8, 2020, the record of Patient 8 was reviewed. Patient 8 was admitted to the agency on April 30, 2018, with admitting diagnoses including diastolic congestive heart failure (the inability of the left chamber of the heart to fill with blood which could reduce the amount of blood pumped by the heart). The certification reviewed period was October 22, 2019, to December 20, 2019. The agency documents titled, "POC/IDG Review," dated November 12 and 26, 2019, and December 23, 2019, were reviewed. There was no documented evidence the MSW participated in the POC/IDG review for Patient 8 on November 12 and 26, 2019. There was no documented evidence the MSW and chaplain participated in the POC/IDG review for Patient 8 on December 23, 2019. On January 9, 2019, at 4:10 p.m., an interview and record review was conducted with the AD. The AD stated there was no documentation the MSW participated in the POC/IDG review for Patient 8 on November 12 and 26, 2019, and December 23, 2019. The AD stated there was no documentation the chaplain participated in the POC/IDG review of Patient 8 on December 23, 2019. 6. On January 7, 2020, the record of Patient 9 was reviewed. Patient 9 was admitted to the agency on October 29, 2019 with admitting diagnoses including atherosclerosis. The certification period reviewed was October 29, 2019, to December 27, 2019. The agency documents titled, "POC/IDG Review," dated November 12 and 26, 2019, December 10 and 23, 2019, were reviewed. There was no documented evidence the MSW participated in the POC/IDG review on November 12 and 26, 2019, and December 10 and 23, 2019. There was no documented evidence the IDG members participated in the POC/IDG review on December 23, 2019. On January 10, 2020, at 11:35 a.m., an interview and record review was conducted with the AD. The AD stated there was no documentation the MSW participated in the POC/IDG review for Patient 9 on November 12 and 26, 2019, and December 10 and 23, 2019. The AD confirmed there was no documentation the IDG members participated in the POC/IDG review for patient 9 on December 23, 2019. 7. On January 9, 2019, the record of Patient 10 was reviewed. Patient 10 was admitted to the agency on November 22, 2019, with admitting diagnoses including cirrhosis of the liver (liver disease). The certification period reviewed was November 22, 2019, to January 20, 2020. The agency documents titled,"POC/IDG Review," dated November 26, 2019, December 10 and 23, 2019, were reviewed. There was no documented evidence the MSW participated in the POC/IDG review for Patient 10 on November 26, 2019, and December 10 and 23, 2019. There was no documented evidence the chaplain participated in the POC/IDG review for Patient 10 on December 23, 2019. On January 9, 2020, at 4:20 p.m., an interview and record review was conducted with the AD. The AD confirmed there was no documentation the MSW participated in the POC/IDG review of Patient 10 on November 26, 2019, and December 10 and 23, 2019. The AD confirmed there was no documentation the chaplain participated in the POC/IDG review of Patient 10 on December 23, 2019. 8. On January 9, 2020, the record of Patient 11 was reviewed. Patient 11 was admitted to the agency on January 19, 2019, with admitting diagnoses including atherosclorotic heart disease (heart condition due to the hardening of the blood vessels). The certification periods reviewed were September 19, 2019, to December 17, 2019, and December 18, 2019, to March 16, 2020. The agency documents titled, "POC/IDG Review," dated September 30, 2019, October 15 and 28, 2019, were reviewed. There was no documented evidence the MSW participated in the POC/IDG review for Patient 11 on September 30, 2019, and October 15 and 28, 2019. There was no documented evidence the chaplain participated in the POC/IDG review for Patient 11 on September 30, 2019. On January 10, 2020, at 4:35 p.m., an interview and record review was conducted with the AD. The AD confirmed there was no documentation the MSW participated in the POC/IDG review for Patient 11 on September 30, 2019 and October 15 and 28, 2019. The AD confirmed there was no documentation the chaplain participated in the POC/IDG review for Patient 11 on September 30, 2019. On January 9, 2019, at 4:30 p.m., the AD was interviewed. The AD stated the IDG members included the MSW, chaplain, and physician. The agency's policy and procedure titled, "Interdisciplinary Group Membership and Responsibilities," revised April 2011, was reviewed. The policy indicated, "...The interdisciplinary team/group will collaborate with the patient's attending physician to develop a patient-directed plan of care...The hospice interdisciplinary team/group members will include, at a minimum: Physician...Social worker...Pastoral or other counselor...The interdisciplanry group will...Participate in the establishment of the plan of care for each patient admitted to the hospice care...Participate in the periodic review and updating of the plan of care for each patient and family receiving hospice services...Provide and/or supervise and coordinate hospice care and services...Review and resolve conflict of care and ethical issues..."
