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 ______________ 		07/20/2022
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)
L0798      
36471 Based on interview and record review, the agency failed to notify the Department of an allegation of mistreatment for 1 of 2 sampled patients (1). As a result, the Department could not verify the patient's safety. Findings: Patient 1 was admitted to the agency on 1/26/22 with diagnoses which included malignant neoplasm of the biliary tract (cancer in the slender tubes that carry the digestive fluid bile through the liver) per the agency's Case Sheet. A review of Patient 1's clinical record was conducted. Per the Home Health Aide/Homemaker Note, dated 3/29/22, Certified Home Health Aide (CHHA) 1 documented that she tried to take Patient 1's shirt off and complained of pain when CHHA 1 touched Patient 1, so CHHA 1 requested to see the bottle of medication to see if Patient 1 could take pain medication at this time, the family member got mad and asked CHHA 1 to leave [Patient 1] alone. On 5/11/22 at 9:55 A.M., an interview was conducted with the Patient Care Administrator (PCA) 1. PCA 1 stated on 3/29/22, when CHHA 1 was supposed to provide a bed bath, there was no allegation of abuse or mistreatment. PCA 1 said the family member requested CHHA 1 to leave their house. PCA 1 stated mid-April when Adult Protective Service called and filed a complaint against CHHA 1. PCA 1 said the investigation and in-progress. On 5/12/22 at 1:50 P.M., an interview was conducted with the CHHA 1. CHHA 1 stated she was unfamiliar with Patient 1, and on 3/29/22, she was supposed to provide a bed bath to Patient 1. CHHA 1 said she did not ask Patient 1 about pain before removing the clothes, and when she lifted Patient 1's arm to remove the clothing, Patient 1's complained of pain, so she inquired about giving Patient 1 pain medicine and the family member got mad. The family member asked CHHA 1 to leave the house. CHHA 1 explained herself to the family member and called PCA 1. On 5/12/22 at 4:43 P.M., an interview was conducted with Skilled Nurse (SN) 1. SN 1 stated she was the nurse that visited Patient 1 the next day after CHHA 1. SN 1 said the family member told her that CHHA 1 was too rough with Patient 1. SN 1 stated she listened to the family member but did not ask further questions as she did not want to be involved. SN 1 further said the family member told her the agency was aware of the incident. On 6/6/22 at 3 P.M., an interview was conducted with PCA 1. PCA 1 stated she did not report the allegation of abuse to the Department and should have been reported. On 6/14/22 at 1 P.M., an interview was conducted with the Social Worker (SW). The SW stated on 4/26/22 at 3:30 P.M., she received a report from the Adult Protective Services about CHHA 1 mishandling Patient 1 and relayed the information to PCA 1 the same day. There was no documented evidence that the allegation of mistreatment was reported to the Department by the agency. Per the agency's Management Standard, dated 2021, titled Reportable Events, "... the program senior management is responsible for ensuring suspicion is reported no later than 24 hours after notification of the suspicion. The report must be made directly to local law enforcement and the state survey agency within 24 hours..."