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
551744 A. BUILDING __________
B. WING ______________ 		05/03/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
BAKERSFIELD COMMUNITY HOSPICE, INC 1811 OAK ST, STE 160, BAKERSFIELD, CA, 93301
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)
L0503      
34510 Based on interview and record review, the agency failed to ensure Advance Directives were completed for two of 11 sampled patients (Patient 10 and Patient 6). This failure had the potential to result in patients/responsible party (RP) not being able to make decisions concerning their medical care including the right to accept or refuse medical or surgical treatment. Findings: 1. During a concurrent interview and record review, on 5/4/21, at 10:05 AM, with Registered Nurse (RN) 1, Patient 10's Advance Directives, undated was reviewed. RN 1 stated, "The Advance Directive was not signed. He [Patient 10] was admitted on 10/12/20. The Advance Directives should have been completed." RN 1 verified the finding. 31589 2. During a concurrent interview and record review on 5/4/21, at 1:42 PM, with RN 2, Patient 6 "Clinical Record" (CR) dated 1/27/21 was reviewed. RN 2 stated, Patient 6 is currently in the hospital. RN 2 was asked to provide Patient 6's Advance Directives. RN 2 stated Patient 6 was admitted under Hospice care on 1/27/21, but the Advance Directives was not completed. RN 2 was unable to provide written evidence the Advance Directives was discussed or information was provided concerning Advance Directives to the patient or Responsible Party. During a review of the agency's policy and procedure (P&P) titled, "Advance Directives" dated 10/15, the P&P indicated under "PROCEDURE: Upon admission the clinician will provide information regarding the patient's rights to make decisions concerning health care, which include the right to accept or refuse medical or surgical treatment, even if that treatment is life-sustaining. Written information designed for this purpose will be provided to the adult patient. The clinician will document in the clinical record that the information was provided and record all discussions concerning Advance Directives."
L0524      
31589 Based on observation, interview, and record review, the agency failed to follow the plan of care for skin assessment for one of 11 sampled patients (Patient 1). This failure had the potential to not identify and address Patient 1's possible skin issues. Findings: During an observation on 5/3/21, at 11:15 AM, in Patient 1's home, with Licensed Vocational Nurse (LVN) 2, LVN 2 stated, Patient 1 was Spanish speaking only. LVN 2 was observed taking Patient 1's vital signs and arranged his medications in the pill box. There was no time noted LVN 2 assessed or inspect Patient 1's skin. LVN 2 verified the finding. During a concurrent interview and record review on 5/4/21, at 10:08 AM, with RN 2, Patient 1's Plan of Care (POC) dated 5/3/21, was reviewed. The POC indicated under Integumentary/Skin "Assess alteration in skin every visit." The LVN Visit Note dated 5/3/21, indicated, "No edema [swelling] noted to extremities, although pt [patient] states he does elevate his feet when he feels they are swollen." Registered Nurse (RN) 2 was informed regarding the documentation of LVN 2 and RN 2 was asked how are the nurses assessing the patient for edema to the lower extremities. RN 2 stated, "They should inspect and palpate [examine part of the body by touch]." RN 2 was informed LVN 2 did not inspect or palpate Patient 1's lower extremities. No further information was provided by RN 2. During a review of the agency's policy and procedure (P&P) titled, "Ongoing Comprehensive Assessments- Home Visit", dated 10/15, the P&P indicated, ". . . 2. The nurse will assess the patient on each visit, for: . . . G. Skin integrity."
L0530      
34510 Based on observation, interview, and record review, the agency failed to accurately review the medication regimen for one of 11 sampled patients (Patient 2's) when Licensed Vocational Nurse (LVN) 1 did not identify Patient 2's medication was given at the wrong times by the Caregiver. This failure had the potential to result in Patient 2's ineffective pain management, overdosing, and further health decline. Findings: During an observation and interview on 5/3/21, at 3 PM, in Patient 2's home, LVN 1 was noted reviewing Patient 2's drug profile. LVN 1 stated, "All medications are correct." LVN 1 did not review the times medication was given and did not educate the Caregiver about the times. During a review of Patient 2's Medication Administration Record (MAR), dated 5/2021, the MAR indicated, "Acetaminophen Codeine #3 [strong narcotic pain medication] take 1 tab [tablet] PO [by mouth] every 6 hours routinely for pain." Patient 2's MAR, dated 5/2021, indicated the medication were given at 8 AM, 12 PM, 5 PM, and 8 PM (medication were not given every six hours as per physician's order). During an interview on 5/3/21, at 3:04 PM, with the Caregiver, Caregiver stated, "The Admin [house Administrator] said to do it [give medications on those times] like that, to put the times that way if it's four times a day." During an interview on 5/3/21, at 3:05 PM, with LVN 1, LVN 1 stated, "I did not check the time. I matched the MAR to our records. I don't do medication reconciliation, I only do orders and refill. I could have done it and catched it [medications not given every six hours]." During a review of the agency's policy and procedure (P&P) titled, "Medication Management", dated 12/2015, the P&P indicated, "During subsequent hospice visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver, as well as other clinicians, understand the medication regimen. This includes, but will not be limited to: Using the medication profile to teach drug purposes, dosages, routes, times, side effects, and contraindications."
