Vitas Healthcare Corporation of California

“It is required that the hospice designates a registered nurse member of the IDG: ensure the implementation of the interdisciplinary plan of care. Hospice care and services provided to patients and families follow the individualized plan of care. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy “Frequency” (dated 08/15/2023) stated in part, “Frequency is part of the Plan of Care (POC). Frequency is based on assessment... Frequency is based on the IDG/patient care plan week- starts the day after the team meeting and ends on the next team meeting day ... frequency is individualized based on assessed patient and family needs ... Declined visits - document the declination and reason if known in the clinical record ...” In 11 of 19 (58%) clinical records reviewed, the agency did not ensure that the hospice care and services provided followed the plan of care (POC). Clinical Record 1: The patient elected the hospice benefit on 01/11/2024 with a diagnosis of malignant neoplasm of the brain. The patient resided at a facility for people with intellectual disabilities. The plan of care dated 07/09/2024 to 09/07/2024 ordered two (2) skilled nurse (SN) visits for the week of 07/19/2024. A review of the clinical record revealed three (3) SN visits dated 07/20/2024, 07/22/2024, and 07/23/2024 for the week of 07/19/2024. The POC ordered five (5) SN visits for the week of 07/26/2024. A review of the clinical record revealed four (4) SN visits dated 07/26/2024, 07/28/2024, 07/29/2024, and 07/30/2024 for the week of 07/26/2024. The Interdisciplinary Group ordered three (3) SN visits for the week of 08/16/2024. A review of the clinical record revealed one (1) visit dated 08/16/2024 for the week of 08/16/2024. The POC ordered one (1) SN visit for the week of 08/23/2024. No SN visit was documented for the week of 08/23/2024. Clinical Record 2: The patient elected the hospice benefit on 06/13/2024 with the diagnoses of cerebral atherosclerosis and severe vascular dementia with behavioral disturbance. The patient resided in an assisted living facility (ALF). The POC dated 06/13/2024 to 08/12/2024 did not order Chaplain visits for the week of 06/14/2024. The Chaplain documented one (1) visit dated 06/17/2024. The week of 06/21/2024, the POC ordered one (1) Chaplain visit. The Chaplain documented two (2) visits (06/21/2024 and 06/25/2024) for the week of 06/21/2024. The week of 07/12/2024, the POC ordered one (1) Chaplain visit. The Chaplain documented two (2) visits (07/12/2024 and 07/18/2024) for the week of 07/12/2024. The Interdisciplinary Group ordered two (2) Chaplain visits for the week of 07/19/2024. The Chaplain documented one (1) visit (07/25/2024) for the week of 07/19/2024. In addition, the POC ordered three (3) Skilled Nurse (SN) visits during the week of 08/02/2024. The SN documented two (2) visits (08/06/2024 and 08/07/2024) for the week of 08/02/2024. The week of 08/09/2024, the POC ordered one (1) Chaplain visit. No Chaplain visit was documented for the week of 08/09/2024. Clinical Record 3: The patient elected the hospice benefit on 03/13/2023 with a diagnosis of Alzheimer’s dementia. The patient resided at home with family. The POC dated 07/05/2024 to 09/03/2024 ordered a Skilled Nurse (SN) two (2) times for the week of 07/12/2024. No SN visit was documented for the week of 07/12/2024. The week of 07/19/2024, the POC ordered one (1) SN visit. Two (2) SN visits were documented (07/21/2024 and 07/24/2024) for the week of 07/19/2024. Clinical Record 4: The patient elected the hospice benefit on 05/25/2024 with the diagnosis of chronic obstructive pulmonary disease. The patient resided at home with family. The POC dated 06/23/2024 to 08/22/2024 did not order SN services for the week of 06/28/2024. One SN visit was documented on 06/29/2024 for the week of 06/28/2024. The POC dated 06/23/2024 to 08/22/2024 did not order SN services for the week of 07/05/2024. Two (2) SN visits were documented (07/08/2024 and 07/10/2024) for the week of 07/05/2024. Four SN visits were ordered for the week of 07/19/2024. Five (5) SN visits were documented (07/21/2024, two (2) visits on 07/22/2024, 07/23/2024, and 07/25/2024) for the week of 07/19/2024. Clinical Record 5: The patient elected the hospice benefit on 07/01/2024 with the diagnosis of end-stage heart failure. The patient resided at home with family. The POC dated 07/01/2024 to 08/30/3035 ordered SN services twice (2) for the week of 07/05/2024. One (1) SN