Vitas Healthcare of Dothan

“It is required that the documented comprehensive assessment include a drug profile that contains the patient’s current: prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; [and] other alternative treatments that could affect drug therapy. The drug profile is updated per the hospice policy and procedure, but, at a minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review and interview. In 2 of 7 (29%) clinical records reviewed of patients with oxygen, the agency did not ensure that oxygen was added to the drug profile. CLINICAL RECORD 2:The patient elected hospice care on 07/15/2025 with diagnoses of malignant neoplasm of the colon, seizures, diabetes mellitus type 2, and dependence on oxygen. The patient resided in a skilled nursing facility (SNF). A clinical record review revealed a physician’s order dated 09/25/2025 ordering “2L of oxygen as needed and spot check oxygen saturations.” Oxygen was not included or added to the patient’s medication profile. CLINICAL RECORD 6: The patient elected hospice care on 08/11/2025 with a diagnosis of malignant neoplasm of the lung. A clinical record review revealed a physician’s order dated 10/13/2025 that ordered, “Inhale oxygen at 2 liters per minute (LPM) via nasal cannula continuous.” Oxygen was not included or added to the patient’s medication profile. In an interview on 10/29/2025, the National Clinical Manager confirmed that oxygen was not included on the medication profiles and stated, “This helps me. I can see now how they are entering oxygen in the system and why it is not going to the medication profile.””

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 2 of 13 (15%) clinical records reviewed of patients who received Hospice Aide (HA) services, the agency did not ensure that the Hospice Aide received written patient care instructions from the Registered Nurse (RN) to meet the patient’s needs. CLINICAL RECORD 1: The patient elected hospice care on 04/17/2024 with a diagnosis of senile degeneration of the brain. The patient resided in a skilled nursing facility (SNF). The patient started on oxygen at 1 liter per minute via nasal cannula, effective 09/17/2025. As of 10/27/2025, the HA care plan dated 06/24/2025, with HA services twice a week, had not been updated to include oxygen or information related to oxygen for the HA. The patient had a Foley catheter placed on 08/15/2025, and it was discontinued on 09/05/2025. During that time period, the HA continued to see the patient twice per week, but the HA care plan was not updated to reflect that the patient required Foley care. CLINICAL RECORD 2:The patient elected hospice care on 07/15/2025 with diagnoses of malignant neoplasm of the colon, seizures, diabetes mellitus type 2, and dependence on oxygen. The patient resided in a SNF. The skilled nurse (SN) assessment dated 07/15/2025 documented that the patient required a (gastrostomy tube) G-tube, was (nothing by mouth) NPO, and oxygen dependent. The HA care plan developed on 07/15/2025 did not include instructions for the HA regarding the patient’s NPO status, G-tube, or oxygen dependence. During an interview on 10/29/2025, the National Clinical Director reviewed the clinical record and confirmed that the clinical records did not contain the required elements of the HA care plan, stating, “Aide care plans will be going on our education plan.””

“It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. The agency did not ensure that hospice volunteers provided day-to-day administrative or direct patient care services in an amount that equals five percent (5%) of the total patient care hours. A review of the Volunteer Services scorecard for the parent and branch locations revealed that the rolling percentage of volunteer hours for the parent and the ADS from 09/01/2024 to 08/31/2025 (as reported on 10/22/2025) totaled 1.4%. A performance improvement plan (PIP) for the volunteer hours was initiated on 04/01/2025. The PIP documentation revealed that the volunteer hours between 04/01/2025 and 06/30/2025 were 2.3%, July 2025 1.9%, and August 2025 0.4%. During an interview on 10/29/2025, the Volunteer Service Manager stated that it was difficult to onboard volunteers without having someone in the office at all times. They also stated that the orientation process is lengthy, and if someone is not present when the volunteer is available, they can become lost in the process and drop out. The National Clinical Manager provided data and stated in an interview on 10/29/2025, “We know we are not where we need to be with volunteers, but we have an active PIP.” The agency did not ensure that volunteer services equal a total of 5% of patient care hours.”

“It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. The hospice has written policies and procedures describing the method(s) of assessing competency and: maintains a written description of the in-service training provided during the previous 12 months. This standard was not met as evidenced by document review, interview and personnel record review. In 1 of 10 (10%) personnel records reviewed, the agency did not ensure that skills and competencies were assessed on all individuals providing care prior to independent functioning. Personnel Record 2: The Chaplain was hired on 05/25/2025. A personnel record review revealed a 13-page orientation skills checklist initiated on 05/20/2025, but not completed. The Chaplain’s self-assessment competency form was not found in the personnel record. During an interview on October 30, 2025, the National Clinical Manager reported that they spoke to the Chaplain, who recalled completing the self-assessment competency and the orientation skills checklist; however, the documented evidence could not be located. The documents were reviewed and recreated on 10/30/2025.”