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
551721 A. BUILDING __________
B. WING ______________ 		08/25/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
HAVEN HEALTH 2895 TEMPLE AVE, SIGNAL HILL, CA, 90755
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)
L0536      
14065 Based on interview and record review, the Hospice Agency failed to meet the Condition of Participation for Interdisciplinary Group, Care Planning, and Coordination of Services by failing to provide instructions of the use and storage of Comfort Kit pack (hospice emergency medications kit) to the patient's family members, for one of five sampled patients (Patient 1). (Refer to L544) The cumulative effect of these systemic practices resulted in the hospice agency's inability to ensure the provision of quality health care in a safe environment.
L0544      
14065 Based on interview and record review, the Hospice Agency failed, for one of five sampled patients (Patient 1), to provide instructions of the use and storage of Comfort Kit pack (prescribed set of medications that are kept in patient's home should a medical crisis strike at home) to Patient 1's family members. This deficient practice resulted in Patient 1 was transferred to the general acute care hospital (GACH) after she drank 15 milliliters (mls - unit of measurement) of liquid Morphine Sulfate (pain medicine) 20 milligram (mg - unit of measurement)/ml on 5/31/2021. Findings: A review of the form titled, "RN Initial Assessment" for Patient 1, with visit date of 5/21/2021, indicated Patient 1 was diagnosed with dementia (a group of thinking and social symptoms that interferes with daily functioning) due to Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and chronic kidney disease. The form indicated Patient 1 was alert with periods of confusion. A review of the Skilled Nursing Visit notes, dated 5/24/2021 and 5/25/2021, indicated Patient 1 was disoriented and forgetful. Patient 1 required maximum assist in all the activities of daily living. A review of Patient 1's physician's order, dated 5/21/2021, indicated an order for a Comfort Kit pack which included the medication for Roxanol (Morphine Sulfate Liquid - pain medicine) 0.25 milliliter (ml - unit of measurement) sublingual (under the tongue) every two hours as needed for pain and shortness of breath. A review of the physician's order, dated 5/31/2021, at 1:18 a.m., indicated to transfer Patient 1 to the general acute care hospital (GACH) after she drank 15 mls of liquid Morphine Sulfate 20 mg/ml. A review of the undated document with a title, "Ticket #409," was conducted with the Director of Nursing (DON) on 8/23/2021, at 12:15 p.m.. The document indicated that Patient 1 was found by a family member (Family member 1) sitting in the couch very lethargic, confused and sweating. An empty bottle of Morphine Sulfate was found on the floor next to Patient 1. When assessed by the agency's Licensed Vocational Nurse (LVN), Patient 1 was found confused and extremely sleepy. Patient 1's skin was cold and clammy (sticky). Her pupils were pinpoint and her fingertips were bluish. Patient 1 complained of being nauseous. Her breathing was slow and irregular. The document indicated 911 (emergency service) was called and the physician was notified. When the paramedics arrived at Patient 1's home, Patient 1 was given an intranasal dose of narcan (a medication used to treat narcotic overdose, such as Morphine Sulfate, in an emergency situation). Patient 1 was later transferred to the GACH per physician's order due to drinking 15 ml bottle of liquid Morphine Sulfate 20 mg/ml. During a concurrent interview with the DON, the DON stated Patient 1 has dementia and all medications should have been kept away from the patient. The DON stated it was a learning experience for the agency to make changes to prevent the incident from happening again. The DON further stated the Comfort Kit (Comfort Pack) should have been kept in a locked box or in a place where Patient 1 could not reach it. A review of Patient 1's Emergency Department Physician Notes dated 5/31/2021 indicated Patient 1 arrived in the GACH by ambulance with the complaint of taking too much of her liquid Morphine Sulfate. The final diagnosis for Patient 1 was accidental overdose. Patient 1 was admitted to the GACH for further psychiatric evaluation. During an interview on 8/24/2021, at 1:10 p.m., the Social Worker stated it is not safe to leave medications near Patient 1 because she is not capable of administering her own medication especially narcotics (drugs that relieve pain) due to her dementia and depression (feeling sad). During an interview on 8/24/2021, at 3 p.m., Family Member 1 stated she did not know where or how Patient 1 got a hold of the Morphine Sulfate. Family Member 1 stated she did not know what the Comfort Kit pack look like or that it existed. She stated that the skilled nurse who comes to the home has never educated her on the medication in the Comfort Kit pack. Family Member 1 also stated no staff had ever instructed them to keep the Comfort Kit pack in a locked box. During an interview on 8/24/2021, at 3:15 p.m., Family Member 2 stated she did not know where or how Patient 1 got a hold of Morphine Sulfate. Family Member 2 stated she was not even aware that the medication was in the house. Family Member 2 stated that the skilled nurse who comes to the home had never educated her on the medication in the Comfort Kit pack and she did not even know a Comfort Kit pack existed. She also stated Patient 1 was extremely depressed and has dementia and she would not leave medications near Patient 1 for fear that she would take them all at once. During an interview on 8/24/2021, at 4:10 p.m., Licensed Vocational Nurse 1 (LVN 1) stated the routine medications were explained to Patient 1's family members but not the contents of the Comfort Kit pack. LVN 1 stated she did not have any documentations that instructions were provided to Patient 1's family members regarding the safe administration and storage of the Comfort Kit pack. During an interview and a concurrent record review conducted with the DON on 8/25/2021, at 10 a.m., the DON stated she could not provide any documentation that the use of Comfort Kit packs for Patient 1 were discussed with the IDT before ordering them from the pharmacy. The DON stated she did not find any documentation in Patient 1's record indicating that education regarding the use and storage of the Comfort Kit packs were discussed with Patient 1, Patient 1's families or caregivers. A review of the policy and procedure, titled "Medication Management", dated 6/1/2016, indicated " ... It is the policy of this agency to educate employees/patients/families and caregivers the importance of the proper and safe storage, documentation and administration of medication ... Controlled substances in the patient's home will be reviewed with families/patient/caregiver on proper administration, safe storage and side effects that may occur ... Comfort Packs will be developed by the IDT (Interdisciplinary Team) and provided to patients when deemed appropriate by IDT. Families/patients/caregivers will be provided with proper education on storage, administration and usage of comfort pack ..."
