Vitas Healthcare Corporation of Florida

“Based on record reviews and interviews the hospice organization failed to ensure care and services related to assessing and determining death were provided in accordance with accepted standards of practice for 4 out of 4 patients reviewed for death determination, out of a total sample of 6 patients (#2, #3, #4, #6). Findings: A record review of patient #2’s medical record revealed the patient was admitted to home hospice care on 4/14/26 for malignant neoplasm of the colon. On 5/4/26 at 3:15 AM, a social worker pronounced death at patient’s home by direct observation as evidenced by the social worker documenting the absence of tactile, verbal, and pupillary response.A review of patient #3’s medical record revealed the patient was admitted to home hospice care on 11/25/25 for a malignant neoplasm of the cecum. On 5/30/26 at 9:30 PM, a Licensed Practical Nurse (LPN) pronounced death at patient’s home by direct observation as evidenced by the LPN documenting the absence of vital signs, tactile, verbal and pupillary response.A record review of patient #4’s medical record revealed the patient was admitted to hospice care on 5/24/25 for a malignant neoplasm of the frontal lobe. On 7/21/25 at 4:08 PM, a Chaplain pronounced death at patient’s home by direct observation as evidenced by the chaplain documenting the absence of tactile, verbal, and pupillary response.A review of patient #6’s medical record revealed the patient was admitted to home hospice care on 7/7/25 for a malignant neoplasm of the sinus. On 7/13/25 at 3:50 PM, a social worker pronounced death at patient’s home by direct observation as evidenced by the social worker documenting absence of tactile, verbal and pupillary response.A record review of Death Attendance policy and procedure updated on 10/24/25, identified staff were instructed to perform a patient assessment to determine death. The assessment included, confirming identity, assessing for the absence of pulse and respirations, and documenting time of death. The policy further stated that in Florida “anyone” may pronounce death, including registered nurses, licensed practical nurses, social workers and chaplains.During the survey, the facility was requested to provide the legal, regulatory, licensing, or nationally recognized professional standards supporting its policy permitting social workers, chaplains and Licensed Practical Nurses (LPN) to determine and pronounce death. The facility was unable to provide supporting state statutes, regulations, professional licensing guidance, nationally recognized hospice standards or other accepted standards of practice supporting the policy or its implementation prior to the time of exit.A record review of the social worker and chaplain job descriptions and orientation competency records identified responsibilities related to psychosocial assessments, spiritual care, bereavement services, interdisciplinary collaboration, documentation, and remain within each discipline’s scope of practice.A record review of the Workforce Development and Training document, “Things Hospice Innovators Need to Know About: Death Pronouncement and How to Check for Absence of Pulse and Respirations,” dated December 2025, revealed education for hospice social workers and chaplains on pronouncement of death. The document included a physical exam, documentation, and how to check for a pulse. The physical exam included, “listen for the absence of heart sounds (no heartbeat heard) with a stethoscope.” The documentation included, “Note the time the physical assessment is completed – this becomes the Time of Death (TOD).”A telephone interview was conducted on 6/11/26 at 8:08 AM with Social Worker (SW) E. SW E She stated the administration asked the social workers to pronounce by observation, but the social workers are “terrified” to go in and declare death because it requires clinical skills. She stated that she does not want “to be responsible for saying a patient is dead and the patient is not dead.”A telephone interview was conducted on 6/11/26 at 1:43 PM with SW D. She stated that the process for a death at home, if a nurse is not present, is for the social worker to “check the neck or hand for absence of pulse, observe absence of breathing, and document time of death.”An interview was conducted on 6/11/26 at 4:14 PM with the Patient Care Administrator (PCA). The PCA acknowledged the Death Attendance Policy and Procedure included an assessment of the patient, the determination of the absence of pulse and respirations and time of death. She agreed that pulse and respirations were part of an assessment.A videocall interview was conducted on 6/11/26 at 4:32 PM with the Chief Nursing Officer (CNO). The CNO stated, “Florida doesn’t specify who can pronounce.” She stated that the regulations did not prohibit social workers or chaplains from pronouncing death. She further stated, “It is a simple process. You don’t have to be a clinician. You are not breathing, you don’t have a pulse, plus we do hospice care and expect the person to die.”A telephone interview was conducted on 6/11/26 at 2:42 PM with Medical Doctor (MD) C. The MD C stated death pronouncement requires an in-person clinical assessment and that chaplains and social workers do not carry stethoscopes or perform clinical assessments within their scope of practice. He stated that is he were a chaplain; he would not pronounce death and would instead report that the patient appeared not to be breathing until a clinician completed the assessment.”

“Based on record reviews and interviews the organization failed to ensure legally authorized personnel acted within the scope of his or her state license, or state certification, or registration for 4 out of 4 patients reviewed for death pronouncement, of a total sample of 6 patients, (#2, #3, #4, #6). Findings: A record review of patient #2’s medical record revealed the patient was admitted to home hospice care on 4/14/26 for malignant neoplasm of the colon. On 5/4/26 at 3:15 AM, a social worker pronounced death at patient’s home by direct observation as evidenced by documented absence of tactile, verbal, and pupillary response.A review of patient #3’s medical record revealed the patient was admitted to home hospice care on 11/25/25 for a malignant neoplasm of the cecum. On 5/30/26 at 9:30 PM, a Licensed Practical Nurse pronounced death at patient’s home by direct observation as evidenced by documented absence of vital signs, tactile, verbal and pupillary response.A record review of patient #4’s medical record revealed the patient was admitted to hospice care on 5/24/25 for a malignant neoplasm of the frontal lobe. On 7/21/25 at 4:08 PM, a Chaplain pronounced death at patient’s home by direct observation as evidenced by documented absence of tactile, verbal, and pupillary response.A review of patient #6’s medical record revealed the patient was admitted to home hospice care on 7/7/25 for a malignant neoplasm of the sinus. On 7/13/25 at 3:50 PM, a Social Worker pronounced death at patient’s home by direct observation as evidenced by documented absence of tactile, verbal and pupillary response.A record review of the agency’s VS Death Attendance policy and procedure, updated on 10/24/25, identified steps to perform on a death visit. Steps during the death visit included assessment of the patient to “determine (pronounce) death.” For determining death, the list included confirmation of identity, absence of pulse, and absence of respirations to determine the time of death. The policy included a list of states and identified who can pronounce death by state. Florida was listed as “anyone” could pronounce death and the comment section stated, “Specialized training or qualifications are not required to pronounce another person dead (RN (Registered Nurse), LVN/LPN (Licensed Vocational Nurse/License Practical Nurse), SW (Social Worker), Chaplain).”During the survey, the facility was requested to provide the legal, regulatory, and/or professional references supporting the Death Attendance policy. The facility was unable to provide supporting state statutes, regulations, licensing board guidance, or accepted standards of practice prior to the time of exit.A review of the Bereavement Visit policy and procedure, dated 10/14/25, revealed when two staff members attended a death visit, a clinical staff member completed the “Died-Pronouncement Visit” while the other staff person would complete a “Focused Encounter – Bereavement” note.A review of Policy #9:19 titled Job Descriptions: Social Worker, with a revision date of 8/20/25, revealed the primary function of a social worker was to perform psychosocial assessments, counseling, case management, bereavement support, consultation and coordination of community resources. Additional responsibilities included performing “bio-psycho-social-spiritual assessments of patients/families, rather than diagnostic assessment” and other duties assigned by their supervisor or management. The qualifications listed in the job description included “Equivalent experience or licensure may be considered where allowable by State Regulations (i.e. a bachelor’s in science of nursing (BSN) or bachelor’s in social work (BSW) in Florida or Wisconsin).”The record review for Policy 9:18, Job Descriptions: Chaplain with revision date of 7/24/06, revealed the primary role of the chaplain was to provide spiritual assessments, pastoral counseling, spiritual consultation to the interdisciplinary group, bereavement services, and documentation of the spiritual care provided. The qualifications listed in the job description included bachelor’s degree, Master of Divinity, ordination, endorsement by faith body, and pastoral experience.The record review for Policy 9:15, Job Descriptions: Vitas Nurse, LPN/LVN, with revision date of 5/21/26, revealed the primary function of the Vitas Nurse, LPN/LVN as providing care according to the plan of care and direction received by the nurse in accordance with the Nurse Practice Act. The essential duties and responsibilities included performing “selected acts” under the supervision of a registered nurse. The “acts” were identified as administration of treatments and medications and reporting significant findings or changes in patient condition to the registered nurse, team manager or physician.Record review of Policy 9:14, Job Descriptions: Vitas Nurse, RN (Registered Nurse), with revision date of 5/21/26, revealed the primary function of registered nurses is to “provide coordination of care, ensure continuous assessment of each patient’s and family’s needs, initiate interventions for patients and families and implementation and oversight of the interdisciplinary plan of care.” The job responsibilities stated the registered nurse followed policy and standards and practices within the scope of the “RN license”, reports any requests to perform duties outside their scope of licensure, provides services requiring specialized nursing skill, and determines the appropriate delegation of nursing tasks. The policy further identified the registered nurse as responsible for coordinating and managing the patient’s plan of care through professional nursing oversight.A record review of Vitas Record of Orientation Skills Checklist – Social Worker (SW) dated 6/30/23 revealed under the supervision of the social worker mentor, “Stays within scope of practice and develops the plan of care according to the individual needs of the patient.”A record review of Vitas Record of Orientation Skills Checklist – Chaplain dated 10/14/24 revealed “Completes assessments of patients in a systematic manner and as per scope of practice.” The record identified under clinical and technical competencies, “Stays within scope of practice.”A telephone interview was conducted on 6/11/26 at 8:08 AM with SW E. SW E had been at the facility for two years and two months as a social worker. She stated as a social worker, she called funeral homes and assisted with the needs of the family. She revealed that death pronouncement had been completed by social workers and Chaplains since she started working at the facility. She stated that during her onboarding training, she was required to attend three deaths. She stated she observed nurses taking vital signs to determine death. She stated about six months ago, a new social worker left because she was not comfortable with pronouncing. She stated administration had conducted a meeting with social workers to discuss concerns with the pronouncing practice. She stated the administration asked the social workers to pronounce by observation, but the social workers were “terrified” to go in and declare death because it required clinical skills. She stated that she did not want “to be responsible for saying a patient is dead and the patient is not dead.”A telephone interview was conducted on 6/11/26 at 1:43 PM with SW D. SW D had been with the facility as a social worker for two years. She stated the process for a death at home, if a nurse was not present, was for the social worker to “check the neck or hand for absence of pulse, observe absence of breathing, and document time of death.” She stated that if she was not confident, she could contact a nurse. She stated she provided emotional support, assisted with contacting the funeral home and provided community resources. SW D stated she had pronounced death while at the facility. She stated that during her orientation, her manager “went through how to pronounce death.”A telephone interview was conducted on 6/11/26 at 2:57 PM with Chaplain B. Chaplain B had been with the facility for 33 years. He stated his role was to provide spiritual and emotional support for patients and families. He stated he was on call on Tuesdays between the hours of 1:00 AM to 8:00 AM. He stated he “sometimes goes to calls of death by himself.” He stated he had pronounced deaths when responding alone but if a nurse was there he or she would pronounce. He stated he felt the patient’s neck and carotid artery, looked at the body and looked at the eyes to see if the color had changed. He stated by the time he arrived, the family already knew the patient was dead. He officially determined the time and documented the time of death. He stated, “I have had families ask if a nurse would come and I tell them that I am allowed to pronounce but if they want a nurse and insist on a nurse, I call telecare and let them know that the family wants a nurse to pronounce.” He stated that it had been a while since he last pronounced death and that this was something discussed with the family especially during the patient’s late stages. He stated he recalled an in-service about pronouncing which included “nurses teaching and showing how to check.”A telephone interview was conducted on 6/11/26 at 3:11 PM with Chaplain A. Chaplain A had been with the facility for one year. He stated he was usually called for spiritual guidance when nearing death. He stated there had been a few times when he had arrived without a nurse and the patient had already expired. He stated he observed the chest not rising or falling and putting finger on the patient’s neck to determine no pulse. He stated during orientation he went on three visits to pronounce with another chaplain, a Medical Social Worker (MSW), or nurse before he was able to “do one on my own.” He stated in the past few months during team meetings and the MSW and Chaplain meeting, concerns regarding pronouncement and not being clinical had been discussed.An interview was conducted on 6/11/26 at 3:45 PM with the Patient Care Administrator (PCA) F and General Manager (GM). The PCA has been with the facility for 14 years and the GM has been with the facility for 14 years. PCA F stated when the family called telecare to report the patient has died, telecare looked for a nurse. If no nurse was available, they would send a MSW or Chaplain to the death visit. PCA F stated the MSW was permitted to pronounce death if they have received training upon hire and have attended three death visits. PCA F stated the training included the pronouncement process and a checklist of what to do at a death visit. The GM stated she “thinks” the definition of pronouncement was the absence of pulse and breath sounds. PCA F stated the definition of pronouncement was absence of pulse and absence of respirations. PCA F read from the death visit policy and acknowledged the policy stated, “assess the patient.” PCA F stated, “an assessment is a function that the MSW can do.” The PCA further stated that a hospice patient was considered an attended death and did not require a doctor or nurse to assess to pronounce. PCA F stated the MSW and Chaplain trained mainly with their discipline. PCA F stated training visits could be with any discipline during a death visit, but their final training was with their own discipline for death visits. PCM F and GM both stated they were nurses in the field prior to their current position, and the death process had been the same and had not changed.An interview was conducted on 6/11/26 at 4:14 PM with the National Patient Care Administrator (NPCA). The NPCA acknowledged the Death Attendance Policy and Procedure included an assessment of the patient, the determination of the absence of pulse and respirations and time of death. She agreed that pulse and respirations were part of an assessment. She stated that in the State of Florida, there was no special requirement for pronouncement of death. She further stated the State did not require specialized qualifications or training for pronouncing death.A videocall interview was conducted on 6/11/26 at 4:32 PM with the Chief Nursing Officer (CNO). The NPCA was also present during the interview. NPCA stated that the policy for pronouncing was based on the expectation that hospice patients would be expected to die. She stated, “Florida doesn’t specify who can pronounce, just defines it as an unattended death.” The CNO stated that the term “pronouncement” was “loosely used all across the country, basically speaking, they anticipate having absences of pulse and not breathing.” She stated the value of the MSW and Chaplain who answered the call for the death visit was “humungous”, and it was a “hard time” for the families. She stated they were attending a death, and the patients were considered an attended death. Additionally, she stated the regulations did not prohibit social workers or chaplains from pronouncing death. The CNO stated, “Families would call and say they died; they just have to go there and confirm it.” She stated she was confident they have looked at the scope of practice “more than once” and that it did not change very frequently. She further stated, “It is a simple process. You don’t have to be a clinician. You are not breathing, you don’t have a pulse, plus we do hospice care and expect the person to die.”A telephone interview was conducted on 6/11/26 at 2:42 PM with Medical Doctor (MD) C. MD C had been with the facility for seven years. He stated that Advanced Registered Practice Nurses (APRN), Registered Nurses (RN), and physicians could pronounce death. He stated pronouncement of death was not done over the phone and required someone to go and assess the patient in person. He stated in the “off hours”, they had APRN and RN “runners”. He stated the manager was a nurse and on call during the off hours. He stated that during working hours, a team would converge at the patient’s home which included the social worker and chaplain. MD C stated that clinical social workers have more latitude than civilians. “Chaplains and social workers do not carry a stethoscope and would be touching the patient to identify death. They might be the first responder, but the nurse will follow-up.” He stated, “Some families have challenged the assessment if it wasn’t with a stethoscope.” MD C stated that if the family was uncertain of the patient’s condition, “a chaplain would not be the first call. They have things to do related to their scope of practice.” He further stated, “A chaplain could say what they see but cannot assess.” He stated, “If I were a chaplain, I would not say I pronounced, I would just mention the patient was not breathing. A clinician would officially be pronouncing death.” He stated he received a text message when a patient died in the off hours but did not receive who pronounced in the text. MD C further stated scope of practice was important and he was not aware of non-clinicians pronouncing death. He reiterated that pronouncing death required a clinical assessment.”

