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 ______________ 		01/18/2022
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)
L0536      
22303 Based on observation, interview, and record review, the hospice agency failed to ensure that the care and services were provided as indicated in the individualized plan of care for four of six sampled patients (Patient 2, 4, 5 and 6). Patient 2, 4, 5, and 6 were residing in a private house, and one licensed vocational nurse ( LVN 1), one certified nursing assistant(CNA), and one caregiver were providing nursing care to these patients, 24 hours a day, without a physician's order. (Refer to L 543) This deficient practice placed the patients at risk for not being assessed for hospice care needs and for not receiving approriate care.
L0543      
22303 Based on observation, interview, and record review, the hospice agency failed to ensure that the care and services were provided as indicated in the individualized plan of care for four of six sampled patients (Patient 2, 4, 5 and 6). Patient 2, 4, 5, and 6 were residing in a private house, and one licensed vocational nurse ( LVN 1), one certified nursing assistant (CNA), and one caregiver were providing nursing care to these patients, 24 hours a day, without a physician's order. This deficient practice placed the patients at risk for not being assessed for hospice care needs and for not receiving approriate care. Findings: a. A review of Patient 2's face sheet indicated admission to hospice on 7/24/20, with primary diagnosis of unspecified cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it). A review of Patient 2's "Plan of Care (POC)" dated 11/17/21, indicated the Skilled Nurse (SN) visit was once a week and as needed, the Medical Social Worker (MSW) visit was one time then as needed, the hospice aide (HA) service was declined. On 1/14/22, at 11:30 a.m., a home visit was conducted at Patient 2's residence. Patient 2 was observed lying in bed, alert, oriented, well-groomed, and able to move both upper and lower extremities. There were one LVN, one caregiver, and one CNA observed working in the patient's home. b. A review of Patient 4's face sheet indicated admission to hospice on 11/5/20, with primary diagnosis of senile generation of the brain. A review of Patient 4's "Plan of Care (POC)" dated 11/3/21 indicated the Skilled Nurse (SN) visit was once a week and as needed, the Medical Social Worker (MSW) visit was one time then as needed, and the hospice aide (HA) service was declined. On 1/14/22, at 11:30 a.m., a home visit was conducted at Patient 4's residence. Patient 4 was observed walking at the hallway using a walker. There were one LVN, one caregiver, and one CNA were observed working in the patient's home. c. A review of Patient 5's face sheet indicated admission to hospice on 3/16/21 with primary diagnosis of cerebral infarction. A review of Patient 5's "Plan of Care (POC)" dated 11/11/21, indicated the Skilled Nurse (SN) visit was once a week and as needed, the Medical Social Worker (MSW) visit was one time then as needed, the hospice aide (HA) service was declined. On 1/14/22, at 11:30 a.m., a home visit was conducted at Patient 5's residence. Patient 5 was observed lying in bed sleeping. There were one LVN, one caregiver, and one CNA observed working in the patient's home. d. A review of Patient 6's face sheet indicated admission to hospice on 12/17/21 with primary diagnosis of cerebral infarction. A review of Patient 6's "Plan of Care (POC)" dated 12/17/21 indicated the Skilled Nurse (SN) visit was once a week and as needed, the Medical Social Worker (MSW) visit was one time then as needed, and the hospice aide (HA) service was declined. On 1/14/22, at 11:30 a.m., a home visit was conducted at Patient 6's residence. Patient 6 was observed lying awake, alert, and oriented. There were one LVN, one caregiver, and one CNA observed working in the patient's home. On 1/14/22, at 1:45 p.m., during an interview with LVN 1, he stated that he works from Monday to Sunday, 8 a.m. to 7 p.m., at the house where Patients 2, 4, 5 and 6 were residing. There are six tenants/hospice patients who chose to live in the house, and they pay their rent monthly coming out of their pockets. LVN 1 stated when he is off from work, there is an LVN on-call (LVN 2) for the patients. LVN 1 stated he lives 5 minutes away from the facility so if he is ever needed at night, he comes over to take care of the issues. LVN 1 also stated that his duties are to administer the medications, to provide wound treatment, supervise his staff with total patient care, and coordinate with patient's family and doctor with their appointments. He also stated that there is always an assigned one CNA and one caregiver scheduled to work during morning shift (7 a.m. to 7 p.m.) and afternoon/night shift (7 p.m. to 7 a.m.) everyday from Monday to Sunday. LVN 1 stated their duties are to provide bed baths, to assist with showers and feeding, change their diapers if soiled, clean the facility, and assist with patients ADLs. LVN 1 further stated that the assigned CNA, caregivers, and including himself are employed by the hospice agency. They provide 24 hour nursing care to the six active patients living in this house. In an interview on 1/18/22 at 1:00 p.m., the administrator stated the agency's corporation is leasing the house with a leasing company and considered this house as an "independent living environment." The administrator stated the agency pays the salary of LVN 1, CNA, and caregiver. The administrator stated that the agency gets reimbursed for hospice services from Medicare.
