Sap-24-201512106 PM PROCARE OXNARD 805-983-15?8 2 i 6 sec or: HEALTH AND HUMAN ssawcas PRINTED: oust/2015 WET 0F Dsi-lcleivcrEs VIDERISUPPLIERIGLIA CONETRUCTIDM AND PLAN or CORRECTION on) TEENTIFICATIDN NUMBER: fw- mag-$111335" 0 061710 EWING 07/01/2515 Ween on SUPPLIER cm. corsets coos 1700 LOMBARD or 51's 21d SPICE PRDGARE HO OXNARD. CA 93030 (X4) ID SUMMARY STATEMENT OF DEFICIENGIES ID p?ovm?ng PLAN op 0(5) (EACH oesiclancv mus-r as ensceoso av FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE commotion TAB REGULATORY DR L3G IDENTIFYING INFORMATION) TAB CROSS-REFERENCE TO THE APPROPRIATE DATE poo Exercise of Rights/?ance for 000 INITIAL COMMENTS (Ky The following reflects the ?ndings of the L511 1' Collfornia Department of Public Health. Licensing i; Milo? Taken 9? and Certi?cation, during an investigation of one - UPON ?913Wi to the PGEPIE 0* potential 8 Entity Reported Incident (ERI) on a Complaint violation of patients rights. violation ls K.) Validation survey. Wired! - 2.Actlon to Protect Patients: ?a ERI CA00443873 Su betantlated. .All patients and families are informed of 3 he occurrence. Facilities and their staff are L) Representing the Department: informed . C) HFEN -31401 b. Patients and families are instructed to request and Inspect picture name badge The Inspection was limited to the speci?c entity Prior to admission of staff member to that reported incident and does not represent the 5,11 home and to report immediately to the if ?ndings or a full Inspection of the agency. hospice any person attempting entry 511 EXERCISE OF Ithout proper identification. FOR [The hospice must] (iv) Ensure that veri?ed violations are reported to State and local bodies having jurisdiction (including to the State survey and certi?cation agency) within 5 working days of becoming aware of the violation. This STANDARD is not met as evidenced by: Based on Interview and record review, the Hospice Agency failed to report to California Department of Public Health. Licensing and Certification when: Two of five patients (Patients 1 and 2) Morphine (controlled medication for pain) were stolen from the patients' homes. 2. A person claiming to be the agency's staff entered Into three of ?ve patients (Patients 3, 4, and 5) homes and attempted to access the patients' Morphine. This failure placed the d. Visit calendars updated with names of hospice team members and by assigned team members. Implemented: .lncident report to be completed and faxed to the Departrnentof Health and Human Services 805 604-29? within 5 days of initial occurrence. a. Fax con?rmation must be received and attached to the Incident report verifying report has been received by the Department of Health in. QUAPI review initiated c. Staff In-Serviced (see next page) c. etari immediately distribute5 staff mete-i1 families to match to picture identification; - alternate team members to be introduced - a. Police Report is ?led. 3 Immediate and Systemic Changes u. .4 ?l x6 (go/1, UV DATE LABORATORY Ditty REPRESENTATIVES RE TITLE - die . CZ cm eve/.5? ?upshot-hm statement ending with an satchel-t denotes a I clency i: a Institution may be circus tr safeguards provide suf?cient protection to the padenis. (See instructions.) Except for nursing homes, hes-inr- or not a pien of demotion It; provided. For parsing homes. the above .cnowing the dot: of survey documents are made available to the facility. If de?ciencies are died, an approved plan of correction Is requisite to continued days following the data these program participation. FORM Chis-2567(oznss) Previous Versions Obsolete Event ID: GXDGII Facility ID: CAWCIUD 1252 cot-re rig providing etermine the ?ndings stated above are discloseble on days ?ndings and plans of oorrec?don are disclossble 14? If continuation sheet Page 1 of 5 Sap-24-201512106 PM PROCARE HDQPECE OXNARD DEPARTMENTGF HEALTH AND HUMAN SERVICES 805-983-1578 3H5 PRINTED: 092112015 FORM APPROVED CENTERS FDR MEDICARE tit MEDICAID SERVIQES OMB NO. 0933-0391 . STATEMENT oI= DEFICIENGIES (x1) Fncwoesisuenusarcun {x2} MULTIPLE cons-raccoon (X3) DATE sunvsv AND PLAN on cossecnon IDENTIFICATION NUMBER: A BUILDING Cowman 051710 swme - 07l01i2015 NAME or esowosn on suppose? STREET noosess. CITY. stars. as once 1700 LOMBARD ST are :10 PROGARE HOSPICE DXNARD. CA 93030 (my In summer CF ID snot/Incas PLAN on coaasonon {an} (EACH oerchencv must" as Fasceoeo sv FULL PREFIX (EACH connecnvencnon snooto sE COMPLETION 1m aseuwosv on TAG cases-assessment To THE APPROPRIATE om DEFICIENCY) 511 Continued From page 1 511 patients at risk for harm. C. Staff In-servlced . . - Picture Identi?cation required 0 Educate patients/families A review of the agency?s "Risk Management lnoldentioccurrenoe Report? (RMIIDR) dated 3128/15. indicated from 3/1315 to 3120/1 5. an unidenti?ed person claiming to be the Agency?s hospice nurse entered the homes of Patients 2. 