L0543
L0543	37626 Based on interview and record review the agency failed to ensure the individualized plan of care (POC) established by the interdisciplinary group (IDG) for the frequency of visits was implemented, for eight of 14 patients reviewed (Patients 3, 4, 6, 7, 8, 9, 10, and 11). This failure resulted in missed visits by the hospice aide (HA), skilled nurse (SN), medical social worker (MSW), and spiritual counselor (SC) for Patients 3, 4, 6, 7, 8, 9, 10, and 11. In addition, this failure had the potential for the patients to not receive the needed care and services timely. Findings: 1. On January 6, 2020, Patient 3's record was reviewed. Patient 3 was admitted to the agency with the start of care (SOC) date of October 24, 2019, with diagnoses including Parkinson's disease (nervous system disorder which affect the muscle movements). The POC for the certification period from October 24, 2019, to March 20, 2020, was reviewed. The facesheet indicated the SOC was begun on October 24, 2019. The undated document titled, "POC Summary," indicated, "...Frequency of Visit...(HA: 5 [five] per week, (SN: 2 [two] per week-). The record indicated the ordered skilled nurse visits (SNVs) and hospice aide visits (HAVs) were not completed according to the POC, as followed: - One missed SNV between October 27, 2019, to November 2, 2019; - One missed SNV between November 10, 2019, to November 16, 2019; - One missed SNV between November 17, 2019, to November 23, 2019; - One missed SNV between November 24, 2019, to November 30, 2019; - One missed SNV between December 8, 2019, to December 14, 2019; - One missed SNV between December 22, 2019, to December 28, 2019; and - One missed HAV each on November 28, 2019, November 29, 2019, December 31, 2019, January 1, 2020, and January 2, 2020 (total of five missed HAVs). On January 9, 2020, at 2:54 p.m., an interview was conducted with HA 1. HA 1 stated she missed the visits for Patient 3 on November 28, 2019, November 29, 2019, December 31, 2019, January 1, 2020, and January 2, 2020. On January 9, 2020, at 4:06 p.m., an interview was conducted with the Registered Nurse/Director of Patient Care Services (RN/DPCS). The RN/DPCS confirmed the missed skilled nurse visits. The RN/DPCS stated Licensed Vocational Nurse (LVN) 1 should have made skilled nurse visits to Patient 3 on Tuesdays. The RN/DPCS stated Patient 3 was to be covered by another HA on November 28, 2019, November 29, 2019, December 31, 2019, January 1, 2020, and January 2, 2020. The RN/DPCS stated there was no documentation indicating the HAVs were done. 2. On January 6, 2020, Patient 4's record was reviewed. Patient 4 was admitted to the agency with the SOC date of October 25, 2019, with diagnoses including heart failure (the inability of the heart to pump blood effectively). The POC for the certification period from October 25, 2019, to March 21, 2020, was reviewed. The facesheet indicated the SOC was begun on October 25, 2019. The undated document titled, "POC Summary," indicated, "...Frequency of Visit...(SN: 2 per Week..." The record indicated there was an additional SNV made by the RN/DPCS on December 1, 2019. There was no documented evidence an additional SNV was ordered for Patient 4. On January 9, 2020, at 4:23 p.m., the RN/DPCS was interviewed. The RN/DPCS stated there was no documentation an additional SNV was ordered for Patient 4. 3. On January 6, 2020, Patient 6's record was reviewed. Patient 6 was admitted to the agency on October 24, 2019, with diagnoses including kidney failure (the inability of the kidneys to filter waste from the blood sufficiently), hypertension (high blood pressure), congestive heart failure (the inability of the heart to pump blood effectively), and diabetes mellitus (abnormal blood sugar). The POCs for the certification periods from October 24, 2019, to December 22, 2019, and December 22, 2019, to February 20, 2020, were reviewed. The facesheet indicated the SOC was begun on October 24, 2019. The undated document titled, "POC Summary," indicated, "...Frequency of Visit...