Vitas Innovative Hospice Care of Greater Wash, DC

“It is required that each patient’s individualized written plan of care: Identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. THIS IS A CONTINUED REQUIRED ACTION This standard was not met as evidenced by clinical record review and interview. In 1 of 6 (17%) clinical records reviewed, the hospice did not ensure that the patient’s written plan of care identified planned interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 2: The patient elected hospice care on 02/27/2024 with the diagnosis of Parkinson’s’ Disease. The initial comprehensive assessment completed by the Registered Nurse (RN) on 02/27/2024 documented that a Foley catheter was in place, the updated comprehensive assessments also documented the continuation of the Foley catheter. The updated plans of care did not include interventions or goals for the maintenance and the care of the Foley catheter. During an interview with the regional national patient care center manager stated that concentration on areas of their plan of correction had only recently been addressed, and they were making progress.”

“It is required that each patient’s individualized written plan of care: includes all services necessary for the palliation and management of the terminal illness, including the following: a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. THIS IS A CONTINUED REQUIRED ACTION This standard was not met as evidenced by clinical record review and interview. In 1 of 6 (17%) clinical records reviewed, the hospice did not ensure that the patient’s written plan of care included a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. Clinical Record 4: The patient elected hospice care on 05/06/2024 with a primary diagnosis of cerebral vascular disease. The initial comprehensive assessment completed by the RN on 05/06/2024 documented the identification of a pressure ulcer. The plan of care dated 05/18/2024 identified the problem of stage 4 sacral wound with an intervention to; “clean site with wound spray and pat dry, apply calcium alginate, cover with gauze bordered dressing.” The interventions did not document the frequency of the wound care to be provided. During an interview with the Regional National Patient Care Center Manager stated that concentration on areas of their plan of correction had only recently been addressed, and they were making progress.”

“It is required that each patient’s individualized written plan of care: includes all services necessary for the palliation and management of the terminal illness, including the following: medical supplies and appliances necessary to meet the needs of the patient. THIS IS A CONTINUED REQUIRED ACTION This standard was not met as evidenced by clinical record review and interview. In 2 of 6 (33%) clinical records reviewed, the hospice did not ensure that the written plan of care included the medical supplies necessary to meet the needs of the patients. Clinical Record 2: The patient elected hospice care on 02/27/2024 with a primary diagnosis of Parkinson’s Disease. The initial comprehensive assessment completed by the Registered Nurse (RN) on 02/27/2024 documented that the patient had a Foley catheter to a dependent large bag drainage. All updated assessments documented that the catheter was still in place as of the review on 05/23/2024. The plan of care medical supplies did not include documentation of the Foley catheter and the supplies to care for the Foley catheter. Clinical Record 4: The patient elected hospice care on 05/16/2024 with a primary diagnosis of cerebral vascular disease. The RN documented that the agency provided wound care to the patient’s stage 4 sacral wound, including calcium alginate, bordered gauze, and wound spray. The plan of care medical supplies did not include documentation of the wound care supplies. During an interview, the Regional National Patient Care Center Manager stated that the concentration on areas of their plan of correction had only recently been addressed, and they were making progress.”

“It is required that a hospice aide provides services: ordered by the Interdisciplinary Group; included in the plan of care; permitted to be performed under state law and regulation; [and] consistent with the hospice aide training. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION of participation was not met as evidenced by clinical record reviews and interviews with the Regional Patient Care Administrator which revealed the following: Failure of the hospice to ensure that the Hospice Aide received written patient care instructions prepared by a Registered Nurse (RN) responsible for the supervision of the Hospice Aide in 8 of 10 (80%) clinical records reviewed [HCDT.15.I/L625]; Failure of the hospice to ensure that the Hospice Aide provided visits as ordered by the Interdisciplinary group in 2 of 10 (20%) clinical records reviewed [HCDT.16.I/L626]; Failure of the hospice to ensure that the Hospice Aide provided services as instructed in the Hospice Aide care plan in 3 of 10 (30%) clinical records reviewed [HCDT.16.I/L626]; and Failure of the hospice to ensure that the Hospice Aide reported changes in the patient’s needs to the RN in 5 of 10 (50%) clinical records reviewed [HCDT.16.I/L628]. The cumulative effect of these deficiencies has resulted in the hospice agency’s ability to ensure the provision of quality hospice care for the condition of participation CFR 418.76, Hospice Aide and Homemaker Services. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice aide services from the agency.”

