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
921795 A. BUILDING __________
B. WING ______________ 		03/17/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
DEVOTED HEALTHCARE, INC 675 W FOOTHILL BLVD SUITE 310, CLAREMONT, CA, 91711
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)
L0577      
35893 Based on observation, interview and record review, the Hospice Agency failed to ensure the Condition of Participation for Infection Control was met as follows: The hospice agency failed to follow the guidelines for reporting to the appropriate agencies for one patient and three staff members who were positive for the Coronavirus virus ( COVID-19 a highly contagious respiratory disease caused by a virus that can spread from person to person). The hospice agency failed to monitor quarantine time for staff exposed to COVID-19. The hospice agency failed to establish effective surveillance (close observation or monitoring) for both patients and staff in regards to quarantine time, temperature check, a sign/symptom check for staff prior to visiting patients, and contact tracing ( a system used to slow down the spread of COVID 19) for Patient 1 and Patient 2's caregiver who were both COVID-19 positive. The hospice agency failed to provide infection control education to both staff and caregivers that are current with the CDPH (California Department of Public Health) & CDC (Center for Disease Control) COVID-19 guidelines. The hospice agency failed to provide current in-service training to staff regarding COVID-19. The hospice agency failed to follow accepted standards of practice when allowing the patient and family members to not wear mask (to prevent the transmission of COVID 19) during the home visit and not implementing the use of standard precaution developed by government agencies such as the Centers for Disease Control and Prevention (CDC), the California Department of Public Health (CDPH), and the Acute Communicable Disease Control Program. These failures had the potential for the spread of the virus COVID-19 and potentially cause of death. The cumulative effect of these systemic practices resulted in the Hospice Agencys failure to ensure infection control practices were followed to ensure patients, their family members, and staff were not exposed to COVID 19 which had the potential to be deadly.
L0579      
35893 Based on observation, interview and record review, the Hospice Agency failed to report one patient (Patient 1) in a sample size of six, and three employees who tested positive for the Coronavirus (COVID-19 a highly contagious respiratory disease caused by a virus that can spread from person to person) according to acceptable standards of practice and there agency policy and procedure. This deficient practice resulted in the hospice agency's failure to conduct surveillance and contact tracing for Patient 1 and Patient 2's caregiver who tested positive for COVID-19, and failure to follow accepted standards of practice to prevent the transmission of infections and communicable diseases, including the use of standard precaution developed by government agencies such as the Centers for Disease Control and Prevention (CDC. These failures had the potential for the spread of COVID-19. Findings: a. During a review of the start of care ( SOC) worksheet, Patient 1's start of care dated 8/5/19 indicated a skilled nurse (SN) visit once a week and as needed for symptom management. The physician's certification of terminal illness (CTI) indicated the patient was admitted to hospice for routine level of care with the admitting diagnosis of chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs). During a review of Patient 1's clinical record COVID-19 test results dated 10/6/20 revealed an abnormal result. A joint home visit was conducted on 3/16/21 at 11 a.m. with licensed vocational nurse ( LVN 1) at the home of Patient 1 who was observed sitting upward in a chair and appeared comfortable. During this same date and time Patient 1's caregiver was present. She stated that Patient 1 was exposed to COVID-19 because both herself and her partner tested positive. She further stated that she did call the hospice agency as soon as she received her positive test results on 9/30/20. During an interview with LVN 1 on 3/16/21 at 11:40 a.m., he stated that the temperature checks and sign/symptom check for COVID -19 for staff did not start until 1/26/21 which is roughly 3 months after Patient 1 tested positive. The LVN stated that on the days he conducts home visits he usually sees 5-6 patients on the same day. He stated that he was not aware he had to quarantine himself because of exposure to a positive patient, nor did the agency inform him, or enforce a quarantine period. b. During a review of the SOC worksheet, Patient 2's start of care dated 10/22/20 indicated for the SN to visit once a week and as needed for symptom management. The physician's certification of terminal illness (CTI) indicated the patient was admitted to hospice for routine level of care with the admitting diagnosis of atheroslcerotic heart disease (narrowing of the arteries caused by a buildup of plaque). During a home visit at Patient 2's residence on 3/16/21 at 1 p.m. with LVN 1, Patient 2's caregiver indicated she was positive for COVID-19 on 12/12/20 and informed the agency. The care giver also confirmed both the nurse and social worker conducted in person visits after 12/12/20 while she was present. During an interview with Patient 2's social worker on 3/17/21 at 2 p.m. she confirmed that she did conduct a visit to the patient on 12/16/20 with the caregiver present and was not aware she was positive or informed by the agency. She confirmed that the agency didn't start temperature checks with sign/symptom checks her COVID 19 protocol until 1/26/21. An interview with patient to nurse was attempted but unsuccessful. The Director of Patient Care Services confirmed that the nurse did see Patient 2 after 12/12/20 on 3/15/12 at 2: 14 p.m. During an interview with the DPCS on 3/17/21 at 2:14 p.m., she confirmed there was no surveillance or contact tracing conducted for both Patient 1 & 2. She was not aware Patient 2's caregiver was COVID-19 positive and stated that the staff should not have visited the patient and should have quarantined at home to prevent the spread of COVID-19. She also stated the three positive cases of staff ( social worker, volunteer coordinator and certified health aid) were not reported because the agency was not aware they had to report positive COVID-19 cases. The DPCS confirmed that temperature check and sign/symptom check for COVID -19 for both field staff and office staff did not start until 1/26/21. They are currently working on a policy in conjunction with CDPH and CDC quidelines. A review of the hospice agency's