visit was documented (07/09/2024) for the week of 07/05/2024. Additionally, the POC ordered one (1) Social Work (SW) visit. No SW visit was completed for the week of 07/05/2024. Clinical Record 6: The patient elected the hospice benefit on 02/12/2024 with the diagnosis of atherosclerotic heart disease of the native coronary artery with coronary atherosclerosis due to a calcified lesion. The patient resided at home with family. The plans of care dated 04/12/2024 to 06/11/2024 and 06/11/2024 to 08/10/2024 ordered SN services twice the week of 06/07/2024. No SN visits were documented for the week of 06/07/2024. The POC ordered no SW services for the week of 08/02/2024. One (SW) visit was documented (08/02/2024) for the week of 08/02/2024. Clinical Record 9: The patient elected the hospice benefit on 04/30/2022 with the diagnosis of chronic systolic congestive heart failure. The patient resided in an ALF. The POC dated 06/18/2024 to 08/17/2024 ordered SN services three (3) visits for the week of 07/05/2024. One SN visit was documented (07/09/2024) for the week of 07/05/2024. The POC did not order Chaplain (CH) visits for the week of 07/05/2024. One was documented (07/10/2024) for the week of 07/05/2024. The POC ordered SN services three (3) visits for the weeks of 07/26/2024 and 08/09/2024 and six (6) times for the week of 08/16/2024. Two (2) SN visits were documented (07/28/2024 and 08/01/2024) for the week of 07/26/2024, and two (2) SN visits were documented ( 08/13/2024 and 08/15/2024) for the week of 08/09/2024. Two (2) SN visits were documented (08/20/2024 and 08/22/2024) for the week of 08/16/2024. The POC did not order CH visits for the weeks of 07/26/2024, 08/02/2024, and 08/14/2024. One (1) CH visit was documented (07/31/2024) for the week of 07/26/2024, two (2) CH visits were documented (08/02/2024 and 08/07/2024) for the week of 08/02/2024, and one (1) CH visit was documented for the week of 08/14/2024. Additionally, during the week of 08/16/2024, the POC ordered one (1) Chaplain visit, but none were documented. Clinical Record 10: The patient elected the hospice benefit on 01/01/2024 with the diagnosis of unspecified severe protein-calorie malnutrition. The patient lived alone at home. The plans of care dated 03/31/2024 to 06/29/2024 and 06/29/2024 to 08/28/2024 ordered SN visits two (2) times for the week of 06/14/2024 and three (3) times for the week of 07/19/2024. One (1) SN visit was documented (06/19/2024) for the week of 06/14/2024, and two (2) SN visits were documented (07/19/2024 and 07/22/2024) for the week of 07/19/2024. Clinical Record 11: The patient elected the hospice benefit on 10/15/2021 with the diagnosis of multiple sclerosis. The patient resided in a nursing facility (NF). The POC dated 06/01/2024 to 07/31/2024 ordered SW services one (1) visit for the week of 07/19/2024. No SW visit was documented for the week of 07/19/2024. The POC did not order CH services for the week of 06/14/2024. One (1) CH visit was documented (06/20/2024) for the week of 06/14/2024. Clinical Record 12: The patient elected the hospice benefit on 07/05/2022 with the diagnosis of Alzheimer’s disease. The patient resided at an ALF. The plans of care dated 05/25/2024 to 07/24/2024 and 07/24/2024 to 09/22/2024 ordered SN visits two (2) times for the week of 07/05/2024, three (3) times for the weeks of 07/12/2024 and 07/19/2024, and two (2) times for the week of 07/26/2024. One (1) SN visit was documented (07/09/2024) for the week of 07/05/2024, two (2) SN visits were documented (07/12/2024 and 07/16/2024) for the week of 07/12/2024, two (2) SN visits were documented (07/21/2024 and 07/25/2024) for the week of 07/19/2024, and one (1) SN visit was documented (07/28/2024) for the week of 07/26/2024. Clinical Record 13: The patient elected the hospice benefit on 10/07/2023 with the diagnosis of unspecified heart disease. The patient resided in an ALF. The POC dated 06/03/2024 to 08/02/2024 ordered SN services two (2) visits the week of 06/28/2024, three (3) visits the week of 07/12/2024, and four (4) visits the week of 07/19/2024. One (1) SN visit was documented (06/28/2024) for the week of 06/28/2024, two (2) SN visits were documented (07/12/2024 and 07/16/2024) for the week of 07/12/2024, and three (3) SN visits were documented (07/19/2024 (two visits), and 07/24/2024) for the week of 07/19/2024. During a joint clinical record review and interview, the Patient Care Administrator (PCA) confirmed that these visits did not follow the plan of care.”

