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
751551 A. BUILDING __________
B. WING ______________ 		12/14/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
LOS FELIZ HOSPICE HEALTH CARE 732 N DIAMOND BAR BLVD SUITE 228, DIAMOND BAR, CA, 91765
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)
L0512      
33037 Based on observation, interview, and record review, the facility failed to ensure interventions for symptom control were implemented for two of 14 sampled patients (Patient 9 and Patient 14) when: 1. Patient 9 did not receive Ativan (medication used to treat anxiety) indicated for agitation. This failure resulted in unmanaged agitation for Patient 9. 2. Patient 14 did not receive oral care according to policy while on Continuous Care (advanced level of care necessary when symptoms are not well controlled and the patient requires sustained nursing care to achieve symptom control.) This failure had the potential for Patient 14 to experience discomfort from dry mouth and thirst. Findings: 1. During a review of Patient 9's clinical record, the clinical record indicated, Patient 9's start of care dated was 9/23/20. Patient 9's admitting diagnosis was Parkinson's disease (a central nervous system disorder that affects movement, including tremors or involuntary shaking). During a review of Patient 9's list of medications with Registered Nurse 1 (RN 1), it indicated, Ativan 0.5 mg (milligram, unit measurement), one tablet by mouth every 6 hours and as needed for agitation was prescribed on 12/03/20. During Patient 9's home visit conducted with Licensed Vocational Nurse 2 (LVN 2) on 12/08/20 at 9:10 AM, Patient 9 was observed to be restless and agitated. Patient 9's primary caregiver (PC) followed Patient 9 around her home to redirect her to ensure she did not leave out of the house or remove items from the kitchen. Patient 9 became agitated and argued with her PC. The PC stated, "This is her [Patient 9] all the time, I can't rest because she does not stop." Patient 9 walked around her home while LVN 2 conducted her assessment and provided care. LVN 2 stated that Patient 9's Ativan for agitation was not available to administer after it was ordered on 12/3/20 (five days ago). LVN 2 stated that Patient 9 did not receive Ativan for agitation as ordered. During an interview with the Director of Patient Care Services (DPCS) on 12/10/20 at 8:40 AM, she stated that the Ativan was ordered by the physician on 12/3/20, to address Patient 9's agitation based on LVN 2's report of Patient 9's behaviors. The DPCS stated it usually takes 24 hours for the medication to be delivered to the patient. During an interview with LVN 2 on 12/10/20 at 10:50 AM, LVN 2 stated he was responsible for ensuring prescribed medications for Patient 9 were ordered. LVN 2 stated they did not communicate the Ativan order for Patient 9 and failed to follow-up with the pharmacy. A review of the facility's undated, policy and procedure titled, "Administration and Documentation of Medication" Policy No. 4-52.1. The document noted, "Purspose: To provide guidelines for the administration of medications by licensed personnel. Policy: Licensed nursing personnel will administer and document... medications which have been ordered by the physician, as a part of plan of care and have been approved for safe administration and monitoring during a hospice visit." A review of Licensed Practical/Vocational Nurse Job description, noted under, "Essential Job Functions/Responsibilities: 3. Provide accurate and timely documentation of patient services to reflect the plan of care. 5. Participates in coordination of hospice services, appropriate reporting the identified needs to the interdisciplinary group. 7. Provides appropriate... symptom management..." A review of Registered Nurse Job description, noted under, "Essential Job Functions/ Responsibilities; 3. Assesses and evaluates patient's status by: B. Regularly re- evaluate patient and family/caregiver needs." 