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LAGUNA HONDA HOSPITAL & REHABILITATION CENTER
Basis and Scope
Tag No.: A0008
The facility failed to meet the hospital definition, under the provider agreement, to be primarily engaged in providing care to inpatients when the average daily census for the last twelve months was less than 2 patients per day.
Findings:
The first attempt to conduct a Recertification of Laguna Honda Hospital was on 11/12/19.
The team entered the facility at 08:00 AM on 11/12/19.
During an interview with RN 1 at 9:00 AM, the team was informed that the current census of the hospital
was one patient.
During an interview with concurrent document review on 11/12/19 at 12 PM, the Director of Quality, he was
asked to provide the daily census for the last 12 months.
The following shows the record of the monthly census from November 2018 to October 2019:
Month Total # of Monthly Patient
Days Census
Nov. 2018 30 21
Dec. 2018 31 10
Jan. 2019 31 22
Feb. 2019 28 83
Mar. 2019 31 20
Apr. 2019 30 19
May 2019 31 80
June 2019 30 17
July 2019 31 11
Aug.2019 31 32
Sept. 2019 30 111
Oct. 2019 31 48
________________________________________
Total 365 days 474
Average daily
census 365/474 = 1.29
During an exit conference on 11/13/19 at 11:20 AM, the Administrator and Director of Quality were informed
that the Recertification Survey was aborted because they had less than two inpatients at the time of the survey.
A second attempt to do a Recertification Survey at the hospital was conducted on 1/18/20. The team arrived at 8AM.
During an interview with RN 1 on 1/18/20 at 8:05 AM, RN 1 informed the team that the current census of the hospital
was one patient who was admitted for fever.
During an interview on 1/18/20 at 8:15 AM, the House supervisor confirmed that the census in the GACH was one patient.
CMS Officer was notified by phone on 1/18/20 at 8:20 AM and gave instruction for the survey team to abort the survey.
During an exit conference with the House Supervisor on 1/18/20 at 8:30 AM, she was informed that the Recertification Survey will be aborted as directed by CMS because the facility has only one patient.