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
751649 A. BUILDING __________
B. WING ______________ 		12/04/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
AASTA HOSPICE 19350 BUSINESS CENTER DR SUITE 112, NORTHRIDGE, CA, 91324
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)
L0549      
22303 Based on interview and record review, the hospice staff failed to administer Albuterol medication and provide oxygen as ordered for one of 5 sample patients. (Patient 4), who was experiencing shortness of breath. This deficient practice placed the patient at a potential risk for additional breathing problems which could affect the overall health status. Findings: A review of Patient 4's clinical record indicated admission to the hospice agency on 1/13/20, with primary diagnosis of end stage cerebrovascular disease (disorder that affect the blood vessels and blood supply to the brain and affects how body functions). A review of Patient 4's "Plan of Care (POC)/IDG Review" dated 11/25/20, indicated the Registered Nurse (RN) was to visit every 14 days for ongoing comprehensive assessment and supervisory visit/ recertification assessment per schedule for skilled assessment and intervention. The Licensed Vocational Nurse (LVN) to visit once a week and as needed, to promote comfort and symptom management, and assess respiratory (lungs and breathing) status. A review of a "Physician's Order" dated 11/6/20, indicated to administer Albuterol 0.083 percent(%) solution one vial via hand held nebulizer every 4 hours as needed for shortness of breath and wheezing (A high-pitched whistling sound made while breathing.). Skilled nurse to assess respiratory status and provide Oxygen inhalation at 2 liters via nasal cannula (nasal tubing) as needed for mild dyspnea (difficulty breathing) with respiratory rate of 21-22 breaths per minute. A review of a "LVN Visit Notes" dated 10/30/20, indicated the patient's (Patient 4) oxygen saturation (amount of oxygen that is in a person's bloodstream) in room air was 93 percent, with having diminished breath sound (Reduced airflow to part of the lungs.) and shortness of breath. There was no documented evidence the visiting nurse gave the Albuterol medication and applied Oxygen per 2 liters as ordered. During an concurrent interview and record review on 12/3/20, at 1 p.m., with the Director of Patient Care Services (DPCS) Patient 4's clinical record with the "LVN Visit Note" dated 10/30/20 was reviewed. The note indicated the Albuterol medication and oxygen were not given to relieve the patient's shortness of breath and diminished lung sounds. The DPCS stated, "The visiting nurse assigned to the patient (Patient 4) on 10/30/20, was out of town and unavailable for interview. The Albuterol medication and Oxygen were not given to the patient (Patient 4) during the visit. All prescribed medications should be given to the patient (Patient 4) when needed during the skilled nursing visits."
L0552      
25046 Based on interview and record review, the hospice agency failed to ensure a plan of care (POC) identified and included the management of pace maker (small device that's placed in the chest or abdomen to help control abnormal heart rhythms) according to their policy for one of 5 sampled patients (Patients 3). This failure placed the patient at a potential risk for health complications due to malfunction of the pacemaker. Findings: A review of Patient 3's clinical record indicated a start of care (SOC) date of 3/28/2019, with diagnoses of acute diastolic congestive heart failure (weakness of the heart that leads to a buildup of fluid in the lungs and surrounding body tissues) and atrial fibrillation (An irregular, often rapid heart rate that commonly causes poor blood flow). A review of the "Physician's Certification for Hospice Benefit" dated 3/28/19, indicated the patient had comorbidities of atrial fibrillation, bradycardia (Slower-than-expected heart rate, generally beating fewer than 60 beats per minute.), and had epicardial pacemaker (An electrical box placed within the outer muscle layer of the heart to control irregular heart beats.) placed on 2/26/2019. A review of Patient 3's "Plan of Care (POC) dated 12/1/2020, indicated Registered Nurse (RN) visit was initial and every 14 days, Skilled Nurse (SN) visit was once per week, to assess all body systems including cardiovascular (heart and circulation). Auscultate (listen) to apical (heart) pulse, assess heart rate, rhythm, blood pressure, and peripheral pulses (pulses in the femoral (groin), popliteal (back of the knee), posterior tibial (ankle), and dorsalis pedis (foot) areas. The POC did not include the information of pacemaker such as type of pacemaker, rate and pace maker test. There was no parameter of pulse rate either. A review of Patient 3's clinical record indicated there was no documentation the patient's pacemaker was assessed. A review of the agency's policy of "The Plan of Care" revised on April 2017 indicated the plan of care will identify the patient's needs and services to meet those needs. A review of the agency's undated policy of "Pacemaker" indicated as follows: * The purpose - to provide appropriate care and monitoring for patient's pacemaker. * Content - information of pacemaker shall be recorded in the patient's medical record when available. ( For hospice pacemaker monitoring is not required as the hospice is palliative and not curative approach). 1. Type of pacemaker 2. date of insertion 3. Rate at which pacemaker is set 4. Pacemaker test ordered by the physician. * Nursing and Care duties: 1. Recording pacemaker information when available 2. Addressing pacemaker on the patient's care plan On 12/4/2020, at 12:05 p.m. during an interview with the Director of Patient Care Services (DPCS), she was not able to provide any documentation regarding the pacemaker. She stated, "I did not even know the patient (Patient 3) had a pacemaker. The agency did not develop the plan of care regarding the pacemaker because the hospice service is providing comfort care, not curative, and the patients are dying." The DPCS agreed the agency "Pacemaker "policy had a discrepancy regarding the verbiage "For hospice pacemaker monitoring is not required as the hospice is palliative and not curative approach."