3. 4. and 5. and accessed the patients' Morphine. Dn 3112115. after the unidenti?ed person entered Patient ?l's home. a Licensed Nurse (LN visited the patient and noted the Morphine belonging to the Patient 1 was missing. On smarts. the unidenti?ed person. entered Patient 2's home and stole Morphine out of the E?kit. The unidenti?ed person entered Patient 3's home twice on 3? 9115. but the patients? family members denied the unidentified person access to the patients' medications. On amend the unidenti?ed person entered Patient 4's home and checked the . patients temperature. The report further Indicated on 3120MB. the unidentified person went to a nursing facility where Patient 5 was. and attempted to access the patients medication. but the facility denied access. Review of the Agency's Risk Management 2 Report [Rial/DR) Indicated. - the incident was not reported to the State i Licensing Department. During an Interview on 6110115. the Hospice . Agency's co- administrator stated "The State i Licensing Department was not informed of the . incident within ?ve days of discovery as our former Director of Pedant Care Services DPDS) 4. 5. rights Maintain visit calendar with names of assigned staff. HIPPA/Corporate compliance policy State mandated reporting Fax confirmation Monitoring of medications Failure to comply may result in termination Monitoring Process: a. QI Coordinator to review all Incident reports Reportable incidents have fax con?rmation to Department of Health Services within 5 days of occurrence Incident reports reflect Corporate Compliance Policy has been followed Report to Governing board of any reportable Incidents. Staff in-servlces as necessary for compliance Dates accomplished: a. Staff inuservices held 3/23/15. 4/28/2015 and ongoing. Review of Corrective action plan scheduled after IDT 9/24/15 b. d. FORM time-2557:0399) Previous Varslons Obsolete Event Facility ID: if continuation sheet Page 2 of - Sap-2420151206 PM PROCARE OXNAFID 805-983-157? 4/6 PRINTED: 0921:2015 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED . CE 5 F0 MEDICARE SERVICES 0MB ND. 0938-0391 srarsmsur oF on) PROVIDERIEUPFLIERICLIA do} MULTIPLE CONSTRUCTION (as) cars mo PLAN or: CORRECTION NUMBER: A BUILDING 0 051710 I. WING DTIO1IZD15 NAME or aeowose on cn-Y. STATE. ZIP cons 1700 Louisan 81' are are PROCARE HOSPICE OXNARD. CA 53030 (M, I STATEMENT or DEFICIENDIES 1 ID I PRovIoee-e PLAN OF awesome {tits} Pnenx (EACH oercIencY near as Peacecec eY FULL I FREFIK (EACH ACTION se CUMPLETIDN TAG REGULATORY on LSC IDENTIFYING TAG shoes-REFEReNceo To THE APPROPRIATE DATE DEFICIENCY) 511 Continued From page 2 511 L651 failed to do so. She assured all of us here she ?led a report but we were not able to ?nd any 1' Atria? Taken/2.5ystemlc copy Of it Cha nges. a. QA report reviewed Review of the facility's Policy and Procedure titled C00 "Quality of Services and Products" dated 10/2010 1 b- Incidents violating patients stated "The clinician will submit a verbal report of rights reported immediately the suspected abuse to the proper authorities in to COD In addition to DPCS accordance with the state law. The organization and Q1 Coordinator will report all suspected cases of abuse. neglect. 2. Process to Monitor: exploitation in compliance with the appropriate mg to verify fax state statutes to appropriate protection organizations. Exploitation ~Unexplained loss of social security or pension checks materiel goods con?rmation to Department of Health is attached to taken In exchange for care any evidence that . Incident report and '5 dated personal belongings are taken without the Within dill/5 01? occurrence consent or approval of the patient." and appropriate action has 651 413.100(h) GOVERNING BODYAND 551 been taken. ADMINISTRATOR Report to governing Board Agoverning body (or designated persons so functioning) assumes full legal authority and i 3. Implemented 7/15! 