415600184-7-16-2021-14-AS-KHOS-C69JHR-20210826070423

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415600184
Report Date: 07/16/2021
Date Signed: 07/16/2021 01:16:16 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/08/2020 and conducted by Evaluator Michael Garcia

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20200608123902

FACILITY NAME:	ATRIA BURLINGAME		FACILITY NUMBER:	415600184
ADMINISTRATOR:	JEFF SUMABAT		FACILITY TYPE:	740
ADDRESS:	250 MYRTLE RD		TELEPHONE:	(650) 343-2747
CITY:	BURLINGAME	STATE: CA	ZIP CODE:	94010
CAPACITY:	90	CENSUS: 41	DATE:	07/16/2021
		UNANNOUNCED	TIME BEGAN:	11:20 AM
MET WITH:	Jeff Sumabat		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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-- Facility staff did not administer medication to resident as prescribed.

INVESTIGATION FINDINGS:

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On July 16, 2021, Licensing Program Analyst (LPA) Michael Garcia conducted a complaint tele-visit to deliver the finding regarding the above allegation. Due to COVID-19 pandemic, the visit was conducted via video call with facility executive director/administrator Jeff Sumabat.

According to staff interviews, there was a delay in receiving the complete doctor’s order on how to administer the ALFUZOSIN medication for Resident 1 (R1) due to R1 was a new enrollee to the facility's medication program and R1 having multiple physicians prescribing medications and it was unknown which physician prescribed it according to administrator. Facility staff can only administer medications with a signed doctor’s order according to the facility resident services director as described in the facility's Prescriber Medication Orders Policy. CONTINUE ON NEXT PAGE...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Michael Garcia	TELEPHONE: (650) 380-4608
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 14-AS-20200608123902

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: ATRIA BURLINGAME	FACILITY NUMBER: 415600184
	VISIT DATE: 07/16/2021

NARRATIVE

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According to records review, R1 was able to store and administer own medications per R1’s Physician’s Report dated May 29, 2019. R1 has several medications prescribed by multiple doctors per Medication List printed on May 28, 2020 and the ALFUZOSIN medication was listed as prescribed by “Provider Unknown, MD.” On June 4, 2020, R1 enrolled in the facility’s medication program per R1’s Resident Functional Needs Service Plan.

According to staff interviews and signed documentation log, on May 31, 2020, facility staff started to attempt to obtain the signed doctor's order by contacting the Primary Care Physician (PCP)’s office but the PCP was unavailable. The on-duty doctor refused to sign the medication order stating that only the Prescribing Physician (RxP) or the PCP can send the order according to S2. On June 04, 2020, the ALFUZOSIN medication order was written and electronically signed by the RxP and submitted to Safeway Pharmacy (Safeway Rx) per Rx Image, which was an error according to S1 due to the ALFUZOSIN medication was not a Safeway Rx drug, which was confirmed by LPA on the Rx bottle. In addition, the Prescribing Pharmacy (Rx Phar) refused to provide the medication order to facility due to patient confidentiality according to the Health Insurance Portability and Accountability Act (HIPAA) per S1. R1's Responsible Party (RP) was contacted to discuss the medication order issues from June 02, 2020 to June 05, 2020 according to two staff. The RP was also unsuccessful in obtaining the medication order according to S1. On June 07, 2020, the Rx Phar was contacted but no one was available to answer the phone per S2. On June 8, 2020, the facility obtained the Medication Clarification FAX Order submitted to the RxP on June 01, 2020 for the ALFUZOSIN medication after S1 contacted the PCP, RxP, Rx Phar, and Safeway Rx according to two staff, which was the earliest facility record of administration listed for R1’s ALFUZOSIN medication per facility’s Medication Administration Record.

An in-person visit to the pharmacies, and physicians’ clinics may have expedited in obtaining the signed doctor's order, but it was not advisable at the time due to COVID-19 pandemic according to the resident services director.

Based on staff interviews and record reviews the allegation was deemed UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred.

Report was discussed with the administrator. An electronic copy of the report was emailed to the administrator at the end of the investigation.

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Michael Garcia	TELEPHONE: (650) 380-4608
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2021

LIC9099 (FAS) - (06/04)

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