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 ______________ 		07/20/2022
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)
L0505      
36805 Based on observation, interview, and record review, the facility failed to ensure privacy was maintained during care for Patient 6. This failure resulted in Patient 6's dignity not being respected. Findings: During a review of Resident 6's "Personal Information", (PI), dated 5/5/22, the "PI" indicated, Patient 6's diagnosis was Alzheimer's disease (a brain disorder in which the memory loss and other cognitive abilities interfere with daily life). During an observation on 7/18/22, at 3:22 PM, in Patient 6's bedroom, nursing care was being provided to Patient 6. During perineal care (the area between the genitals and anus) for Patient 6, the bedroom door was left open. During a concurrent observation looking out Patient 6's bedroom door, Patient 12 was observed to be looking towards Patient 6's bedroom. During an interview on 7/18/22, at 3:53, PM, with Registered Nurse (RN 1), indicated the bedroom door should be closed during patient care. During a review of RN 1"s, facility's Job Descriptions", (JD), dated 5/7/22, the "JD" indicated "...Essential Job Functions/Responsibilities... Provides privacy during patients care..."
L0647      
37627 Based on interview and record review, the facility failed to ensure it met and tracked the five percent requirement for the volume of care provided by volunteers on two consecutive years, 2021 and 2022. The Volunteer's (VT) timesheet hours for the month of July 2022 were incorrect. These failures resulted in noncompliance with the facility's policies and procedures on tracking and meeting the volume of care provided by volunteers. Findings: A review of the report titled, "Hospice-MD Volunteer Savings Report," indicated the following: *From 1/1/22 to 7/19/22, the total patient care hours for all paid hospice employees and contract staff were 5,409.2 hours. The total volunteer hours were zero hours. The total percentage of volunteer services were 0% percent for 2022. *From 1/1/21 to 12/31/21, the total patient care hours for all paid hospice employees and contract staff were 15,014.3 hours. The total volunteer hours were one hour. The total percentage of volunteer services were 1% percent for 2021. An interview was conducted with the Volunteer Coordinator (VC) on 7/19/22 at 12:02 PM and at 1:41 PM. VC confirmed, the hospice agency did not meet the minimum five percent requirement for 2021 and 2022, because the volunteer percentage amount was one percent from 1/1/21 to 12/31/21 and zero percent from 1/1/22 to 7/19/22. VC stated, it was her mistake because she had not gotten the chance to track and document the volunteer hours on the 2021 and 2022 reports. VC stated, she had been busy but should have done this. VC confirmed, the reports for 2021 and 2022, were the only one's available at the time requested by the surveyor. VC stated, it was the responsibility of the volunteer coordinator to track and document volunteer patient care and administrative hours on the volunteer cost savings report. A concurrent interview and record review was conducted with the Volunteer (VT) on 7/20/22 at 10:36 AM, the timesheet record indicated VT had worked from 9 AM to 5 PM, with a 30-minute lunch break from 1 PM to 1:30 PM. This equal eight hours per day, 7/5/22 through 7/8/22 and 7/11/22 through 7/15/22. The timesheet record indicated the total hours documented by VT for the above dates added up to 72 hours total. *This surveyor calculated the timesheet hours and the total hours added up to 67.5 hours. VT confirmed, the above findings. A review of the facility's policy titled, "Volunteer Services," revised 4/2021, indicated, "The volunteer coordinator will track the use of volunteers, cost savings achieved, and the hours of volunteer services exceed 5% of the total day-to-day administrative or direct patient care hours of paid and contracted hospice personnel." A review of the facility's policy titled, "Documentation of Volunteer Utilization," revised 4/2021, indicated, "The Volunteer Coordinator will compile and analyze the data monthly. The Volunteer Coordinator will document the following: A. The continuing level of volunteer activity and the expansion of care and services achieved through the use of volunteers; B. Volunteer service hours to show that volunteer hours equal at least 5% of the total day-to-day administrative or direct patient care hours of all paid hospice and contract staff."