L0686      
14065 This condition is not met as evidenced by: Based on observation, interview, and record review, the Hospice Agency (HA) failed to meet the Condition of Participation for Compliance with Federal, State, and Local Law for two out of five sampled patients (Patient 1 and Patient 4) for Drug/Biological/Med Supplies by failing to: 1. Ensure the medication used to manage anxiety (mental disorder) or agitation (state of anxiety) was provided as ordered for one of five sampled patients (Patient 4). This deficient practice had the potential for the patient to delay in receiving the needed medication. (Refer to L 687) 2. Ensure that written policies and procedures for safe management of controlled drugs in the patient's homes were developed for one of five sampled patients, (Patient 1). This deficient practice resulted in Patient 1 was transferred to the general acute care hospital (GACH) after she drank 15 milliliters (mls - unit of measurement) of liquid Morphine Sulfate (pain medicine) 20 milligram (mg - unit of measurement)/ml on 5/31/2021. (Refer to L 694) The cumulative effect of these systemic practices resulted in the hospice agency's inability to ensure the provision of quality health care in a safe environment.
L0687      
35893 Based on observation, interview, and record review, the facility failed to ensure the medication used to manage anxiety (mental disorder) or agitation (state of anxiety) was provided as ordered for one of five sampled patients (Patient 4). This deficient practice had the potential for the patient to delay in receiving the needed medication. Findings: A review of Patient 4's clinical record indicated a start of care date of 7/14/2021 with a primary diagnosis of heart failure (failure of the heart to function properly). The plan of care for the period of 7/14/2021 to 9/11/2021 included an order for the skilled nurse (SN) visit once a week for 8 weeks. A review of Patient 4's physician's order indicated an order for Lorazepam [a medication for anxiety or agitation] 0.5 milligram (mg) sublingual (under the tongue) every 6 hours for anxiety or agitation. During a home visit at Patient 4's residence on 8/24/2021 at 10:15 a.m. Patient 4 was observed in bed while Registered Nurse (RN 1) was observed checking the patient's medications. RN 1 stated and confirmed that Lorazepam was not in the stock. During an interview with the Director of Nursing (DON) on 8/25/2021 at 11 a.m. she stated the medications for all the patients must be available and checked every week. A review of the agency's policy and procedure titled, "Medication Management" dated 6/1/16 indicated all medications will be reviewed during each visit.