“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. Agency policy #5:16 “Interdisciplinary Team Policies Assessment” (reviewed 11/15/2016) stated in part, “A comprehensive assessment completed by IDG members identified in the initial assessment, in consultation with the attending physician (if any) s started on or before the effective date of election and will be completed within five (5) days of the effective date of election.” In 21 of 58 (36%) clinical records reviewed from patients who accepted Chaplain (SC) services, the agency did not ensure that the SC, when requested, provided a full spiritual assessment within the first 5 days. CLINICAL RECORD 7: The patient elected the hospice benefit on 01/18/2026 with a primary diagnosis of sepsis. The initial comprehensive assessment dated 01/18/2026 documented a request for spiritual services. The first contact documented by the Chaplain was on 02/18/2026, with a voicemail left to arrange a visit, with 30 days outstanding. CLINICAL RECORD 15: The patient elected the hospice benefit on 12/24/2026 with a primary diagnosis of subdural hemorrhage. The initial comprehensive assessment dated 12/24/2025 documented a request for spiritual services. The Chaplain completed the assessment visit on 02/06/2026, 44 days outstanding. There was no evidence of prior communication. CLINICAL RECORD 17: The patient elected the hospice benefit on 01/16/2026 with a primary diagnosis of cerebral atherosclerosis. The initial comprehensive assessment dated 01/16/2026 documented a request for spiritual services. The Chaplain completed the assessment visit on 03/12/2026, 55 days outstanding. There was no evidence of prior communication. CLINICAL RECORD 20: The patient elected the hospice benefit on 01/21/2026 with a primary diagnosis of congestive heart failure. The initial comprehensive assessment dated 01/21/2026 documented a request for spiritual services. There was no evidence that the Chaplain contacted the patient until 02/03/2026, when an assessment visit was documented, 10 days outstanding. CLINICAL RECORD 21: The patient elected the hospice benefit on 10/15/2025 with a primary diagnosis of senile degeneration. The initial comprehensive assessment dated 10/15/2025 documented a request for spiritual services. The Chaplain documented an assessment visit on 12/16/2025, 62 days outstanding. There was no reason the assessment was not completed within the first 5 days, nor was there evidence of communication with the family regarding spiritual care. CLINICAL RECORD 24: The patient elected the hospice benefit on 12/02/2025 with a primary diagnosis of cerebral vascular disease. The initial comprehensive assessment dated 12/02/2025 documented a request for spiritual services. There was no evidence that the Chaplain contacted the patient as of 03/26/2026, with 114 days outstanding. CLINICAL RECORD 26: The patient elected the hospice benefit on 12/24/2025 with a primary diagnosis of breast cancer. The initial comprehensive assessment dated 12/26/2025 documented a request for spiritual services. The Chaplain documented in the IDG (interdisciplinary group meeting) note 02/10/2026 that Chaplain services were declined. There was no contact note documenting how this information was obtained. There was no documentation of the Chaplain’s attempts to offer services in the first 5 days. The IDG note was documented on day 15. CLINICAL RECORD 27: The patient elected the hospice benefit on 10/27/2026 with a primary diagnosis of heart failure. The initial comprehensive assessment dated 10/27/2025 documented a request for spiritual services. There was no evidence that the Chaplain (SC) contacted the patient as of 03/29/2026. The IDGs dated 01/29/2026 and 03/12/2026 documented that the patient and caregiver accepted spiritual care services. The IDG dated 02/12/2026, documented ongoing pastoral care. No assessment visit was documented by the Chaplain. CLINICAL RECORD 33: The patient elected the hospice benefit on 01/23/2026 with a primary diagnosis of heart failure. The initial comprehensive assessment dated 01/23/2026 documented a request for spiritual services. The SC documented a “focus” visit on 02/05/2026. No comprehensive spiritual assessment was completed, with 12 days outstanding. CLINICAL RECORD 34: The patient elected the hospice benefit on 01/20/2026 with a primary diagnosis of chronic obstructive pulmonary disease. The initial comprehensive assessment dated 01/20/2026 documented a request for spiritual services. The SC documented the assessment visit on 03/20/2026. The IDGs dated 02/04/2026, 02/18/2026, 03/04/2026, and 03/18/2026 documented that the SC was prn (as needed). CLINICAL RECORD 39: The patient elected the hospice benefit on 01/29/2026 with a primary diagnosis of cortisol degeneration. The initial comprehensive assessment dated 01/30/2026 documented a request for spiritual services. As of the review on 03/30/2026, the SC had not documented an assessment, 58 days outstanding. CLINICAL RECORD 41: The patient elected the hospice benefit on 02/05/2026 with a primary diagnosis of cerebral atherosclerosis and vascular dementia. The initial comprehensive assessment dated 02/05/2026 documented a request for spiritual services. As of the review on 03/26/2026, the SC had not documented an assessment, 49 days outstanding. CLINICAL RECORD 42: The patient elected the hospice benefit on 02/23/2026 with a primary diagnosis of intrahepatic bile duct carcinoma. The initial comprehensive assessment dated 02/23/2026 documented a request for spiritual services. As of the review on 03/26/2026, the SC had not documented an assessment, 31 days outstanding. CLINICAL RECORD 43: The patient elected the hospice benefit on 01/21/2026 with a primary diagnosis of cerebral atherosclerosis. The initial comprehensive assessment dated 01/21/2026 documented a request for spiritual services. The SC documented an assessment visit on 01/28/2026, 7 days outstanding. CLINICAL RECORD 44: The patient elected the hospice benefit on 02/09/2025 with a primary diagnosis of malignant neoplasms of the colon. The initial comprehensive assessment dated 02/09/2026 documented a request for spiritual services. The SC documented an assessment visit on 02/27/2026, 18 days outstanding. CLINICAL RECORD 45: The patient elected the hospice benefit on 01/22/2026 with a primary diagnosis of cerebral atherosclerosis. The initial comprehensive assessment dated 01/22/2026 documented a request for spiritual services. As of the review on 03/30/2026, the SC had not documented an assessment, 67 days outstanding. CLINICAL RECORD 46: The patient elected the hospice benefit on 02/03/2026 with a primary diagnosis of cerebrovascular disease. The initial comprehensive assessment dated 02/04/2026 documented a request for spiritual services. As of the review on 03/26/2026, the SC had not documented an assessment, 50 days outstanding. CLINICAL RECORD 48: The patient elected the hospice benefit on 12/18/2025 with a primary diagnosis of end-stage heart failure. The initial comprehensive assessment dated 12/19/2025 documented a request for spiritual services. The SC documented an assessment visit on 01/12/2026, 24 days outstanding. CLINICAL RECORD 50: The patient elected the hospice benefit on 07/31/2025 with a primary diagnosis of malignant neoplasm of the gallbladder. The initial comprehensive assessment dated 08/01/2025 documented a request for spiritual services. The SC documented an assessment visit on 08/12/2025,11 days outstanding. CLINICAL RECORD 51: The patient elected the hospice benefit on 01/15/2026 with a primary diagnosis of cerebral atherosclerosis. The initial comprehensive assessment dated 01/15/2026 documented a request for spiritual services. The SC documented an assessment visit on 01/26/2026, 6 days outstanding. CLINICAL RECORD 60: The patient elected the hospice benefit on 03/18/2026 with a primary diagnosis of Sepsis. The initial comprehensive assessment dated 03/18/2026 documented a request for spiritual services. The SC assessment visit dated 03/23/2026 (in the IPU (inpatient unit)) documented “During this encounter, the patient was asleep. No PCG (primary caregiver) or family was present. According to staff, patient is resting comfortably. As Chaplain observed, it appeared patient is resting comfortably. Chaplain quietly prayed for patient.” There was no documentation of an attempt to reach the PCG or the family for assessment. During the interview on 04/01/2026, the Director of Psychosocial Services (Social Work (SW) and SC), stated that the state in which services were provided required the SW to evaluate for the need of the Chaplain and that if accepted, the Chaplain was to visit within the first 5 days of the benefit period, if the family allowed. During the interview, the National Patient Care Administrator stated that the need for an updated comprehensive assessment was identified at the beginning of January 2026, and education was provided.”

“It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene. This standard was not met as evidenced by document review, interview, and observation. In 3 of 14 (21%) home visits observed, the agency did not ensure that hand hygiene was performed correctly and when indicated in accordance with the agency policy. Agency policy “Hand Hygiene” (last updated on 09/12/2025) stated in part, “wash hands before and after contact with each patient...after contact with environmental surfaces in the immediate vicinity of patients...apply [antiseptic hand cleanser] product to the palm of one hand and rub hands together, covering all the surfaces of the hands and fingers, until hands are dry.” HOME VISIT 1/CLINICAL RECORD 1: The patient elected hospice care on 04/25/2025 and is residing in an assisted living facility (ALF). During the home visit (Survey Team member Medical Social Worker (MSW)) with the Chaplain (SC) [Personnel Record 1] on 03/24/2026, the SC did not wash their hands before entering the patient’s room. While in the room, the SC shook hands with the patient’s husband and touched the patient. After leaving the room, the SC applied antiseptic hand cleanser to the palm of one hand but did not rub their hands together. HOME VISIT 7/CLINICAL RECORD 55: During the home visit (IPU 1) (Survey Team RN) with the Skilled Nurse (SN) [Personnel Record 8] on 03/25/2026, the SN providing oral Roxanol for the patient, entered the medication room, verified the dose on a paper record, left the room to clarify with the other nurse, returned to the medication room, and proceeded to draw up the medication with no hand hygiene preformed. In the patient room (IPU 1), gloves were donned, the medication was given to the patient, the call bell was provided to the patient, the gloves were removed, and the SN left the room, gathering the patient record, which was filed at the nurses’ station. No hand hygiene was observed during the visit. HOME VISIT 8/CLINICAL RECORD 55: During the home visit (IPU 1) (Survey Team RN) with the Skilled Nurse (SN) [Personnel Record 8] on 03/25/2026, the SN providing Roxanol and Ativan for the patient, entered the medication room, verified the dosages, and signed out the medications from the locked storage. The Ativan was crushed and mixed with the Ativan. No hand hygiene was performed by the SN during medication preparation. In the patient room (IPU 1), gloves were donned, and the medications were given to the patient. No hand hygiene was performed. The SN removed the gloves and returned to the desk to file the paper record; no hand hygiene was performed.”

“It is required that consistent with current professional standards of practice, licensed professionals actively participate in the coordination of all aspects of patient care including: conducting ongoing interdisciplinary comprehensive assessments This standard was not met as evidenced by clinical record review and interview. The “Infusion Therapy Standards of Practice” (REVISED 2021) stated in part, “In outpatient or home care settings, assess VAD at every visit and teach the patient or caregiver to check the VAD site with each infusion or at least once per day or, for continuous PIVC infusions, every 4 hours during waking hours for signs of complications and to report signs/symptoms or altered dressing integrity immediately to their home care or other health care provider...3. Related to each regular assessment of the access site or VAD: condition of the site, dressing, type of catheter securement, dressing change, site care, patient report of discomfort/pain, and changes related to the VAD or access site.5,16 (V)” In 1 of 4 (25%) clinical records reviewed of patients with an infusion line, tube, or drain, the agency did not ensure that the initial comprehensive assessment documented the assessment of the surrounding skin or patency of the tube, line, or drain and the patency of the tube, drain, or infusion line in accordance with current professional standards of practice. CLINICAL RECORD 7: The patient elected the hospice benefit on 01/18/2026 with a primary diagnosis of sepsis. The initial comprehensive assessment dated 01/18/2026 documented a midline for the daily infusion of an antibiotic (Invanz). The assessment did not include documentation of an assessment of the skin around the midline, the midline location, when the line was inserted, the dressing status, or the date the last dressing was changed. The order included instructions to remove the midline at completion of antibiotics and to change the dressing weekly. During the interview on 04/01/2026, the National Patient Care Administrator stated that the line was documented on the interdisciplinary conference note on 01/21/2026 as being located in the right arm. It did not document the insertion site or the line’s patency.”