“It is required that the hospice Interdisciplinary Group, in consultation with the individual’s attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 4 of 19 (21%) clinical records reviewed, the agency did not ensure that the initial comprehensive assessment was completed no later than five (5) calendar days after the election of hospice care. Clinical Record 1: The patient elected hospice care on 02/05/2024 and accepted Chaplain services. The initial plan of care ordered a spiritual counselor visit “1 x within 5 days.” The Registered Nurse (RN) and Social Worker (SW) visit notes dated 02/05/2024 through 02/10/2024 did not document a spiritual assessment. A review of the clinical record revealed a spiritual assessment documented on 02/16/2024, with 11 days outstanding. There was no evidence of communication with the patient or documented reason the initial assessment was not completed within five (5) days after the election of hospice care. Clinical Record 4: The patient elected hospice care on 02/09/2024 and accepted SW and Chaplain services. The initial plan of care ordered a spiritual counselor visit “1 x within 5 days.” No spiritual assessment was documented as of 04/16/2024. Additionally, a review of the RN and SW visit notes dated 02/09/2024 through 02/14/2024 revealed no evidence of a documented psychosocial assessment. There was no evidence of communication with the patient or documented reason the initial assessments were not completed. Clinical Record 5: The patient elected hospice care on 03/28/2024 and accepted SW and Chaplain services. The initial plan of care ordered spiritual and SW visit frequency of “1x within 5 days.” The RN visit notes visit notes dated 03/28/2024 through 04/16/2024 did not include documentation of a spiritual assessment or psychosocial assessment. There was no evidence of communication with the patient or documented reason the initial assessments were not completed. Clinical Record 7: The patient elected hospice care on 08/02/2023 and accepted Chaplain services. The initial plan of care ordered a spiritual counselor visit frequency of “1 x within 5 days.” The RN and SW visit notes dated 08/02/2023 through 08/07/2023 did not include documentation of a spiritual assessment. No spiritual assessment was documented as of 04/16/2024. There was no evidence of communication with the patient or documented reason the initial assessments were not completed. During an interview and a joint record review on 04/16/2024, the Regional Patient Care Administrator confirmed that the initial assessments were not documented. As of the conclusion of the site review on 04/18/2024, no further documentation was provided.”

“It is required that the documented comprehensive assessment includes 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 medication review process includes the identification of the following: the effectiveness of drug therapy; drug side effects; actual or potential drug interactions; duplicate drug therapy; [and] drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at 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 3 of 19 (16%) clinical records reviewed, the agency did not ensure that the medication profile included the patient’s current medications. Clinical Record 2: The patient elected hospice care on 02/27/2024. The initial comprehensive assessment completed by the Registered Nurse (RN) on 02/27/2024 documented that the patient was using oxygen at 3 liters per minute (LPM) via nasal cannula. Oxygen was not included on the medication profile at the time of the review on 04/16/2024. Clinical Record 3: The patient elected hospice care on 08/08/2023. The initial comprehensive assessment completed by the RN on 08/08/2023 documented that the patient was using oxygen at 3 LPM via nasal cannula. Oxygen was not included on the medication profile at the time of the review on 04/16/2024. Clinical Record 12: The patient elected hospice care on 03/02/2024. The initial comprehensive assessment completed by the RN on 03/02/2024 documented that the patient was using oxygen at 3 LPM via nasal cannula. Oxygen was not included on the medication profile at the time of the review on 04/16/2024. During an interview and a joint record review on 04/16/2024, the Regional Patient Care Administrator confirmed that oxygen was not included in the patient’s medication profile. As of the conclusion of the site visit on 04/18/2024, no further documentation was provided.”

“It is required that each patient’s individualized written plan of care: reflects patient and family goals; [and] 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 and interview. In 2 of 19 (11%) clinical records reviewed, the agency did not ensure that the written plans of care identified planned interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 5: The patient elected hospice care on 03/28/2024 with the diagnosis of Amyotrophic lateral sclerosis (ALS). The initial comprehensive assessment completed by the Registered Nurse (RN) on 03/28/2024 documented that a gastrostomy tube (G-tube) was in place and that the patient received six (6) cans of ensure daily. The plan of care did not include documentation of interventions or goals for the maintenance of the G-tube and assessment of the G-tube site. Clinical Record 15: The patient elected hospice care on 10/03/2023 with the diagnosis of Malignant Neoplasm of the Prostate. The initial comprehensive assessment completed by the RN on 10/03/2023 documented that the patient had a foley catheter. The plan of care did not include documentation of interventions or goals for the maintenance of the foley catheter. During an interview and a joint record review on 04/16/2024, the Regional Patient Care Administrator confirmed the findings.”