34448 2. During review of the clinical record for Patient 14, the clinical record indicated, Patient 14's start of care date was 3/14/20. Patient 14's admitting diagnosis was congestive heart failure (a weakness of the heart that leads to a buildup of fluid in the lungs and surrounding body tissues). Patient 14 expired on 4/1/20. A review of the Continuous Care Nursing note, dated 3/30/20 from 11:59 PM to 3/31/20 at 12 PM (12 hour night shift), signed by Certified Home Health Aide 1 (CHHA 1, a non-licensed staff who provides activities of daily living such as bathing, oral care, and toileting) was conducted. There was no documented evidence to show Patient 14 received hourly oral care. A review of the Continuous Care Nursing note, dated 3/31/20 for the night shift, signed by Licensed Vocational Nurse 2 (LVN 2) was conducted. The Clinical Observation area indicated Patient 14 received oral care at 7:30 AM and 10:30 AM. There was no documented evidence to show Patient 14 received hourly oral care. On 12/10/20 at 9:58 AM, an interview was conducted with CHHA 1. CHHA 1 stated she cared for Patient 14, on 3/30/20, night shift. CHHA 1 stated Patient 14 was not alert and infrequently would open her eyes. CHHA 1 stated she provided oral care to Patient 14 every one and half to two hours and would document the care in the computer. CHHA 1 stated, "Honestly, I don't remember if I documented it. I should have." On 12/10/20 at 11:24 AM, an interview was conducted with LVN 2. LVN 2 stated there was not a set number of times when oral care was supposed to be completed during a shift. LVN 2 stated she provided Patient 14 with oral care on 4/1/20 at 7:30 AM and 10:30 AM. LVN 2 stated, "I guess that's the only time I did it because at that time her mouth was dry. If I did it, I would document it." On 12/10/20 at 10:24 AM, an interview was conducted with the Director of Patient Care Services (DPCS). DPCS stated at the end of life Patient 9's mouth became dry due to mouth breathing. DPCS stated CHHA 1 and LVN 2 should have provided oral care hourly and documented the intervention in Patient 14's clinical record. A review of the facility's policy and procedure (P&P) titled, "Oral Care in Patients at the End of Life" undated, the P&P indicated, "... Hourly mouth swabbing if patient too unwell to keep mouth moist..." A review of the facility's policy and procedure (P&P) titled, "Charting Guidelines For Continuous Care," undated, the P&P indicated, "... Documentation should include... All medical and nursing interventions, including personal care, skilled nursing tasks, counseling and teaching."
L0532      
34448 Based on interview and record review, the facility failed to ensure one of 14 sampled patients (Patient 14) comprehensive assessment included an assessment of Patient 14's right great toe. The facility also failed to provide a referral to a Podiatrist (a doctor that diagnoses and treats conditions affecting the foot, ankle and related structures of the leg) for Patient 14. These failures had the potential to result in substandard quality of care for Patient 14. Findings: During a review of the clinical record for Patient 14, the clinical record indicated Patient 14's hospice start of care date was 3/14/20. Patient 14's admitting diagnosis was congestive heart failure (a weakness of the heart that leads to a buildup of fluid in the lungs and surrounding body tissues). Patient 14 expired on 4/1/20. A review of a Nursing Note, dated 3/24/20 at 9 AM, completed by Licensed Vocational Nurse 3 (LVN), revealed, Patient 14 had intermittent, sharp pain to her right great toe. LVN 3 documented, "Methadone (pain medication) 5 mg (milligrams) for pain mg't [management] and effective." During an interview on 9/23/20 at 12:50 PM, with LVN 3, LVN 3 stated Patient 14 complained of right foot pain on 3/24/20. LVN 3 stated Patient 14's right great toe was bluish and painful to the touch. LVN 3 stated Patient 14's primary caregiver (PC) wanted a Podiatrist to assess Patient 14's toenail. LVN 3 stated she did not document her observation of Patient 14's toe. LVN 3 also stated she did not remember whom she notified at the hospice regarding the request for a Podiatrist referral. During an interview on 12/10/20 at 10:58 AM, with Patient 14's Friend (occasionally relieved Patient 14's PC), Patient 14's Friend stated, "I was trying to use my own nail drill to