L0587      
22303 Based on observation, interview and record review, the agency failed to ensure the Condition of Participation were met as follows: The facility failed to maintain an accurate records of the receipt and disposition of all controlled drugs for 4 out o4 patients (#2,#4,#5,#6). The cumulative effect of these systemic practices resulted in the agency's failure to ensure 4 of 4 patients met the dispensing of drugs and biological criteria for hospice. This had the potential for unnecessary care or treatment for the patients.
L0591      
22303 Based on observation, interview and record review, the RN Supervisor 1 (registered nurse) failed to maintain an accurate records of the receipt and disposition of all controlled drugs for four of 6 patients (Patient 2, 4,5 and 6). RN Supervisor 1 who visits the patients should be checking all their medications during their visits. This deficient practice placed the patient's care in poor outcomes for patients and liability issues for the facility. Findings: a. A review of Patient 2's face sheet indicated admission to hospice on 7/24/20, with primary diagnosis of unspecified cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it). A review of Patient 2's "Plan of Care (POC)" dated 11/17/21, indicated the Skilled Nurse (SN) visit was once a week and as needed, the Medical Social Worker (MSW) visit was one time then as needed, the hospice aide (HA) service was declined. There was a physician's order dated 7/24/20, to administer Morphine Sulfate IR (Roxanol) 20 mg (milligrams) per ml (milliliters) 5 mg/0.25ml oral/sublingual every 6 hours as needed for severe pain, to administer Ativan 0.5 mg one tab oral every four hours as needed for anxiety On 1/14/22, at 11:30 a.m., a home visit was conducted at Patient 2's residence. Patient 2 was observed lying in bed, alert and oriented, well groomed and able to move both upper and lower extremities. At 11:50 a.m., During an observation and a concurrent medication reconciliation with LVN 1, he showed the bottles of medications and medication bubble packs the patient were currently taking. There was a bottle of Morphine Sulfate 100 mg/5ml medication and there were 5 ml contents left in the bottle. The label stated the bottle had 15 ml contents when it was filled on 8/14/21. A total of 10 ml of medication were dispensed from the bottle. A review of Patient 2's Morphine Sulfate 100mg/5ml Controlled Medication Record sheet indicated no documented evidence of record of date when the medication was administered, amount, dosage who administered the medication. The Controlled Medication Record sheet was left blank. There was an Ativan 0.5 mg bubble pack medication with a label stating there were 27 tablets with a filled date of 8/14/21. A total of 2 tablets were dispensed from the bubble pack and there were 25 tablets remaining in the bubble pack. A review of Patient 2's Ativan 0.5 mg medication Controlled Medication Record sheet indicated no documented evidence of record of date when the medication was administered, amount, dosage who administered the medication. The Controlled Medication Record sheet was left blank. On 1/14/22, at 12:10 p.m., during an interview with LVN 1, he stated he administers Morphine Sulfate and Ativan medications for Patient 2. He also stated that he did not document the Morphine and Ativan medication administered to the patient in the Controlled Medication Record sheet. b. A review of Patient 4's face sheet indicated admission to hospice on 11/5/20, with primary diagnosis of senile generation of the brain. A review of Patient 4's "Plan of Care (POC)" dated 11/3/21, indicated the Skilled Nurse (SN) visit was once a week and as needed, the Medical Social Worker (MSW) visit was one time then as needed, the hospice aide (HA) service was declined. There was a physician's order dated 11/5/20, to administer Morphine Sulfate IR (Roxanol) 20 mg (milligrams) per ml (milliliters) 5 mg/0.25ml oral/sublingual every 6 hours as needed for severe pain, to administer Ativan 0.5 mg one tab oral every four hours as needed for anxiety On 1/14/22, at 11:30 a.m., a home visit was conducted at Patient 4's residence. Patient 4 was observed walking at the hallway using a walker. At 12:35 p.m., during an observation and a concurrent medication reconciliation with LVN 1, he showed the bottles of medications and medication bubble packs the patient were currently taking. There was a bottle of Morphine Sulfate 100 mg/5ml medication and there were 12 ml contents left in the bottle. The label stated the bottle had 15 ml contents when it was filled on 6/15/21. A total of 3 ml of medication were dispensed from the bottle. A review of Patient 4's Morphine Sulfate 100mg/5ml Controlled Medication Record sheet indicated that on 10/6/21 at 2:30 p.m., .25 ml of Morphine was administered and there was 12 ml left in the bottle. However, there was no documented evidence of record of date when remaining 2.75 ml of Morphine medication was administered, amount, dosage who administered the medication. The Controlled Medication Record sheet was left blank. There was an Ativan 0.5 mg bubble pack medication with a label stating there were 22 tablets with a filled date of 6/15/21. A total of 9 tablets were dispensed from the bubble pack and there were 13 tablets remaining in the bubble pack. A review of Patient 4's Ativan 0.5 mg medication Controlled Medication Record sheet indicated no documented evidence of record of date when the medication was administered, amount, dosage who administered the medication. The Controlled Medication Record sheet was left blank. On 1/14/22, at 12:50 p.m., during an interview with LVN 1, he stated he administers Morphine Sulfate and Ativan medications for Patient 4. He also stated that he did not document the