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
050103 A. BUILDING __________
B. WING ______________ 		09/01/2023
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
ADVENTIST HEALTH WHITE MEMORIAL 1720 CESAR E CHAVEZ AVENUE, LOS ANGELES, CA, 90033
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)
E0007 Ep Program Patient Population
Corrected On:
46739 Based on interview and record review the facility failed to provide an Emergency Preparedness Program (intended to facilitate and organize employer and worker actions during workplace emergencies) Patient Population Policy that outlines the persons at-risk, the types of services that patients require, and the needs of the patients at the facility. This deficient practice had the potential to affect how the facility addresses the needs of patients during an emergency, which may cause patient harm and/or death. Findings: During an interview on 9/1/2023, at 12:00 p.m., with the Manager for Accreditation, Regulatory Compliance (MARC), a list outlining the documents needed for the Emergency Preparedness (EP) review was presented to the MARC. It was requested that the facility staff provide all the EP documents, including the EP Program Patient Population Policy, and the MARC stated that he would deliver the list to the Director of Emergency Management (DEM) and that the DEM would prepare all the requested documents for review. During a concurrent interview and record review on 9/1/2023, 3:30 p.m., with the DEM, a document titled "AH White Memorial Population Assessment 2022" was presented as the EP Program Patient Population Policy. The policy did not include details of the patient population, including, persons at-risk; the type of services the facility could provide in an emergency; and continuity of operations, including delegations of authority and succession plans. The Population Assessment was noted to include details of the ethnicity, age, and income ranges of the patients that are served by the facility. The DEM stated that was the available population policy and that he would look for another population policy that included the details about the persons at-risk and the type of services the facility could provide in an emergency. During an interview on 9/1/2023, at 4:00 p.m., with the DEM, it was requested that the DEM provide the Emergency Preparedness Program Patient Population Policy with the persons at-risk; the type of services the facility could provide in an emergency; and continuity of operations, including delegations of authority and succession plans. It was noted that the DEM, nor any other facility staff, did not provide any other Emergency Preparedness Program Patient Population Policy to the survey team before the exit conference on 9/1/2023 at 6:30 p.m.
E0018 Procedures For Tracking Of Staff And Patients
Corrected On:
46739 Based on interview and record review, the facility failed to maintain functional Procedures for Tracking of Staff and Patients Policy. This failure had the potential for staff to lose track of patients during an emergency power outage, which could pose a risk to patient safety. Findings: During a concurrent interview and record review, on 9/1/2023, at 3:30 p.m., with the Director of Emergency Management (DEM), the DEM provided "Policy No. 22128, Department: Emergency and Disaster Management, Policy: Department Emergency Response Procedures Manual" for review to meet the requirements of the Procedures for Tracking of Staff and Patients Policy. The DEM stated that HICS (Hospital Incident Command System-assists hospitals and healthcare organizations in improving their emergency management planning, response, and recovery capabilities for unplanned and planned events) 260 – Patient Evacuation Tracking Form would be used to track patients during an emergency. The DEM also said that the policy indicated "The HICS 260 – Patient Evaluation Tracking Form documents details and account for patients transferred to another facility." The DEM stated that the HICS 260 Forms would need to be printed out for use during an emergency. The DEM further said that it would not be possible to print the forms during a power outage and that the HICS 260 Form would therefore not be available to be used during a power outage. During a review of the record titled, "Policy No. 22128, Department: Emergency and Disaster Management, Policy: Department Emergency Response Procedures Manual," last reviewed on 8/19/2021, the policy did not indicate how the facility would provide staff with forms during a power outage.