try and help alleviate the pain. When I touched her toe, she moaned." During a concurrent interview on 12/10/20 at 10:24 AM, with the Administrator and Director of Patient Care Services (DPCS). The Administrator stated, "I didn't hear anything about if they needed a Podiatrist to see the patient. We send a Podiatrist right away if it is needed. No staff reported that." During the same interview, the DPCS stated she conducted a home visit on 3/31/20, and assessed Patient 14's toe. DPCS stated she did not document an assessment. DPCS stated, "She may have had an ingrown toenail, but I did not see anything that I have to write an assessment about for the toe." The DPCS stated LVN 3 notified her that Patient 14's PC requested a referral to a Podiatrist. DPCS stated she contacted the Podiatrist that LVN 3 had provided, but because of the current pandemic, the Podiatrist was not making house calls. DPCS stated the hospice Physician was not notified of Patient 14's painful right great toe. During the same interview, the Administrator also stated the Interdisciplinary Group Meetings (IDG, a group of healthcare providers from different fields who work together to provide the best care for a patient) were held every two weeks. DPCS stated she could not remember if Patient 14's right great toe pain or the request for referral to a Podiatrist had been discussed during the IDG Meeting. The DPCS further stated Patient 14's right great toe assessments and interventions should have been documented in the clinical record. A review of the facility's undated, policy and procedure (P&P) titled, "Hospice Nursing Care," the P&P indicated, "The hospice nurse will participate in developing and implementing the plan of care and will report the condition of patient and family/caregiver to the attending physician, medical director and interdisciplinary group on a regular basis, as well as changes in the plan of care. The hospice nurse will... Manage discomfort and provide symptom relief... Prepare clinical and progress notes that demonstrate progress toward established goals... Coordinate all patient and family/caregiver services and prioritization of needs with the interdisciplinary group..." The P&P further indicated, "Licensed practical/vocational nurses will supplement the nursing care needs of the patient as provided by the registered nurse; this may include... Preparing clinical and progress notes documenting outcomes of interventions... Assisting the registered nurse in carrying out the plan of care... Insuring communication of information to appropriate team members."
L0533      
34448 Based on observation, interview, and record review, the facility failed to ensure two of 14 sampled patients (Patient 6) received a thorough assessment when Patient 6 fell after receiving Ativan (medication to treat anxiety) and sustained injuries. The facility also failed to implement new interventions to protect Patient 6 from reoccurring falls. These failures had the potential to result in recurrent falls and severe harm for Patient 6. Findings: During a review of the clinical record for Patient 6, the clinical record, indicated, Patient 6's start of care date was 9/22/20. Patient 6's terminal diagnoses was end stage Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). The Nursing Admission Assessment, dated 9/22/20, completed by Registered Nurse (RN) 1, revealed that Patient 6 was confused with episodes of aggressive behaviors. The Assessment further indicated Patient 6 ambulated with an unsteady gait and needed assistance with walking. A review of an Interdisciplinary Group Meeting (IDG, a group of healthcare providers from different fields who work together to provide the best care for a patient) note, dated 11/24/20, indicated upon admission Patient 6 had been identified as a fall risk and a care plan was developed. A Physician's Order, dated 11/25/20 at 9 AM, indicated, Patient 6 was to receive Ativan (medication used to treat anxiety) 0.5 milligrams (mg), one tablet by mouth, every six hours as needed for agitation. During a home visit conducted on 12/8/20 at 11 AM, escorted by Licensed Vocational Nurse 2 (LVN 2), Patient 6 was seated in a chair in