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
A01538 A. BUILDING __________
B. WING ______________ 		09/22/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
CHARTER HOSPICE OF SAN DIEGO LLC 16955 VIA DEL CAMPO , SUITE 100, SAN DIEGO, CA, 92127
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)
L0526      
36708 Based on interview and record review, the agency failed to ensure a comprehensive assessment included safety risk factors for one sampled patient (1). As a result, Patient 1's ability and risk for committing suicide was not fully assessed. Findings: An investigation of an entity reported adverse event was initiated on 2/18/20. It was reported to the California Department of Public Health that on 1/22/20, Patient 1 committed suicide. Per the hospice agency's Patient Profile, Patient 1 was admitted to the agency on 11/18/19, with diagnoses that included malignant neoplasm (cancer) of the prostate. During an interview on 2/18/20 at 1 P.M. with the Administrator (Admin), the Admin stated Patient 1 lived at home with the wife as his caregiver; on 1/21/20, the wife left for 20 minutes, came back home and found Patient 1 deceased in their backyard and that he had shot himself. During a record review on 2/18/20, a document titled Hospice Nursing Initial Comprehensive Assessment, dated 11/19/19 indicated a section titled Living Arrangements/Environmental, Risk factors that may impact Care Plan; nothing was marked or written on this section. On the section titled Psychosocial, Psychosocial/ Environmental Care Plan Items, this was marked as N/A (not applicable), no Psychosocial/Environmental problems identified. There was no section or documentation if Patient 1 and his wife were asked if they kept guns in the house. Additional records were reviewed on 2/18/20, a document titled Medical Social Services Assessment dated 11/19/19, the section Environmental was marked no safety issues were identified. During an interview with the Admin on 2/18/20 at 1:50 P.M., the Admin stated that on 1/21/20, the day of the incident, Patient 1's wife said they owned guns and they were stored in a locked cabinet. The Admin further stated the agency did not have a specific protocol to ask about guns. During interviews on 2/19/20 at 10:30 A.M. with Registered Nurse (RN) 1 and the Social Worker (SW), RN 1 stated on his admission assessment, there was no discussion related to weapons kept at home. The SW stated on her visits, Patient 1 had expressed interest in the California End of Life Option Act but his physicians would not sign it. The SW further stated Patient 1 had not expressed suicidal ideations during visits. The agency did not have a policy and procedure or best practice checklist related to safety at home that included questions about weapons kept at home.