(HA: 3 [three] per Week-), (SN: 2 per Week..." Patient 6's record indicated one SNV was missed on the following dates: - October 29, 2019; - December 17, 2019; - December 24, 2019; and - December 31, 2019. Patient 6's record indicated one HAV was missed on the following dates: - October 31, 2019; - November 7, 2019; - November 14, 2019; - November 19, 2019; - November 26, 2019; - December 3, 2019; - December 12, 2019; - December 31, 2019; and - January 2, 2020. On January 9, 2020, at 4:29 p.m., an interview was conducted with the RN/DPCS. The RN/DPCS confirmed the missed SNVs. The RN/DPCS stated LVN 1 should have visited Patient 6 on Tuesdays. The RN/DPCS stated Patient 6 was to be covered by another HA three times a week, but confirmed only two HAVs were being made per week on the specified dates. 4. On January 9, 2020, the record of Patient 7 was reviewed. Patient 7 was admitted to the agency on May 3, 2019, with admitting diagnoses including Alzheimer's disease (loss of memory). The certification period reviewed was October 30, 2019 to December 28, 2019. The agency document titled, "POC/IDG Review (plan of care/interdisciplinary group)," dated November 26, 2019, was reviewed. The document indicated, "...Frequency: SN: 1x/wk (one time per week); CHHA(Hospice Aide): 3x/wk (three times per week); SW (medical social worker [MSW]): 1x/mo (one time per month); SC (Chaplain): 1x/mo (one time per month)..." Patient 7's record indicated the following missed visits: - One SNV between December 1, 2019, to December 7, 2019; - Six HAVs between October 30, 2019, to November 9, 2019; - One HAV between November 24, 2019, to November 30, 2019; and - One HAV between December 22, 2019, to December 28, 2019. There was also no documented evidence MSW and SC visits were made between October 30, 2019, to December 28, 2019. There was no documented evidence of the reasons for the missed visits. On January 9, 2020, at 3:45 p.m., the record of Patient 7 was reviewed with the Administrator Designee (AD). During a concurrent interview, the AD confirmed the missed visits of the SN, HA, MSW, and SC between October 30, 2019, to December 28, 2019. The AD stated the reasons for the missed visits should have been documented. 5. On January 8, 2020, the record of Patient 8 was reviewed. Patient 8 was admitted to the agency on April 30, 2018, with admitting diagnoses including diastolic congestive heart failure (the inability of the left chamber of the heart to fill with blood causing the heart to pump inadequate blood). The certification period reviewed was October 22, 2019, to December 20, 2019. The agency document titled, "POC/IDG Review," dated November 12, 2019, was reviewed. The document indicated, "...Frequency: SN 1x/wk; CHHA (hospice aide): 3x/wk; MSW: 1x/mo..." There was no documented evidence an MSW visit was made between October 22, 2019, to December 20, 2019. On January 9, 2020, at 4:10 p.m., the record of Patient 8 was reviewed with the AD. During a concurrent interview, the AD confirmed there was no documentation the MSW visited Patient 8 between October 22, 2019, to December 20, 2019. 6. On January 7, 2020, the record of Patient 9 was reviewed. Patient 9 was admitted to the agency on October 29, 2019, with admitting diagnoses including atherosclerosis (hardening of the blood vessels). The certification period reviewed was October 29, 2019, to December 27, 2019. The agency document titled, "POC/IDG Review," dated November 12, 2019, indicated, "...Frequency: SN: 1x/wk; HA: 3x/week; MSW: 1x/mo; Chaplain: 1x/mo..." Patient 9's record indicated the following missed visits: - One SNV between November 17, 2019, to November 23, 2019; - Three HAVs between October 29, 2019, to November 2, 2019; - Two HAVs between November 3, 2019, to November 9, 2019; and - Two medical social worker visits between October 29, 2019, to December 27, 2019. On January 10, 2020, at 11:35 a.m., the record of Patient 9 was reviewed with the AD. During a concurrent interview, the AD confirmed the missed visits of the SN, HA, and MSW between October 29, 2019, to December 27, 2019 (as listed above). 