the living room. Patient 6 smiled when greeted, but was unable to converse coherently. Patient 6 was observed to have left forehead bruise approximately one (1) centimeter in diameter. During a concurrent interview with LVN 2 and Patient 6's Primary Caregiver (PC), PC stated Patient 6 had fallen recently. PC stated, "I gave her the Ativan 0.5 mg and it was too strong. That is why she fell. She had bruises on her shoulder and forehead." PC stated she had reported the fall to LVN 2 during a previous home visit. LVN 2 stated she notified Registered Nurse 1 (RN 1) that Patient 6 had fallen after the administration of Ativan. LVN 2 stated she did not know if RN 1 had completed a Post-Fall Assessment for Patient 6. During a review of Patient 6's Nursing Notes, completed by LVN 2, indicated, during the home visit on 12/1/20 at 11 AM, PC reported that Patient 6 was found on the floor by the bed after being administered Ativan. LVN 2 documented, "Noted purple bruise on left side of forehead, bruise on lateral side of the orbit of left eye, and bruise on left side to the nose distal to left eye, purple bruise on left upper arm below shoulder, notified." The Nursing Note did not indicate whom LVN 2 notified. During a review of Patient 6's "RN Hospice Reassessment," completed by RN 1, dated 12/1/20 at 5:15 PM (hours after LVN 2's home visit on 12/1/20 at 11 AM), Patient 6's Reassessment did not include the bruises identified by LVN 2. There was no documented evidence to show that RN 1 conducted a Post-Fall Assessment for Patient 6. During a review of Patient 6's Nursing Notes, completed by LVN 2, indicated, during the home visit on 12/3/20 at 1:05 PM (two days after RN 1's home visit on 12/3/20), it indicated, that Patient 6's bruises were still present. LVN 2 documented, "Pt (patient) continues with bruises on left forehead, lateral side of the orbit of left eye, left side of the nose, and left upper arm." During a concurrent interview on 12/8/20 at 3:29 PM, with the Administrator, Director of Patient Care Services (DCPS), and RN 1, RN 1 stated he did not observe Patient 6's bruising. RN 1 stated he found out Patient 6 had fallen when he did the RN Hospice Reassessment on 12/1/20. RN 1 stated he should have completed a Post-Fall Assessment and an Incident Report. The DPCS stated she did not know Patient 6 had fallen. DPCS stated, "After a fall, the Physician should have been notified and the Ativan should have been discontinued." During a concurrent interview with the Administrator and DPCS on 12/10/20 at 10:24 AM, the Administrator stated an IDG meeting was held on 12/8/20, but Patient 6's fall was not discussed. The Administrator stated Patient 6's fall should have been discussed during that IDG meeting, and Patient6's Care Plan should have been updated with new interventions for the patient's protection. A review of the facility's policy and procedure (P&P) titled, "Comprehensive Assessment," undated, the P & P indicated, "... 5. The comprehensive assessment is updated by the interdisciplinary group as frequently as the patient's condition requires but at a minimum every 15 days.. If there has been a change in the patient's condition/status, then the comprehensive assessment must be updated." A review of the facility's undated, policy and procedure (P&P), titled, "Incident Reporting," included, "When an incident occurs, the individual discovering the incident will: A. Notify your supervisor immediately (including after hours) with observations or identification of the incident. B. Follow-up with the patient and family/caregiver, and/or patient's physician, if indicated by your supervisor or designee... D. Complete an incident report form within 24 hours of the incident. The form should include the following... Type of incident... Description of the incident or injury... witness of the incident... Any drugs taken by the patient within eight (8) hours before the incident, including the dose, route, and time administered, especially for reporting falls... Any action taken by the physician... The Program Director or designee will review and sign the incident report form, request any necessary follow-up from appropriate personnel..."