Morphine and Ativan medication administered to the patient in the Controlled Medication Record sheet. c. A review of Patient 5's face sheet indicated admission to hospice on 3/16/21, with primary diagnosis of cerebral (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it). A review of Patient 5's "Plan of Care (POC)" dated 11/11/21, indicated the Skilled Nurse (SN) visit was once a week and as needed, the Medical Social Worker (MSW) visit was one time then as needed, the hospice aide (HA) service was declined. There was a physician's order dated 3/16/21, to administer Morphine Sulfate IR (Roxanol) 20 mg (milligrams) per ml (milliliters) 5 mg/0.25ml oral/sublingual every 6 hours as needed for severe pain, to administer Ativan 0.5 mg one tab oral every four hours as needed for anxiety On 1/14/22, at 11:30 a.m., a home visit was conducted at Patient 5's residence. Patient 5 was observed lying in bed sleeping. At 1 p.m., during an observation and a concurrent medication reconciliation with LVN 1, he showed the bottles of medications and medication bubble packs the patient were currently taking. There was a bottle of Morphine Sulfate 100 mg/5ml medication and there were 5 ml contents left in the bottle. The label stated the bottle had 15 ml contents when it was filled on 6/15/21. A total of 10 ml of medication were dispensed from the bottle. A review of Patient 5's Morphine Sulfate 100mg/5ml Controlled Medication Record sheet indicated no documented evidence of record of date when the medication was administered, amount, dosage who administered the medication. The Controlled Medication Record sheet was left blank. There was an Ativan 0.5 mg bubble pack medication with a label stating there were 26 tablets with a filled date of 3/16/21. A total of 4 tablets were dispensed from the bubble pack and there were 22 tablets remaining in the bubble pack. A review of Patient 5's Ativan 0.5 mg medication Controlled Medication Record sheet indicated no documented evidence of record of date when the medication was administered, amount, dosage who administered the medication. The Controlled Medication Record sheet was left blank. On 1/14/22, at 1:30 p.m., during an interview with LVN 1, he stated he administers Morphine Sulfate and Ativan medications for Patient 5. He also stated that he did not document the Morphine and Ativan medication administered to the patient in the Controlled Medication Record sheet. d. A review of Patient 6's face sheet indicated admission to hospice on 12/17/21, with primary diagnosis of cerebral (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it). A review of Patient 65's "Plan of Care (POC)" dated 12/17/21, indicated the Skilled Nurse (SN) visit was once a week and as needed, the Medical Social Worker (MSW) visit was one time then as needed, the hospice aide (HA) service was declined. There was a physician's order dated 12/17/21, to administer Morphine Sulfate IR (Roxanol) 20 mg (milligrams) per ml (milliliters) 5 mg/0.25ml oral/sublingual every 6 hours as needed for severe pain, to administer Fentanyl Patch 25 mcg (micrograms) per hour to apply one patch transdermally every 72 hours for pain management. On 1/14/22, at 11:30 a.m., a home visit was conducted at Patient 6's residence. Patient 6 was observed lying awake, alert and oriented. At 2 p.m., during an observation and a concurrent medication reconciliation with LVN 1, he showed the bottles of medications and medication bubble packs the patient were currently taking. There was a bottle of Morphine Sulfate 100 mg/5ml medication and there were 5 ml contents left in the bottle. The label stated the bottle had 15 ml contents when it was filled on 12/18/21. A total of 10 ml of medication were dispensed from the bottle. A review of Patient 6's Morphine Sulfate 100mg/5ml Controlled Medication Record sheet indicated no documented evidence of record of date when the medication was administered, amount, dosage who administered the medication. The Controlled Medication Record sheet was left blank. There was one package of Fentanyl Patch medication with a total of 2 Fentanyl Patch left in the packet. The Fentanyl Patch packet had a label stating there were 5 Fentanyl Patch medications inside one packet with a filled date of 12/18/21. A total of 3 patches were dispensed and there were only two Fentanyl Patches left in the pack. A review of Patient 6's Fentanyl Patch 25 mcg/HR medication Controlled Medication Record sheet indicated no documented evidence of the 3 Fentanyl Patches that were administered for the record of date when the medication was administered, amount, dosage and who administered the medication. The Controlled Medication Record sheet was left blank. On 1/14/22, at 2:30 p.m., during an interview with LVN 1, he stated he administers Morphine Sulfate and Fentanyl Patch medications for Patient 6. He also stated that he did not document the Morphine and Fentanyl Patch medications administered to the patient in the Controlled Medication Record sheet. On 1/18/22, at 1 p.m., during an interview with RN Supervisor 1, she stated that she does supervisory visit at the patient's residence. She also stated that during her visits, she she checks physician's orders and medication reconciliation and refills. She also stated her last visit was on 1/11/22, and there were no issues with all the patient's medications. On 1/18/22, at 1:30 p.m., during an interview with the DPCS (director of patient care services), she stated that 1 should be documenting administered narcotic medications in the narcotic sheet at all times . A review of the agency policy "Home Use and Disposal Of Controlled Substances", indicated that controlled drugs will be accounted for on a narcotic count record, which will be maintained as part of the clinical record.