7. On January 9, 2019, the record of Patient 10 was reviewed. Patient 10 was admitted to the agency on November 22, 2019, with admitting diagnoses including cirrhosis of the liver (liver disease). The certification period reviewed was November 22, 2019, to January 20, 2020. The agency document titled,"POC/IDG Review," dated November 26, 2019, was reviewed. The document indicated, "...Frequency: SN: 2x/wk (two times per week); HA: 3x/wk..." Patient 10's record indicated there were three HA visits missed between November 24 to 30, 2019. On January 9, 2020, at 4:20 p.m., an interview and record review was conducted with the AD. The AD confirmed there was no documentation visits were made by the HA to Patient 10 between November 24 to 30, 2019. 8. On January 9, 2020, the record of Patient 11 was reviewed. Patient 11 was admitted to the agency on September 19, 2019, with admitting diagnoses including atherosclerotic heart disease (a heart condition due to the hardening of the blood vessels). The certification periods reviewed were September 19, 2019, to December 17, 2019, and December 18, 2019, to March 16, 2020. The agency document titled, "POC/IDG Review," dated September 30, 2019, was reviewed. The document indicated, "...Frequency of Visit...HA: 2 per Week...SN: 2 per Week..." Patient 11's record indicated the following missed visits: - One SNV between November 22, 2019, to November 28, 2019; - One SNV between November 24, 2019, to November 30, 2019; - One SNV between December 1, 2019, to December 7, 2019; - Two HAVs between September 19, 2019, to September 21, 2019; - Two HAVs between September 29, 2019, to October 5, 2019; - One HAV between November 3, 2019, to November 9, 2019; - Two HAVs between November 10, 2019, to November 16, 2019; - Four HAVs between November 17, 2019, to November 30, 2019; and - One HAV between December 1, 2019, to December 7, 2019. Patient 11's record indicated four HAVs and one SNV extra visits were made during the certification period between September 19, 2019, to December 17, 2019. There was no documented evidence for the rationale of the extra SNVs and HAVs made during the certification period between September 19, 2019, to December 17, 2019. There was no documented evidence the physician was notified of the extra SNV's and HSV's between September 19, 2019, to December 17, 2019. On January 9, 2020, at 4:35 p.m., the record of Patient 11 was reviewed with the AD. During a concurrent interview with the AD, the AD confirmed the missed and extra SNVs and HAVs for Patient 11. The AD stated the staff should notify the agency for the missed and extra visits and the agency should notify the physician of the missed and extra visits. The agency policy and procedure titled, "INTERDISCIPLINARY GROUP COORDINATION OF CARE," revised April 2011, was reviewed. The policy indicated,"...(Name of agency)...will utilize a case management system to guide an interdisciplinary group to provide comprehensive, coordinated, hospice care patients and family/caregivers...It will be the responsibility of the RN (Registered Nurse) Case Manager to facilitate communication about changes in the patient's status... (Name of agency) personnel will communicate changes in a timely manner via telephone, one-to-one meetings, interdisciplinary group meetings, and home visits. Documentation of all communications will be included in the clinical record on a communication note...Documentation will include the date and time of the communication, individuals involved with the communication, information discussed, and the outcome of the communication...All interdisciplinary group members...will have access to the plan of care to ensure coordination and continuity...Continuity of care will be maintained throughout the patient's course with hospice..." The agency policy and procedure titled, "INTERDISCIPLINARY GROUP MEETING," revised April 2011, was reviewed. The policy indicated, "...An interdisciplinary group meeting plan of care update form will be used for update of the patient and family/caregiver...It will note changes...which may include...Increases or decreases in frequency of visits by team members and reason for the change..."
