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 ______________ 		02/19/2020
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)
L0554      
38443 Based on interview and record review, the hospice agency failed to ensure the policy was followed related to a potential threat or suicide for 1 of 1 sampled patients. (1) This failure had the potential to place Patient 1's safety and/or life at risk. Findings: Patient 1 was admitted to the hospice agency on 10/7/19 with diagnoses which included heart failure (failure of the heart to function properly) and ischemic cardiomyopathy (disease of heart muscle, narrowing of arteries which supply blood to the heart). Per the document, titled "Supplemental Interdisciplinary Note," indicated that on 10/24/19 at 11:50 P.M., Patient 1's primary caregiver informed the hospice agency that patient 1 had taken ten baclofen (muscle relaxant), two Norco (pain medications) and one Ativan (antianxiety medication). On 1/31/20 at 1:03 PM, Chaplain 1 stated he made a visit to the patient's home at approximately 3:15 P.M. on 10/25/19, to check on Patient 1. Chaplain 1 stated the primary caregiver did not grant him access inside the home and also the primary caregiver informed him patient had taken "10 muscle relaxers." Chaplain 1 stated he did not call 911. On 1/31/20 at 1:30 P.M., the Team Manager Licensed Nurse, stated she was made aware of the potential drug overdose on 10/25/19 at approximately 8:25 a.m. The Team Manager stated she did not call 911 to have a welfare check done, (8-hour and 35 minutes after first contact with agency regarding the possible overdose). On 1/31/20 at 2:15 P.M., Chaplain 2 stated he spoke with the primary caregiver on 10/24/19 at 11:50 P.M., and was informed patient had taken "10 muscle relaxants, 2 oxycodone, and Lorazepam." He stated he did not call 911. On 1/31/20 at 2:25 P.M., the Social Worker stated when she arrived at Patient 1's home, she could not immediately gain access, and could not reach the primary care giver by phone. The Social Worker further stated she did not call 911. On 1/31/19 at 3:30 P.M., the Patient Care Administrator stated 911 was not called, and further stated 911 should have been called by the hospice staff as soon as they were aware of the potential overdose, to have a welfare check done. Per the Hospice agency's VITAS Standard, titled "VS Responding to Suicidal Ideation or Suicide, updated 6.12.19, ...3. If team member receives notification via a phone call from a patient or family member that threat for suicide is immediate: i. Call 911, explain the situation and give the location ..." and, iii go to the patient/family's home/facility once emergency staff have arrived ..."