L0648      
22303 Based on observation, interview, and record review, the hospice agency failed to ensure its governing body oversighted the agency's operation and managed the provision of hospice program by failing to: Ensure the care and services were provided as indicated in the individualized plan of care for four of six sampled patients (Patient 2, 4, 5 and 6). Patient 2, 4, 5, and 6 were residing in a private house, and one licensed vocational nurse ( LVN 1), one certified nursing assistant (CNA), and one caregiver were providing nursing care to these patients, 24 hours a day, without a physician's order. (Refer to L 651) This deficient practice had a potential to result in affecting the provision of quality care to the patients under hospice services.
L0651      
22303 Based on observation, interview, and record review, the hospice agency failed to ensure its governing body oversighted the agency's operation and managed the provision of hospice program by failing to: Ensure the care and services were provided as indicated in the individualized plan of care for four of six sampled patients (Patient 2, 4, 5 and 6). Patient 2, 4, 5, and 6 were residing in a private house, and one licensed vocational nurse ( LVN 1), one certified nursing assistant (CNA), and one caregiver were providing nursing care to these patients, 24 hours a day, without a physician's order. This deficient practice had a potential to result in affecting the provision of quality care to the patients under hospice services. Findings: a. A review of Patient 2's face sheet indicated admission to hospice on 7/24/20, with primary diagnosis of unspecified cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it). A review of Patient 2's "Plan of Care (POC)" dated 11/17/21, indicated the Skilled Nurse (SN) visit was once a week and as needed, the Medical Social Worker (MSW) visit was one time then as needed, the hospice aide (HA) service was declined. On 1/14/22, at 11:30 a.m., a home visit was conducted at Patient 2's residence. Patient 2 was observed lying in bed, alert, oriented, well-groomed, and able to move both upper and lower extremities. There were one LVN (license vocational nurse), one caregiver, and one CNA (certified nursing assistant) observed working in the patient's home. b. A review of Patient 4's face sheet indicated admission to hospice on 11/5/20, with primary diagnosis of senile generation of the brain. A review of Patient 4's "Plan of Care (POC)" dated 11/3/21 indicated the Skilled Nurse (SN) visit was once a week and as needed, the Medical Social Worker (MSW) visit was one time then as needed, and the hospice aide (HA) service was declined. On 1/14/22, at 11:30 a.m., a home visit was conducted at Patient 4's residence. Patient 4 was observed walking at the hallway using a walker. There were one LVN, one caregiver, and one CNA were observed working in the patient's home. c. A review of Patient 5's face sheet indicated admission to hospice on 3/16/21 with primary diagnosis of cerebral infarction. A review of Patient 5's "Plan of Care (POC)" dated 11/11/21, indicated the Skilled Nurse (SN) visit was once a week and as needed, the Medical Social Worker (MSW) visit was one time then as needed, the hospice aide (HA) service was declined. On 1/14/22, at 11:30 a.m., a home visit was conducted at Patient 5's residence. Patient 5 was observed lying in bed sleeping. There were one LVN, one caregiver, and one CNA observed working in the patient's home. d. A review of Patient 6's face sheet indicated admission to hospice on 12/17/21 with primary diagnosis of cerebral infarction. A review of Patient 6's "Plan of Care (POC)" dated 12/17/21 indicated the Skilled Nurse (SN) visit was once a week and as needed, the Medical Social Worker (MSW) visit was one time then as needed, and the hospice aide (HA) service was declined. On 1/14/22, at 11:30 a.m., a home visit was conducted at Patient 6's residence. Patient 6 was observed lying awake, alert, and oriented. There were one LVN (license vocational nurse) , one caregiver, and one CNA (certified nursing assistant) observed working in the patient's home. On 1/14/22, at 1:45 p.m., during an interview with LVN 1, he stated that he works from Monday to Sunday, 8 a.m. to 7 p.m., at the house where Patients 2, 4, 5 and 6 were residing. There are six tenants/hospice patients who chose to live in the house, and they pay their rent monthly coming out of their pockets. LVN 1 stated when he is off from work, there is an LVN on-call (LVN 2) for the patients. LVN 1 stated he lives 5 minutes away from the facility so if he is ever needed at night, he comes over to take care of the issues. LVN 1 also stated that his duties are to administer the medications, to provide wound treatment, supervise his staff with total patient care, and coordinate with patient's family and MD with their appointments. He also stated that there is always an assigned CNA and one caregiver scheduled to work during morning shift (7 a.m. to 7 p.m.) and afternoon/night shift (7 p.m. to 7 a.m.) everyday from Monday to Sunday. LVN 1 stated their duties are to provide bed baths, to assist with showers and feeding, change their diapers if soiled, clean the facility, and assist with patients ADLs. LVN 1 further stated that the assigned CNA, caregivers, and including himself are employed by the hospice agency. They provide 24 hour nursing care to the six active patients living in this house. In an interview on 1/18/22 at 1:00 p.m., the administrator stated the agency's corporation is leasing the house with a leasing company and considered this house as an "independent living environment." The administrator stated the agency pays the salary of LVN 1, CNA, and caregiver. The administrator stated that the agency gets reimbursed for hospice services from Medicare. A review of the agency's governing body minutes indicated that there was no documented evidence that a governing body exists that addressed the functioning hospice operations at the house of Patient 2, 4, 5, and 6.