“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 9 of 51 (18%) clinical records reviewed of patients who received Hospice Aide services, the agency did not ensure that the Hospice Aide (HA) received written patient care instructions to meet the patient’s needs. CLINICAL RECORD 2: The patient elected the hospice benefit on 03/19/2026 with a primary diagnosis of cerebral vascular disease. The initial comprehensive assessment documented the patient’s confusion. The HA care plan assigned the HA the tasks: provide feeding assistance as needed and provide fluids as needed at every visit. There was no designated decision-maker for the “as needed” direction. CLINICAL RECORD 4/HOME VISIT 4: The patient elected the hospice benefit on 02/26/2026 with a primary diagnosis of cerebral atherosclerosis and a secondary diagnosis of vascular dementia. The patient resided in a skilled nursing facility (SNF). The HA care plan dated 02/27/2026 to 03/20/2026 assigned the HA the tasks: assist with sponge bath for patient as needed, assist with peri care as needed, assist with shampooing hair as needed, assist with dressing as needed, assist with feeding as needed. No documented decision-maker was identified for the “as needed” tasks. During the home visit with the Registered Nurse (RN) [Personnel Record 4] on 03/30/2026, the patient was observed wearing bilateral heel protectors. During an interview, the RN stated that the patient “has been wearing them at all times while in bed for about 2 months.” The HA care plan did not include a notification about the heel protectors or specific instructions for their use during tasks. CLINICAL RECORD 18: The patient elected the hospice benefit on 11/10/2025 with a primary diagnosis of kidney cancer. The HA care plan dated 01/10/2026 assigned the HA the tasks: bathing/inspection of feet at every visit. The assigned bath did not include the type of bath to be provided. The patient was admitted with a Foley catheter, but no Foley care or instructions were assigned at the time of the 03/25/2026 review. CLINICAL RECORD 28: The patient elected the hospice benefit on 11/25/2025 with a primary diagnosis of chronic pulmonary disease. The HA care plan dated 11/26/2025 assigned the HA the tasks: coordinate bathing and inspecting feet as needed; coordinate inspecting and applying lotion to the skin as needed; coordinate personal care transfers as needed, every visit. The “as-needed” tasks did not identify a decision maker. The patient’s medications as of 02/10/2026 documented use of morphine, four (4) times a day, and Dilaudid, three (3) times a day. When admitted, the patient was oriented times 3. As of January 2026, the patient was documented as becoming forgetful and, with the medications, was no longer a decision maker. There was no documented decision maker. CLINICAL RECORD 41: The patient elected the hospice benefit on 02/05/2026 with a primary diagnosis of cerebral atherosclerosis. The HA care plan dated 02/06/2026 assigned the HA the tasks: position change as needed; range of motion exercises as needed; change linens as needed; sponge bath as needed; showering each visit; cover wound dressing during bathing as needed; assist personal care transfers for patient as needed.” There was no documented caregiver, and the initial comprehensive assessment documented the patient’s confusion. CLINICAL RECORD 43: The patient elected the hospice benefit on 01/22/2026 with a primary diagnosis of cerebral atherosclerosis. The hospice aide care plan dated 01/22/2026 to 02/03/2026 included the following tasks: Assist to toilet as needed, perform sponge bath as needed, dressing patient as needed, and toileting patient as needed. There was no documented decision maker. The patient was documented as forgetful. CLINICAL RECORD 46: The patient elected the hospice benefit on 02/03/2026 with a primary diagnosis of cerebral vascular disease. The hospice aide care plan dated 02/11/2026 included the following tasks: “position change as needed; change linens as needed; cleaning patient area as needed; filing of non-diabetic fingernails for patient as needed; filing of non-diabetic toenails as needed; inspecting and lotion the skin as needed; assist protective cream application as needed; feeding assistance as needed; assist with fluids when required as needed; assist personal care transfers for patient as needed.” There was no documented decision maker. The patient was documented as forgetful on the initial comprehensive assessment. CLINICAL RECORD 57: The patient elected the hospice benefit on 03/22/2026 with a primary diagnosis of cerebral atherosclerosis. The initial nursing assessment, dated 03/22/2026, documented that the patient had a “urinary catheter.” The HA care plan dated 03/22/2026 did not provide the HA with specific instructions for catheter care during personal care. CLINICAL RECORD 59: The patient elected the hospice benefit on 03/27/2026 with a primary diagnosis of stomach cancer. The patient’s admission order dated 03/27/2026 included an 18 French Foley catheter. The HA care plan dated 03/27/2026 did not provide the HA with specific instructions for care of the catheter during personal care. During interviews and joint record reviews on 03/30/2026 and 04/01/2026, the National Patient Care Administrators stated that the HA care plans needed to be corrected and that they would work with their IT department on computer changes.”

“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 6 of 51 (12%) clinical records reviewed of patients who received Hospice Aide (HA) services, the agency did not ensure that the Hospice Aide provided services as ordered by the Interdisciplinary Group (IDG). CLINICAL RECORD 1: The patient elected hospice care on 04/25/2025 with a primary diagnosis of Alzheimer’s Disease. The patient resided in an assisted living facility (ALF). The plan of care ordered HA services twice weekly. The HA care plan dated 06/10/2025 assigned the HA the following tasks at every visit: sponge bath; shower, one (1) time a week; peri care; brush teeth; ROM (range of motion); and fall precautions. The HA visit notes dated 06/24/2025 and 01/13/2026 documented both baths as performed. The HA visit notes dated 02/25/2026 and 03/24/2026 documented that a sponge bath and shower were performed. CLINICAL RECORD 19: The patient elected hospice care on 02/27/2026 with a primary diagnosis of Parkinson’s disease. The plan of care ordered HA services twice a week. The HA care plan assigned the following tasks to the HA at every visit: sponge bath, dressing, and toileting. The first HA visit note was dated 03/05/2026. None of the HA visit notes as of 03/25/2026 documented that the assigned tasks were performed. The HA visit notes did not document that the patient refused the services or why the tasks were not performed. CLINICAL RECORD 23: The patient elected hospice care on 02/16/2026 with a primary diagnosis of lung cancer. The HA care plan assigned the following tasks to the HA at every visit: sponge bath, brush hair, and offer a bedpan. The HA visit note dated 02/23/2026 did not document that the assigned tasks were performed. The HA visit notes did not document that the patient refused the services or why the tasks were not performed. The HA visit note dated 02/16/2026 did not document a sponge bath. A sponge bath and brushing hair were not documented as performed in the HA visit note dated 02/17/2026. The HA visit notes did not document that the patient refused the services or why the tasks were not performed. CLINICAL RECORD 26: The patient elected hospice care on 12/16/2025 with a primary diagnosis of breast cancer. The patient resided in an ALF. The HA care plan assigned the following tasks to the HA at every visit: linen change, peri care, dressing, toileting, and passive ROM (range of motion). The HA visit notes dated 12/26/2025 and 01/23/2026 did not document that these tasks were provided. The HA visit notes did not document that the patient refused the services or why the tasks were not performed. CLINICAL RECORD 28: The patient elected hospice care on 11/25/2025 with a primary diagnosis of chronic obstructive pulmonary disease (COPD). The HA care plan dated 11/26/2025 assigned the following tasks to the HA: coordinate bathing and inspecting of feet as needed, coordinate inspecting and lotioning the skin as needed, and coordinate personal care transfers for the patient as needed. The HA visit notes dated 03/13/2026, 03/06/2026, and 02/27/2026 did not document that the bathing task was performed. The HA visit notes did not document that the patient refused the services or why the tasks were not performed. CLINICAL RECORD 29: The patient elected hospice care on 01/29/2026 with a primary diagnosis of Alzheimer’s disease. The HA care plan dated 01/30/2026 assigned the following tasks to the HA to be completed every visit: change linens, sponge bath, shampoo, dressing, and brush hair. The HA visit note dated 02/10/2026 did not document that the tasks were performed. The HA visit notes did not document that the patient refused the services or why the tasks were not performed. During interviews and joint record reviews on 03/30/2026 and 04/01/2026, the National Patient Care Administrators stated that the aide plans needed to be corrected and that they would work with their teams to make corrections.”

“It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services provided to patients/families are in a defined role and under the supervision of a designated hospice employee. Volunteer services are noted in the plan of care; [and] documented in the patient record, including the time spent. This standard was not met as evidenced by clinical record review, document review, and interview. In 5 of 15 (33%) clinical records reviewed for patients who requested a volunteer, the agency did not ensure that documentation of the patient’s identified volunteer needs and the duties that met those needs was maintained. Agency policy #5:40 “Interdisciplinary Team Policies Use of Volunteers” [reviewed 07/24/2026] “Agency routinely utilizes volunteers in its provision of care and services. Agency volunteers are considered employees for the purpose of compliance with all applicable standards, policies, and procedures; therefore, personnel policies referring to employees also apply to volunteers.” Volunteer Referral Process/Procedure: “General Instructions: Team and patient/Family identification of need for volunteer for caregiver relief, emotional support/socialization, light household chores, shopping assistance, bereavement support, telephone assurance, specialty (pet, companionship, 11th hour) recreation (reading, games, music) If no volunteer is available, the team manager assigns applicable team members to perform interventions - resource EMR - volunteer POC. Once an intervention is assigned to a volunteer, the contact is made to volunteer services. The assignment is made, and the volunteer calls the patient. The volunteer completes a volunteer note and immediately reports any changes in patient condition or volunteer interventions. Notes are submitted.” Job Description “Volunteer Coordinator” [revision date 05/12/2004], stated in part, “matches and assigns volunteers with patients and families; informs patients and families of volunteer availability and assess patient/family needs for volunteer services.” CLINICAL RECORD 6: The patient elected the hospice benefit on 01/04/2026 with a primary diagnosis of vascular dementia. The initial comprehensive assessment, dated 01/04/2026, documented that a volunteer had been requested. The original request documented: “(until volunteer match is made, all needs will be met by visiting IDG members).” As of 03/31/2026, there was no documentation that the volunteer had been followed up on for specific needs and availability. There was no assigned intervention plan or documentation indicating whether a volunteer was available. During an interview on 04/01/2026, the National Patient Care Administrator stated that on 01/05/2026, the extra tasks for the aide, including shopping and meal prep, met the patient’s identified needs of the volunteer request. CLINICAL RECORD 18: The patient elected the hospice benefit on 01/10/2026 with a primary diagnosis of kidney cancer. The initial comprehensive assessment, dated 01/10/2026, documented that a volunteer had been requested. The original request documented: “(until volunteer match is made, all needs will be met by visiting IDG members).” As of 03/25/2026, there was no documentation that the volunteer had been followed up on for specific needs and availability. There were no updates or documentation from the Volunteer Coordinator as to the progress of this request. There was no assigned intervention plan or documentation indicating whether a volunteer was available. During an interview on 04/01/2026, the National Patient Care Administrator (NPCA) stated that on 02/03/2026, the aide was to clean the patient area, which met the patient’s identified need for the volunteer. The NPCA stated that the specific needs requested were not identified and produced no documentation indicating whether other needs were identified. CLINICAL RECORD 25: The patient elected the hospice benefit on 01/28/2026 with a primary diagnosis of vascular dementia. The initial comprehensive assessment, dated 01/29/2026, documented that a volunteer had been requested. The original request documented: “(until volunteer match is made, all needs will be met by visiting IDG members).” As of 03/26/2026, there was no documentation that the volunteer had been followed up on for specific needs and availability. There were no updates or documentation from the Volunteer Coordinator as to the progress of this request. There was no assigned intervention plan or documentation indicating whether a volunteer was available. During an interview on 04/01/2026, the National Patient Care Administrator (NPCA) stated that on 02/03/2026, the aide was to clean the patient area, which met the patient’s identified need for the volunteer. The NPCA stated that the specific needs requested were not identified and produced no documentation indicating whether other needs were identified. CLINICAL RECORD 30: The patient elected the hospice benefit on 02/03/2026 with a primary diagnosis of protein-calorie malnutrition. The initial comprehensive assessment, dated 02/03/2026, documented that a volunteer had been requested. The original request documented: “(until volunteer match is made, all needs will be met by visiting IDG members).” As of 03/26/2026, there was no documentation that the volunteer had been followed up on for specific needs and availability. There were no updates or documentation from the Volunteer Coordinator as to the progress of this request. There was no assigned intervention plan or documentation indicating whether a volunteer was available. CLINICAL RECORD 34: The patient elected the hospice benefit on 01/20/2026 with a primary diagnosis of COPD. The initial comprehensive assessment, dated 01/20/2026, documented that a volunteer had been requested. The original request documented: “(until volunteer match is made, all needs will be met by visiting IDG members).” As of 03/26/2026, there was no documentation that the volunteer had been followed up on for specific needs and availability. There were no updates or documentation from the Volunteer Coordinator as to the progress of this request. There was no assigned intervention plan or documentation indicating whether a volunteer was available. During an interview on 04/01/2026, the National Patient Care Administrator, who conferred with their team about the volunteer program, stated that the IDG (interdisciplinary group) provided the services with increased aide, social work, or chaplain services, but did not have documentation for the identified need or which duties exactly were meeting the identified need.”

“It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy “Discharge Policy” (last revision 03/06/2025) stated in part, “The Transfer/Discharge Instructions/Summary... should be completed for all alive discharges and should be provided to the patient, legal representative, receiving facility, and or attending physician...Discharged Revocation. The Transfer/Discharge Summary should be completed via the focus visit... Forward a copy of the Transfer/Discharge Summary to the attending physician, along with the most recent POC (plan of care) review and latest orders. The clinical record may be sent when requested.” In 1 of 3 (33%) clinical records reviewed of patients with a live discharge, the agency did not ensure that the discharge summary was forwarded to the patient’s attending physician. CLINICAL RECORD 52: The patient elected the hospice benefit on 12/20/2024 for a diagnosis of vascular dementia, severe. The patient was discharged from hospice services on 01/20/2026. A clinical record review revealed no evidence that the discharge summary had been faxed to the attending physician. The discharge summary was not located. A discharge summary was documented on 03/30/2026 as a “late entry.” During interviews and joint clinical record reviews on 03/20/2026 and 03/31/2026, the Patient Care Administrators (PCA) stated that the “discharge summary had been completed as late entries during the post plan of care reviews and not at the time of discharge.””

“It is required that a hospice-operated inpatient care facility complies with all applicable federal, state and local health and safety codes, including: 1. The applicable provisions of the Life Safety Code (LSC) of the National Fire Protection Association NFPA 101, Life Safety Code 2012 edition; and, (L827-418.110(d)) a) Tentative Interim Amendments (TIA) 12-1, TIA 12–2, TIA 12–3, and TIA 12–4; and, 2. The Health Care Facilities Code NFPA 99, 2012 edition, and Tentative Interim Amendments TIA 12–2, TIA 12–3, TIA 12–4, TIA 12–5, TIA 12–6 – except Chapters 7, 8, 12, and 13 that do not apply to hospice. This standard was not met as evidenced by document review, interview, and observation. A tour of the agency’s inpatient unit (IPU) revealed that the agency did not ensure compliance with all NFPA 99 requirements, specifically regarding the use of power strips in patient rooms. IPU TOUR 1: During the tour of the agency’s IPU 1 on 03/25/2026, power strips were observed in 10 of the 16 patient rooms, all of which were accessible without intruding on the patient and family without their consent. The electric hospital beds in each of these rooms were plugged into the power strips. In some rooms, table lamps were also plugged into the power strips. Additionally, this references K920 “Electrical Equipment – Power Cords and Extension Cords Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 1. .3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5.” During an interview on 03/25/2026, the IPU nurse who was present for the tour confirmed that the power strips were used for routine purposes, including powering the bed and for patient and family use, such as charging their phones. During an interview on 03/25/2026, the Regional Facilities Maintenance Director, who was present for the tour of the patient rooms, confirmed the presence of the power strips and that they were not being used temporarily. The Regional Facilities Maintenance Director confirmed that wall outlets were available to power the hospital beds and meet other needs. A tour of the agency’s inpatient unit (IPU) revealed that the agency did not ensure that all requirements of the NFPA 99 were followed, specifically concerning the use of power strips in patient rooms.”