L0563      
36406 Based on interview and record review, the facility failed to have an effective, ongoing, hospital-wide data-driven Quality Assessment and Performance Improvement program (QAPI- is a data driven and pro-active approach designed to involve all members of an organization to continuously identify opportunities for improvement in the overall quality of care and services delivered to patients). There was no documented evidence to show that the hospice collected and analyzed patient care and administrative quality data and used that data to identify, prioritize, implement, and evaluate performance improvement projects to improve the quality of services furnished to hospice patients. This failure had the potential to adversely affect the quality of care provided by the facility. Findings: On 12/7/20 at 11:20 AM, an interview was conducted with the Director of Patient Care Services (DPCS). The DPCS stated the facility's QAPI Meetings were conducted on a quarterly basis. During a review of the QAPI Meeting Minutes for three (3) quarterly meetings held in 2020 (April, July and October), the QAPI Meeting Minutes had no data to track quality indicators (a measurable element of the agency's practice that can be used to assess the quality of care provided to examine all the aspects of the agency's operation) including patient care and other relevant data in the design of the program. The documentation showed QAPI discussed the following topics during each quarter: a. Chart audit b. Medication/management audit c. Falls d. Complaints e. Infections There was no documented evidence to show: a. Data was collected to analyze b. How quarterly performance problems were identified c. Corrective actions were implemented and monitored On 12/8/20 at 10:10 AM, a concurrent interview was conducted with the Administrator, and the Director of Patient Care Services (DPCS). The DPCS and the Administrator were unable to explain what quality indicators facility used, how the data was collected, monitored, the facility actions/interventions and the effectiveness or outcome of the services provided each quarter. The Administrative staff was unable to produce documented evidence to show the hospice collected and analyzed patient care and administrative quality data and used that data to identify, prioritize, implement, and evaluate performance improvement projects to improve the quality of services furnished to hospice patients. The Administrator stated the hospice had no current program improvement projects to discuss in their QAPI meetings. Review of the undated, facility policy and procedure titled, "Quality Assessment and Performance Improvement Plan" indicated, hospice has established an ongoing program of quality assessment and performance improvement. The policy also indicated the QAPI Committee would be responsible for coordinating all QAPI activities, reviewing and analyzing data collection, the interventions and effectiveness of its actions.
L0588      
34448 Based on interview and record review, the facility failed to ensure for one of 14 sampled patients (Patient 14) Continuous Care (This advance level of care necessary when symptoms are not well controlled and the patient requires sustained nursing care to achieve symptom control) was provided by hospice staff. Findings: During a review of the clinical record for Patient 14 on 8/3/20, the clinical record indicated Patient 14's start of care date was 3/14/20. Patient 14's admitting diagnosis was congestive heart failure (a weakness of the heart that leads to a buildup of fluid in the lungs and surrounding body tissues). Patient 14 expired on 4/1/20. A review of the Continuous Care note, dated, 3/30/20 for the night shift (11:59 PM to 12 PM [12 hours]), was signed by Certified Home Health Aide 1 (CHHA, a non-licensed staff who provide activities of daily living such as bathing, oral care, and toileting). A review of the Continuous Care note dated, 3/31/20 for the night shift, was signed by Licensed Vocational Nurse 1 (LVN 1). There were no documented evidence to show Continuous Care notes on 3/31/20 and 4/1/20, for the day shifts. On 12/10/20 at 9:58 AM, an interview was conducted with CHHA 1. CHHA 1 stated she provided Continuous Care for Patient 14, on 3/30/20, for the night shift. CHHA 1 stated Patient 14's Friend took over on 3/31/20 for the day shift. On 12/10/20 at 1:23 PM, an interview was conducted with LVN 2. LVN 2 stated she provided Continuous Care for Patient 14, on 4/1/20, for the night shift. LVN 2 stated, "When my shift was over, a lady (Patient 14's Friend) came and took over. I do not know if she worked for the hospice." On 12/10/20 at 10:58 AM, an interview was conducted with Patient 14's Friend (occasionally relieved Patient 14's primary caregiver). Patient 14's Friend stated she was asked by the Director of Patient Care Services (DPCS) if she would take over for Patient 14, during the day. Patient 14's Friend stated she told the DPCS, "Well I'm not qualified and she [DPCS] stated we'll pay you, and I said great." Patient 14's Friend also stated, "I did not receive any information about how to care for her (Patient 14). I was confused about her medications, because no one had told me anything about the medications." Patient 14's Friend further stated after she started caring for Patient 14, she told the DPCS she was not trained on how to do things. On 12/10/20 at 10:24 AM, a concurrent interview was conducted with the Administrator and DPCS. The Administrator stated, "Towards the end the patient [Patient 14] was in pain, because the pain medications were not being given on time. That is why we did Continuous Care days before she expired." The Administrator also stated it was hard to find staff to go so far to Patient 14's home. The Administrator stated Patient 14's Friend had been helping Patient 14's Caregiver, so he offered to pay her if she would take over on 3/31/20 and 4/1/20, for the day shift. The Administrator stated, "I paid [Patient 14's Friend] a couple of times. I paid her with my own personal check." The Administrator further stated Patient 14's Friend was not an employee of the hospice, and she did not received hospice training. A review of the facility's job description for the Executive Director/Administrator, undated, the job description indicated, "... Essential Job Functions/Responsibilities... Ensuring adequate and appropriate staffing ..."