“It is required that each patient’s individualized written plan of care: includes all services necessary for the palliation and management of the terminal illness, including the following: measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (11%) clinical records reviewed, the agency did not ensure that the written plan of care included measurable outcomes anticipated from the implementation and coordination of the plan of care. Clinical Record 1: The patient elected hospice care on 02/05/2024 with the diagnosis of Malignant Neoplasm of the unspecified Breast. The plan of care documented “other-comfort meds” as a problem on 02/05/2024 with the documented goal “symptoms will be managed at an acceptable level.” The goal did not include a documented measurable outcome for “acceptable level.” Clinical Record 3: The patient elected hospice care on 08/08/2023 with the diagnosis of Amyotrophic lateral sclerosis (ALS). The RN plan of care documented the patient’s difficulty breathing with the documented goal “pt/cg will verbalize understanding of difficulty breathing.” The goal did not include documentation of a measurable outcome or timeframe. During an interview and a joint record review on 04/16/2024, the Regional Patient Care Administrator stated that the goals were not measurable.”

“It is required that each patient’s individualized written plan of care: includes all services necessary for the palliation and management of the terminal illness, including the following: drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 3 of 19 (16%) clinical records reviewed, the agency did not ensure that the plan of care included the medications necessary to meet the patient’s needs. Clinical Record 2: The patient elected hospice care on 02/27/2024. The initial comprehensive assessment completed by the Registered Nurse (RN) on 02/27/2024 documented that the patient was using oxygen at 3 liters per minute (LPM) via nasal cannula. Oxygen was not documented on the plan of care. Clinical Record 3: The patient elected hospice care on 08/08/2023. The initial comprehensive assessment completed by the RN on 08/08/2023 documented that the patient was using oxygen at 3 LPM via nasal cannula. Oxygen was not documented on the plan of care. Clinical Record 12: The patient elected hospice care on 03/02/2024. The initial comprehensive assessment completed by the RN on 03/02/2024 documented that the patient was using oxygen at 3 LPM via nasal cannula. Oxygen was not documented on the plan of care. During an interview and a joint record review on 04/16/2024, the Regional Patient Care Administrator confirmed the findings. No further documentation was provided as of the conclusion of the site visit on 04/18/2024.”

“It is required that each patient’s individualized written plan of care: includes all services necessary for the palliation and management of the terminal illness, including the following: medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 5 of 19 (26%) clinical records reviewed, the hospice did not ensure that the written plan of care included the medical supplies necessary to meet the needs of the patients. Clinical Record 1: The patient elected hospice care on 02/05/2024 with a diagnosis of malignant neoplasm of unspecified site. The Registered Nurse (RN) documented that the agency provided briefs, wipes, under pads and gloves. The plan of care medical supplies did not include documentation of briefs, wipes, underpads, and gloves. Clinical Record 2: The patient elected hospice care on 02/27/2024 with a diagnosis of Parkinson’s Disease. The RN documented that the patient was incontinent of bowel and bladder and that the hospice provided briefs, wipes, under pads, and gloves. The plan of care medical supplies did not include documentation of briefs, wipes, underpads, and gloves. Clinical Record 3: The patient elected hospice care on 08/08/2023 with a diagnosis of Amyotrophic lateral sclerosis (ALS). The RN documented that the hospice provided briefs, wipes, underpads, and gloves. The plan of care medical supplies did not include documentation of briefs, wipes, underpads, and gloves. Clinical Record 4: The patient elected hospice care on 02/09/2024 with a diagnosis of chronic obstructive pulmonary disease (COPD). The RN documented that the hospice provided briefs and underpads. The plan of care medical supplies did not include documentation of briefs and underpads. Clinical Record 5: The patient elected hospice care on 03/28/2024 with a diagnosis of ALS. The RN documented that the hospice provided briefs, wipes, underpads, and gloves. However, the plan of care medical supplies did not include documentation of these items. The Regional Patient Care Administrator confirmed the findings during an interview and a joint review of the records on 04/16/2024. As of the conclusion of the site visit on 04/19/2024, no further information was provided.”