“It is required that the hospice inpatient facility provides meals to each patient that are palatable, attractive, and served at the proper temperature. This standard was not met as evidenced by document review, interview, and observation. The agency did not ensure that the hospice inpatient facility provided meals to each patient served at the proper temperature. The agency’s “Inpatient Unit Manual” section entitled “Serving of Meals” stated in part, “All meals shall be served at the proper temperature and shall be attractive when served...Staff will complete test tray check to ensure: correct temperature for cold foods, < or equal to 40 degrees; correct temperature for hot food, > or equal to 135 degrees.” IPU TOUR 1: During a tour of the agency’s IPU 1 on 03/25/2026, no log of food-temperature recordings prior to serving food to patients could be produced. During an interview on 03/25/2026, the IPU 1 Registered Nurse (RN), who was present for the tour of IPU 1, stated that the nurses and aides who prepare meals for patients, who mostly heat frozen prepared meals in a microwave, checked the temperature of the meals with a thermometer. However, the RN had to search three different locations within the kitchen to locate a meat thermometer. The RN also stated that, since the meals did not contain raw meat and were already cooked, they did not need to be checked for temperature. The RN confirmed that they do not keep a log of the food temperature checks. A tour of the agency’s inpatient unit (IPU) revealed that the agency did not ensure that all food being served to the patients was being served at the proper temperatures.”

“It is required that the hospice inpatient facility provides meals to each patient that are obtained, stored, prepared, distributed, and served under sanitary conditions. This standard was not met as evidenced by interview and observation. The agency did not ensure that the food provided at the inpatient facility was not expired. IPU TOUR 1: During a tour on 03/25/2026 of the agency’s IPU 1, the following items located in the refrigerator in the family kitchen area had expired: Dole individual serving of peaches (unopened) with an expiration date of 11/19/2025 and Dole individual serving of mandarin oranges (unopened) with an expiration date of 11/19/2025. The following items located in the refrigerator in the main kitchen had expired: Country Crock spreadable margarine (45 oz tub, opened and mostly full) with an expiration date of 01/26/2026 and French’s mustard (40 oz container, opened and mostly full) with an expiration date of 03/03/2026. The following item, located in the dry pantry of the main kitchen, had expired: Velveeta Cheesy Bowls (9 oz, unopened), with an expiration date of 09/07/2025. During an interview on 03/25/2026, the Regional Patient Care Administrator, who was present for the IPU 1 tour, confirmed that the items had expired and were available for use in feeding the patients. A tour of the agency’s inpatient unit (IPU) revealed that the agency did not ensure that all food that was available for patient use was not expired.”

“Based on record review, interview and policy review, the provider failed to ensure assessments, treatments and services related to wound care were accurately documented in accordance with patients’ conditions and physician’s orders for 2 of 3 patients reviewed for wound care of a total sample of 12 patients, (#23, #25). Findings:1.Patient #23 was admitted to Vitas Hospice on 6/30/22 with terminal diagnosis of cerebral infarction. She was being seen by the hospice staff in the home care setting and was discharged from services on 5/21/25 because the physician’s medical judgment was that her prognosis extended beyond 6 months. Review of patient #23’s medical record revealed inaccurate and incomplete information regarding location of her wounds, size of wounds, progress toward wound healing, type of wound care being provided at discharge or what the wound care orders were at the time of her discharge.Review of documentation dated 3/21/25 by Registered Nurse (RN) F revealed a Focus Visit note dated 3/21/25 for patient #23 read, “Interventions Performed…Overall teaching on wound care management & infection control. CG [caregiver] verbalized understanding of teaching”. The documentation did not specify wound location or type of wound care that was taught.RN F documented Interdisciplinary Plan of Care Revision/Physician Orders dated 3/25/25. Symptom read, “stage two right foot bridge” and Interventions were to “cleanse wound with wound cleanser apply betadine three times a week and as needed on right foot bridge & blister on right upper back”.Advanced Practice Registered Nurse (APRN) H documented an Interdisciplinary Plan of Care Revision/Physician Orders Interventions dated 3/27/25 read, “Left ankle-1. Paint with betadine daily. 2. Offload heals. Right ankle-1. Cleanse with wound cleanser and pat dry. 2. Apply calcium alginate silver to wound bed. 3. Change dressing 3 times a week and as needed if soiled”.RN F documented Focus Visit noted dated 3/28/25 interventions performed, “Wound assessed & cleansed with N/S [normal saline] pat dry and apply betadine cover with 4x4 gauze. CG verbalized understanding of wound care”. The nurses did not include size or locations of wounds, nor did she follow physician order dated 3/27/25.RN D documented Focus Visit note on 4/7/25 interventions performed read, “educated pcg [primary caregiver] in wound plan of care. PCG verbalized understanding. Ordered foam dressings for wound prevention in bony prominence with discoloration…”. The nurses’ note did not include location or size of wounds.Hospice Medical Doctor (MD) E documented review note dated 4/16/25 read, “She has had a stage II sacral wound, which healed in December, and she has a small stage II wound on her right heel currently, which is undergoing wound management.”“Stage 2:Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough or bruising” (retrieved on 11/7/25 at 11:24 AM from Pressure Ulcer/Injury Coding Pocket Guide).RN D documented 4/17/25, “Foot and sacral wounds stable with no changes”. This contradicted MD E’s documentation on 4/16/25 that the sacral wound was healed and did not specify which foot, location on the foot or stage of the wounds.RN D documented Nursing-Updated Comprhensive Assessment note dated 4/25/25 under Integumentary/Wound(s), “1. Pressure Ulcer stage 2 Rt [right]foot 2. Pressure Ulcer stage 1 lt [left] foot 3. Pressure Ulcers Rt side vaginal stage 2…” The nurses note did not include documentation regarding wound size, undermining, surrounding tissue appearance or if any exudate (drainage) and odor present.RN D documented Nursing-Updated Comprehensive Assessment dated 5/1/25 for patient #23 under Integumentary/Wound(s), “1. Pressure Ulcer Sacral 2. Pressure Ulcer Lt RT Foot…” The nurse failed to include wound stage, size, undermining, surround skin, wound tissue appearance of if any drainage and odor were present.RN D documented Nursing-Updated Comprehensive Assessment dated 5/5/25 under Integumentary/Wound(s) “1. Pressure Ulcer stage 2 Rt foot 2. Pressure Ulcer stage 1 Lt foot 3. Pressure Ulcer stage 1 sacral…” The nurse failed to include wound size, undermining wound tissue appearance and if there was any drainage or odor present.RN D documented Plan of Care Review note dated 5/15/25 and 5/25/25 for patient #23 read, “Stage 2 wounds stable with no changes”. The RN did not specify the location of the wounds.RN D documented Nursing-Updated Comprehensive Assessment dated 5/19/25 under Integumentary/Wound(s) “1. Pressure Ulcer Rt & left foot 2”. The nurse did not include size, undermining, surrounding skin appearance, wound tissue description or if any drainage and odor present.Interview was conducted on 11/5/25 with Patient Care Administrator (PCA) A between 12:45 PM to 1:54 PM. PCA A said, the documentation for patient #23 did not include what the actual wound care orders were at the time of the patient discharge from hospice services, specific locations type and stages of wounds. PCA A could not provide any evidence that the wounds had ever been measured and said the nurses are supposed to measure wounds at least weekly. On 11/5/25 at 3:09 and 3:45 PM a telephone interview was conducted with patient #23’s primary nurse RN D. Even after reviewing her documentation the RN could not recall the actual location of the wounds on the patients’ feet, the stage of both wounds or what type of wound care was being provided at the time of discharge from hospice. The RN verified she had only been working for Vitas Hospice since March of this year and when asked how often she was supposed to measure wounds stated, “monthly”.On 11/5/25 at 4:32 PM PCA G verified she is the supervisor for RN D and said, nurses should measure patients’ wounds at least weekly and include stage, location, exudate, measurements, description and if any signs or symptoms of infection in the documentation. 2. Patient #25 was admitted to Vitas Hospice provider on 10/6/25 with terminal diagnoses of severe protein calorie malnutrition and secondary diagnosis of Alzheimer’s disease.Review of RN B’s Updated Comprehensive Assessment Encounter dated 10/29/25 for patient #25 revealed that the patient had the start of a stage II pressure wound on the coccyx that was 100% granulating and had no slough/fibrin (dead tissue) in the wound bed.“Granulation tissue is reddish connective tissue that forms on the surface of a wound when the wound is healing” (definition retrieved on 11/7/25 at 1:38 PM from https://biologydictionary.net). Review of patient #25’s medical record revealed RN Updated Comprehensive Assessment Encounter dated 11/4/25 documented by RN C. The documentation revealed patient #25 had a coccyx wound stage II with 100% slough/fibrin present however the prior RN assessment dated 10/29/25 showed wound with 100% granulation tissue and no slough/fibrin present in the wound bed.On 11/5/25 at 2:38 PM RN C verified that she is the primary nurse for patient #25 and documented appearance of his coccyx wound in error on 11/4/25. The nurse verbalized that the wound appeared red and white but was not covered with fibrin/slough (dead tissue). On 11/5/25 at 4:05 PM PCA A said, the nurses are supposed to document wound stage, location, exudate, measurements, description and if any signs of symptoms of infections at least weekly. PCA A verified nursing documentation dated 11/4/25 was inaccurate regarding patient #25’s wound because you cannot have a stage 2 wound if there is 100% slough/fibrin present it would be considered an unstageable wound.Review of the Vitas Hospice undated policy and procedure for Wound Care General Instructions for Assessment, Observation and Documentation read, “Documentation of complete wound assessment included: 1. Location 9s) of wound(s)-be specific about the body part and area 2. Stage of Classification 3. Size…4. Odor: Presence of lack thereof 5. Undermining: The presence of a cavity under the peri-wound tissue…6. Tunneling…7. Peri-wound: Describe the tissue surrounding the wound 8. Exudate: Be sure to record the amount…9&gt; Color of wound bed: describe as pink, red, yellow, whit…10. Necrotic tissue: Non-viable tissue that is typically black-brown…11. Granulation tissue: Granulation can be pink or beefy-red tissue…Best Practices for Documentation of Multiple Wounds…Assign a number to each wound…Document each numbered wound on the POC [Plan of Care] along with the treatment for each wound….””

