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
751505 A. BUILDING __________
B. WING ______________ 		02/07/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
HOLISTIC CARE HOSPICE 4740 GREEN RIVER ROAD STE 318, CORONA, CA, 92880
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)
L0553      
37626 Based on interview and record review, the agency failed to ensure the plan of care (POC) was updated when the patient had dry and itchy skin, for one of four patients reviewed (Patient 1). This failure had the potential for the patient to not receive the necessary care and treatment timely. Findings: On January 16, 2020, at 10:50 a.m., an unannounced visit was conducted at the agency to investigate a complaint. On January 16, 2020, the record of Patient 1 was reviewed. Patient 1 was admitted to the agency on November 4, 2017, with diagnoses which included Alzheimer's disease (loss of memory). The recertification periods reviewed were October 25, 2019 to December 23, 2019 and December 24, 2019 to February 21, 2020. A "CURRENT TREATMENT/MEDICATION/DME LIST," was reviewed. The document included a physician's order, dated June 8, 2018, which indicated, "...benadryl (medication used for allergy such as rash or itching) 25 mg (milligrams-unit of measurement) 1 (one) tablet by mouth Twice (sic) a day routinely itching..." A "Re-Cert (recertification) Assessment," dated December 18, 2019, was reviewed. The document indicated, "...Skin Status...Dry...Wound/Skin Impairment Yes..." There was no documented evidence the POC of Patient 1 was updated to include Patient 1's dry and itching skin. On January 30, 2020, at 1:22 p.m., the Registered Nurse (RN) was interviewed. The RN stated Patient 1 was on the medication Benadryl for dry and itching skin related to liver and kidney problem. She stated the POC for Patient 1 should have been updated. The agency's policy and procedure titled, "THE PLAN OF CARE," revised October 2016, was reviewed. The policy indicated, "...To ensure that an individualized plan of care is completed that complies with accepted standards of care and regulatory issues...The plan of care will be based on the initial, comprehensive and ongoing comprehensive assessments performed by members of the interdisciplinary group...This plan will focus on identified problems... The plan of care will identify the patient's needs and services to meet those needs, including the management of...discomfort and symptom relief...Care decisions and services to be provided will be made as a result of the care planning process, analysis of initial and ongoing comprehensive assessments... The plan of care will be reviewed and revised as frequently as deemed necessary...Any change in the patient's condition must result in a change in the plan of care, prior to the implementation of the new service..."