Harbor-UCLA Los Angeles County Board of Supervisors Gloria Molina Fata Mark Riley-Thomas Sree Duel Zev Yaroslavshy Don Knabe foun Bite Michael. Antonovich BME chio Finley, MPP, FACHE he est Hal Yee, MD, PhD ing Ct ae er Peggy Nazarey, RN Sree Oe 1000 West Cason Set Tonnes, CA 30509 Yet 10) 2222101 Fax (310) 5259528 www.dhs.lacouty.gov Health Services March 16, 2012 CMS Certification Number (CCN): 05-0376 Rufus Arther, Manager NLTC Survey, Certification & Enforcement Branch Division of Survey and Certitication San Francisco Regional Office 90 - 7" Street, Suite 5-300 (SW) San Francisco, CA 94103-8707 Dear Mr. Arther: This is in response to your letter and Statement of Deficiencies (Form) CMS-2567) dated March 8, 2012. For your consideration, enclosed is a Plan of Correction that provides credible evidence that required improvements have been made to ensure correction of the identified deficiencies during a January 12, 2012 full validation survey. ‘The Plan of Correction addresses compliance in the following Conditions of Participation (COPs): 42 C.F.R. § 498.20 - 498.25 Please contact me or Julie Rees, our Accreditation and Licensing ‘Administrator at (310) 222-2106 if any additional information is necessary or if you have any questions regarding the information provided. Sincerely, hebvewskio Gon in fol Delvecchio Finley, MPP, FACHE Chief Executive Officer DF jr Enclosures c: Jacqueline Lincer Calvin Kwan Kim McKenzie, RNDEPARTMENT OF HEALTH AND HU’ *4N SERVICES: PRINTED: 02/02/2012 FORM APPROVED OMB NO. 0938-0391 CENTERS FOR MEDICARE & MEDItuy) SERVICES sat STATEMENT OF DEFICIENCIES | (Kt) PROVIDERISUPPLIERIGUA (xa) MULTIPLE CONSTRUCTION oa) DATE suRvey [AND PLAN OF CORRECTION. \DENTIFICATION NUMBER Comex reo a autos 050376 oe o12r2012 | nae NBME OF PROVIDER OR SUPPLIER LACIHARBOR-UCLA MED CENTER STREET ADDRESS, CITY, STATE, ZF CODE +1000 W CARSON ST TORRANCE, CA 90509 ‘UNWARY STATEMENT OF DEFIOIENDIES peep iD | date | (GACH DEFICIENCY MUST BE PRECEDED BY FULL TAS REGULATORY OR LSC IDENTIFYING INFORMATION) =| 4.000, INITIAL COMMENTS | The following reflects the findings of the Department of Public Health during @ FULL MEDICARE CERTIFICATION survey after a ‘complaint : Representing the Department of Public Health: Surveyors 21262, HFEN; 22773, HFEN; 22553, HFEN; 25720, HFEN: 18338, Pharmacy Consultant, 27873, Pharmacy Consultant; 27187, Nutrition Consultant; 17108, Medical Consultant. The survey team entered the hospital at 0830+ hours on 1/9/12. The hospital identified their inpatent census as 299. The sampled patients | totaled 49 ' - i ‘An entrance conterence was convened on 1/9/12 | | at 0800 hours, with the hospital's Chief Executive | Officer, Chief Operating Officer, two Assistant Hospital Administrators, Infection Contro} Director, Associate Medical Director, Chief ! Nursing Officer and two Associate Nursing Directors. The survey team leader introduced the survey team which included three Life Safety | Code staff, and explained the survey process and purpose, explaining expectations for document requests, interviews and observations needed to complete the survey, ‘An exit conference was conducted on 1/12/12 at | ''1730 hours. This included the Life Safety Code survey staff. Attendees were the above mentioned Administrative Staff with addition of | the Acting Chief Medical Officer, Director of | Quality and Patient Safety, and President of the Professional Staff Association. All deficiencies found were propted ar are was allowed for (RBORATORY Oy fie A OPALER REPRESENTATIVES SIGNATURE 0 ‘PROVIDERS PLAN OF CORRECTION =, PREFK , _ (EACH CORRECTIVE ACTION SHOULD BE _ | COMPLETION TA8 CHOSS-AEFERENCED To THEAPPROPRIATE | DATE DEFICIENCY) A000 Tine Co Chief Executive Officer 3/15/12 7 ny stator eng wi pe stsuarcs prove ste Pat fr asteriek() denotes a deficiency which the insttution may be excusee from correcting providing tls determined aon fo the patients, (See insinictons,) Except for nursing homes, he ‘ndings stated above are csclosabie 90 days: ng the date of survey wetheFor nota pian of catrecton is avovided. For nursing homes, the above finéings and plans of correction ae cisclosable 14 days folowing the cate these documents are ma program gartcipation FORM CMS-2567(02.99) Previous Versions Obeclete Event: Gest ‘avalable to the facity, W deticencies are ced, an approved plan of correction is requisite to continued acs 0: CAos0000077 "continuation sheet Page 1 of 68DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED OMB NO, 0938-0351 CENTERS FOR MEDICARE & MEDIC) SERVICES [STATEMENT OF DEFICIENCIES [(X1) PROVIJWMISUPPLIERICLIA x2) MULTIPLE CONSTRUG aa joo) DATE suavey | IDENTIFICATION NUMBER: ‘COMPLETED | JA BUILDING | 8. Wan, 050378 01/42/2012 nat’ OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1000 W CARSON ST cr -t LAC/HARBOR-UCLA MED CENTER TORRANCE, CA 90509 ea) t ‘SUMMARY STATEMENT OF OEFIGIENGIES ‘0, PROVIDER'S PLAN OF CORRECTION m5) PREF (EACH DEFICIENCY MUST BE PRECEDEO BY FULL | PREFIX (EACH CORRECTIVE ACTION SHOULD BE | coMMLETON TAG, REGULATORY OR LSC IDENTIFYING INFORMATION) =| TAG GROSS REFERENZED TO THE APPROPRIATE oar, | } FICIENCY} 1 | 000 | ‘A000! Continued From page 1 { questions or discussion ‘ Glossary " ADC - Automated Drug Cabinet ‘AMAO - Adult Medication Admission Orders | ANSVAAMI - American National Standard | Institute/American Association for the ‘Advancement of Medical Instrumentation ‘AORN - Association of periOperative Registered | Nurses Atropine - Medication used to treat slow heart | beats. BBW or Black Box Warning - Warning required by the FDA for potentially serious effects of a medication BGIBS - Blood Glucose/Blood Sugar \ BP - Blood Pressure C- Centigrade CDC - Centers for Disease Control and Prevention Chemotherapeutic medications - Potentially | hazardous drugs used to treat cancer | MO - Chief Medical officer | CNA - Certified Nursing Assistant CNM - Clinical Nutrition Management ENO - Chief Nursing Officer { CQO - Chief Quality Officer Crash cart - emergency equipment and medication cart CRNA - Cetified Registered Nurse Anesthetist 2S - Central Service/Supsly CT - Computerized Tomography Scan | Dantrolene - Medication used to treat malignant hyperthermia | Dextrose - A chain of ghicose molecules | Dobutamine - Medication used to increase the | force of heart contractions FORM cMS-2567(05-49) Prev Verzane Onesie Event 66651 acy © capeno000zT Weortinuation sheet Page 2 of 68