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
551741 A. BUILDING __________
B. WING ______________ 		04/27/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
OC HOSPICE 13522 NEWPORT AVE, SUITE 200, TUSTIN, CA, 92780
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)
L0521      
31929 39210 Based on interview and record review, the hospice failed to ensure the comprehensive assessment included all skin problems for one of two sampled patients (Patients D), creating the risk of not addressing the care needs of the patient. Findings: Review of Patient D's clinical record was initiated on 7/5/22. The clinical record showed the SOC was 5/3/21. The patient was certified for hospice services during the certification period from 5/11/22 to 7/9/22. Review of the SN Visit Notes dated 6/20 and 6/24/22, showed Patient D had arterial ulcers (open sores due to inadequate blood supply to the affected area) to the right and left legs, abrasions/excoriations (superficial injuries of the skin) to the right and left buttocks, and skin tears to the left shin (front part of the leg), left and right elbows, and left upper arm. The Physician's Order dated 6/28/22, showed an order to apply triple antibiotic ointment to the sacrum excoriation area with each dressing change and as needed. Further review of the clinical record showed the SN had completed the recertification comprehensive assessment on 6/28/22. However, the recertification comprehensive assessment showed no documented evidence of the assessment for the sacrum excoriation area. The SN note dated 6/29/22, showed the SN performed wound care to the sacrum area. On 7/5/22 at 1445 hours, an interview and concurrent clinical record review was conducted with the QAPI Coordinator. The QAPI Coordinator was informed and acknowledged the finding.
L0548      
31929 39539 Based on interview and record review, the hospice failed to ensure the POC included measurable outcomes for two of two sampled patients (Patients C and D), creating the risk of not evaluating the POC and providing appropriate care and services to these patients. Findings: 1. Review of Patient C's clinical record was initiated on 7/5/22. The clinical record showed the SOC was 7/22/21. The patient was certified for hospice services during the certification period from 5/18/22 to 7/16/22. Review of the POC/IDG Review dated 6/22/22, showed the patient's identified problems included deficit in self-care, potential for altered bowel elimination, incontinence, potential for harm due to alteration in posture, potential for altered nutritional status, and dyspnea (difficulty or labored breathing) with activity. The goals were established for these identified problems. However, the goals listed were not measurable and specific to the patient's care needs. For example, the goal for dyspnea with activity was for the patient to have optimal level of oxygen on a day to day basis within the certification period. There was no documented evidence showing the expected optimal level of oxygen for the patient. On 7/5/22 at 1520 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS verified the findings. 39210 2. Review of Patient D's clinical record was initiated on 7/5/22. The clinical record showed the SOC was 5/3/21. The patient was certified for hospice services during the certification period from 5/11/22 to 7/9/22. The POC/IDG Review dated 6/22/22, showed the patient's identified problem included deficit in self-care related to increasingly dependent on assistance for activities of daily living, potential for altered cardiac status related to edema, and potential for altered bowel elimination related to constipation. The goals were established for these identified problems. * However, the goals listed were not measurable and specific to the patient's care needs. For example, the goal for deficit in self- care was for the patient's activities of daily living needs will be met to an optimal level during the certification period. There was no documentation of measurable outcome as to what the optimal level was expected for the patient. On 7/5/22 at 1445 hours, an interview and concurrent clinical record review was conducted with the QAPI Coordinator. The QAPI Coordinator was informed and acknowledged the findings.
L0552      
31929 39539 Based on interview and record review, the hospice failed to revise the POC for two of two sampled patients (Patients C and D), creating the risk of not addressing the care needs for these patients. Findings: The hospice's P&P titled Plan of Care (undated) showed a written individualized interdisciplinary team care plan be established and maintained for each individual admitted to hospice and the care provided to the individual will be in accordance with the care plan. The IDG (in collaboration with the individual's attending physician, if any) must review, revise, and document the individual plan as frequently as the patient condition requires, but no less than frequently than every 15 calendar days. 1. Review of Patient C's clinical record was initiated on 7/5/22. The clinical record showed the SOC was 7/22/21. The patient was certified for hospice services during the certification period from 5/18/22 to 7/16/22. a. Review of the SN note dated 6/21/22, showed the patient had intermittent discoloration on the extremities and used compression boots as needed. Review of the POC/IDG Review dated 6/22/22, showed the care plan problems were developed. However, there was no documented evidence the written individualized POC was updated to address the discoloration on the patient's extremities as identified by the SN. b. Review of the POC/IDG Review dated 6/22/22, showed the IDG discussed the patient's dysphagia (difficulty swallowing) and behavior of pocketing food more frequently. Review of the SN note dated 6/28/22, showed the PCG reported that the patient was often pocketing food. Review of the POC showed a care plan problem addressing the patient's potential for altered nutritional status related to loss of appetite; however, there was no documented evidence the written individualized POC was updated to address the patient's dysphagia and behavior of pocketing food. On 7/5/22 at 1520 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and verified the findings. 39210 2. Review of Patient D's clinical record was initiated on 7/5/22. The clinical record showed the SOC was 5/3/21. The patient was certified for hospice services during the certification period from 5/11/22 to 7/9/22. The POC/IDG Review dated 6/22/22, showed a care plan problem addressing altered cardiac status related to hypertension. The goal showed the patient will verbalize/express understanding of medication/treatment orders and side effects. The interventions included to assess/monitor cardiac status every visit, assess and monitor effectiveness of medications, and instruct the patient/family/PCG in positioning as tolerated to promote optimal circulation. * However, there was no documented evidence the written individualized POC was updated to address how the patient would verbalize/express understanding of the medication/treatment orders and side effects. On 7/5/22 at 1445 hours, a telephone interview and concurrent clinical record review was conducted with the QAPI Coordinator. The QAPI Coordinator was informed and acknowledged the finding.