L0691      
33037 Based on observation, interview, and record review, the facility failed to ensure the medication reconciliation (MR-verification of current list of medication and compared to what is available in patient's home) was implemented for one of 14 sampled (Patient 9). This failure had the potential to adversely affect Patient 9's health and safety. Findings: During a review of Patient 9's clinical record, the clinical record indicated, Patient 9's start of care was date 9/23/20. Patient 9's admitting diagnosis was Parkinson's disease (a central nervous system disorder that affects movement, including tremors or involuntary shaking). A review of Patient 9's list of medications was conducted with Registered Nurse 1 (RN 1) on 12/7/20 at 2:45 PM. RN 1 stated Patient 9's medication list was updated and current. it indicated, Patient 9's list of medications included the following: a. Ativan (anti-anxiety medication) 0.5 mg. (milligram, unit measurement), one (1) tablet by mouth every 6 hours and as needed for agitation. b. Imodium (anti-diarrheal medication) 2 mg, 1 tablet by mouth as needed for loose stool. c. Tylenol (pain relief medication) 325 mg by mouth every 6 hours as needed for mild pain. d. Verapamil Hydrochloride (medication to treat hypertension) 80 mg, 1 tablet by mouth 3 times a day for hypertension. During Patient 9's home visit conducted with the Licensed Vocational Nurse 2 (LVN 2) on 12/08/20 at 9:10 AM, LVN 2 was asked to explain how MR was conducted. LVN 2 was unable to compare Patient 9's list of medications with prescribed drugs available in Patient 9's home. The Ativan, Tylenol, and Verapamil Hydrochloride medications were not available for comparison. During the inspection, Imodium was the only drug available in the home. LVN 2 stated, "I don't know where the medications are." During an interview with Patient 9's primary caregiver (PC) on 12/08/20 at 9:55 AM, The PC stated, "She (Patient 9) does not use the Imodium and the Tylenol, and the Ativan has not been delivered." The PC stated the medication for hypertension was in her car." The PC retrieved the hypertension medication from her car. During a follow-up interview with LVN 2 on 12/08/20 at 10:10 AM, LVN 2 stated a copy of the medication list was printed from computerized chart and was used to check the medications during MR. LVN 2 stated, "No reconciliation was done, there were no medications in there and that's an issue." A review of LVN 2's notes for Patient 9's visits for 12/1/20 and 12/3/20 was conducted with RN 1 on 12/8/20 at 10:50 AM. There was no documented evidence to show a MR for 12/1/20, outlining active medications available in Patient 9's home. LVN 2 documented on 12/3/20, "Medication reconciled and managed." During an interview with RN 1 on 12/8/20 at 10:50 AM, RN 1 stated the medications on the list were compared to the actual bottle of the medication in the patient's home. RN 1 stated the active list of medications should match the available medications in the patient's home. RN 1 stated any discrepancies should have been reported and if refills are needed that should have been reported. A review of the facility's undated, policy and procedure titled, "Administration And Documentation Of Medication" policy No. 4-052.1 noted on the procedure, "1. As part of the assessment process, a drug ...and a comparison made between physician's orders and the current medication the patient is taking. Any discrepancies ... should be reported to the physician for resolution. 5. Nurses who are providing ... home visits will document ... medications ..."