L0664      
22303 Based on observation, interview and record review, the hospice facility failed to ensure the Condition of Participation for Medical Director was met as evidenced by: The medical director or physician designee (who is a hospice employee or under contract with the hospice) has the responsibility for the medical component of the hospice's patient care program, including initial certifications and recertifications of terminal illness for three of six sampled patients (Patients 1, 2 and 4) (refer to L 667). The cumulative effect of this systemic practice resulted in the failure of the hospice to deliver statutorily mandated compliance with Medical Director services to ensure highest quality of patient care are provided to the eligible patients certified for hospice services.
L0667      
35893 Based on observation, interview, and record review, the hospice medical director failed to ensure three of three patients (Patients 1, 2 and 4) in a sample of six included accurate clinical information necessary to certify the patients to receive hospice services. This deficient practice resulted in the provision of hospice services to patients who were not clinically eligible to receive hospice services. Findings: a. A review of Patient 1's face sheet indicated a start of care date of 11/26/21 with a primary diagnosis of heart disease (type of thickening or hardening of the arteries). A review of Patient 1's physician's orders dated 11/26/21, indicated Skilled Nurse (SN) services to visit the patient once a week as needed. The medical social worker (MSW), chaplain and volunteer services were ordered but indicated these services were declined. A review of Patient 1's Certification of Terminal Illness dated 11/26/21 was signed by the Medical Director. During an interview with the Director of Patient Care Services (DPCS) on 1/13/22 at 11:30 a.m., she stated the referral for hospice is received by the primary physician and sometimes via fax. The insurance and eligibility is checked if patient is qualified. The local coverage determination (LCD- provide guidance in determining medical necessity of services) is utilized by the nurse completing the initial assessment to determine hospice eligibility. On 1/14/22 at 10:40 a.m., a home visit was conducted at the board and care facility where Patient 1 resided. Patient 1 was observed in bed resting comfortably. During the visit Registered Nurse (RN 1) performed a head to toe assessment and vital signs. During an interview with RN 1 on 1/4/22 at 11:15 a.m., she stated the Patient 1's eligibility to receive hospice service was determined on the patient's need of assistance, depression, medication management, and decrease in appetite. RN 1 was queried about the LCD documentation for hospice eligibility, RN 1 stated LCD was used also but she did not check off the supporting factors for history/progression because she did not know. RN 1 stated she did not know the patient's primary physician or have no access to these records. During an interview with Patient 1 on 1/14/22 at 11:15 a.m., the patient stated that he needs help to get out of bed and does not have to use oxygen to be able to breathe. Patient 1 stated the nurse comes every week and checks his vital signs and listens to his lungs. Patient 1 stated he does have a primary physician before residing in the board and care. Patient 1 further stated he does not need additional services such as chaplain, social worker, and volunteers. During an interview with Patient 1's family member (FM) on 1/18/22 at 10: 50 a.m., FM stated Patient 1 needs assistance with care and help with mobility. FM stated that Patient 1 does not use any of the services from hospice (social worker, chaplain, and volunteer). FM stated Patient 1's health has been stable to the best of his knowledge. FM was unable to recall who referred the Patient 1 to hospice. During an interview with the Medical Director (MD) on 1/18/22 at 11:10 a.m., MD confirmed that there was no coordination between him and the Patient 1's attending or primary physician and did not know the patient primary physician. MD also confirmed he had not done the face to face encounter to Patient 1. MD used the nurse assessment and any documents from past medical history to determine the patient's hospice eligibility. During an interview with the Administrator at the board and care on 1/18/22 at 11:56 a.m., he stated he referred Patient 1 to hospice because they could not locate a primary physician. Patient 1 told the Administrator that he had a primary physician but Patient 1 could not recall the name and contact number. A review of Patient 1's supporting documentation provided by the Administrator revealed an assessment completed by a Rehabilitation Doctor located in Upland, CA in San Bernardino county. Phone calls and messages were made to the physician's telephone number identified in the assessment but no response received. 