“It is required that each patient’s individualized written plan of care: reflects patient and family goals; identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy “Care Planning” (05/16/2023) stated in part, “Hospice uses a collaborative team approach to care planning in order to address each symptom from an interdisciplinary point of view. A plan of care is a dynamic document that changes as the patient’s condition changes. Goals, outcomes, and interventions often require frequent revision or discontinuation or the creation of new goals, outcomes, and interventions unique to that patient... Updates to the POC are based on assessment findings and used to update interventions, goals, and outcomes for all care planning, including physician orders and non-pharmacological (nursing, psychosocial, and spiritual interventions) ... symptoms are care planned under related symptom categories ... Psychosocial for example: anxiety, depression, impaired coping, etc...Care plan components - symptom/problem - issues identified by the patient and family and/or ...through assessment ... by the interdisciplinary team...” In 1 of 19 (5%) clinical records reviewed, the agency did not ensure that the patient’s plan of care (POC) identified planned interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 16: The patient elected the hospice benefit on 10/04/2023 and was discharged on 04/11/2024. The plans of care dated 10/04/2023 to 01/01/2024, 01/01/2024 to 04/01/2024, and 04/01/2024 to 05/31/2024 ordered SW services: once weekly for the weeks of 01/05/2024, 02/23/2024, and 03/22/2024. In the visit note dated 02/28/2024, the SW documented providing education on anticipatory grief, and “Visit was completed with daughter ... coping appropriately and provided education and grief needs...” On 03/27/2024, the SW documented working with the patient’s daughter on anticipatory grief. The “Plan of Care reviews/Interdisciplinary Group Meetings” for 02/01/2024, 02/15/2024, 02/29/2024, 03/14/2024, and 04/11/2024 documented that the SW visited the patient once a month. A clinical record review revealed no “Interdisciplinary Plan of Car Revision/Physician Order for the SW. No SW interventions were documented on the plan of care or plan of care updates. Interventions documented were within the Social Worker’s visit notes. During a joint clinical record review and interview, the Patient Care Administrator confirmed the findings.”

“It is required that a revised plan of care includes: information from the patient’s updated comprehensive assessment; [and] record of the patient’s progress toward the outcomes and goals specified in the plan of care. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy “Care Planning” (05/16/2023) stated in part, “Hospice uses a collaborative team approach to care planning in order to address each symptom from an interdisciplinary point of view. A plan of care is a dynamic document that changes as the patient condition changes. Goals, outcomes, and interventions often require frequent revision or discontinuation or the creation of new goals, outcomes, and interventions unique to that patient... Updates to the POC are based on assessment findings and used to update interventions, goals, and outcomes for all care planning, including physician orders and non-pharmacological (nursing, psychosocial, and spiritual interventions) ... symptoms are care planned under related symptom categories ... Psychosocial for example: anxiety, depression, impaired coping, etc...Care plan components - symptom/problem - issues identified by the patient and family and/or ...through assessment ... by the interdisciplinary team...” In 6 of 19 (32%) clinical records reviewed, the agency did not ensure that the patient’s revised plan of care (POC) included information from the patient’s updated comprehensive assessment and progress toward the outcomes and goals specified in the plan of care. Clinical Record 6: The patient elected the hospice benefit on 02/12/2024. The “Interdisciplinary Plan of Care Revision/Physician Orders” dated 02/15/2024 ordered the Social Worker (SW) to assist the patient/family with community resources and to educate regarding the patient’s disease progression. The plans of care dated 04/12/2024 to 06/11/2024 and 06/11/2024 to 08/10/2024 ordered Chaplain (CH) services: one (1) visit the week of 06/14/2024, and Social Worker (SW) services: one (1) visit the weeks of 06/21/2024 and 06/28/2024. In the “Psychosocial/Spiritual Updated Comprehensive Assessment” dated 06/18/2024, the Chaplain documented, “Pt stated that he was experiencing some pain in his back... Interventions performed: active socialization, devotional, prayer...” In the “Psychosocial/Spiritual Updated Comprehensive Assessment” dated 06/272024, the SW documented, “Funeral in place ... pt grateful for Veteran’s