“Based on review of the Hospice’s Policy, record review, interview, and observation, the provider failed to conduct appropriate wound assessments for 3 of 3 sampled patients (Patient #2, #3, and #1). The findings include:1) The Hospice’s standard of care titled, “VS (Vitas Standard) Wound Care,” undated, documents, under Assessment and Observation, “A VITAS nurse will visualize the wound and document in the integumentary section of the Nursing Updated Comprehensive Assessment Encounter every 7 days even if the family or LTC staff is performing the wound care,” and under Documentation – Non-EMR (non-electronic medical record), “Documentation of a complete wound assessment includes: 1. Location(s) of wound(s)-- be specific about the body part and area 2. Stage or Classification 3. Size: in cm [centimeters] (L x W x D) [Length x Width x Depth] 4. Odor: presence or lack thereof 5. Undermining: The presence of a cavity under the peri-wound tissue that is caused by shear forces 6. Tunneling: A tunnel is a tract or sinus extending into the underlying tissues from any point in the wound bed 7. Peri-wound: Describe the tissue surrounding the wound 88. Exudate: Be sure to record the amount (none, scant, minimal, moderate, copious) and type (serous, serosanguineous, sanguineous, purulent) 9. Color of wound bed: describe as pink, red, yellow, white, black, purple, gray, tan, brown, or green 10. Necrotic tissue: Non-viable tissue that is typically black, brown (eschar) or yellow (slough) 11. Granulation tissue: Granulation can be pink or beefy-red tissue and has a moist, shiny and granular appearance.” Review of Patient #2’s record reveals they were admitted to the Hospice’s Inpatient Unit on 07/10/25 with a terminal diagnosis. Patient #2’s VIPU [VITAS Inpatient Unit] RN [Registered Nurse]-Initial Comprehensive Assessment dated 07/10/25 documents for Wound(s)/Integumentary, “Pressure ulcer right hip open wound. Left foot large blister fluid filled from eating [sic] pad. Bilateral nephrostomy drains site. Colostomy site. Left upper chest port site” and includes no measurements or further description of the right hip wound and foot blister or description of skin condition at the nephrostomy and colostomy sites. Patient #2’s VIPU Interdisciplinary Care Plan Revision/Comprehensive Assessment dated 07/10/25 documents for Skin integrity, “assess skin every shift” and “notify doctor for any skin change.” Patient #2’s nursing notes (VIPU RN-Updated Comprehensive Assessment and Addendum: VIPU Shift Care Note) for 07/11/25 on day shift (7 AM-7:30 PM) document, “Pressure ulcer sacrum wound. Left leg blister or foot blister” and on night shift (7 PM-7:30 AM) document, “R [right] hip wound, left foot blister” without further description/assessments of those wounds. Patient #2’s nursing notes for 07/12/25 on day shift document, “R hip wound” with no mention of the foot blister, and on night shift document, “left foot blister filled fluid” and for Integumentary/Wounds, “Right thigh wound, foot blister.” Patient #2’s nursing notes document: on 07/13/25 day shift, “Integumentary/Wounds: L thigh” and night shift, “Pressure ulcer: unstageable wound to the R hip” and “functional colostomy”; on 07/14/25 day shift, “wound in right hip” and night shift, “Stage II [2] wound to right hip”; and on 07/15/25 day shift, “Rt [right] hip wound” but at 7:50 AM, “no edema or wounds noted.” An unstageable pressure ulcer is an open wound with necrotic (dead) tissue, eschar (hardened, dry dead tissue that forms a scab like covering) or a non-removable dressing that makes it difficult to determine the extent of tissue damage. A Stage 2 pressure ulcer is a shallow wound with partial-thickness skin loss. Patient #2’s Plan of Care Review/Updated Comprehensive Assessment dated 07/15/25 documents for Integumentary (Skin): “skin is intact” and does not document the presence, status, and treatment plan for the right hip wound, colostomy and nephrostomy tube sites, or of a large ventral foot blister (top of foot) that was also noted on admission. Further review of nursing notes reveal the following documentation: on 07/15/25 night shift, “Stage II wound noted to right hip”; 07/16/25 day shift, “Stage 2 sacrum” and “skin tear to buttocks” and on night shift, “Stage 2 right hip”; on 07/17/25 day shift, “wound in right upper hip” and “dressing done” and on night shift, “Stage II R hip”; on 07/18/25 day shift, diaper change with no mention of any wound and on night shift, “#1 right hip, size “Stage II”; #2 midback, size “unstageable wound.” Dressing done, barrier cream applied”; on 07/19/25 day shift, “Rt hip wound” and night shift, “Stage II wound to hip, unstageable wound to midback”; on 07/20/25 day shift, “pressure ulcer Stage II R hip. #2 Pressure ulcer unstageable sacrum” and night shift, “Stage 2 to (R) hip. Unstageable to upper back”; on 07/21/25 day shift, “L hip stage 2, midback unstageable” and night shift, “pressure ulcer midback unstageable, pressure ulcer left hip Stage II”; on 07/22/25 day shift, “left hip stage 2, unstageable sacrum wound” and night shift, “left hip stage 2, unstageable sacrum.” Patient #2’s Plan of Care Review/Updated Comprehensive Assessment dated 07/22/25 documents for Integumentary, “left hip stage 2, unstageable sacrum wound” with no further description/assessment, or the status of the colostomy and bilateral nephrostomy tube sites, or foot blister. Continued review of nursing notes reveal the following documentation: on 07/23/25 day shift, “Stage II hip (R). unstageable upper midback. Other: blister left foot” and “Wound care provided” with no documentation of what was done to which wounds or sites, and on night shift, “Stage 2 (R) hip; unstageable upper back and “Wound care.” During wound care observation with Registered Nurse, Staff A on 07/25/25 beginning at 5:01 PM with Register, Patient #2’s left hip wound was observed to be a crater-like wound exposing fat with undermining (wound extends underneath and beyond the skin edges). A Stage 3 ulcer has full-thickness skin loss and may appear as a deep crater and expose fat tissue, but not muscle or bone, and indicates significant tissue damage. During interview with the nurse assigned to Patient #2 on 07/25/25 beginning at 2:30 PM, Registered Nurse, Staff A stated she also provided care to Patient #2 during the day on 07/20/25, that wound assessments are done every day in the daily assessment but she was not aware of the policy for frequency or components of wound assessments, that she does not measure wounds or describe the wound bed every time she assesses but said if there was a change she would, and that if there was new odor or slough she would assess the wound and call the wound specialist or doctor. 2) Review of the record reveals Patient #3 was admitted on 06/17/25 to the Hospice Inpatient Unit and had previously resided in a nursing home where Patient #3 had active wound care orders for daily dressing changes of a sacral wound at the time of the transfer. Patient #3’s VIPU RN (Registered Nurse)-Initial Comprehensive Assessment dated 06/17/25 documents the presence of a Stage 4 pressure ulcer that measures 6x6 cm (centimeters) but includes no further description of the wound or whether signs of infection, such as purulent drainage or odor, were present. A Stage 4 pressure ulcer is the most severe type of pressure ulcer, has a high risk of infection, and extends to the deep tissues, such as muscle, tendons, and ligaments, and may expose cartilage and bone. Patient #3’s Plan of Care Review/Updated Comprehensive Assessment dated 06/24/25 documents for Integumentary, Response to Care & Updates to Comprehensive Assessment: “Stage IV (4) sacral wound. Seen by wound MD (physician) today with orders” but no further assessment or status of the wound. Patient #3’s Plan of Care Review/Updated Comprehensive Assessment dated 07/02/25 documents for Integumentary, Response to Care & Updates to Comprehensive Assessment: “Stage IV sacrum wound c (with) Mepilex (a type of covering dressing)” but no further assessment or status of the wound. Patient #3’s Plan of Care Review/Updated Comprehensive Assessment dated 07/08/25 documents for Integumentary, Response to Care & Updates to Comprehensive Assessment: merely “Wound Sacral Stage 4.” Patient #3’s Plan of Care Review/Updated Comprehensive Assessment dated 07/15/25 documents for Integumentary, Response to Care & Updates to Comprehensive Assessment, “Stage 4 wound in sacrum.” Patient #3’s Plan of Care Review/Updated Comprehensive Assessment dated 07/22/25 documents for Integumentary, Response to Care & Updates to Comprehensive Assessment, “Stage 4 sacrum.” Patient #3’s Plan of Care Review/Updated Comprehensive Assessment dated 07/24/25 documents for Integumentary, Response to Care & Updates to Comprehensive Assessment, “Stage 4 to sacrum” with no further description of the wound. During interview on 07/25/25 at 2:02 PM, Patient Care Administrator, Staff B reported she could find no documentation of wound care assessments except by a physician on 06/24/25 and confirmed wound care was not ordered until 06/24/25, as informed by the wound care physician on 06/24/25. 3) Review of the record reveals Patient #1 was admitted to the hospice inpatient unit on 03/11/25 with a terminal diagnosis and went home on 03/13/25 with hospice “Routine Home Care.” Patient #1’s Nursing-Updated Comprehensive Assessment/ Comprehensive Assessment dated 03/23/25 documents skin was assessed and there were no wounds. Patient #1’s Nursing-Updated Comprehensive Assessment/ Comprehensive Assessment dated 03/24/25 documents presence of a wound as “III [3] Sacrum.” Patient #1’s Focus Visit by nursing on 03/25/25 documents wound care to the sacrum, at which time it was described as “Stage 2” and “wound bed pink.” A Nurse “Focus Visit” dated 03/26/25 documents wound care, without location of the wound, and “Wound signs healing no s/s [signs/symptoms] infection.” A Nurse “Focus Visit” dated 03/28/25 also documents wound care without a location of the wound and “wound healing appropriately no s/s infection.” Patient #1’s Nursing-Updated Comprehensive Assessment/ Comprehensive Assessment dated 03/31/25 documents a “pressure ulcer Stage 3” without further description/assessment of the wound. Patient #1’s Plan of Care Review/Updated Comprehensive Assessment dated 04/01/25 documents “Stage 3 sacrum wound” and redness to sacrum. Patient #1 went to the hospital on 04/02/25 and was admitted for aggressive care, revoking hospice.”

“Based on review of the Hospice’s Policy, record review, interview, and observation, the provider failed to revise individualized plans as needed or at least every 15 days to meet the needs of 3 of 3 sampled patients (Patients #2, #3, and #1). The findings include: 1) The Hospice’s standard of care titled VS [Vitas Standard] Wound Care documents, under Care Planning, “The overall strategy and scope of the treatment plan implemented will depend on the patient’s condition, prognosis, patient/caregiver goals, and outcomes,” and “Identify the most appropriate outcome for the patient i. Minimizing or managing harmful or unpleasant effects such as pain, infection, odor, etc; ii. Healing the wound; iii. Preventing further skin breakdown,” and “The appropriate care for patients at the end of life who have wounds is based on the patient’s treatment preference, number of risk factors and co-morbid conditions...” and “Patients who are not rapidly declining or who have a good potential for wound healing may benefit from more aggressive wound care.”Review of the record reveals Patient #2 was admitted to the Hospice on 07/10/25. Patient #2’s VIPU (VITAS Inpatient Unit) RN (Registered Nurse)-Initial Comprehensive Assessment dated 07/10/25 documents “pressure ulcer right hip open wound,” a large fluid-filled blister to the left foot, bilateral nephrostomy drains (tubes on each side to drain urine from the kidneys), and a colostomy. Patient #2’s Physician Orders on 07/10/25 include directions for wound care to the right hip wound daily, bilateral nephrostomy drain flushes with saline normal every 12 hours, and colostomy care daily PRN (as needed) but do not include skin care to the nephrostomy sites or directions for colostomy care such as appliances and products to be used and how often they should be changed. Patient #2’s VIPU (VITAS Inpatient Unit) Interdisciplinary Care Plan Revision/Comprehensive Assessment dated 07/10/25 documents interventions to “prevent skin breakdown” but does not address the wound or nephrostomy and colostomy sites. Patient #2’s nursing notes (VIPU RN-Updated Comprehensive Assessment and Addendum: VIPU Shift Care Note) dated 07/15/25 for the day shift (7 AM-7:30 PM) document the presence of right hip wound, colostomy and nephrostomy; but also, document under Response to care “No edema or wounds noted.” However, Patient #2’s Plan of Care Review/Updated Comprehensive Assessment dated 07/15/25 documents for Integumentary (Skin): “skin is intact” and does not document the presence of a pressure ulcer and treatment plan for the right hip wound, colostomy and nephrostomy tube sites, or of a large foot blister that was also noted on admission. Nursing notes dated 07/15/25 for night shift (7 PM to 7:30 AM) document the presence of colostomy bag, nephrostomy catheters to both sides, and a Stage II wound to the right hip. (Stages 1 through 4 are used to describe the extent of tissue damage in pressure ulcers and a Stage 2 wound is a shallow wound with partial-thickness skin loss.) Nursing notes dated 07/22/25 for both day and night shifts document a left hip Stage 2 wound and unstageable sacrum wound. Patient #2’s Plan of Care Review/Updated Comprehensive Assessment dated 07/22/25 documents for Integumentary, “left hip stage 2, unstageable sacrum wound” and does not address progress of the right hip wound towards goals, such as size and description of the wound to indicate whether it was healing, deteriorating, or had signs of infection; does not include the recently identified midback wound; and does not include treatment plans for any of the wounds; or the status and treatment plan/care of the colostomy and bilateral nephrostomy tube sites. During wound care observation on 07/25/25 beginning at 5:01 PM, Patient #2’s right hip wound was observed to be a crater-like wound exposing fat with undermining (the wound extends underneath and beyond the skin edges). A Stage 3 ulcer has full-thickness skin loss, may appear as a deep crater and expose fat tissue, and indicates significant tissue damage. A partial thickness wound (Stage II) was also observed to Patient #2’s sacrum. No wound was seen on her left hip. Patient #2’s mid and upper back were not observed. Without the benefit of wound assessments by which to identify the progress of the wound, the interdisciplinary team was not aware of the right hip wound’s status and did not revise the plan of care (or obtain orders) for new pressure wounds identified on the midback and sacrum to meet Patient #2’s needs. 2) Review of the record reveals Patient #3 was admitted on 06/17/25 to the Hospice Inpatient Unit and had previously resided in a nursing home where Patient #3 had active wound care orders for daily dressing changes of a sacral wound at the time of the transfer. Patient #3’s VIPU RN (Registered Nurse)-Initial Comprehensive Assessment dated 06/17/25 documents the presence of a Stage 4 pressure ulcer that measures 6x6 cm (centimeters) but includes no further description of the wound. A Stage 4 pressure ulcer is the most severe type of pressure ulcer, has a high risk of infection, and extends to the deep tissues, such as muscle, tendons, and ligaments, and may expose cartilage and bone. Patient #3’s VIPU Interdisciplinary Care Plan Revision dated 6/17/25 documents for the symptom Skin Integrity, the Outcome to prevent skin breakdown and Interventions to assess patients skin every shift, reposition every two hours as needed, apply barrier cream, and change dressing wound as ordered. However, Patient #3’s Physician Orders on 06/17/25 included a wound care consult but no orders for dressing changes/care of the sacral wound. Patient #3’s Plan of Care Review/Updated Comprehensive Assessment dated 06/24/25 documents for Integumentary, Response to Care & Updates to Comprehensive Assessment: “Stage IV (4) sacral wound. Seen by wound MD today with orders” but no further assessment or status of the wound or description of the treatment plan. Patient #3’s Plan of Care Review/Updated Comprehensive Assessment dated 07/02/25 documents for Integumentary, Response to Care & Updates to Comprehensive Assessment: “Stage IV sacrum wound c (with) Mepilex (a type of covering dressing)” but no further assessment or status of the wound for progress towards goals, or indication of the goal for this patient’s wound. Patient #3’s Plan of Care Review/Updated Comprehensive Assessment dated 07/08/25 documents for Integumentary, Response to Care & Updates to Comprehensive Assessment, “Wound Sacral Stage 4” and no documentation of the treatment plan and goals related to the wound. Patient #3’s Plan of Care Review/Updated Comprehensive Assessment dated 07/15/25 documents for Integumentary, Response to Care & Updates to Comprehensive Assessment: Stage 4 wound in sacrum” and no progress of treatment, treatment plan or goals for the wound. Patient #3’s Plan of Care Reviews/Updated Comprehensive Assessments dated 07/22/25 and 07/24/25 also document for Integumentary, Response to Care & Updates to Comprehensive Assessment the presence of a “Stage 4” to the sacrum with no further description of the wound, wound treatment plan, response to treatment or the wound progress towards healing. During interview on 07/25/25 at 2:02 PM, Patient Care Administrator, Staff B reported she could find no further documentation of wound care assessments/progress except by a physician on 06/24/25. 3) Review of the record reveals Patient #1 was admitted to the hospice inpatient unit on 03/11/25 with a terminal diagnosis and went home on 03/13/25 with hospice “Routine Home Care.” Patient #1’s Plan of Care Review/Updated Comprehensive Assessment, dated 03/13/25 documents “redness to sacrum & perianal area. “Patient #1’s Nursing-Updated Comprehensive Assessment/ Comprehensive Assessment dated 03/23/25 documents skin was assessed and there were no wounds. Patient #1’s Nursing-Updated Comprehensive Assessment/ Comprehensive Assessment dated 03/24/25 documents the presence of a wound as “III Sacrum” and that wound care was provided by cleaning with NS pat dry, applying Medi honey, and covering with ABD (abdominal pad) and tape. Patient #1’s Focus Visit by nursing on 03/25/25 documents wound care to the sacrum, at which time it was described as “Stage 2” and “wound bed pink” but does not specify what was done for wound care. Additional Focus Visits to Patient #1 by nursing documented on 03/26/25 and 03/28/25 include wound care with normal saline, Medi honey, ABD and tape. However, no physician order for Patient #1’s sacral wound care was found in the medical record. Patient #1’s Nursing-Updated Comprehensive Assessment/ Comprehensive Assessment dated 03/31/25 documents a “pressure ulcer Stage 3” and that wound care was provided without further description/assessment of the wound. Patient #1’s Plan of Care Review/Updated Comprehensive Assessment dated 04/01/25 documents “Stage 3 sacrum wound” and “redness to sacrum” without a treatment plan or goal for care of the wound. There was no update to the Patient #1’s Plan of Care between 03/13/25 and 04/01/25, more than 15 days later. Patient #1 went to the hospital on 04/02/25 and was admitted for aggressive care, revoking hospice. Review of the record reveals Patient #1 was readmitted to hospice on 05/25/25. Patient #1’s Pre-Admit Evaluation dated 05/25/25 documents Stage 4 decubitus ulcer on coccyx, healing left pressure wound and “Contact precautions – MRSA in wound, VRE.” MRSA and VRE are 2 types of antibiotic-resistant bacteria, which makes infections with these organisms more difficult to treat. Patient #1’s VIPU RN-Initial Comprehensive Assessment documents, “Pressure Ulcer Stage 4 sacrum, size 6x5x1 cm, maceration [softening and breakdown of skin from excessive moisture exposure], wound tissue 20% slough [yellow or white dead tissue] 80% granulation [healing tissue].” Patient #1’s Admissions Orders/Hospice Certification/Initial Plan of Care dated 05/25/25 document his Level of Care was General Inpatient Care and the order “wound care consult.” Patient #1’s Interdisciplinary Care Plan/Initial General POC (Plan of Care) dated 05/25/25 documents End of Life General Needs as “Pain Management/Wound Care.” Patient #1’s Plan of Care Review/Updated Comprehensive Assessment dated 05/25/25 documents for Integumentary, “Stage 4 wound to sacrum, Blister under 5th toe of left foot. Wound consult” and “Pain noted upon movement and during wound care, Wound consult ordered” but includes no treatment plan for wound care while waiting for the wound consult. Patient #1 had no orders for wound care until the wound care consult was performed on 05/27/25.”