22303 b. A review of Patient 2's face sheet indicated admission to hospice on 7/24/20, with primary diagnosis of unspecified cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it). A review of Patient 2's "Plan of Care (POC)" dated 11/17/21, indicated the Skilled Nurse (SN) visit was once a week and as needed, the Medical Social Worker (MSW) visit was one time then as needed, the hospice aide (HA) service was declined. A review of Patient 2's Certificate of Terminal Illness (CTI), dated 7/24/20, Benefit period #1 were signed by the Medical Director and Physician 1 signed the attending physician section indicated Patient 1 had a life expectancy of six months or less, if the terminal illness runs its normal course. On 1/14/22, at 11:30 a.m., a home visit was conducted at Patient 2's residence. Patient 2 was observed lying in bed, alert and oriented, well groomed and able to move both upper and lower extremities. On 1/14/22, at 11:40 a.m., during an interview with Patient 2, she stated she does not need hospice care and she was not dying. Patient 2 also stated that she had a slight stroke and all she needed was physical therapy (PT) service. Patient 2 further stated that the hospice administrator told her in order to get PT service, she needs to sign up for their hospice services and her daughter referred her to this hospice facility. During an interview with the Medical Director (MD) on 1/18/22, at 11 a.m., he stated that he was not the attending physician and did not know who the attending physician was for Patient 2. MD also stated that since the patient was admitted to their hospice service, he is now the patient's attending physician. He further stated that he does not do a face to face encounter with the patient during their admission and he determines the patient is eligible for hospice services based on the patient's medical records provided by the hospital and assessment report given by the registered nurse upon her initial visit to the patient. On 1/18/22, at 12 p.m., during a phone interview with Patient 2's family member (FM), stated that she was not aware that Patient 2 had 6 months to live and patient does not need hospice services. FM also stated that Patient 2 had a slight stroke and she needs rehabilitation. On 1/18/22, at 1 p.m., during an interview with the DPCS was queried how the hospice facility admits their patients. DPCS stated that all patients being admitted to their hospice service should be referred by their attending physician with a referral order for hospice service. The hospice will send the registered nurse to perform the initial visit at the patient's residence and perform head to toe assessment using the Local Coverage Determination (LCD- provide guidance in determining medical necessity of services) guidelines to determine if the patient is hospice eligible and will report findings to their medical director. c. A review of Patient 4's face sheet indicated admission to hospice on 11/5/20, with primary diagnosis of senile generation of the brain. A review of Patient 4's "Plan of Care (POC)" dated 11/3/21, indicated the Skilled Nurse (SN) visit was once a week and as needed, the Medical Social Worker (MSW) visit was one time then as needed, the hospice aide (HA) service was declined. A review of Patient 4's Certificate of Terminal Illness (CTI), dated 11/5/20, Benefit period #1 was signed by the Medical Director and on the attending physician section (referring to hospice service) indicated Patient 1 had a life expectancy of six months or less, if the terminal illness runs its normal course. During an interview with the Medical Director (MD) on 1/18/22, at 11 a.m., he stated that he was not the attending physician and did not know who the attending physician was for Patient 4. MD also stated that since the patient was admitted to their hospice service, he is now the patient's attending physician. MD further stated that he does not do a face to face encounter with the patient during their admission and he determines the patient is eligible for hospice services based on the patient's medical records provided by the hospital and assessment report given by the registered nurse upon her initial visit to the patient. On 1/18/22, at 1 p.m., during an interview, the DPCS was queried how their hospice agency admits the patients, and stated that all patients being admitted to their hospice service should be referred by their attending physician with a referral order for hospice service. The agency will send their registered nurse to do the initial visit to the patient's residence and perform a head to toe assessment using the Local Coverage Determination (LCD- provide guidance in determining medical necessity of services) guidelines to determine if the patient is hospice eligible and will report findings to their medical director. On 1/18/22, at 2:05 p.m., during an interview with Patient 4's family member, he stated Patient 4 was not dying but she was getting weaker and needed assistance with her activities of daily living and medication regimen. Family member also stated that he referred the patient to this hospice facility with the help of the administrator. A review of the policy titled, "Admission Criteria and Process," indicated the patient must have a life-limiting illness with a life expectancy of six months or less as determined by the attending physician and hospice medical director, utilizing standard clinical prognosis criteria in the organization's intermediary local coverage determination.
L0686      
22303 Based on observation, interview and record review, the hospice facility failed to ensure the Condition of Participation for Drugs and Biologicals Medical Supplies and Dme was met as evidenced by: The hospice must maintain current and accurate records of the receipt and disposition of all controlled drugs (Refer to L 691). The cumulative effect of this systemic practice resulted in the failure of the hospice to deliver statutorily mandated compliance with dispensing of controlled drugs to ensure accountability and safe administration of drugs to the patients.