L0541      
34510 Based on interview and record review, the agency failed to include a Master of Social Work (MSW) in the Interdisciplinary Group (IDG - is the team responsible for the holistic care of the hospice beneficiary and is responsible for development and review of the beneficiary's plan of care) for one of 11 sampled patients (Patient 11). This failure had the potential to negatively impact Patient 11's and/or families/caregivers' psychosocial support needs. Findings: During a concurrent interview and record review on 5/4/21, at 10:16 AM, with Registered Nurse (RN) 1, Patient 11's "Interdisciplinary Group" (IDG) notes, dated 5/28/20, was reviewed. RN 1 stated, "There is no signature of MSW in the IDG notes and no documented MSW visit notes [from 5/30/20 until 5/4/21]. Patient 11's Plan of Care (POC), dated 5/4/21 was reviewed, the POC indicated, Patient 11's admission date was 5/28/20. Patient 11's POC indicated, "Frequency of visit: MSW 1 per month and PRN [as needed]." RN 1 stated, "There is no care plan or documentation of refusal of social services." RN 1 stated, there should be an ongoing psychosocial and MSW services. During a review of Patient 11's "Medical Social Work Assessment" (MSWA), dated 5/29/20, (first and last MSW notes), the "MSWA" indicated, "MSW to maintain monthly contact to establish relationship and provide continued support with pt [Patient 11] and pt's family." During an interview on 5/4/21, at 3:05 PM, with MSW, MSW stated, "[Patient 11] no longer wanted social services." When asked about the ongoing psychosocial services, MSW did not provide an answer. MSW stated, she did not document Patient 11's refusal, did not develop care plan for refusal, and did not discuss refusal in the IDG. During a review of the agency's policy and procedure (P&P) titled, "Psychosocial Services", dated 10/2015, the P&P indicated, "[name of agency] will provide psychosocial services by qualified social workers (MSW, BSW) under the direction of a physician and in accordance with the plan of care. A social worker will be assigned to each patient and family/caregiver based on the patient's and family's needs and acceptance of these services. The social worker will be a member of the interdisciplinary group and will participate in the development, implementation, and revision of the plan of care. The social worker will contribute to the comprehensive assessment and ongoing update to the comprehensive assessment based on the needs of the patient."
L0575      
34510 Based on interview and record review, the agency failed to address identified concerns in the Quality Assurance and Performance Improvement (QAPI - is a data driven and proactive approach to quality improvement. Used to ensure services are meeting quality standards and assuring care reaches certain level) regarding absence of a Chaplain (Spiritual Counselor). This failure had the potential for the agency not addressing issues on patients not receiving spiritual services and negatively impacting hospice patients' care who are in need of a Spiritual Counselor during their end of life. Findings: During a concurrent interview and record review on 5/4/21, at 3:46 PM, with Program Director (PD), the QAPI minutes meeting dated 4/2021 were reviewed. PD stated, "We did not discuss the absence of a Chaplain in the QAPI in April [2021]. We did not have a Chaplain since January 2021." During a review of the agency's policy and procedure (P&P) titled, "Improving Organizational Performance", dated 11/15, the P&P indicated, "The organization will implement performance improvement processes that routinely assess and improve all services provided directly and by written agreement. . . 2. The Administrator will ensure that an integrated patient safety program is implemented throughout the organization by: . . . E. Establishing procedures for immediate response to system or process failures, and the internal and external reporting of such failures."