L0559
L0559	37626 Based on interview, the agency failed to develop, implement, and maintain an effective, ongoing, agency-wide data driven quality assessment and performance improvement (QAPI) program. The cumulative effect of this systemic problem had the potential for the agency to not be able to evaluate the care and services provided to the patients and the patients' families. In addition, the agency will not be able to determine the necessary changes to the care and services to be provided to the patients and their families. Findings: On January 10, 2020, at 11:45 a.m., the records of the agency's QAPI program was requested from the Registered Nurse/Director of Patient Care Services (PN/DPCSDPCS). The RN/DPCS was not able to provide documentation related to the agency's QAPI program. There was no documented evidence the agency had developed, implemented, and maintained a QAPI program. In a concurrent interview, the DPCS stated she has no knowledge about the agency's QAPI program. On January 10, 2010, at 11:50 a.m., the Administrator Designee (AD) was interviewed. The AD stated she has no knowledge about the agency's QAPI program. The AD stated she could not find any information and documentation related to the agency's QAPI program.
L0594
L0594	32192 Based on interview and record review, the agency failed to ensure medical social services was provided, for four of 14 patients reviewed (Patients 7, 8, 9, and 1). These failures had the potential for Patients 7, 8, 9, and 1, to not receive information regarding supportive services for terminal illness, the dying process, and community resources. Findings: 1. On January 9, 2020, the record of Patient 7 was reviewed. Patient 7 was admitted to the agency on May 3, 2019, with admitting diagnoses including Alzheimer's disease (loss of memory). The certification period reviewed was for October 30, 2019 to December 28, 2019. The agency document titled, "POC/IDG (plan of care/interdisciplinary group) Review," dated October 28, 2019, was reviewed. The document indicated, "...Frequency...SW (MSW, medical social worker): 1x/mo (one time per month)..." There was no documented evidence a visit was made by the MSW for Patient 7 between October 30, 2019, to December 28, 2019. There was no documented evidence of the reasons for the missed visits by the MSW to Patient 7 between October 30, 2019, to December 28, 2019. On January 9, 2020, at 3:45 p.m., the record of Patient 7 was reviewed with the Administrator Designee (AD). During a concurrent interview, the AD confirmed there was no visit made by the MSW between October 30, 2019, to December 28, 2019. The AD stated there was no documentation of the reasons for the missed visits by the MSW to Patient 7 between October 30, 2019, to December 28, 2019. The AD stated the reasons for the missed visits should have been documented. 2. On January 8, 2020, the record of Patient 8 was reviewed. Patient 8 was admitted to the agency on April 30, 2018, with admitting diagnoses including diastolic congestive heart failure (left chamber of the heart does not fill with blood). The certification period reviewed was October 22, 2019, to December 20, 2019. The agency document titled, "POC/IDG Review," dated November 12, 2019, was reviewed. The document indicated, "...Frequency...MSW: 1x/mo..." There was no documented evidence the MSW made a visit to Patient 8 between October 22, 2019, to December 20, 2019. On January 9, 2020, at 4 :10 p.m., the record of Patient 8 was reviewed with the AD. During a concurrent interview, the AD confirmed there was no MSW visit made between October 22, 2019, to December 20, 2019. 3. On January 7, 2020, the record of Patient 9 was reviewed. Patient 9 was admitted to the agency on October 29, 2019, with admitting diagnoses including atherosclerosis (hardening of the blood vessels). The certification period reviewed was October 29, 2019, to December 27, 2019. The agency document titled, "POC/IDG Review," dated November 12, 2019, indicated,"... Frequency...SW: 1x/mo (one visit a month)..." Patient 9's record indicated there were two MSW visits missed between October 29, 2019, to December 27, 2019. On January 10, 2020, at 11:35 a.m., the record of Patient 9 was reviewed with the AD. During a concurrent interview, the AD confirmed the missed visits of the MSW between October 29, 2019, to December 27, 2019. 4. On January 6, 2020, Patient 1's record was reviewed. Patient 1 was admitted to the agency with the start of care (SOC) date of December 13, 2019, with diagnoses including hypertensive heart disease with heart failure (the inability of the heart to pump blood effectively due to high blood pressure). The POC for the certification period from December 13, 2019, to March 11, 2020, was reviewed. The document titled, "POC/IDG Review," dated December 23, 2019, indicated, "...Frequency of Visit...(MSW: 1 per Month [one time a month] + [plus] 1 PRN Visits [sic, one as needed visit])..." There was no documented evidence the MSW completed a visit to Patient 1 between December 23, 2019, to January 8, 2020. On January 8, 2020, at 9:15 a.m., the binder of the agency policies and procedures was provided by the Intake Coordinator (IC). The binder was concurrently reviewed. There was no documented evidence the agency had a policy for the provision of social worker services. In a concurrent interview, the IC stated the binder contained all of the agencies policies and procedures. On January 8, 2020, at 3:52 p.m., the Administrator Designee (AD) was interviewed. The AD stated there was no a MSW working for the agency since December 23, 2019.
