Vitas Healthcare Corporation of California

“It is required that the hospice inpatient facility has documented and dated written reports of Life Safety Code fire drills at varied times on all shifts. This standard was not met as evidenced by document review and interview. A review of the inpatient facility fire drill logs revealed the agency did not ensure compliance with the National Fire Protection Act (NFPA) section 18/19.7.1.6, which stated, “Fire drills conducted at unexpected times under varying conditions, at least quarterly, on each shift.” The inpatient facility’s fire drill logs documented for the first quarter of 2024 included 01/12/2024 from 1530-1600, 02/20/2024 from 1800-1820, and 03/07/2024 from 0815-0845. The inpatient unit had three (3) shifts (0730-1600, 1530-2400, and 2330-0800). There was no evidence of a fire drill conducted for the third shift (2330-0800) in the first quarter of 2024. Following the joint review of the fire drill logs on 06/19/2024, the team manager confirmed that no fire drill was conducted for the third shift (2330-0800). A review of the fire drill logs revealed the agency did not ensure compliance with the National Fire Protection Act (NFPA) section 18/19.7.1.6 which stated, “Fire drills conducted at unexpected times under varying conditions, at least quarterly, on each shift.””

“It is required that the Interdisciplinary Group, in collaboration with the individual’s attending physician (if any), reviews, revises, and documents the individualized care plan. 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 and interview. In 3 of 30 (10%) clinical records reviewed, the agency did not ensure that the patient’s plan of care included information from the patient’s updated comprehensive assessment and the patient’s progress toward the outcomes and goals specified in the plan of care. Clinical Record 6: The patient elected the hospice benefit on 11/15/2023 with a diagnosis of cerebral atherosclerosis. A clinical record review revealed the “Plan of Care Review” paper forms, which were utilized to document updates to the comprehensive assessment, responses to care, and plan of care review. The “Plan of Care Review” forms dated 11/28/2023, 12/12/2023, and 01/09/2024 were photocopied with only the date they were signed changed. The “Plan of Care Review” forms dated 03/26/2024, 04/09/2024, and 04/23/2024 were photocopied with only the date they were signed changed. During a joint record review, the National Patient Care Administrator confirmed that the forms had been copied and there was no other documentation to support that the plans of care were reviewed, revised, or showed patient progress towards goals. Clinical Record 7: The patient elected the hospice benefit on 01/19/2024 with a diagnosis of chronic obstructive pulmonary disease (COPD). The Chaplain signed the documented initial psychosocial/spiritual assessment dated 01/21/2024. Per that assessment, the patient answered “yes” to the question, “Do you want help to change or complete your final arrangements?” The forms completed for the plan of care updates, titled “Plan of Care Review,” included a section for response to care and updates to comprehensive assessments for “End of Life Choices” in which the clinicians documented, “DNR (do not resuscitate) - needs final arrangements” on 01/24/2024, 02/07/2024, 02/21/2024, 03/06/2024, 03/20/2024, 04/03/2024, 04/10/2024, 04/17/2024, 05/01/2024, 05/15/2024, 05/29/2024, and 06/12/2024. A clinical record review revealed no documented evidence that hospice staff were assisting the patient with progressing toward this goal. On 06/19/2024, the Patient Care Administrator (PCA) reported that they contacted the Social Worker for this patient, who said, “(The patient) had final arrangements but hadn’t provided the hospice agency a copy yet.” On 06/21/2024, the PCA confirmed the record did not contain additional documentation to support revisions to this care plan or the patient’s progress toward the goal of completing the final arrangements. Clinical Record 12: The patient elected the hospice benefit on 05/20/2023 with a diagnosis of COPD. A clinical record review revealed the paper forms titled “Plan of Care Review,” which were utilized to document updates to the comprehensive assessment, responses to care, and plan of care review. The “Plan of Care Review” forms dated 05/30/2023 and 06/14/2023 were photocopied with only the date they were signed changed. During a joint record review, the National Patient Care Administrator confirmed that the forms had been copied and there was no other documentation to support that the plans of care were reviewed, revised, or showed patient progress towards goals.”

“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. In 5 of 30 (17%) clinical records reviewed, the agency did not ensure that the patient records contained legible and authenticated documents. Document 1: “Correcting an Error in the Clinical Record” (no date), stated in relevant parts, “The patient’s medical record is considered a legal document...You may NOT use whiteout or any other substance to cover what is written in a legal document...You may NOT attempt to fix an error by writing over something already written.” Clinical Record 5: The patient elected hospice care on 09/06/2023. A clinical record review revealed the paper form titled “Plan of Care Review.” The “Plan of Care Review” forms signed by the Registered Nurse (RN) on 05/07/2024 and 06/04/2024 documented words covered with white corrective fluid and written over. During a joint review of the record on 06/18/2024, the Patient Care Administrator (PCA) [Personnel Record 2] confirmed the presence of the corrective fluid in two areas within the record. Clinical Record 6: The patient elected hospice care on 11/15/2023. A clinical record review revealed the paper form titled “Plan of Care Review.” The “Plan of Care Review” form was utilized to document updates to the comprehensive assessment, responses to care, and the plan of care review. The “Plan of Care Review” forms dated 11/28/2023, 12/12/2023, and 01/09/2024 were photocopied with only the date they were signed changed. The “Plan of Care Review” forms dated 03/26/2024, 04/09/2024, and 04/23/2024 were photocopied with only the date they were signed changed. The nurse’s signature on the forms had been photocopied. During a joint review of the record on 06/19/2024, the National Patient Care Administrator confirmed the forms, including the signatures, had been photocopied. Clinical Record 10: The patient elected hospice care on 04/17/2024. A review of the clinical record revealed the paper form titled “Nursing-Updated Comprehensive Assessment,” signed by the RN and dated 05/31/2024. The form contained a section documenting the patient’s and caregivers’ reported level (0-10) of concern. Both sections documented a number that had been scribbled over the top of another number, making it illegible. Clinical Record 12: The patient elected hospice care on 05/20/2023. A clinical record review revealed the paper form titled “Plan of Care Review.” The “Plan of Care Review” form was utilized to document updates to the comprehensive assessment, responses to care, and the plan of care review. The “Plan of Care Review” forms dated 05/30/2023 and 06/14/2023 were photocopied, and only the date they were signed was changed. The nurse’s signature on the forms had been photocopied. During a joint review of the record on 06/19/2024, the National Patient Care Administrator confirmed the forms, including the signatures, had been photocopied. Clinical Record 29: The patient elected hospice care on 06/16/2024. A review of the clinical record revealed the paper form titled “VIPU RN-Initial Comprehensive Assessment,” signed by the RN and dated 06/16/2024. The document contained areas where words had been scribbled over, making them illegible. During a joint clinical record review, the Inpatient Unit (IPU) Team Manager confirmed multiple areas where words were scribbled over.”