package... Interventions performed: provided emotional support and life reflection....Visit completed w/pt and spouse in their room. Pt hard of hearing (HOH), alert x2 w/ no pain at this time.... Provided emotional support to pt and spouse who are coping well ...” The “Plan of Care Reviews/Interdisciplinary Group Meetings” dated 05/09/2024, 05/23/2024, 06/06/2024, 06/20/2024, and 06/27/2024 documented that the SW visited the patient once (1) a month. The revised plans of care did not include documentation, including the SW’s updated assessments and the patient’s progress toward the SW’s goals. Clinical Record 8: The patient elected the hospice benefit on 03/01/2023. The “Interdisciplinary Plan of Care Revision/ Physician Order” dated 03/03/2023 ordered the SW to encourage the patient’s/family’s expression of thoughts and feelings regarding the patient’s terminal progression and to provide education and materials on end-of-life and grief for adults and children. The plans of care dated 04/24/2024 to 06/23/2024 and 06/23/2024 to 08/22/2024 ordered SW services: once a week for the weeks of 06/14/2024 and 06/28/2024. In the “Psychosocial/Spiritual Updated Comprehensive Assessment” dated 06/14/2024, the SW documented, “Pt in bed, a/o x0, nonresponsive during the visit. PCG has no new identified concerns ... PCG and family have yet to finalize mortuary - have resources but due to culture are not comfortable finalizing yet. SW will continue to monitor and support EOL choices.” The “Plan of Care Reviews/Interdisciplinary Group Meetings” dated 05/09/2024, 05/23/2024, 06/06/2024, 06/13/2024, and 06/20/2024 documented that the social worker was visiting the patient monthly. The revised plans of care did not include documentation, including the SW’s updated assessments and the patient’s progress toward the SW’s goals. Clinical Record 10: The patient elected the hospice benefit on 01/01/2024. The “Interdisciplinary Plan of Care Revision/ Physician Order” dated 01/03/2024 ordered the SW to assist the patient with their fear of loss of autonomy with life reflections, acceptance, and education. The POC dated 06/29/2024 to 08/28/2024 ordered SW services: one (1) visit the week of 07/05/2024. In the “Psychosocial/Spiritual Updated Comprehensive Assessment” dated 05/28/2024, the SW documented, “Interventions performed ... education and support provided ... Plan of Care - interventions effective, continue the plan…Visit w/pt and daughter .... Pt alert x3 w/no pain reported and doing well. Pt has good safety awareness and doesn’t overdo it. Lots of support in place w/no needs.” On 7/10/2024, the SW documented, “Funeral in place ... pt still able to safely remain in home…Interventions performed ... Education re: decline; emotional support…Plan of Care - interventions effective, continue plan…Visit done w/pt and dtr in living area. Pt alert x4. Denied any pain...continues to do well at home w/help. No issues reported...” The “Plan of Care Reviews/ Interdisciplinary Group Meetings” dated 05/09/2024, 05/23/2024, 06/06/2024, 06/20/2024, 06/27/2024, 07/11/2024, 07/18/2024, 08/01/2024, 08/15/2024, and 08/29/2024 documented that the SW was visiting the patient once a month. The revised plans of care did not include documentation, including the SW’s updated assessments and the patient’s progress toward the SW’s goals. Clinical Record 15: The patient elected the hospice benefit on 12/19/2023 and died on hospice services on 04/28/2024. The “Interdisciplinary Plan of Care Revision/Physician Order” dated 12/21/2023 ordered the SW to assist the patient/family with coping skills utilizing life reflection and active listening to support maximum adjustment to the patient’s terminal illness and to assist the patient with acceptance of the decline in health status. Additionally, the SW planned to assist and support the family with grief needs. The plans of care dated 12/19/2023 to 03/18/2024 and 03/18/2024 to 06/16/2024 ordered the SW once a week for the weeks of 02/16/2024, 03/15/2024 and 03/29/2024. In the “Psychosocial/Spiritual Updated Assessment” dated 02/16/2024, the SW documented, “Mortuary still pending ... Interventions performed: life reflection and social support...” On 04/03/2024, the SW visit note documented, “Mortuary still pending... active listening and support provided ... Pt lethargic and reports no appetite and just being tired all the time. Provided emotional support ... “The “Plan of Care Reviews/Interdisciplinary Group Meetings” dated 02/01/2024, 02/15/2024, and 02/29/2024 documented only that the social worker visited the patient once a month. The psychosocial problems/interventions section of “Plan of Care Reviews/Interdisciplinary Group Meetings” dated 03/14/2024, 03/28/2024, 04/11/2024, and 04/25/2024 was blank. The revised plans of care did not include documentation, including the SW’s