Survey Report for 051528

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
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION	051528	A. BUILDING __________ B. WING ______________	02/12/2020
NAME OF PROVIDER OR SUPPLIER	STREET ADDRESS, CITY, STATE, ZIP
ELIZABETH HOSPICE	500 LA TERRAZA BLVD SUITE 130, ESCONDIDO, CA, 92025
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)
L0511
L0511	36471 Based on interview and record review, the agency failed to report an allegation of physical abuse to the State Department, licensing and certification for 1 of 2 sampled patients. As a result, there was a potential for the abuse incident not to have been investigated by the State Department. Findings: Patient 1 was admitted to the agency on 11/7/17 with diagnoses which included carcinoma (a type of cancer), per the agency's Patient Information. On 1/30/20, a record review was conducted. Per the Charts/Clinical Notes, dated 12/12/18, Medical Social Worker (MSW) documented a volunteer made the MSW aware that Patient 1 reported someone had tried to give her a shower and when she refused, they hit Patient 1. On 1/30/20 at 1:30 P.M., an interview was conducted with the Director of Quality and Compliance Privacy Officer (DQCPO). The DQCPO stated all allegation of abuse should be reported to the Department and staff should follow the agency's standard of practice. The DQCPO stated all employees were mandated reporters, whoever discovered or suspected any abuse should report. The DQCPO further stated there was no evidence that the MSW reported the allegation to the State Department. Per the agency's standard of practice, revised 1/20, titled Reporting Suspected Abuse, Neglect and Exploitation, "...If the suspected abuse was physical...Submit the written report (California Department of Social Services SOC341) to law enforcement, LTCOP [Long-Term Care Ombudsman Program] and appropriate licensing agency within 24 hours..."