L0588      
34510 Based on interview and record review, the agency failed to provide medical social services (MSW) and spiritual counseling (SC) for two of 11 sampled patients (Patient 8 and Patient 9). This failure had the potential to impede patients and their families reaching the maximum benefit for hospice care and services during end of life care. Findings: During a review of Patient 8's "Plan of Care" (POC), dated 5/4/21, the POC indicated, Patient 8 start of care was 4/22/21. The POC indicated, "Frequency of Visit: MSW [Medical Social Worker] 1 per month and PRN visits [as needed] and SC 1 per month and PRN visits." During a concurrent interview and record review on 5/4/21, at 9:58 AM, with Registered Nurse (RN) 1, Patient 8's clinical record was reviewed. RN 1 stated, "I can't find any documentation of visit notes from the MSW and SC. They [MSW and SC] did not provide any services to this patient [8] at all." During a review of Patient 9's "Plan of Care" (POC), dated 5/4/21, the POC indicated, Patient 9 start of care was 4/6/21. The POC indicated, "Frequency of Visit: MSW 1 per month and PRN visits." During a concurrent interview and record review, on 5/4/21, at 10 AM, with RN 1, Patient 9's clinical record was reviewed. RN 1 stated, "There is no psychosocial assessment and no documentation of MSW visit for this patient [9]." During an interview on 5/4/21, at 1:45 PM, with the Chaplain, Chaplain stated, "I was just hired three weeks ago. I barely started, SC should be provided within five days from start of care. I only saw 13 patients since I was hired." During an interview on 5/4/21, at 3:04 PM, with MSW, MSW stated, "I only work per diem [per day]. I was advised on April 19th, someone else was hired as MSW and let her [new MSW] to perform the MSW services to the new patients." During an interview on 5/4/21, at 4 PM, with the Program Director (PD), PD stated, "We did not have a Chaplain since January 2021. We hired a new MSW, I am not sure why she had not visited Patient 8." During a review of agency's policy and procedure (P&P) titled, "Psychosocial Services", dated 10/15, the P&P indicated, "[name of agency] will provide psychosocial services by qualified social workers (MSW, BSW) under the direction of a physician and in accordance with the plan of care. A social worker will be assigned to each patient and family/caregiver based on the patient's and family's needs and acceptance to these services." During a review of agency's policy and procedure (P&P) titled, "Spiritual Care Counseling Services", dated 10/15, the P&P indicated, "A chaplain will be assigned to each patient based on the patient's needs and acceptance of these services. The chaplain will be a member of the interdisciplinary group and will participate in the development, implementation and revision of the plan of care."
L0598      
31589 Based on interview and record review, the agency failed to ensure a spiritual assessment was conducted for one of 11 sampled patients (Patient 1). This failure had the potential for the patient to have unmet spiritual needs. Findings: During an interview on 5/3/21, at 11:48 AM, with Patient 1, Patient 1 was a Spanish speaking only and Friend/Interpreter (F/I) interpreted for Patient 1. Patient 1 was asked if there was a person (Spiritual Chaplain) from the Hospice agency who talked with him regarding his spiritual concerns/needs. Patient 1 stated there was nobody from the Hospice agency who spoke with him regarding his spiritual concerns/needs since he was admitted under Hospice care (11/6/20). During a concurrent interview and record review on 5/4/21, at 10:35 AM, with Registered Nurse (RN) 2, Individual 1's "Clinical Record (CR)" was reviewed. RN 2 stated since Patient 1's admission on 11/6/20, there was no Spiritual Chaplain visit yet. She also stated it was supposed to be once a month visit. During a review of the agency's policy and procedure (P&P), titled "Spiritual Care Counseling Services", dated 10/15, the P&P indicated, "Hospice will provide spiritual care counseling in keeping with the patient's and family/caregiver's belief system and practice, and in accordance with the plan of care. "
L0796      
31589 Based on interview and record review, the facility failed to follow its policy and procedure on "SELECTION/HIRING OF PERSONNEL" for one of five sampled employees (Medical Doctor) 1. This had the potential to compromise the safety of patients from potentially inappropriate staff. Findings: During an interview and record review on 5/4/21, at 2:16 PM, the employee file for MD 1 was reviewed. MD 1's date of hire was 11/6/19. There was no Criminal Background check done before hiring. The Director of Patient Care Services (DPCS) stated "Yes, we don't have it." During a review of the agency's policy and procedures titled "SELECTION/HIRING OF PERSONNEL" dated 10/15, under Hiring: ". . . 2. A criminal background check will be obtained for positions required by law, regulation or organization policy."