15 and responsibility for the management of the hospice, DHQOIHQ the provision of all hospice services. its ?scal operations. and continuous quality assessment and performance Improvement. A quali?ed administrator appointed by and reporting to the . governing body ls responsible for the dey-to-dey i - - operation of the hospice. The administrator must i -- be a hospice employee and possess education - 3g and experience required by the hospice's governing body. I This STANDARD is not met as evidenced by: Based on interview and record review. the Hospice Agency?s governing body failed to ensure stolen morphine from patients' home (controlled . medication for pain) were reported to the local FORM CMS-zse?dH-ea) Previous Versions Dhlolete Event ID: Facility 1D: sweetness It continuation sheet Page 3 of ti Sap-24-20?15?12iO? PM RROCARE OXNAFID 805-983-1578 5/6 PRINTED: 09i2112015 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS MEDICARE a MEDICAID SERVICES MB NO. 0938-03 1 STATEMENT OF phi PROVIDERIEUPPLIERICDA n2) MULTIPLE CONSTRUCTION eta) DATE suevev AND PLAN OF CORRECTION IDENTWICATIDN NUMBER: A. BUILDING COMPLEFED 0 051710 a. Irvine NAME OF PROVIDER OR EUPPLIER CITY, STATE. ZIP CODE 1700 LOMEARD ST STE 21D PRDDARE HOSPICE OXNARD, CA 93030 (Mi in SUMMARY STATEMENT OF in PLAN OF co our poceix (EACH DEFICIENCY MUET EIE PRECEDED er PREFIR CORRECTIVE ACTION SHOULD as common TAG REGULATORY OR Lac IDENTIFYING INFORMATION) mo TO THE APPROPRIATE DATE 1 DEFICIENCY) 551 Continued From page 3 i. 651 L651 . I . state ?Gem ?9 agency I 4. Action Taken/2.5ystemic Changes: Findings: c. QA report revtewed by C00 - d. Incidents violating patient?s During a review of the agency's document on rights reported immediately 6/11112 . the document titled "Risk Management I to (:00 In addition to DPCS lnoidantiDccurrenoe Report? (RMIIDR) dated and DI Coordinator 3/26/15. revealed from 3/1315 to BIZOHE, an 5, Process to Monitor: unidenti?ed person claiming to be a hospice (:00 to verify fax nurse entered the homes of Patients 1. 2. s, 4, and 5. and accessed the patients morphine. The incident was not reported to the local state con?rmation to Department of Health is attached to licensing department. incident report and is dated . within five days of occurrence 1. During an interview on 6/10115. the Hospice and appropriate action has i Agency's co- administrator stated "The State been taken. I Licensing Department was not informed of the . incident with in ?ve days of discovery as our Report to governing Board former Director of Patient Care Services DPCS) failed to do so. She assured all of us her in the E. Implemented 7/ 15/15 and agency that she ?led a report but we were not . able to ?nd any copy of it ongoing Review of the Hospice Agency?s organizational chart indicated. the Chief Operating Of?cer (600) was responsible for the agency's daily operations. During an interview on 6/12115 at 11:30 am. the COD stated "i assume all responsibility for this mistake. I did not have any knowledge that I report was not ?led to the state licensing agency i when the Incident happened. i trusted my staffto do what they were hired to do. so when the 1 former Director of Patient Care Services (DPGS) assured all of us that a report was filed. I took her word for it and did not look or asked for the actual FORM cmsaseriozosi Previous Versions Event Facility iD: oneronoizss if continuation sheet Page 4 of 5 Sap-2420151206 PM PROCAFIE PASPICE OXNARD 6/6 PRINTED: 08(2112015 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED . CENTERS FOB MEDICARE MEDICAID SERVICES OMB NC). 0938-0391 BTATEMENT 0F oEFIoIenoIEs on) psowoewsueeuswotm (X2) MULTIPLE oonsreucnou {er DATE sunvsv AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED 05171!) 3- WING NAME OF ssowosn on suppose STREET Anoness. om: ZIP cone 17m: LOMBARD ST 515 PROCARE HOSPICE OXNARD. CA 53030 SUMMARY STATEMENT oI= DEFICIENCIEB In snowmen-s PLAN OF senses-non :qu mam (EACH DEFICIENGY MUST BE eseososo FULL . (EACH conneoTws AETIDN SHOULD BE TAG REGULATORY UR LSC IDENTIFYING INFORMATIQN) TAG TD THE APPROPRIATE DATE DEFICIENCY) 651 Continued From page 4 651 reporting form anymore. I had all the opportunities to do so during the meetings we had regarding this incident but I feiisd to do it. This incident Is a learning curve for all of us and I ma especlally.? i I I I FORM EMS-25670393) Previous versions Obsolete Event ID: 5x061 1 Faollity ID: If continuation shut Page 5 of 5