“Based on review of the Hospice’s Policy, record review, interview, and observation, the provider failed to include assessment information for the progress of wound care in the revised plans of care for 3 of 3 sampled patients (Patient #2, #3, and #1). The findings include:1) The Hospice’s standard of care titled VS (Vitas Standard) Wound Care documents, under Assessment and Observation, “A VITAS nurse will visualize the wound and document in the integumentary section of the Nursing Updated Comprehensive Assessment Encounter every 7 days even if the family or LTC staff is performing the wound care,” and under Care Planning, “The overall strategy and scope of the treatment plan implemented will depend on the patient’s condition, prognosis, patient/caregiver goals, and outcomes.”Review of the record reveals Patient #2 was admitted to the Hospice on 07/10/25. Patient #2’s VIPU (VITAS Inpatient Unit) RN (Registered Nurse)-Initial Comprehensive Assessment dated 07/10/25 documents “pressure ulcer right hip open wound,” a large fluid-filled blister from a heating pad burn to the left foot, bilateral nephrostomy drains (tubes on each side to drain urine from the kidneys), and a colostomy. Patient #2’s Physician Orders on 07/10/25 include wound care to a right hip wound daily. Patient #2’s VIPU (VITAS Inpatient Unit) Interdisciplinary Care Plan Revision/Comprehensive Assessment dated 07/10/25 documents for Skin Integrity, “prevent skin breakdown” and preventative interventions but does not include wound care or any wound assessment information. Patient #2’s Plan of Care Review/Updated Comprehensive Assessment dated 07/15/25 documents for Integumentary (Skin): “skin is intact” and does not document the presence of a pressure ulcer and treatment plan for the right hip wound, colostomy and nephrostomy tube sites, or of a large foot blister that was also noted on admission. However, nursing notes (titled VIPU RN-Updated Comprehensive Assessment and Addendum: VIPU Shift Care Note) dated 07/15/25 for the day shift (7 AM-7:30 PM) document the presence of right hip wound, colostomy and nephrostomy; but also, document under Response to care “No edema or wounds noted.” Nursing notes dated 07/15/25 for night shift (7 PM to 7:30 AM) document the presence of colostomy bag, nephrostomy catheters to both sides, and a Stage II wound to the right hip. (Stages 1 through 4 are used to describe the extent of tissue damage in pressure ulcers and a Stage 2 wound is a shallow wound with partial-thickness skin loss.) Nursing notes dated 07/16/25 for day shift document a Stage 2 wound to the sacrum. Nursing notes dated 07/18/25 and 07/19/25 for night shift each document an “unstageable wound” to the midback, as well as “Stage II” wound to the right hip wound. Nursing notes dated 07/20/25 for day shift document a Stage II pressure ulcer to the right hip and unstageable pressure ulcer to the sacrum and for night shift document a Stage 2 wound to the right hip and unstageable wound to the upper back. Nursing notes dated 07/21/25 for day and night shifts document a left hip Stage 2 wound and midback unstageable wound. Nursing notes dated 07/22/25 for both day and night shifts document a left hip Stage 2 wound and unstageable sacrum wound. Patient #2’s Plan of Care Review/Updated Comprehensive Assessment dated 07/22/25 documents for Integumentary, “left hip stage 2, unstageable sacrum wound” and does not address progress of the right hip wound, such as size and description of the wound to indicate whether it was healing, deteriorating, or had signs of infection; does not include assessments for the recently documented/identified left hip, midback or sacral wounds, treatment plans for any of the wounds, or the status and treatment plan/care for the colostomy and bilateral nephrostomy tube sites. Nursing notes dated 07/23/25 for day shift document a Stage II wound to the right hip, unstageable wound to the upper midback, and a blister on the left foot, and for night shift document a Stage II wound to the right hip and unstageable wound to the upper back. No further descriptions or measurements of the wounds were found in the nursing notes or care plans. During wound care observation on 07/25/25 beginning at 5:01 PM, Patient #2’s right hip wound was observed to be a crater-like wound exposing fat with undermining (the wound extends underneath and beyond the skin edges). A Stage 3 ulcer has full-thickness skin loss, may appear as a deep crater and expose fat tissue, and indicates significant tissue damage. A partial thickness wound (Stage II) was also observed to Patient #2’s sacrum. No wound was seen on Patient #2’s left hip. Without the benefit of wound assessments by which to identify the progress of the wound, the interdisciplinary team was not aware of the right hip wound’s status and did not revise the plan of care (or obtain orders) for new pressure wounds identified on the midback and sacrum to meet Patient #2’s needs. 2) Review of the record reveals Patient #3 was admitted on 06/17/25 to the Hospice Inpatient Unit and had previously resided in a nursing home where Patient #3 had active wound care orders for daily dressing changes of a sacral wound at the time of the transfer. Patient #3’s VIPU RN (Registered Nurse)-Initial Comprehensive Assessment dated 06/17/25 documents the presence of a Stage 4 pressure ulcer that measures 6x6 cm (centimeters) but includes no further description of the wound. A Stage 4 pressure ulcer is the most severe type of pressure ulcer, has a high risk of infection, and extends to the deep tissues, such as muscle, tendons, and ligaments, and may expose cartilage and bone. Patient #3’s VIPU Interdisciplinary Care Plan Revision dated 6/17/25 documents for the symptom Skin Integrity, the Outcome to prevent skin breakdown and Interventions to assess patients skin every shift, reposition every two hours as needed, apply barrier cream, and change dressing wound as ordered. However, Patient #3’s Physician Orders on 06/17/25 included a wound care consult but no orders for dressing changes/care of the sacral wound. Patient #3’s Plan of Care Review/Updated Comprehensive Assessment dated 06/24/25 documents for Integumentary, Response to Care & Updates to Comprehensive Assessment: “Stage IV (4) sacral wound. Seen by wound MD today with orders” but no further assessment or status of the wound or description of the treatment plan. Patient #3’s Plan of Care Review/Updated Comprehensive Assessment dated 07/02/25 documents for Integumentary, Response to Care & Updates to Comprehensive Assessment: “Stage IV sacrum wound c (with) Mepilex (a type of covering dressing)” but no further assessment or status of the wound for progress towards goals, or indication of the goal for this patient’s wound. Patient #3’s Plan of Care Review/Updated Comprehensive Assessment dated 07/08/25 documents for Integumentary, Response to Care & Updates to Comprehensive Assessment: merely “Wound Sacral Stage 4.” Patient #3’s Plan of Care Review/Updated Comprehensive Assessment dated 07/15/25 documents for Integumentary, Response to Care & Updates to Comprehensive Assessment: Stage 4 wound in sacrum.” Patient #3’s Plan of Care Review/Updated Comprehensive Assessment dated 07/22/25 documents for Integumentary, Response to Care & Updates to Comprehensive Assessment: “Stage 4 sacrum.” Patient #3’s Plan of Care Review/Updated Comprehensive Assessment dated 07/24/25 documents for Integumentary, Response to Care & Updates to Comprehensive Assessment: “Stage 4 to sacrum” with no further description of the wound or response to treatment and progress towards healing. During interview on 07/25/25 at 2:02 PM, Patient Care Administrator, Staff B reported she could find no documentation of wound care assessments except by a physician on 06/24/25 and confirmed wound care was not ordered until 06/24/25, as informed by the wound care physician on 06/24/25. During interview with Registered Nurse, Staff A on 07/25/25 at 2:30 PM, Staff A reviewed her documentation for Patient #3 from 06/18/25 and stated a wound consult request was emailed and she would have cleansed the wound with normal saline, patted it dry and covered it with an “ABD” (abdominal pad) and tape because there was no order for wound care yet. Staff A did not explain why she did not contact a physician to get an order for wound care. Further review of the record revealed the wound consult did not take place until 06/24/25 and the first orders for wound care to the sacrum were written on 06/24/25. 3) Review of the record reveals Patient #1 was admitted to the hospice inpatient unit on 03/11/25 with a terminal diagnosis and went home on 03/13/25 with hospice “Routine Home Care.” Patient #1’s Nursing-Updated Comprehensive Assessment/ Comprehensive Assessment dated 03/23/25 documents skin was assessed and there were no wounds. Patient #1’s Nursing-Updated Comprehensive Assessment/ Comprehensive Assessment dated 03/24/25 documents the presence of a wound as “III Sacrum” and that wound care was provided by cleaning with NS pat dry, applying Medi honey, and covering with ABD and tape. Patient #1’s Focus Visit by nursing on 03/25/25 documents wound care to the sacrum, at which time it was described as “Stage 2” and “wound bed pink” but does not specify what was done for wound care. Additional Focus Visits to Patient #1 by nursing documented on 03/26/25 and 03/28/25 include wound care with normal saline, Medi honey, ABD (abdominal pad) and tape. However, no physician order for Patient #1’s sacral wound care was found in the medical record. Patient #1’s Nursing-Updated Comprehensive Assessment/ Comprehensive Assessment dated 03/31/25 documents a “pressure ulcer Stage 3” and that wound care was provided without further description/assessment of the wound. Patient #1’s Plan of Care Review/Updated Comprehensive Assessment dated 04/01/25 documents “Stage 3 sacrum wound” and redness to sacrum. Patient #1 went to the hospital on 04/02/25 and was admitted for aggressive care, revoking hospice. Review of the record reveals Patient #1 was readmitted to hospice on 05/25/25. Patient #1’s Pre-Admit Evaluation dated 05/25/25 documents Stage 4 decubitus ulcer on coccyx, healing left pressure wound and “Contact precautions – MRSA in wound, VRE.” MRSA and VRE are 2 types of antibiotic-resistant bacteria, which makes infections with these organisms more difficult to treat. Patient #1’s VIPU RN-Initial Comprehensive Assessment documents, “Pressure Ulcer Stage 4 sacrum, size 6x5x1 cm, maceration [softening and breakdown of skin from excessive moisture exposure], wound tissue 20% slough [yellow or white dead tissue] 80% granulation [healing tissue].” Patient #1’s Admissions Orders/Hospice Certification/Initial Plan of Care dated 05/25/25 document his Level of Care was General Inpatient Care and the order “wound care consult.” Patient #1’s Interdisciplinary Care Plan/Initial General POC (Plan of Care) dated 05/25/25 documents End of Life General Needs as “Pain Management/Wound Care.” Patient #1’s Plan of Care Review/Updated Comprehensive Assessment dated 05/25/25 documents for Integumentary, “Stage 4 wound to sacrum, Blister under 5th toe of left foot. Wound consult” and “Pain noted upon movement and during wound care, Wound consult ordered” but includes no further wound assessment information or treatment plan for wound care while waiting for the wound consult. Patient #1 had no orders for wound care until the wound care consult was performed on 05/27/25.”