L0648
L0648	37626 Based on interview, the agency failed to ensure a functioning governing body who was responsible of the agency's ongoing operations was organized. The cumulative effect of this systemic problem had the potential to result in patients to not receive the needed care and services as indicated in the patients' plans of care and may have resulted in the inavailability of a medical social worker and a chaplain to meet the patients' needs. In addition, the cumulative effect of this systemic problem may have resulted in the lack of required members of the interdisciplinary group, namely, the physician, social worker, and chaplain. Findings: On January 10, 2020, at 11:45 a.m., the Director of Patient Care Services (DPCS) was interviewed. The DPCS stated she has no knowledge of the agency's governing body. On January 10, 2020, at 11:50 a.m., the Administrator Designee (AD) was interviewed. The AD stated she has no knowledge of the agency's governing body. The AD was not able to provide information and documentation related to the agency's governing body.
L0662
L0662	41348 Based on interview and record review, the agency failed to ensure orientation was provided to employees, for three of six employee files reviewed (Registered Nurse/Director of Patient Care Services [RN/DPCS], Registered Nurse [RN] 1, and Medical Director (MD). This failure had the potential for the employees to not receive information such as performance standards, responsibilities, and performance expectations. Findings: On January 6, 2020, the file of the RN/DPCS was reviewed. The RN/DPCS was hired March 17, 2014. There was no documented evidence the DPCS completed an employee orientation. On January 6, 2020, the employee file of RN 1 was reviewed. RN 1 was hired December 5, 2019. There was no documented evidence RN 1 completed an employee orientation. On January 9, 2020, the MD's file was reviewed. The MD was hired December 26, 2019. There was no documented evidence the MD completed an employee orientation. On January 10, 2020, at 10:45 a.m., an interview and record review was conducted with the Administrator Designee (AD). The AD stated there was no documentation the RN/DPCS, MD, and RN completed an employee orientation. The policy titled, "Environmental Safety and Equipment Management Program," revised April 2011 was reviewed. The policy indicated, "...To promote safe, effective patient and organization environments and equipment use...Hospice personnel will receive an orientation to the environmental safety components..." The policy titled, "Infection Prevention and Control," revised April 2012 was reviewed. The policy indicated, "...(Name of hospice agency) will educate all personnel on infection control policies, procedures, and their responsibilities...Provides education on the flu vaccine during orientation..." The policy titled, "Home Glucose Monitoring," revised April 2012 was reviewed. The policy indicated, "...To provide guidelines for the safe use of home glucose monitoring devices...Orientation to the organization's process for monitoring..." The policy titled, "Organization Security-Personnel Safety," revised April 2012 was reviewed. The policy indicated, "...To provide guidelines for hospice personnel to ensure their personal safety and security...Safety review and training will be provided during orientation..."
