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Los Angeles County Harbor-UCLA Medical Center's response to 2-18-11 inspection

Los Angeles County Harbor-UCLA Medical Center's response to 2-18-11 inspection

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Published by Daily Breeze
This is Harbor-UCLA Medical Center's "Plan of Correction" for deficiencies cited in a federal inspection report on February 18, 2011. Medicare had threatened to end funding based on dirty equipment and infection risk.

Story on the reports: http://www.dailybreeze.com/ci_20299924/harbor-ucla-medical-center-makes-changes-after-series
This is Harbor-UCLA Medical Center's "Plan of Correction" for deficiencies cited in a federal inspection report on February 18, 2011. Medicare had threatened to end funding based on dirty equipment and infection risk.

Story on the reports: http://www.dailybreeze.com/ci_20299924/harbor-ucla-medical-center-makes-changes-after-series

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Published by: Daily Breeze on Mar 31, 2012
Copyright:Attribution Non-commercial

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04/26/2012

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?T!!A..'........
·cr
"'~rbor-UCLA
',-",ICALCENTER
LosAngelesCountyBoardofSupervisors
GloriaMolina
FirstDistrict
MarkRidley-Thomas
SecondDistrict
ZevYaroslavsky
ThirdDistrict
DonKnabe
FourthDistrict
MichaelD.Antonovich
FifthDistrict
MiguelOrtiz-Marroquin
ChiefExecu~veOfficer
GailV.Anderson,Jr.,MD
ChiefMedicalOfficer
PeggyNazarey,RN
ChiefNursingOfficer
1000WestCarsonStreetTorrance,CA90502Tel:(310)222-2101Fax:(310)
xxx.xxxx
Toimprovehealththroughleadership,serviceandeducation
June29,2011CMSCertificationNumber(CCN):05-0376RufusArther,ManagerNLTCSurvey,Certification
&
EnforcementBranchDivisionofSurveyandCertificationSanFranciscoRegionalOffice90-
yth
Street,Suite5-300(5W)SanFrancisco,CA94103-6707DearMr.Arther:ThisisinresponsetoyourletterandStatementofDeficiencies(FormCMS-2567)datedJune10,2011.Foryourconsideration,enclosedisaPlanofCorrectionthatprovidescredibleevidencethatrequiredimprovementshavebeenmadetoensurecorrectionoftheidentifieddeficienciesinourInfectionControlProgram.ThePlanofCorrectionaddressescomplianceinthefollowingConditionsofParticipation(COPs):42C.F.R.
§
482.4242C.F.R.
§
482.51InfectionControlSurgicalServicesPleasecontactmeorJulieRees,ourAccreditationandLicensingAdministrator,at(310)222-2106ifanyadditionalinformationisnecessaryorifyouhaveanyquestionsregardingtheinformationprovided.Sincerely,
'l1
ifldrA
4
/11c,
v
't-'A
MiguelOrtiz-MarroquinChiefExecutiveOfficerMOM:jrc:KimMcKenzieCalvinKwan
 
DEPARTMENTOFHEALTHANDHUMANSERVICESCENTERSFORMEDICARE&MEDICAIDSERVICES
PRINTED:
06/10/2011
FORMAPPROVED
OMBNO0938-0391
STATEMENTOFDEFICIENCIESANDPLANOFCORRECTION(X1)PROVIDER/SUPPLIER/CLIAIDENTIFICATIONNUMBER:
050376
NAMEOFPROVIDERORSUPPLIER
LAC/HARBOR-UCLAMEDCENTER
02/18/2011
(X2)MULTIPLECONSTRUCTIONA.BUILDING
01-
MAINBUILDING
01
B.WING_(X3)DATESURVEYCOMPLETEDSTREETADDRESS,CITY,STATE,ZIPCODE
1000WCARSONST
TORRANCE,CA90509
(X4)IDPREFIXTAG(X5)COMPLETIONDATESUMMARYSTATEMENTOFDEFICIENCIES(EACHDEFICIENCYMUSTBEPRECEDEDBYFULLREGULATORYORLSCIDENTIFYINGINFORMATION)PROVIDER'SPLANOFCORRECTION(EACHCORRECTIVEACTIONSHOULDBECROSS-REFERENCEDTOTHEAPPROPRIATEDEFICIENCy)IDPREFIXTAG
K000INITIALCOMMENTSRepresentingtheCaliforniaDepartmentofPublicHealth:MaxineMcKaig,HFEIISPatriciaHardy,HFE1ZeinaNaser,HFE1K012NFPA101LIFESAFETYCODESTANDARD
LABORATORYDIRECTOR'SfRPROVIDERISUPP~"'REPRESENTATlVE'SSIGNATURETITLE(X6)DATE
Vl1
~?tJ
eLi'\.
l!l1cvIfOt..,
r{
tJt
ChiefExecutiveOfficer6/29/11
K3Building:01,02,03K6PlanApproval:MainBuilding-1960FamilyMedicalClinic-N-24-1940Upgradedin2010K7SurveyUnder:2000ExistingSTRUCTURETYPE:MainBuilding-TypeI,partiallysprinklered.ClinicBuildings-TypeV,FamilyMedicalClinicissprinklered.ThefollowingreflectsthefindingsoftheCaliforniaDepartmentofPublicHealth,duringaFullValidationLifeSafetyCodesurvey.ThefindingsareinaccordancewiththeNFPA(NationalFireProtectionAssociation)101,LifeSafetyCode2000edition(existing).Thefacilitywassurveyedinaccordancewith42CFR(CodeofFederalRegulations)483.70(a)forLongTermCareFacilities.Thefacilityisnotincompliancewith42CFR483.70(a).Census:February15,2011:360February16,2011:377February17,2011:380
KOOO
K012
Ar".
'ficien'cystatementendingwithana"'sterisk(*)d~tesadeficiencywhichtheinstitutionmaybeexcusedfromcorrectingprovidingitisdeterminedthatot",........feguardsprovidesufficientprotectiontothepatients.(Seeinstructions.)Exceptfornursinghomes,thefindingsstatedabovearedisclosable90daysfollmm"ngthedateofsurveywhetherornotaplanofcorrectionisprovided.Fornursinghomes,theabovefindingsandplansofcorrectionaredisclosable14daysfollowingthedatethesedocumentsaremadeavailabletothefacility.Ifdeficienciesarecited,anapprovedplanofcorrectionisrequisitetocontinuedprogramparticipation.
FORMCMS-2567(02-99)PreviousVersionsObsoleteEventID:2QK121FacilityID:CA060000027
IfcontinuationsheetPage1of50
 