“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 8 of 10 (80%) clinical records reviewed of patients that received Hospice Aide (HA) services, the agency did not ensure that the Hospice Aide received specific written patient care instructions from the Registered Nurse (RN). Clinical Record 3: The patient elected hospice care on 08/08/2023 with a diagnosis of Amyotrophic lateral sclerosis (ALS). The Hospice Aide (HA) care plan, effective 08/08/2023, assigned the HA the relevant tasks: shower with bath chair and sponge bath every visit. The patient was chair bound and required assistance with activities of daily living. The RN did not provide the HA with specific instructions regarding the type of bath. Clinical Record 4: The patient elected hospice care on 02/09/2024 with a diagnosis of chronic obstructive pulmonary disease (COPD). The initial plan of care dated 02/09/2024 ordered HA services two (2) times a week. The HA provided visits as ordered. A review of the clinical record revealed no documented HA care plan. Clinical Record 5: The patient elected hospice care on 03/28/2024 with a diagnosis of ALS. The HA care plan dated 03/28/2024 assigned the HA the relevant tasks: shower with bath chair and sponge bath every visit. The patient was chair bound and required assistance with activities of daily living. The RN did not provide the HA with specific instructions regarding the type of bath. Clinical Record 6: The patient elected hospice care on 03/15/2024 with a diagnosis of Multiple Sclerosis (MS). The HA care plan dated 03/15/2024 assigned the HA the relevant tasks: shower with bath chair and sponge bath every visit. The RN did not provide the HA with specific instructions regarding the type of bath. Clinical Record 9: The patient elected hospice care on 01/04/2024 with a diagnosis of COPD. The initial aide plan of care dated 01/04/2024 ordered HA services four (4) times a week. The HA provided visits as ordered. A review of the clinical record revealed no documented HA care plan. Clinical Record 10: The patient elected hospice care on 06/26/2023 with a diagnosis of cerebral vascular accident (CVA).The HA care plan dated 06/26/2023 assigned the HA the relevant tasks: shower with bath chair and sponge bath every visit. The RN did not provide the HA with specific instructions regarding the type of bath. Clinical Record 11: The patient elected hospice care on 11/03/2022 with a diagnosis of COPD. The HA care plan dated 11/03/2022 assigned the HA the relevant tasks: shower with bath chair and sponge bath every visit. The RN did not provide the HA with specific instructions regarding the type of bath. Clinical Record 12: The patient elected hospice care on 03/02/2024 with a diagnosis of pulmonary heart disease. The HA care plan dated 03/02/2024 assigned the HA the relevant task: observe the patient. No other tasks were assigned and no further instructions were provided for the HA. During an interview and a joint record review on 04/16/2024, the Regional Patient Care Administrator confirmed the findings. No further documentation was provided prior to conclusion of the site visit.”

“It is required that a hospice aide provides services: ordered by the Interdisciplinary Group. This standard was not met as evidenced by clinical record review and interview. In 2 of 10 (20%) clinical records reviewed of patients that received Hospice Aide (HA) services, the agency did not ensure that the HA provided services ordered by the Interdisciplinary Group (IDG). Clinical Record 8: The patient elected hospice care on 09/20/2023 with a diagnosis of cerebral vascular accident (CVA). The plan of care dated 09/20/2023 ordered Hospice Aide services two (2) times a week. No HA visits were documented until 01/30/2024. There was no evidence of documented missed visits or evidence of a change in visit frequency. Clinical Record 12: The patient elected hospice care on 03/02/2024 with a diagnosis of pulmonary heart disease. The plan of care dated 03/02/2024 ordered Hospice Aide services two (2) times a week. There were two (2) missed HA visits for the week of 03/11/2024 through 03/16/2024. There was no evidence of documented missed visits or evidence of a change in visit frequency. During an interview and a joint record review on 04/16/2024, the Regional Patient Care Administrator confirmed the findings. No further documentation was provided as of the conclusion of the review.”