L0691      
22303 Based on observation, interview and record review, the hospice agency's licensed vocational nurse (LVN 1) failed to maintain accurate records of the receipt and disposition of all controlled drugs for four of six sampled patients (Patient 2, 4, 5 and 6). LVN 1 who administered the patient's controlled medications failed to record date and amount of medication administered in the narcotic sheet. This deficient practice has the potential risk that the accuracy and accountability of the controlled drugs will not be maintained and monitored that could result to unauthorized use of these drugs by the hospice staff and other healthcare personnel. Findings: On 1/14/22, at 11:30 a.m., a joint visit was conducted at the house where Patient 2, 4, 5, and 6 resided. On 1/14/22, at 1:45 p.m., during an interview with LVN 1, he stated that he works at the house from Monday to Sunday, from 8 a.m. to 7 p.m. There are six hospice patients, who are residing in the house. LVN 1 also stated that his duties are to administer the medications, to provide wound treatment, to supervise the CNA and caregiver, and to coordinate with the patients' families and physicians with the patients' appointments. LVN 1 stated that there is one CNA and one caregiver that work during the morning shift from 7 a.m. to 7 p.m. and night shift form 7 p.m. to 7 a.m., daily. LVN 1 stated that the CNA and caregiver duties included to provide bed baths, to assist with showers and feeding, to change their diapers if soiled, and to clean the facility. They provide 24 hour nursing care to the six active patients living in the house. a. Patient 2's clinical record was reviewed. A review of Patient 2's face sheet indicated the patient was admitted to the hospice agency on 7/24/20, with primary diagnosis of unspecified cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it). A review of Patient 2's "Plan of Care (POC)" dated 11/17/21, indicated the Skilled Nurse (SN) visit was once a week and as needed, the Medical Social Worker (MSW) visit was one time then as needed, the hospice aide (HA) service was declined. Patient 2's physician's order dated 7/24/20, to administer Morphine Sulfate IR (Roxanol) 20 mg (milligrams) per ml (milliliters) 5 mg/0.25 ml oral/sublingual every 6 hours as needed for severe pain, to administer Ativan 0.5 mg one tab oral every four hours as needed for anxiety On 1/14/22, at 11:30 a.m., during a home visit at Patient 2's residence, Patient 2 was observed lying in bed, alert and oriented, well groomed and able to move both upper and lower extremities. At 11:50 a.m., during an observation and a concurrent medication reconciliation with LVN 1, he showed the bottles of medications and medication bubble packs the patient were currently taking. There was a bottle of Morphine Sulfate 100 mg/5 ml medication and there were 5 ml left in the bottle. The label stated the bottle had 15 ml when it was filled on 8/14/21. A total of 10 ml of medication were dispensed from the bottle. A review of Patient 2's Morphine Sulfate 100 mg/5 ml Controlled Medication Record sheet indicated no documented evidence of the Sulfate 100 mg/5 ml medication was administered, indicating the dosage given, time, and who administered the medication. The Controlled Medication Record sheet was left blank. Patient 2's medications also included Ativan 0.5 mg bubble pack medication with a label indicating there were 27 tablets with a filled date of 8/14/21. A total of 2 tablets were dispensed from the bubble pack and there were 25 tablets remaining in the bubble pack. A review of Patient 2's Ativan 0.5 mg medication Controlled Medication Record sheet indicated no documented evidence when the medication was administered, amount, dosage, and who administered the medication. The Controlled Medication Record sheet was left blank. On 1/14/22, at 12:10 p.m., during an interview with LVN 1, stated he administered Morphine Sulfate and Ativan medications for Patient 2 and did not document the Morphine and Ativan medication administered to the patient in the Controlled Medication Record sheet. b. Patient 4's clinical record was reviewed. A review of Patient 4's face sheet indicated the patient was admitted to the hospice agency on 11/5/20, with primary diagnosis of senile generation of the brain. A review of Patient 4's "Plan of Care (POC)" dated 11/3/21, indicated the Skilled Nurse (SN) visit was once a week and as needed, the Medical Social Worker (MSW) visit was one time then as needed, the hospice aide (HA) service was declined. Patient 4's physician's order dated 11/5/20, included to administer Morphine Sulfate IR (Roxanol) 20 mg (milligrams) per ml (milliliters) 5 mg/0.25 ml oral/sublingual every 6 hours as needed for severe pain, to administer Ativan 0.5 mg one tab oral every four hours as needed for anxiety On 1/14/22, at 11:30 a.m., during a home visit at Patient 4's residence, Patient 4 was observed walking at the hallway using a walker. At 12:35 p.m., during an observation and a concurrent medication reconciliation with LVN 1, LVN 1 showed the bottles of medications and medication bubble packs the patient were currently taking. There was a bottle of Morphine Sulfate 100 mg/5 ml medication and there were 12 ml contents left in the bottle. The label stated the bottle had 15 ml contents when it was filled on 6/15/21. A total of 3 ml of medication were dispensed from the bottle. A review of Patient 4's Morphine Sulfate 100 mg/5 ml Controlled Medication Record sheet indicated that on 10/6/21 at 2:30 p.m., .25 ml of Morphine was administered and there was 12 ml left in the bottle. However, there was no documented evidence when the remaining 2.75 ml of Morphine medication was administered, amount, dosage, and who administered the medication. The Controlled Medication Record sheet was left blank. There was an Ativan 0.5 mg bubble pack medication with a label stating there were 22 tablets with a filled date of 6/15/21. A total of 9 tablets were dispensed from the bubble pack and there were 13 tablets remaining in the bubble pack. A review of Patient 4's Ativan 0.5 mg medication Controlled Medication Record