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
101536 A. BUILDING __________
B. WING ______________ 		08/06/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
OPUS CARE OF SOUTH FLORIDA 6900 SW 80TH ST, MIAMI, FL, 33143
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)
L0500      
36646 Based on record reviews, observations and interviews, the hospice failed to maintain the patient's rights to be free from sexual abuse for 1 out of 7 sample patients. Sample Patient (SP) #1. While providing care to SP#1, the Hospice Care CNA sexually abused SP #1. The Hospice CNA forcefully held SP #1's hand to stimulate the CNA's penis. (Refer to L517)
L0517      
36646 Based on record review, interview, and video observation, the hospice failed to ensure that the right of the patient to be free from mistreatment, neglect, or verbal, mental, sexual, and physical abuse, be enforced posing risk to patient safety while providing care forcefully holding the patient's hand to stimulation the CNA's penis, posing a likelihood of harm to patient safety for 1 out of 7 sample patients (SP #1). Findings include: Review of patient information for SP #1 showed the patient started hospice care on 5/15/2020. SP#1's Medical Diagnosis: Cerebral atherosclerosis; vascular dementia without behavioral disturbance; essential (primary) hypertension; sepsis unspecified organism. Review of Certification Period 3/11/2021 to 5/9/2021 and 5/10/2021 to 7/8/2021 showed SP #1 receive Aide services 6 times (x) a week for 8 weeks. Intervention included complete bed bath. Interview with the Hospice Administrator on 7/16/2021 at 9:30 AM revealed that on Friday 5/14/2021, the hospice was notified by Department of Children and Families (DCF) they were investigating sexual abuse committed by CNA to SP#1. The Hospice Administrator stated the CNA was immediately terminated. The hospice removed his access to all and any patient information or company data. Their Human Resources (HR) department was notified and the Chief Executive Officer (CEO) of the hospice. The Police requested the hospice have the CNA to come in and from then, upon his arrival he was arrested. The Hospice Administrator stated the sexual abuse happened at the patient's home. Sampled Patient #1's daughter works at home. Sampled Patient #1's daughter reviewed the video at their home, and observed on the video what the CNA did to SP#1. Interview with Sampled Patient #1's daughter on 7/23/2021 at 2:51 PM revealed: She called DCF abuse hot line. She stated the incident happened on 5/7/2021 around 10:04 AM. The daughter stated when she saw the CNA on the side, his hand was holding SP#1's hand and the CNA's hand holding SP#1's hand on top of his penis, over his pants. The daughter stated when she entered the room the CNA turned around, became nervous and he started to talk about other stuff nervously. So she went to her home office and rewound the video and saw what the CNA was doing. The daughter stated SP#1 has advanced Alzheimer's disease. Before May 7th, SP#1 showed disdained for the CNA. She stated SP#1 would punch the CNA. The daughter stated the family thought the behavior was part of SP#1's Alzheimer's. She stated SP#1 would call the CNA names, although he could say one or two words and not complete sentences. The family started noticing more and more of this behavior; and SP#1 was getting more aggressive. Every time SP#1 would see the CNA, SP#1 got so angry. On May 8th, with the new CNA, SP#1 did not punch the CNA. Subsequent too May 7th with the new CNA, SP#1 is not punching; is cooperative; not refusing care. A review of the arrest affidavit obtained from the Miami Police Department conducted on 7/28/2021 revealed the following: On Friday May 7, 2021, at approximately 1004 hours, the defendant (CNA) was seen on video surveillance tending to the care of the victim (SP#1) in his bedroom. At approximately 8:28 PM, Detectives conducted an audio recorded statement of the defendant. The defendant was read his constitutional rights per form in Spanish and he agreed to give a statement without an attorney being present. The Detectives confronted the defendant with the allegations and showed him the video of the incident. The defendant stated he was sorry and felt ashamed. On 8/5/2021, the surveyor observed the video dated 5/7/2021 timed 10:04, and made the following observations: (Video starts at 2021-10:04 and ends at 2021 - 10:07:38) 2021-05:07-CNA grabs patient's right hand and places it on CNA's penis with pants on. 2021-05:33-CNA is holding patient's right hand on his penis with pants on. 2021-05:47-Patient snatches his right hand from CNA's penis with pants on. 2021-05:49-CNA grabs patient's right hand and holds it on his penis with pants on. 2021-05:56-CNA walks off camera. 2021-06:03-CNA is seen undoing his pants. 2021-06:12-CNA grabs patient's right hand and places it on his penis. 2021-06:42 through 2021-07:34-CNA grabs patient's right hand and start using the patient's right hand to stroke his penis in a rapid motion. Simultaneously the patient is seen resisting by removing their right hand, and the CNA continually grabbing and holding the patient's right hand on his penis. 2021-07:34-Female (daughter of patient) enters the room, the CNA is startled and stops using the patient's right hand to stroke his penis. 2021 - 07:38 - end of the video recording.