updated assessments and the patient’s progress toward the SW’s goals. Clinical Record 16: The patient elected the hospice benefit on 10/04/2023 and was discharged on 04/11/2024. The plan of care dated 04/01/2024 to 05/31/2024 ordered SW services: once weekly for the weeks of 01/05/2024, 02/23/2024, and 03/22/2024. In the visit note dated 02/28/2024, the SW documented providing education on anticipatory grief, and “Visit was completed with daughter ... coping appropriately and provided education and grief needs...” On 03/27/2024, the SW documented working with the patient’s daughter on anticipatory grief. The “Plan of Care reviews/Interdisciplinary Group Meetings” for 02/01/2024, 02/15/2024, 02/29/2024, 03/14/2024, and 04/11/2024 documented that the SW visited the patient once a month. The revised plans of care did not include documentation, including the SW’s updated assessments and the patient’s progress toward the SW’s goals. Clinical Record 18: The patient elected the hospice benefit on 03/14/2024 and revoked the hospice benefit on 04/01/2024. An “Interdisciplinary Plan of Care Revision/Physician’s order” dated 03/15/2024 ordered the SW to support the patient/family in making end-of-life choices, encourage life review, explore feelings of loss and grief, and provide support as the finality of loss is absorbed. The plan of care dated 03/14/2024 to 06/11/2024 ordered SW services once a week for the weeks of 03/15/2024 and 03/22/2024. In the “Psychosocial/Spiritual Updated Comprehensive Assessment” dated 03/26/2024, the SW documented, “Patient’s caregiver (PCG) has some concerns about pt leg/swelling. Pt also expressed concern. physician orders for life-sustaining treatment (POLST) was updated ...SW provided education on disease progression ...” The “Plan of Care Reviews/ Interdisciplinary Group Meetings” dated 03/21/2024 and 04/04/2024 documented that the SW visited the patient once a month. The revised plans of care did not include documentation, including the SW’s updated assessments and the patient’s progress toward the SW’s goals. During a joint clinical record review and interview, the Patient Care Administrator confirmed the findings.”

“It is required that all entries in the patient record are legible, complete, and appropriately authenticated and dated by the person performing the care/service in accordance with hospice policy and with currently acceptable standards of practice. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy, “Correcting an Error in the Clinical Record,” (05/06/2020) read in part, “The patient’s medical record is considered a legal document... You may not draw several lines, scribble through, or attempt to obliterate an error. You may not attempt to fix an error by writing over something already written ... Place a single line through the incorrect documentation. Place your initials and the date you made the change directly above the incorrect documentation you lined out ...” In 5 of 19 (26%) clinical records reviewed, the agency did not ensure all entries in the patient’s record were legible, and documentation was corrected per agency policy. Clinical Record 4: The patient elected the hospice benefit on 05/25/2024. On pages one (1), two (2), five (5), and six (6) of the “Nursing Updated Comprehensive Assessment” dated 07/22/2024, the visit dates were marked over and not corrected per the policy. On pages one (1) to six (6) of the “Nursing Updated Comprehensive Assessment” dated 08/27/2024, the visit dates were marked over and not corrected per the policy. Clinical Record 5: The patient elected the hospice benefit on 07/01/2024. The Psychosocial/Spriritual note was updated on 08/12/2024. The visit dates documented at the top of page three (3) were written over and not corrected per agency policy. Clinical Record 11: The patient elected the hospice benefit on 10/15/2021. On page one of the “Nursing Updated Comprehensive Assessment” dated 07/15/2024, the pain score “4” was written over and not corrected per agency policy. Clinical Record 12: The patient elected the hospice benefit on 07/05/2022. On page one of the “Nursing Updated Comprehensive Assessment” dated 06/14/2024, the visit date was written over and not corrected per agency policy. Clinical Record 13: The patient elected the hospice benefit on 10/07/2023. On page two (2) of the “Nursing Updated Comprehensive Assessment” dated 06/21/2024, the class number for the New York Heart Association Class (NYHA) was written over and not corrected per agency policy. On page six (6) of the “Nursing Updated Comprehensive Assessment” dated 08/23/2024, the date was written over and not corrected per policy. During a joint clinical record review and interview on 09/05/2024, the Patient Care Administrator (PCA) confirmed that corrections in the clinical record were not made per agency policy. ...”