L0663
L0663	41348 Based on interview, and record review, the agency failed to ensure skills and competencies of the individuals providing care were assessed and completed, for five of 12 employees. These failures had the potential for patients to receive care from employees who did not possess the appropriate competencies and skills. Findings: 1. On January 6, 2020, the employee file of the Registered Nurse/Director of Patient Care Services (RN/DPCS) was reviewed. The RN/DPCS was hired March 17, 2014. There was no documented evidence the skills checklist was completed by the DPCS for the years 2015, 2016, 2017, and 2019. There was no documented evidence the RN/DPCS received in-services since her hire date of March 17, 2014. There was no documented evidence competency training was completed by the RN/DPCS since October 18, 2018. 2. On January 6, 2020, the employee file of RN 1 was reviewed. RN 1 was hired on December 5, 2019. There was no documented evidence skills checklist was completed by RN 1. There was no documented evidence competency training was completed by RN 1. 3. On January 6, 2020, the employee file of Licensed Vocational Nurse (LVN) 2 was reviewed. LVN 2 was hired April 10, 2010. There was no documented evidence the skills checklist was completed by LVN 2 since September 10, 2010. There was no documented evidence competency training was completed by LVN 2 since September 10, 2010. There was no documented evidence LVN 2 received in-service training since 2011. 4. On January 6, 2020, the employee file of the Administrative Designee (AD) was reviewed. The AD was hired November 22, 2019. There was no documented evidence the skills checklist was completed by the AD. The AD employee file included a self-assessment competency checklist which was completed by the AD on November 22, 2019. There was no documentation the AD's self-assessment competency was verified by the agency. There was no documented evidence the AD received in-service training. 5. On January 9, 2020, the employee file of Hospice Aide (HA) 2 was reviewed. The HA 2 was hired October 11, 2019. There was no documented evidence the skills checklist was completed by HA 2. There was no documented evidence competency training was completed by HA 2. On January 10, 2020, at 10:45 a.m., an interview and record review was conducted with the AD. The AD stated there was no documentation the skills checklists, competency trainings, and in-services were completed by the RN/DPCS, RN 1, LVN 2, AD, and HA 2. The policy titled, "Environmental Safety and Equipment Management Program," revised April 2011 was reviewed. The policy indicated, "...To promote safe, effective patient and organization environments and equipment use...Hospice personnel will receive an orientation to the environmental safety components...Knowledge and competence will be demonstrated during the orientation and probationary period as well as throughout the year...inservices will be scheduled annually. Attendance will be mandatory and will be documented in the personnel file..." The policy titled, "Infection Prevention and Control," revised April 2012 was reviewed. The policy indicated, "...(Name of hospice agency) will educate all personnel on infection control policies, procedures, and their responsibilities...Infection control inservices will be scheduled no less than annually...Attendance will be mandatory and will be documented...Records of inservice attendance will be maintained in the personnel file...Provides education on the flu vaccine during orientation and annually thereafter..." The policy titled, "Home Glucose Monitoring," revised April 2012 was reviewed. The policy indicated, "...To provide guidelines for the safe use of home glucose monitoring devices...Orientation to the organization's process for monitoring...All nurses will receive training in the HGM (Home Glucose Monitoring) devices issued to them...Return demonstration...will be performed at least annually in the presence of the Clinical Supervisor/Nursing Supervisor or designee. This process will be documented and retained in the staff members' personnel file..." The policy titled, "Organization Security-Personnel Safety," revised April 2012 was reviewed. The policy indicated, "...To provide guidelines for hospice personnel to ensure their personal safety and security...Safety review and training will be provided during orientation and as part of ongoing inservice programs...The Executive Director/Administrator is responsible for the development, implementation, and monitoring of security and safety training activities..." The policy titled, "Tuberculosis (TB) Exposure Control Plan," revised April 2011 was reviewed. The policy indicated, "...(Name of agency) will minimize the occupational exposure to TB through the development of a TB exposure plan, organization personnel education...Hospice personnel will...Attend an inservice...All hospice personnel will receive training/education upon hire, and annually thereafter..." The policy titled, "Management of Exposures in Personnel," revised April 2011 was reviewed. The policy indicated, "...All personnel will be informed of the signs and symptoms of TB...Training will be conducted annually...All personal protective equipment will be furnished...Training in proper usage, fit, and storage will be provided..."