policy & procedure titled " Pandemic Infectious Disease" revised on 3/16/21 indicated the employee exposed to COVID-19 should self-isolate for 3 days. The policy and procedure does not include reporting COVID-19 cases to CDPH. 14065 c. A review of Patient 3's Face Sheet indicates the patient's start of care date was 3/9/20 with the diagnosis of chronic kidney disease, end stage heart failure, and dementia (A progressive disease that destroys memory and other important mental functions). A review of the plan of care dated 3/9/20, indicated Patient 4 was alert with periods of increased forgetfulness, but was able to make his needs known. Due to his medical condition, he requires assistance for his activities of daily living. During a home visit on 3/17/21 at 9:30 a.m., Patient 4 was observed sitting at the dining table with no face mask on. There were two other family members ( Family member #1 and Family member #2) at the table who were also not wearing any face masks. LVN 1 proceeded to take Patient 4's blood pressure and began to provide patient teaching regarding medications. During an interview with LVN 1 on 3/17/21 at 10 a.m., he stated he was not aware he should ask the patient and family members to wear a mask. He stated since he was wearing a mask, he thought the other people in the room did not have to. LVN 1 stated he did not have extra masks for the patients. During an interview with Family Member 2 on 3/17/21 at 10:15 a.m., he stated he was recovering from being Covid-19 positive a few weeks ago. He stated the Staff that come to visit Patient 4 did not ask them to wear a mask or provided masks during the home visits. Further interview with the LVN 1 on 3/17/21 at 10:30 a.m., he stated he was not trained by the hospice agency that masks must be worn by the patient during his home visit. He stated he could not explain why the other two family members were sitting at the dining table, in close proximity without wearing a mask. A review of the hospice agency's undated policy, titled, " Pandemic Infectious Disease", indicates the agency would adhere to local, state, and federal guidelines as it relates to Covid-19. Masks and social distance must be adhere to as the virus can transfer between people who are in close contact with one another (approximately within 6 feet). The agency must provide personal protective equipment for the staff members and each patients they visit. The hospice agency failed to implement the above policy. During an interview with the Administrator on 3/16/21 at 3 p.m., he stated the hospice agency was not aware of the newest guidelines from CDC because the agency was not receiving any of the AFL's (all facilities letter) from the Department of Public Health updating the policy for infection control as it relates to Covid-19. He stated he will be re-training their staff in an upcoming in-service. During an interview with the director of patient care services on 3/17/21 at 2 p.m,, she stated she was new to the position and she did not have a current policy regarding mask wearing during home visits. She stated she plans to give training regarding the use of face mask and social distancing in the home setting. She stated they are in the process of developing and updating their policies for Covid-19 related infection control procedures.
L0663      
35893 Based on interview and record review, the hospice agency failed to provide current infection control education regarding the Coronavirus (COVID-19- a highly contagious respiratory disease caused by a virus that can spread from person to person) for employees conducting home visits to patients and their families. This deficient practice had the potential to increase the risk for the spread of COVID-19. Findings: A review of the hospice agencies in-services provided to staff regarding COVID-19 was conducted. The agency in-service documentation was observed and staff received an initial in-service on 2/28/20. An in-service was also provided to staff on 1/27/2021 regarding COVID 19 screening. This in-service was however provided after the surveyor initiated the complaint investigation on 1/25/21. Between 2/28/2020 and 1/25/ 2021 the agency did not conduct in-services to educate and update the staff on current recommendations from the CDC (Center for Disease Control, CDPH (California Department of Public Health), and other government agencies for COVID-19. The Center for disease control updated their recommendations for healthcare personnel during the Coronavirus disease 2019 COVID/19 pandemic. The updates included infection prevention and control practices for routine health care delivery during the pandemic, recommended practices when caring for a patient with suspected or confirmed stars/COVID/2 infection, and identifying isolating and caring for COVID 19 patients. The California Department of Public health sent a all facilities letter (AFL) on September 22, 2020 titled "Corona Virus Disease 2019 Outbreak Investigation and Reporting Thresholds". This AFL for license health facilities indicated requirements for reporting outbreaks and unusual infectious disease, and references to the local health department and licensing and certification district and provided investigation and reporting thresholds for reporting for COVID 19. During an interview with the licensed vocational nurse (LVN 1) on 3/16/21 at 12 p.m., he confirmed there were no in-services regarding COVID-19 besides the initial inservice dated 2/28/20. During an interview with the Director of Patient Care Services (DPCS) on 3/17/21 at 2:14 p.m., she stated that besides the initial COVID-19 in-service on 2/28/20, the staff did not receive any current information regarding COVID-19 but should have been updated. She stated" Will do more frequent in-services to go with the any changes regarding COVID-19". Review of the hospice agencies undated policy and procedure titled "COVID 19 otherwise known as the Coronavirus indicates the following: Devoted Healthcare is responsible for ensuring the health and safety of patients and staff by enforcing the standards required to help each patient attain or maintain their highest level of well-being. In light of the recent spread of COVID 19 were providing additional education to nursing homes, assisted living, patients and families to help control and prevent the spread of the virus. Devoted Healthcare clinical teams are trained on the proper procedures and protocols to minimize the risk of spreading any infectious diseases including COVID 19. Devoted Healthcare will monitor the CDC website for information and resources. Devoted healthcare will contact the local health department if we have questions or suspect the patient to have COVID 19. The agency had no documentation to indicate they followed their policy and procedure for COVID 19.