“Based on review of the Hospice’s Policy, record review, interview, and observation, the provider failed to ensure nursing care needs were met for 3 of 3 sampled patients (Patient #2, #3 and #1). The findings include:1) The Hospice’s standard of care titled VS [Vitas Standard] Wound Care documents, under Assessment and Observation, “A VITAS nurse will visualize the wound and document in the integumentary section of the Nursing Updated Comprehensive Assessment Encounter every 7 days even if the family or LTC staff is performing the wound care,” and under Care Planning, “The overall strategy and scope of the treatment plan implemented will depend on the patient’s condition, prognosis, patient/caregiver goals, and outcomes” and under Documentation – Non-EMR (non-electronic medical record), Documentation of a complete wound assessment includes (in part): 1. Location(s) of wound(s), 2. Stage or Classification, 3. Size: in cm [centimeters] (L x W x D) [Length x Width x Depth], 4. Odor: presence or lack thereof, 5. Undermining: The presence of a cavity under the peri-wound tissue that is caused by shear forces, 6. Tunneling: A tunnel is a tract or sinus extending into the underlying tissues from any point in the wound bed, 7. Peri-wound: Describe the tissue surrounding the wound, 8. Exudate [drainage]: Be sure to record the amount (none, scant, minimal, moderate, copious) and type (serous, serosanguineous, sanguineous, purulent) 9. Color of wound bed, 10. Necrotic tissue: Non-viable tissue that is typically black-brown (eschar) or yellow (slough), and 11. Granulation tissue: Granulation can be pink or beefy-red tissue and has a moist, shiny and granular appearance.Review of Patient #2’s record reveals they were admitted to the Hospice’s Inpatient Unit on 07/10/25 with a terminal diagnosis. Patient #2’s VIPU [VITAS Inpatient Unit] RN [Registered Nurse]-Initial Comprehensive Assessment dated 07/10/25 documents for Wound(s)/Integumentary, “Pressure ulcer right hip open wound. Left foot large blister fluid filled from eating [sic] pad. Bilateral nephrostomy drains site. Colostomy site. Left upper chest port site” and includes no measurements or further description of the right hip wound and foot blister or description of skin condition at the nephrostomy and colostomy sites. Patient #2’s VIPU Interdisciplinary Care Plan Revision/Comprehensive Assessment dated 07/10/25 documents for Skin integrity, “assess skin every shift” and “notify doctor for any skin change.” Patient #2’s Admission Orders/Hospice Certification/Initial Plan of Care dated 07/10/25 document, “Right hip wound daily cleanse with Vashe (brand name of wound cleanser) solution, cover with moist gauze and secure dry dressing on top. Bilateral nephrostomy drains (tubes to drain urine from kidneys) flush 5 ml. (milliliters) NS (normal saline) Q (every)12 h (hours).”Patient #2’s nursing notes (VIPU RN-Updated Comprehensive Assessment and Addendum: VIPU Shift Care Note) for 07/11/25 on day shift (7 AM-7:30 PM) document, “Pressure ulcer sacrum wound. Left leg blister or foot blister” and nephrostomies drained with no mention of the right hip wound or nephrostomy flushes as ordered; and on night shift (7 PM-7:30 AM) document, “R [right] hip wound, left foot blister” without further description/ assessments of those wounds or skin status of the nephrostomy and colotomy sites. Patient #2’s MAR (Medication Administration Record) documents wound care was performed to the right hip wound on 07/11/25 and includes an entry for nephrostomy flushes with normal saline every 12 hours but no documentation of nephrostomy flushes on 07/11/25. Patient #2’s nursing notes for 07/12/25 on day shift document, “R hip wound” with no mention of the foot blister; and on night shift document, “left foot blister filled fluid” and “Right thigh wound, foot blister.” Patient #2’s MAR documents wound care to the right hip wound was performed on 07/12/25 and nephrostomy flushes were performed once, at 10 PM, and not every 12 hours as ordered. Further review of Patient #2’s physician orders, daily nursing notes on both shifts and MARs from 07/10/25 until 07/23/25 revealed no evidence of any nephrostomy flushes after 07/12/25 at 10 PM, although there was no order to discontinue nephrostomy flushes every 12 hours. Review of Patient #2’s daily nursing notes on both shifts and MARs from 07/13/25 until 07/23/25 for evidence of wound care revealed no documentation wound care was performed on 07/13/24, 07/14/25, or 07/15/25, that wound care was performed on 07/16/25 and 07/17/25, and once on night shift from 07/18/25 to 07/19/25 (instead of on both days), that wound care was performed on 07/20/25 but no documentation wound care was performed on 07/21/25 or 07/22/25, and that wound care was next performed on 07/23/25. During observation of Patient #2’s wound care on 07/25/25 beginning at 5:01 PM, Registered Nurse, Staff A cleansed and changed the right hip dressing and was observed to clean the nephrostomy sites with saline and change the split gauze around the sites but did not flush the nephrostomy tubes. Although Patient #2 was observed to have a sacral wound for which Staff A also changed a dressing at that time, review of the record revealed no orders for care of the sacral wound. Further review of the record revealed orders dated 07/10/25 for colostomy care “PRN” (as needed) with no directions for the device and skin care regimen/products to be used or how often the barrier device and/or colostomy bag should be changed. 2) Review of the record reveals Patient #3 was admitted on 06/17/25 to the Hospice Inpatient Unit and had previously resided in a nursing home where Patient #3 had active wound care orders for daily dressing changes of a sacral wound at the time of the transfer. Patient #3’s VIPU RN (Registered Nurse)-Initial Comprehensive Assessment dated 06/17/25 documents the presence of a Stage 4 pressure ulcer that measures 6x6 cm (centimeters) but includes no depth or further description of the wound or whether signs of infection, such as purulent drainage or odor, were present. A Stage 4 pressure ulcer is the most severe type of pressure ulcer, has a high risk of infection, and extends to the deep tissues, such as muscle, tendons, and ligaments, and may expose cartilage and bone. Patient #3’s VIPU Interdisciplinary Care Plan Revision dated 6/17/25 documents for the symptom Skin Integrity, the Outcome to prevent skin breakdown and Interventions to assess patients skin every shift, reposition every two hours as needed, apply barrier cream, and change dressing wound as ordered. However, Patient #3’s Physician Orders on 06/17/25 included a wound care consult but no orders for dressing changes/care of the sacral wound. Patient #3’s MAR (Medication Administration Record) includes an entry for “wound care consult STAT,” order date 6/17/25, that is not initialed as completed for 6/17, 6/18, 6/19, 6/20, 6/21, 6/22, or on 6/23. Patient #3’s nursing notes for 06/18/25 document on day shift, “Wound care provided; wound consult sent” and on night shift, “Pressure ulcer sacrum, size CM (LxWxD) 7x8x1” and “wound care in progress.” Patient #3’s nursing notes for 06/19/25 document on day shift, “Awaiting wound specialist for sacral wounds” and on night shift, “Stage IV wound to sacrum” with no evidence of attempt to contact a physician to request wound care orders until they can be seen by the wound specialist. Further review of Patient #3’s nursing notes reveals no evidence of wound care on 06/19/25 and 06/20/25, that on 06/21/25 the wound was described as pressure ulcer, “granulation, with exudate [healing tissue with drainage, no odor]” and “dressing done”; that on 06/22/25 the wound was “sacrum Stage 4,” measured 7x8x1 cm, with undermining/tunneling 1 cm, and wound care was provided; and that on 06/23/25 the dressing was changed. There was no further description of the wound care that was done on these dates and no evidence of orders for wound care until a wound care consult on 06/24/25, at which time wound care was ordered. Further review of nursing notes on all shifts and dates from 06/25/25 to 07/24/25 as well as Plan of Care Review/Updated Comprehensive Assessments dated 06/24/25, 07/02/25, 07/08/25, 07/15/25, 07/22/25, and 07/24/25 reveal no further measurements or descriptions of the wound bed, wound size, or any drainage or odor. During interview on 07/25/25 at 2:02 PM, Patient Care Administrator, Staff B reported she could find no documentation of wound care assessments except by a physician on 06/24/25 and confirmed wound care was not ordered until 06/24/25, as she stated she was informed by the wound care physician on 06/24/25. 3) Review of the record reveals Patient #1 was admitted to the hospice inpatient unit on 03/11/25 with a terminal diagnosis and went home on 03/13/25 with hospice continuing as “Routine Home Care.” Patient #1’s Nursing-Updated Comprehensive Assessment/ Comprehensive Assessment dated 03/23/25 documents skin was assessed and there were no wounds. Patient #1’s Nursing-Updated Comprehensive Assessment/ Comprehensive Assessment dated 03/24/25 documents presence of a wound as “III [3] Sacrum.” Patient #1’s Focus Visit by nursing on 03/25/25 documents wound care to the sacrum, at which time it was described as “Stage 2” and “wound bed pink.” A Nurse “Focus Visit” dated 03/26/25 documents wound care, without location of the wound, and “Wound signs healing no s/s [signs/symptoms] infection.” A Nurse “Focus Visit” dated 03/28/25 also documents wound care without a location of the wound and “wound healing appropriately no s/s infection.” Patient #1’s Nursing-Updated Comprehensive Assessment/ Comprehensive Assessment dated 03/31/25 documents a “pressure ulcer Stage 3” without further description/assessment of the wound. Patient #1’s Plan of Care Review/Updated Comprehensive Assessment dated 04/01/25 documents “Stage 3 sacrum wound” and redness to sacrum. Patient #1 went to the hospital on 04/02/25 and was admitted for aggressive care, revoking hospice. Review of the record revealed no further wound assessments with description of the wound after 03/25/25, measurements of the wound, or whether there was any exudate or odor, no physician orders for care of Patient #1’s sacral wound during that hospice encounter, and no documentation of attempts by nursing to obtain wound care orders. Review of the record reveals Patient #1 was readmitted to hospice on 05/25/25. Patient #1’s Pre-Admit Evaluation dated 05/25/25 documents Stage 4 decubitus ulcer on coccyx, healing left pressure wound and “Contact precautions – MRSA in wound, VRE.” MRSA and VRE are 2 types of antibiotic-resistant bacteria, which makes infections with these organisms more difficult to treat. Patient #1’s VIPU RN-Initial Comprehensive Assessment dated 05/25/25 documents, “Pressure Ulcer Stage 4 sacrum, size 6x5x1 cm, maceration [softening and breakdown of skin from excessive moisture exposure], wound tissue 20% slough [yellow or white dead tissue] 80% granulation [healing tissue].” Patient #1’s Admissions Orders/Hospice Certification/Initial Plan of Care dated 05/25/25 document his Level of Care was General Inpatient Care and the order “wound care consult.” Patient #1’s Interdisciplinary Care Plan/Initial General POC (Plan of Care) dated 05/25/25 documents End of Life General Needs as “Pain Management/Wound Care.” Patient #1’s Plan of Care Review/Updated Comprehensive Assessment dated 05/25/25 documents for Integumentary, “Stage 4 wound to sacrum, Blister under 5th toe of left foot. Wound consult” and “Pain noted upon movement and during wound care, Wound consult ordered” but includes no treatment plan for wound care while waiting for the wound consult. Patient #1 had no orders for wound care until the wound care consult was performed on 05/27/25.”

“Based on records review and staff interview, the hospice in-patient unit failed to maintain the Emergency Lighting in accordance with NFPA 101. Vitas Healthcare Corporation of Florida’s hospice in-patient unit was located at 9408 SW 87 Ave Suite 107, Miami, Florida 33176 During the records review process at Vitas Healthcare Corporation of Florida located at 9408 SW 87 Ave Suite 107, Miami, Florida 33176 between 11:30 am and 4:00 pm on 10/29/2024 with the Patient Care Administrator could not provide any documented evidence for the performance of emergency lighting annual 90-minutes testing and monthly 30-seconds testing. During the staff interview between 11:30 am and 4:00 pm on 10/29/2024, the Patient Care Administrator acknowledged these findings. NFPA 101 (2021 Edition) 18.2.9.1, 7.9, 7.9.3.1.1(1)-(5)”

“Based on record review and staff interviews, the facility failed to maintain their fire alarm system in accordance with NFPA 101. On 10/29/24 between the hours of 10:00 AM through 3:00 PM while conducting record review at Vitas Healthcare Corp. Delray Beach 5912 West Atlantic Ave. Delray Beach, FL. 33484 with the Administrator and Facilitys Specialist the facility could not provide a current duct detector air stream test. The last report provided was from 05/05/23. An interview was conducted with the Administrator and Facilitys Specialist concurrent with the record review and the findings were confirmed. NFPA 101 (2012 edition) 19.7.6, 4.6.12 NFPA 72 (2010 edition) 14.4.2.2 Table 14.4.2.2, (14) (6) During the records review process of Vitas Healthcare Corporation of Florida (9408 SW 87 Ave Suite 107, Miami, Florida 33176) between 11:30 am and 4:00 pm on 10/29/2024 with the Patient Care Administrator, it was revealed that (1) there was no program for the maintenance and testing of fire alarm system; (2) there was no documentation for the performance of smoke detector sensitivity test within the last 2 years; and (3) there was no documentation for the performance of fire alarm duct detector airstream sampling using a method acceptable to the manufacturer or published instructions. During the staff interview between 11:30 am and 4:00 pm on 10/29/2024, the Patient Care Administrator acknowledged these findings. NFPA 101 (2012 Edition) 18.7.6, 4.6.12, 4.6.12.1 NFPA 72 (2010 Edition) Table 14.4.5”

“Based on records review and staff interview, Vitas Healthcare Corporation of Florida (9408 SW 87 Ave Suite 107, Miami, Florida 33176) failed to maintain the automatic fire sprinkler system in accordance with NFPA 101. During the records review process of Vitas Healthcare Corporation of Florida (9408 SW 87 Ave Suite 107, Miami, Florida 33176) between 11:30 am and 4:00 pm on 10/29/2024 with the Patient Care Administrator, it was revealed that there was no documentation for the performance of timely automatic fire sprinkler system testing and maintenance. The reports provided during survey were dated 10/23/2023 (Annual) and 10/23/2023 (Backflow Annual). No Additional documentation was available during survey. During the staff interview between 11:30 am and 4:00 pm on 10/29/2024, the Patient Care Administrator acknowledged this finding. NFPA 101 (2012 Edition) 18.7.6, 4.6.12, 4.6.12.1 NFPA 25 (2011 Edition) Table 5.1.1.2”

“Based on observations and staff interview, Vitas Healthcare Corporation of Florida (9408 SW 87 Ave Suite 107, Miami, Florida 33176) failed to maintain doors in accordance with NFPA 101. During the Life Safety Survey tour of Vitas Healthcare Corporation of Florida (9408 SW 87 Ave Suite 107, Miami, Florida 33176) at 5:55 pm on 10/29/2024 with the Patient Care Administrator, it was observed that Patient Room 101 door was not latching properly. During the staff interview at 5:55 pm on 10/29/2024, the Patient Care Administrator acknowledged this finding. NFPA 101 (2012 Edition) 18.3.6.3.5”

“Based on observations and staff interviews at Vitas Healthcare Corp. Delray Beach 5912 West Atlantic Ave. Delray Beach, FL. 33484 the facility failed to maintain their Heating, Venting, Air Conditioning (HVAC) system in accordance with NFPA 101. On 10/29/24 between the hours of 10:00 AM through 3:00 PM while conducting facility tour with the Administrator and Facilitys Specialist there were spot coolers being vented into the interstitial space in the ceiling and not venting through an AC return or directly outside in room 109, 139, 140, 141, and 142. An interview was conducted with the Administrator and Facilitys Specialist concurrent with the observations and the findings were confirmed. NFPA 101 (2012 edition) 19.5.2.1, 9.2.1, 4.6.12 NFPA 90A (2012 edition) 4.2.4, 4.3.1, 4.3.11.2 NFPA 90B (2012 edition) 5.3.7”

“Based on record review and staff interview, the facility failed to conduct fire drills in accordance with NFPA 101. On 10/29/24 between the hours of 10:00 AM through 3:00 PM while conducting record review with the Administrator and Facilitys Specialist the facility failed to conduct fire drills for the 2nd quarter of 2024 and the 4th quarter of 2023. An interview was conducted with the Administrator and Facilitys Specialist concurrent with the record review and the findings were confirmed. NFPA 101 (2012 edition) 19.7.1-19.7.1.8 During the records review process of Vitas Healthcare Corporation of Florida (9408 SW 87 Ave Suite 107, Miami, Florida 33176) between 11:30 am and 4:00 pm on 10/29/2024 with the Patient Care Administrator, it was revealed that there was no documentation for fire drills performed in 2023 (4th Quarter / 1st Shift) and in 2024 (1st Quarter / 1st Shift) and (3rd Quarter / 3rd Shift). During the staff interview between 11:30 am and 4:00 pm on 10/29/2024, the Patient Care Administrator acknowledged these findings. NFPA 101 (2012 Edition) 18.7.1.6”