L0694      
14065 Based on interview and record review, the Hospice Agency (HA) failed to ensure that written policy and procedures for safe management of controlled drugs in the patient's homes was developed for one of five sampled patients (Patient 1). This deficient practice resulted in Patient 1 was transferred to the general acute care hospital (GACH) after she drank 15 milliliters (ml's - unit of measurement) of liquid Morphine Sulfate (pain medicine) 20 milligram (mg - unit of measurement)/ml on 5/31/2021. Findings: A review of Patient 1's Physician's Order indicated a start of care date of 5/21/2021 with a terminal illness of dementia (a group of thinking and social symptoms that interferes with daily functioning) without behavioral disturbances, a Comfort Kit pack (prescribed set of medications that are kept in patient's home should a medical crisis strike at home) which included an order for Roxanol (pain medicine) 0.25 ml sublingual (under the tongue) every 2 hours PRN ( as needed) for pain and shortness of breath. A review of Patient 1's Physician's Order dated 5/31/2021, indicated to transfer Patient 1 to the GACH after Patient 1 drank 15 ml of liquid Morphine Sulfate 20 mg/ml. A review of the form titled, "RN Initial Assessment," for Patient 1, with a visit date of 5/21/2021, indicated Patient 1 was diagnosed with dementia due to Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and chronic kidney disease. The form indicated Patient 1 was alert with periods of confusion. A review of Patient 1's skilled nursing visits from 5/24/2021 to 5/31/2021, indicated Patient 1 was disoriented and forgetful. Patient 1 was only oriented to person and not to time or place. Patient 1 was non-ambulatory and required maximum assist in all activities of daily living. A review of the undated document with a title "Ticket #409 " was conducted with the Director of Nursing (DON) on 8/23/2021, at 12:15 p.m. The document indicated Patient 1 was found by a family member ( Family member 1) sitting in the couch very lethargic (sleepy), confused and sweating. An empty bottle of Morphine Sulfate was found on the floor next to Patient 1. When assessed by the agency's Licensed Vocational Nurse (LVN), Patient 1 was found confused and extremely sleepy. Patient 1's skin was cold and clammy (sticky). Her pupils were pinpoint and her fingertips were bluish. Patient 1 complained of being nauseous. Her breathing was slow and irregular. The document indicated 911 (emergency service) was called and the physician was notified. When the paramedics arrived at Patient 1's home, Patient 1 was given an intranasal dose of narcan (a medication used to treat narcotic overdose, such as Morphine Sulfate, in an emergency situation). Patient 1 was later transferred to the GACH per physician's order due to drinking 15 ml bottle of liquid Morphine Sulfate 20 mg/ml. During a concurrent interview with the DON, the DON stated she was unable to explain why the incident report did not have its date and times on the form. The DON stated the incident happened on 5/31/2021 and she followed up on the investigation on 6/4/2021 and could not explain why her investigations were done 4 days after the incident. A review of Patient 1's Emergency Department Physician Notes dated 5/31/2021 indicated Patient 1 arrived in the GACH by ambulance with the complaint of taking too much of her liquid Morphine Sulfate. The final diagnosis for Patient 1 was accidental overdose. Patient 1 was admitted to the GACH for further psychiatric evaluation. In another interview on 8/24/2021 at 10:30 a.m., the DON stated she was unable to locate their written policies and procedures for safe management of controlled drugs in the patient's homes. The DON also stated that, although they did not have a written policy and procedures, it is the expectation of the staff to be mindful of controlled substances in any patient's home. A review of the agency's policy and procedure titled, "Incident Report Form" dated 3/1/2019 indicated the purpose of the policy is to define a method of monitoring quality care by identifying untoward occurrences with patients, caregivers or employees and providing a method to investigate and respond to such occurrence ... Staff are to complete the form completely ... all attempts should be made to report the occurrence factually... All incident reports will be reviewed, investigated, and all information gathered will be documented alongside the incident report. Documentation will include final results of the investigation and any action taken, including policy changes, employee counseling, and education/teaching provided to staff. When submitting incident reports, staffs are to provide facts only including who, what, when, and where in the incident report. A review of the agency's policy and procedure titled, "Medication Management" dated 6/1/2016 indicated the policy of this agency is to educate employees/ patients/ families and caregivers the importance of the proper and safe storage, documentation, and administration of medications. Controlled substances in the patient's home will be reviewed with the patients/families and caregivers on proper administration and safe storage... It also indicated that patients/ families and caregivers will be provided with proper education on storage, administration, and usage of the comfort pack. During an interview with the DON on 8/25/2021 at 10 a.m., she stated she could not provide any documentation that Comfort Kit packs were discussed with the Interdisciplinary (IDT) team for Patient 1 before ordering from the pharmacy for patient's use. During an interview on 8/24/2021, at 1:10 p.m., the Social Worker (SW) stated it is not safe to leave medications near Patient 1 because she is not capable of administering her own medication especially narcotics (drugs that relieve pain) due to her dementia and depression (feeling sad). During an interview on 8/24/2021 at 3 p.m., Family Member 1 stated she did not know where or how Patient 1 got a hold of the Morphine Sulfate. Family Member 1 stated she did not know what the Comfort Kit pack looked like or that it existed. She stated that the skilled nurse, who comes to the home, has never educated her on the medications in the comfort kit pack. Family Member 1 stated no staff had ever instructed them to keep the Comfort Kit pack in a locked box. During an interview on 8/24/2021 at 3:15 p.m., Family Member 2 stated she did not know where or how Patient 1 got a hold of Morphine Sulfate. She stated she was not even aware the medication was in the home. Family Member 2 stated that the skilled nurse who comes to the home had never educated them on the medications in the Comfort Kit pack and she did not even know a Comfort Kit pack existed. She also stated Patient 1 was extremely depressed and has dementia and she would not leave medications near Patient 1 for fear that she would take them all at once. During an interview on 8/24/2021 at 4:10 p.m., Licensed Vocational Nurse 1 (LVN 1) stated the routine medications were explained to Patient 1's family members but not the contents of the Comfort Kit pack. LVN 1 stated that she did not have any documentations that instructions were provided to Patient 1's family members regarding regarding the safe administration and storage of the Comfort Kit pack. The facility's policy and procedure titled " Medication Management", dated 6/1/2016, indicated all medications ordered for the patient will be reviewed during each visit.