sheet indicated no documented evidence when the medication was administered, amount, dosage, and who administered the medication. The Controlled Medication Record sheet was left blank. On 1/14/22, at 12:50 p.m., during an interview with LVN 1, he stated he administers Morphine Sulfate and Ativan medications for Patient 4 and did not document the Morphine and Ativan medication administered to the patient in the Controlled Medication Record sheet. c. Patient 5's clinical record was reviewed. A review of Patient 5's face sheet indicated the patient was admitted to the hospice agency on 3/16/21, with primary diagnosis of cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it). A review of Patient 5's "Plan of Care (POC)" dated 11/11/21, indicated the Skilled Nurse (SN) visit was once a week and as needed, the Medical Social Worker (MSW) visit was one time then as needed, the hospice aide (HA) service was declined. Patient 5's physician's order dated 3/16/21, included to administer Morphine Sulfate IR (Roxanol) 20 mg (milligrams) per ml (milliliters) 5 mg/0.25 ml oral/sublingual every 6 hours as needed for severe pain, to administer Ativan 0.5 mg one tab oral every four hours as needed for anxiety On 1/14/22, at 11:30 a.m., during a home visit at Patient 5's residence, Patient 5 was observed lying in bed sleeping. At 1 p.m., during an observation and a concurrent medication reconciliation with LVN 1, LVN 1 showed the bottles of medications and medication bubble packs the patient were currently taking. There was a bottle of Morphine Sulfate 100 mg/5 ml medication and there were 5 ml contents left in the bottle. The label stated the bottle had 15 ml contents when it was filled on 6/15/21. A total of 10 ml of medication were dispensed from the bottle. A review of Patient 5's Morphine Sulfate 100 mg/5 ml Controlled Medication Record sheet indicated no documented evidence when the medication was administered, amount, dosage, and who administered the medication. The Controlled Medication Record sheet was left blank. There was an Ativan 0.5 mg bubble pack medication with a label stating there were 26 tablets with a filled date of 3/16/21. A total of 4 tablets were dispensed from the bubble pack and there were 22 tablets remaining in the bubble pack. A review of Patient 5's Ativan 0.5 mg medication Controlled Medication Record sheet indicated no documented evidence of when the medication was administered, amount, dosage , and who administered the medication. The Controlled Medication Record sheet was left blank. On 1/14/22, at 1:30 p.m., during an interview with LVN 1, stated he administered Morphine Sulfate and Ativan medications for Patient 5 and did not document the Morphine and Ativan medication administered to the patient in the Controlled Medication Record sheet. d. Patietn 6's clinical record was reviewed. A review of Patient 6's face sheet indicated the patient was admitted to the hospice agency on 12/17/21, with primary diagnosis of cerebral infarction. A review of Patient 6's "Plan of Care (POC)" dated 12/17/21, indicated the Skilled Nurse (SN) visit was once a week and as needed, the Medical Social Worker (MSW) visit was one time then as needed, the hospice aide (HA) service was declined. Patient 6's physician's order dated 12/17/21, to administer Morphine Sulfate IR (Roxanol) 20 mg (milligrams) per ml (milliliters) 5 mg/0.25 ml oral/sublingual every 6 hours as needed for severe pain, to administer Fentanyl Patch 25 mcg (micrograms) per hour to apply one patch transdermally every 72 hours for pain management. On 1/14/22, at 11:30 a.m., a home visit was conducted at Patient 6's residence. Patient 6 was observed lying awake, alert and oriented. On 1/14/22, at 2 p.m., during an observation and a concurrent medication reconciliation with LVN 1, showed the bottles of medications and medication bubble packs the patient were currently taking. There was a bottle of Morphine Sulfate 100 mg/5 ml medication and there were 5 ml contents left in the bottle. The label stated the bottle had 15 ml contents when it was filled on 12/18/21. A total of 10 ml of medication were dispensed from the bottle. A review of Patient 6's Morphine Sulfate 100 mg/5 ml Controlled Medication Record sheet indicated no documented evidence when the medication was administered, amount, dosage, and who administered the medication. The Controlled Medication Record sheet was left blank. There was one package of Fentanyl Patch medication with a total of 2 Fentanyl Patch left in the packet. The Fentanyl Patch packet had a label stating there were 5 Fentanyl Patch medications inside one packet with a filled date of 12/18/21. A total of 3 patches were dispensed and there were only two Fentanyl Patches left in the pack. A review of Patient 6's Fentanyl Patch 25 mcg/HR medication Controlled Medication Record sheet indicated no documented evidence of the 3 Fentanyl Patches that were administered as to when the medication was administered, amount, dosage and who administered the medication. The Controlled Medication Record sheet was left blank. On 1/14/22, at 2:30 p.m., during an interview with LVN 1, stated he administered Morphine Sulfate and Fentanyl Patch medications for Patient 6 and did not document the Morphine and Fentanyl Patch medications administered to the patient in the Controlled Medication Record sheet. On 1/18/22, at 1 p.m., during an interview with RN 1, she stated that she does supervisory visit at the patient's residence. She also stated that during her visits, she she checks physician's orders and medication reconciliation and refills. RN 1 also stated her last visit was on 1/11/22, and there were no issues with all the patient's medications. On 1/18/22, at 1:30 p.m., during an interview with the DPCS (director of patient care services), she stated that staffs should be documenting administered narcotic medications in the narcotic sheet at all times. A review of the agency policy titled, "Home Use and Disposal Of Controlled Substances", indicated that controlled drugs will be accounted for on a narcotic count record, which will be maintained as part of the clinical record.