DEPARTIVIENT
OFHEALTHANDHUMANSERVICESCENTERSFORMEDICARE
&
MEDICAIDSERVICES
r"l1~Icu.UO/IU/'::UII
FORMAPPROVED
OMSNO0938-0391
STATEMENTOFDEFICIENCIES(X1)PROVIDER/SUPPLIER/ellA(X2)MULTIPLECONSTRUCTION(X3)DATESURVEYANDPLANOFCORRECTIONIDENTIFICATIONNUMBER:COMPLETEDA.BUILDING
01-MAINBUILDING01
050376
B.WING
02/18/2011
-
I,
.e
OFPROVIDERORSUPPLIERSTREETADDRESS,CITY,STATE,ZIPCODE
LAC/HARBOR-UCLAMEDCENTER
1000WCARSONST
TORRANCE,CA90509
(X4)IDSUMMARYSTATEMENTOFDEFICIENCIESIDPROVIDER'SPLANOFCORRECTION
(XS)
PREFIX(EACHDEFICIENCYMUSTBEPRECEDEDBYFULLPREFIX(EACHCORRECTIVEACTIONSHOULDBE
COMPLETION
TAGREGULATORYORLSCIDENTIFYINGINFORMATION)TAGCROSS-REFERENCEDTOTHEAPPROPRIATE
DATE
DEFICIENCY}
K012ContinuedFrompage1K012K012BuildingconstructiontypeandheightmeetsoneNFPA101LIFESAFETYCODESTANDARDofthefollowing.·19.1.6.2,19.1.6.3,19.1.6.4,19.3.5.1
CORRECTIVEACTIONS
A.NewlRevisedProcesses
&
Procedures
NA
ThisSTANDARDisnotmetasevidencedby:
B.
RepairlReplacement
~
Mitigatethroughsealingpenetrations,Basedonobservation,thefacilityfailedtorepair/replacementofceilingtiles,maintaintheintegrityofthebuildingconstruction.repair/replacementoffloortilesfortheThiswasevidencedbypenetrationsinthewallsfollowing:andceilings.Thisaffectedtwoofeightfloorsin
7tttFloor:MissingceilingtileinRoom02/15/11themainhospitalandoneoftwoclinics.This7W-27Workorder#46484couldresultinthespreadofsmokeandfire,in
5tttFloor:Ceilingpenetrationaround02/15/11theevent
(If
C1
fire.
,
.
conduitaboveICUchartingstation.Findings:Workorder#464822
4thFloor:WallpenetrationsinRoom4E-02/16/11DUring-the-facilitytourwithstaTf,ffOm
2715/11-
15andHoom4E-17;ceilingpenetrationsinRoomR.R.401Work
2/17/11,
thewallsandceilingsinthemainorder#451892hospitalandtwooutpatientclinicswereobserved.
3
rd
Floor:WallpenetrationinRoom3E-702/16/11Floors2through8ofthehospitalweresurveyedandRoom3E-11,wallpenetrationsinRoom3W-29.Workorder#451966on
2/15/11.
2
nd
Floor:Ceilingpenetrationinmorgue,06/24/117thFloor-
At10:33a.m.,aceilingtilewasmisSinginRoomwallpenetrationsinmorgue,wall7W-27,cleansideutilityroom.ThisexposedanpenetrationsinRoom2W-6,wallapproximately10x10inchpenetrationinthepenetrationsinOR2,ceilingpenetrationsceiling.inOR2
1
st
Floor:WallpenetrationsinDietary02/16/115thFloor-RetailOffice,wallpenetrationsinRoomAt11:01a.m.,therewasanapproximately
1/2
x11C-1.Workorder#452039inchpenetrationaroundaconduitintheleu
Basement:Broken/damagedceilingtiles02/16/11ceilingabovethechartingstation.insterileprocessingarea,wall
,
penetrationbehinddoorofRoom8-154,4thFloor-ceilingpenetrationinroom8-116,wallAt1:09p.m.,thereweretwoapproximately
1/2
xpenetrationsinRoom8-206,wall1inchpenetrationsintherightwall,behindthepenetrationinRoomB-205.Workorder#441968
FORMCMS-2567(02-99)PreviousVersionsObsoleteEvent10:2QK121Facility10:CA060000027
IfcontinuationsheetPage2of·50

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