L0671      
22303 Based on interview and record review, the hospice staff failed to ensure the clinical record contained documentation of pitting edema in the lower extremities for one of 5 sample patients. (Patient 4). This failure resulted in clinical information not being recorded to ensure the patient receives continuity of care from all disciplines. Findings: A review of Patient 4's clinical record indicated admission to the hospice agency on 1/13/20, with primary diagnosis of end stage cerebrovascular disease (disorder that affect the blood vessels and blood supply to the brain which affects how the body functions). A review of Patient 4's "Plan of Care (POC)/Interdisciplinary Group (IDG) Review" dated 11/25/20, indicated the Registered Nurse (RN) was to visit every 14 days for ongoing comprehensive assessment and supervisory visit/ recertification assessment per schedule for skilled assessment and intervention of all body systems. Licensed Vocational Nurse (LVN) to visit once a week and as needed, to promote comfort and symptom management and assess cardiac status. A review of Patient 4's "LVN Visit Notes" dated 10/16/20, 10/23/20, 10/30/20, 11/6/20, 11/13/20, and 11/20/20, indicated Licensed Vocational Nurse (LVN 1) documented the patient (Patient 4) had 1+ edema (Barely detectable impression when finger is pressed into skin.), but did not include which body part was swollen. On 12/2/20, at 11 a.m., during an interview with the Director of Patient Care Services (DPCS), she stated the visiting nurse was on leave and not available, but should have documented the location of the patient's (Patient 4) existing edema on both lower legs.
L0679      
25046 Based on interview and record review, the hospice agency failed to ensure their nursing staff followed the "Computer Access to Information" policy for one of 2 employees (Licensed Vocational Nurse 2) providing continuous care for one of 5 sample patients. (Patient 2) For Patient 2: The licensed vocational nurse (LVN 2), electronically signed a clinical note for care given by a different nurse. This resulted in the continuous care provided to the patient being documented inappropriately and not in accordance with hospice policy. Findings: A review of Patient 2's clinical record indicated readmission to hospice care was 11/3/2020, and primary diagnosis was cerebrovascular disease (diseases, and disorders that affect the blood vessels and blood supply to the brain). A review of the "Physician's Order" dated 11/3/2020, indicated the patient (Patient 2) was placed on continuous level of care (This round-the-clock level of care is provided in the home for brief periods of time when the patient is experiencing a crisis.) due to acute respiratory failure with hypoxia (Hypoxemic respiratory failure means that you don't have enough oxygen in your blood, but your levels of carbon dioxide, what controls your breathing, are close to normal.). A review of the "Continuous Care Visit Notes" from 11/3/2020, at 7 p.m. to 11/4/2020 at 6 a.m., indicated LVN 2 had provided care and electronically signed her name. The "Continuous Care Visit Notes" dated 11/4/2020, from 6 a.m. to 7 p.m. indicated LVN 2 provided care to Patient 2, and electronically signed the note for a total of 23 hours of continuous care. On 12/2/2020, at 11:30 a.m., during a telephone interview with LVN 2, she stated, "I worked from 11/3/2020 at 7 p.m., to 11/4/2020 at 6 a.m., a total of 11 hours. The the next licensed vocational nurse (LVN 3) relieved me and worked after I left. I made a mistake and electronically signed on LVN 3's visit note." When asked how did the mistake happen, signing for care not provided, she offered "no comment." On 12/4/2020, at 11:40 a.m., during an interview with the Director of Patient Care Services (DPCS), she stated both licensed vocational nurses, LVN 2 and LVN 3 are husband and wife. They (LVN 2 and LVN 3), share the same computer. LVN 2 should have not have signed her signature on LVN 3's visit note." A review of the agency's policy of "Computer Access to Information" revised on April 2017 indicated authorized personnel will be assigned passwords and/or access codes and will complete a signed statement that no one else will be allowed to use his/her computer key. Signatures should conform to the following criteria; 1. Unique to the person using it. 2. Capable of verification or authentication. 3. Under the sole control or the person using it.