“It is required that a hospice aide provides services: included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 3 of 10 (30%) clinical records reviewed of patients that received Hospice Aide (HA) services, the agency did not ensure that the HA provided services included in the plan of care. Clinical Record 10: The patient elected hospice care on 06/26/2023 with a diagnosis of a cerebral vascular accident (CVA). The HA care plan dated 06/26/2023 assigned the HA the relevant tasks: shower with bath chair and sponge bath every visit. On 07/08/2023, the HA documented no shower or sponge bath was performed. Clinical Record 11: The patient elected hospice care on 11/03/2022 with a diagnosis of chronic obstructive pulmonary disease (COPD). The HA care plan dated 11/03/2022 assigned the HA the relevant tasks: shower with bath chair and sponge bath every visit. On 11/09/2023, the HA documented no shower or sponge bath was performed. Clinical Record 13: The patient elected hospice care on 03/09/2024 with a diagnosis of CVA. The HA care plan dated 03/09/2024 assigned the HA the relevant task: oral care every visit. On 03/22/2024, the HA documented that oral care was not performed. The Regional Patient Care Administrator reviewed the records during an interview on 04/16/2024 and confirmed the findings. No further information was provided.”

“It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review and interview. In 5 of 10 (50%) clinical records reviewed of patients that received Hospice Aide (HA) services, the agency did not ensure that the HA reported changes in the patient’s needs to the Registered Nurse (RN). Clinical Record 8: The patient elected hospice care on 09/20/2023 with a diagnosis of cerebral vascular accident (CVA). The plan of care dated 09/20/2023 ordered Hospice Aide services two (2) times a week. No HA visits were documented until 01/30/2024. There was no evidence of documented missed visits and no evidence of communication with the RN regarding the change in the patient’s needs. Clinical Record 10: The patient elected hospice care on 06/26/2023 with a diagnosis of cerebral vascular accident (CVA). The HA care plan dated 06/26/2023 assigned the HA the relevant tasks: shower with bath chair and sponge bath every visit. On 07/08/2023, the HA documented no shower or sponge bath were performed. There was no evidence of communication with the RN regarding the change in the patient’s needs. Clinical Record 11: The patient elected hospice care on 11/03/2022 with a diagnosis of chronic obstructive pulmonary disease (COPD). The HA care plan dated 11/03/2022 assigned the HA the relevant tasks: shower with bath chair and sponge bath every visit. On 11/09/2022, the HA documented no shower or sponge bath were performed. There was no evidence of communication with the RN regarding the change in the patient’s needs. Clinical Record 12: The patient elected hospice care on 03/02/2024 with a diagnosis of pulmonary heart disease. The plan of care dated 03/02/2024 ordered Hospice Aide services two (2) times a week. There were two (2) missed HA visits for the week of 03/11/2024 through 03/16/2024. A review of the clinical record revealed no documented evidence of the visits. There was no evidence of documented missed visits and no evidence of communication with the RN regarding the change in the patient’s needs. Clinical Record 13: The patient elected hospice care on 03/09/2024 with a diagnosis of CVA. The HA care plan dated 03/09/2024 assigned the HA the relevant task: oral care every visit. On 03/22/2024, the HA documented that oral care was not performed. There was no evidence of communication with the RN regarding the change in the patient’s needs. The Regional Patient Care Administrator confirmed the findings during an interview and a joint record review on 04/16/2024. No further documentation was provided prior to the conclusion of the site visit.”

“It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of: the hospice discharge summary described in HCDT 40.I; and the patient’s record, if requested. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record review of a patient that transferred to a Medicare/Medicaid certified facility, the hospice did not ensure that the discharge summary was sent to the receiving facility. Clinical Record 16: The patient elected hospice care on 03/09/2023 and transferred to another hospice provider on 06/28/2023. A review of the clinical record revealed no documented evidence that a discharge summary was forwarded to the receiving hospice. During an interview and a joint record review on 04/16/2024, the Regional Patient Care Administrator confirmed that the discharge summary was not sent to the receiving facility.”

“It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the following: a summary of the patient’s hospice stay, including treatments, symptoms, and pain management; the patient’s current plan of care; 3. The patient’s latest physician orders; [and] any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed of patients discharged from hospice services, the hospice did not ensure that a discharge summary was completed. Clinical Record 15: The patient elected hospice care on 10/03/2023 and revoked the election of hospice care on 11/01/2023 to seek aggressive treatment. A review of the clinical record revealed no evidence that a discharge summary was documented. Clinical Record 16: The patient elected hospice care on 03/09/2023 and was transferred to another hospice provider on 06/28/2023. A review of the clinical record revealed no evidence that a discharge summary was documented. During an interview and a joint record review on 04/16/2024, the Regional Patient Care Administrator confirmed that the clinical records did not include a discharge summary.”