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
051597 A. BUILDING __________
B. WING ______________ 		01/30/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
VITAS HEALTHCARE CORPORATION OF CALIFORNIA 9655 GRANITE RIDGE DRIVE, SUITE 300, SAN DIEGO, CA, 92123
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      
38443 Based on interview and record review, the Hospice agency failed to follow the regulation for reporting unusual occurrences to the state licensing and certification agency. This failure caused a delay in investigation by the State Licensing and Certification Agency. Findings: Patient 1 was admitted to the hospice agency on 7/16/19. On 7/25/19, the hospice received a call from patient 1's son, to let the hospice know, Patient 1 lit a cigarette while on oxygen. The oxygen reacted and caused burns to Patient 1's face. A Licensed Nurse (LN), visited patient 1 on 7/25/19 and Patient 1 went to the hospital for evaluation. On 8/7/19 at 1:39 P.M., the hospice called the state agency to report the incident (14 days after the incident occurred). On 8/27/19 at 2:35 P.M., the Patient Care Administrator stated the incident happened on 7/25/19. The Patient Care Administrator further stated she didn't know it needed to be reported to the state licensing and certification agency, until she was informed by the agency's resource consultant. On 8/27/19 at 3:25 P.M., the Patient Care Administrator stated there was a delay in reporting to the State Licensing and Certification Agency Per policy: Page 409 Vitas Management Standard: #4." Team Manager (TM)/Patient Care Administrator (PCA) will evaluate the need to report the incident to a State or Federal Agency. State regulations should be accessed and reviewed via the State's regulatory website in order to assure access to the most current state regulations." Per the California Hospice and Palliative Care Associated Standards of Quality Hospice Care, 2005, Section 6.4 Reporting Requirements, B Unusual Occurrences,1-d Patient injury as a result of medical or nursing malfeasance or nonfeasance. 2. The report shall be made by the next Department workday either by telephone (and confirmed in writing) or in person to the Department..."
L0544      
38443 Based on observation, interview, and record review, the Hospice agency failed to provide education to the patient or their primary caregiver(s) related to safety and use of oxygen for four of 44 sampled residents (1, 2, 3, 4) This failure resulted in Patient 1 smoking while using oxygen and sustained burns to the facial area. In addition, this failure had the potential to place Patient's 2, 3 and 4 at risk for a burn injury. Findings: 1. Patient 1 was admitted to the hospice agency on 7/16/19. On 8/27/19 at 3:10 P.M., a concurrent record review and interview was conducted with the Patient Care Administrator. The Patient Care Administrator was unable to find documentation of patient/caregiver safety training related to the use of oxygen and smoking for Patient 1, who was a known smoker. The Patient Care Administrator stated patient 1 should have received education on the use of oxygen and smoking during the admission assessment. 39448 2. Patient 2 was admitted to the agency on 7/6/19 with diagnoses to include End Stage Kidney Disease (kidney failure) per the agency's Case Sheet. Per the agency's RN-Initial Comprehensive Assessment, dated 7/8/19, Patient 2 was a smoker. Per the agency's Plan of Care Review on 7/16/19, oxygen was available to Patient 2. There was no documentation to indicate the agency provided oxygen safety education to Patient 2. On 12/17/19 at 10:20 A.M., an interview was conducted with the PCA. The PCA stated, if there were smokers in the patient's home, the agency should have provided oxygen safety education. On 12/17/19 at 3:45 P.M., a concurrent interview and record review was conducted with the PCA and the NPCA (National Patient Care Administrator). The NPCA was unable to find documentation of patient/caregiver training related to the use of oxygen and smoking for Patient 2. The NPCA stated, oxygen safety education should have been documented on the care plan for patients with oxygen that was available for use. 3. Patient 3 was admitted to the agency on 7/6/19 with diagnoses to include dementia (a progressive physical and mental decline) per the agency's Case Sheet. Per the agency's Nursing-Updated Comprehensive Assessment, dated 7/29/19, oxygen was available to Patient 3. There was no documentation to indicate the agency provided oxygen safety education to Patient 3. On 12/17/19 at 3:45 P.M., a concurrent interview and record review was conducted with the PCA and the NPCA (National Patient Care Administrator). The NPCA was unable to find documentation of patient/caregiver training related to the use of oxygen for Patient 3. The NPCA stated, oxygen safety education should have been documented on the care plan for patients with oxygen that was available for use. On 1/24/20 at 11:30 A.M., a concurrent interview and record review was conducted with SN 1 (Skilled Nurse). SN 1 stated, she should have documented oxygen education for Patient 3. 4. Patient 4 was admitted to the agency on 1/17/20 with diagnoses to include malignant neoplasm (cancer) per the agency's Case Sheet. On 1/24/20 at 10:09 A.M., an observation and interview was conducted with CM 1 (Case Manager). There was no oxygen safety sign posted outside Patient 4's door. CM 1 stated, Patient 4 started using oxygen on the previous day. CM 1 further stated, Patient 4 was smoking up until a couple days before oxygen was started. On 1/24/20 at 10:30 A.M., an interview was conducted with Patient 4's RP (Responsible Party). The RP stated, she did not remember the hospice agency posting or providing an oxygen safety sign to her when the oxygen was delivered. On 1/24/20 at 10:45 A.M., an observation and interview was conducted with CM 1. CM 1 searched Patient 4's oxygen supplies for an oxygen safety sign, but was unable to locate one in Patient 4's home. CM 1 stated, she did not usually provide an oxygen safety sign to post outside of the patient's home if the patent lived in an assisted living facility or at a home. On 1/24/20 at 12:05 P.M., an interview was conducted with CM 2. CM 2 stated, they should post an oxygen safety sign outside of the door of patients with oxygen in the home regardless of facility type. On 1/29/20 at 8:30 A.M., a telephone interview was conducted with the facility's nurse. The facility's nurse stated, when a hospice patient was using oxygen at their facility, the hospice should have posted an oxygen safety sign at the patient's door. Per the undated Vitas Standard, "...3. Oxygen Safety 1. The POC (Plan of Care) should include patient/family safety education and other related safety measures when oxygen is ordered for the patient, including: 1. No smoking in room with oxygen 1. Applies to both patient and others in the room 2. Post signs stating that oxygen is in use as well as No Smoking signs 3. Avoid open flames (candles, lighters, etc.) within five feet of the oxygen source and the patient..."