“Based on observations and staff interviews at Vitas Healthcare Corp. Delray Beach 5912 West Atlantic Ave. Delray Beach, FL. 33484, the facility failed to maintain their smoking area in accordance with NFPA 101. On 10/29/24 between the hours of 10:00 AM through 3:00 PM while conducting facility tour with the Administrator and Facilitys Specialist there were multiple cigarette butts found in the mulch and grass area around the smoking patio. An interview was conducted with the Administrator and Facilitys Specialist concurrent with the observations and the findings were confirmed. NFPA 101 (2012 edition) 19.7.4 (1-6)”

“Based on observations and staff interview, Vitas Healthcare Corporation of Florida (9408 SW 87 Ave Suite 107, Miami, Florida 33176) failed to maintain the fire doors in accordance with NFPA 101. During the Life Safety Survey Tour of Vitas Healthcare Corporation of Florida (9408 SW 87 Ave Suite 107, Miami, Florida 33176) at 5:51 pm on 10/29/2024 with the Patient Care Administrator, it was observed that the fire door by Patient Room 105 was not closing/latching properly. During the staff interview at 5:51 pm on 10/29/2024, the Patient Care Administrator acknowledged this finding. NFPA 101 (2012 Edition) 18.7.6, 4.6.12, 4.6.12.1, 8.3.3.1 NFPA 80 (2010 Edition) 5.1.1.1, 5.1.3.1”

“Based on records review, observations, and staff interview, Vitas Healthcare Corporation of Florida (9408 SW 87 Ave Suite 107, Miami, Florida 33176) failed to maintain essential electric system in accordance with NFPA 101. During the records review process of Vitas Healthcare Corporation of Florida (9408 SW 87 Ave Suite 107, Miami, Florida 33176) between 11:30 am and 4:00 pm on 10/29/2024 with the Patient Care Administrator, it was revealed that there was no documentation for the performance of (1) main and feeder circuit breaker annual inspection and maintenance in accordance with the manufacturers instructions and industry standards, and (2) a program for periodically exercising the components in accordance with manufacturers instructions. During the staff interview between 11:30 am and 4:00 pm on 10/29/2024, the Patient Care Administrator acknowledged these findings. During the Life Safety Survey tour of the facility at 6:00 pm on 10/29/2024 with the Patient Care Administrator, it was observed that there were no generator high mortality spare parts onsite. During the Staff Interview at 6:00 pm on 10/29/2024, the Patient Care Administrator acknowledged this finding. NFPA 101 (2012 Edition) 18.7.6, 4.6.12, 4.6.12.1 NFPA 110 (2010 Edition) 8.4.7, 8.2.4”

“Based on record review and interview, hospice staff failed to communicate patient appropriate services to the Interdisciplinary Team (IDT), for discussion and provision of subsequent orders, for 1 of 5 sampled patients serviced out of the Port St. Lucie, FL location (Patient #09-9). The findings included: Review of the policy titled, “Interdicsiplinary Team Policies - Interdisciplinary Team” revised 12/09/2009 documented in part, “Procedure: 1. A registered nurse in consultation with patient/family, attending physician and team members will develop and revise as necessary the Plan of Care.” Review of the policy titled, “Interdisciplinary Team Policies - Care Planning” revised 08/09/2019 documented in part, “Procedure: Approach to service delivery. The interdisciplinary group: Works together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the hospice patients and families facing terminal illness and bereavement. Provides the care and services offered by the hospice, and the group, in its entirety.” Review of the record revealed Patient #09-9 was admitted to the hospice provider on 10/03/24. Review of the Pre-Admit Evaluation completed by Staff 09-E, Registered Nurse (RN), on 10/03/24, documented the family requested services to include music therapy and physical therapy. Review of the Psychosocial Spiritual Initial Comprehensive Assessment dated 10/04/24 documented the patient was lonely, loved company, and needed music therapy and massage therapy. Review of the admission orders and initial plan of care dated 10/03/24 along with the initial plan of care review by the IDT dated 10/08/24, both lacked any documented evidence of the discussion regarding and or request for music therapy, physical therapy, or massage therapy. During a phone interview on 10/29/24 at 3:39 PM, when asked the process for the pre-admission evaluation, Staff 09-E, RN, explained she reviews the patient’s record and speaks to the patient and family as able, along with facility staff when applicable, to determine patient requests and needs. When asked how she communicates these requests and needs to the hospice team, Staff 09-E explained she documented everything on the Pre-Admit Evaluation and emailed an approval request to the Patient Care Administrator (PCA) and General Manager. When asked about the specific requests and needs for Patient #09-9, the RN explained the patient had been on their services, went with another hospice provider for some time, then returned to their provider on 10/04/24. Staff 09-E, RN, further explained the patient’s family had requested the physical therapy because she had received that service with the other hospice provider, and had also requested the music therapy. Staff 09-E looked through her email chain and stated the patient had gotten approval for these services from the hospice management. During an interview on 10/30/24 at 11:00 AM, when asked the process to obtain music, massage, and physical therpies, the Port St. Lucie location PCA explained the IDT would discuss the requests and needs. If the IDT deemed them appropriate, the physician would give the order and the Team Manager would send the information to the PCA, the General Manager, and the Medical Director for approval. During a side-by-side record review, the PCA agreed with the requested services of music, message, and physical therapy, and agreed the information had not been communicated with or discussed by the IDT.”

“Based on policy review, observation, interview, record review, and guidance published by the Centers for Disease Control (CDC) the hospice staff failed to follow their infection control policies related to bag technique and hand hygiene for 2 of 2 sampled patients from the Port St. Lucie and Boynton Beach locations, observed during home visits (Patients #09-8 and #09-23), and for 2 of 2 sampled patients from the Boynton Beach In-Patient Unit (IPU) location, observed during medication pass observations (Patients #09-5 and #09-6), and 1 of 1 patient (01-14) sampled for wound care at the Destin In-Patient Unit. The findings included: Review of the policy titled “Bag Technique” updated 08/22/24 documented, “Purpose: To establish a clean work area, prevent contamination of bag (non-wheeled and wheeled), equipment and supplies, and avoid cross infection.” This policy described the use of a program supplied patient care bag with multiple pockets for use, using a barrier, and placing the bag on a clean surface. This policy further instructed if a clip board, other resource books, or multiple patient use items were needed, they should be placed on a barrier. This policy instructed staff to clean equipment as needed prior to returning to the bag. Review of the document titled, “The Dos and Do Nots for Bag Technique” updated 08/22/24 documented, “DO Disinfect your equipment before returning it to the bag.” A home visit observation for Patient #09-8 was made on 10/29/24 beginning at 9:35 AM with Staff 09-D, Registered Nurse (RN). The RN entered the patient’s home and placed her multi-patient use items, to include a clip board, spiral notebook, and medium sized cloth bag that contained her equipment, directly on the patient’s kitchen table. Staff 09-D, RN, did not use any type of barrier. Patient #09-8 was finishing breakfast at the time and also utilized the table for her medication bottles and pill boxes, along with other personal papers. During the continued observation, Staff 09-D, RN, obtained a small cloth bag that continued an oxygen saturation device, from the medium sized bag, placing the small bag on the patient’s table and using the oxygen saturation device on the patient’s finger. The RN returned the device to the small bag, and then into the medium storage back without any type of cleaning or disinfecting. Also, during this observation, the RN obtained a wrist blood pressure cuff from it’s hard plastic case from the medium bag and used it numerous times for Patient #09-8. Staff 09-D had placed the plastic case directly on the patient’s table. After using the blood pressure cuff, the RN returned it to the hard plastic case without cleaning or disinfecting, then returned the hard plastic case to the medium bag without cleaning or disinfecting. During an interview on 10/29/24 at 4:40 PM, when asked the nurse expectations regarding infection control practices in the home, the Port St. Lucie Infection Control Site Manager/Patient Care Administrator (PCA) stated the nurses should utilize proper bag technique to include the use of a barrier and disinfect equipment prior to returning it bag to their bag. On 10/29/24 at 10:04 AM, medication observation for Patient 09-5 performed by Staff A, Registered Nurse (RN) started. Staff A entered the patients room and donned gloves without performing handwashing prior to donning gloves to administer the patients medication. Observation revealed Staff A flushed the patients midline (an Intravenous line) and administered the patient medications via the Midline. On 10/29/24 at 10:28 AM, medication observation for Patient 09-6) performed by 09-Staff A, RN started. 09-Staff A stated the patient had trouble swallowing and had to crush all of the medications. Observation revealed 09-Staff A crushed three of the patients medications using the units device to crush the medications, then opened the medication door, entered the patients room and donned gloves without performing hand washing prior to donning gloves. 09-Staff A then proceeded to reposition the bed and asked 09-Staff B to assist with repositioning the patient. Subsequently, observation revealed 09-Staff B, Certified Nursing Assistant (CNA) and 09-Staff C, CNA entered the patients room. 09-Staff B and 09-Staff C donned gloves without performing hand washing prior to putting (donning) gloves and repositioned the patient. 09-Staff A then proceeded to administered Patients 09-6s medications without changing gloves or performing hand washing after repositioned the bed and the patient. On 10/29/24 at 11:29 AM, a joint interview with 09-Staff A and the team surveyors was conducted. 09-Staff A stated that she washes her hand in the medication room prior to medication administration, knocks at the patients room door, donned gloves and reposition the patient. 09-Staff- H was apprised she did not perform hand washing prior to donning gloves. On 10/29/24 at 11:54 AM, a joint interview with 09-Staff B, CNA, and team surveyors was conducted. 09-Staff B stated before she does patient care, she knocks on the door, washes her hands, pt on gloves, repositions the patient, removed her gloves, do hand washing and put on gloves again. 09- Staff B, CNA confirmed she did not perform hand washing before putting gloves on before providing patient care. On 10/29/24 at 11:55 AM, a joint interview with 09-Staff C, CNA, and team surveyors was conducted. 09-Staff C stated she do hand washing before putting gloves on and after removing them. 09-Staff C confirmed she did not perform hand washing before assisting to reposition Patient 09-23. On 10/29/24 at 4:04 PM, an interview was conducted with the Patient Care Administrator who was apprised of the lack of hand washing prior to donning gloves to provide direct care to Patient 09-5 and 09-6 observed during medication administration observations. On 10/30/24 at 2:27 PM, a home visit observation for Patient 09-23 performed by 09-Staff- H, RN started. Observation revealed 09-Staff- H pulling a rolling suitcase and carrying a clothed hospice bag. 09-Staff- H entered the patients home, greeted the patient and proceeded to do hand washing. Observation revealed 09-Staff- H retrieved a digital wrist blood pressure from a pouch located on her rolling suitcase, placed it on the patients right wrist and after use, put the reusable blood pressure equipment back on the pouch prior to sanitize/disinfect the equipment. Further observation revealed 09-Staff- H retrieved a pair of gloves from a gloves box located in her rolling suitcase, donned gloves, walked with the patient to the bathroom, removed a tube of Remedy- Z-guard paste (a barrier cream) from the bathroom sink drawer and placed on top of the sink counter. 09-Staff- H removed gloves and returned to the rolling suitcase, retrieved a Ziploc bag with wound care supplies, donned gloves without performing hand washing, and placed the supplies bag on top of the bathroom sink. Further observation revealed the lack of a barrier over the bathroom sink prior to placing the supplies bag. 09-Staff- H reached to a wound cleanser bottle and pulled one gauze from an opened packaging, poured the cleanser on one gauze and with her left hand proceeded to clean the patients discolored buttocks skin. Further observation revealed 09-Staff- H continue to wear contaminated pair of gloves and reached again to the opened clean gauzes packing twice to retrieve a gauze to continue cleaning the patients buttocks. Furthermore, observation revealed 09-Staff- H continue to be wearing the contaminated pair of gloves she cleaned the patients buttocks and applied the Remedy- Z-guard paste to the buttocks with her gloved finger. Observation revealed 09-Staff- H removed her pair of gloves, walked to her rolling suitcase and without performing handwashing, retrieved a new clean pair of gloves, donned gloves and without cleansing the patient inguinal area, applied Remedy-Z-guard paste to the area with her gloved finger. The procedure was performed while the patient was standing in the bathroom. 09-Staff- H removed her pair of gloves and placed the Ziploc bag with supplies back to her rolling suitcase without disinfecting the bag. 09-Staff H did not perform hand washing after providing Patient-09-23s skin care. Observation then revealed 09-Staff-H reached to her clothed hospice bag and retrieved her stethoscope and then cleaned the patients oxygen nasal cannula that was on the floor. Further observation revealed 09-Staff- H proceeded to auscultate the patients lungs without performing hand washing prior and placed the stethoscope in the rolling suitcase without disinfecting it first. Observation revealed 09-Staff- H continue her visit without performing hand washing after direct care to the patient and stated she was sending communication (via telephone) to replace the patients oxygen concentrator. On 10/30/24 at 3:40 PM, an interview was conducted with 09-Staff- H who stated she should have a barrier with her supplies on it and should have changed her gloves after she cleaned the area, after removing and donning gloves and added that the home environment was different, and the patient was getting uncomfortable. On 10/30/24 at 4:40 PM, a joint interview with the Team Surveyors, the Patient Care Administrators, the General Manager and the National Patient Care Administrator was conducted, and they were apprised of the home visit findings related to Infection control. On 10/30/2024 at approximately 12:20 pm an observation of wound care for Patient 01-14, performed by staff 01-F, a Licensed Practical nurse (LPN) revealed the LPN did not perform hand hygiene immediately after doffing the gloves used to remove the soiled dressing, and prior to donning clean gloves used to clean the wound. Additionally, hand hygiene was not performed by the LPN in between the glove change in between cleansing the wound and placing a clean dressing on the wound. On 10/30/2024 at approximately 12:25 pm and interview with staff 01-F, the LPN stated, “;I washed my hands before I put gloves on when I started, I didnt realize I did not wash or sanitize them in between glove changes.” On 10/30/24 at approximately 1:11 pm an interview with staff 01-H Patient Care Administrator, an Advanced Practice Registered Nurse (APRN), she stated “;We would expect hand hygiene multiple times between the steps of a dressing change. Hand washing/sanitizing should be done in between each step of wound care after removing gloves and before donning clean gloves.” A review of hospices clinical guidelines “;Plan for Infection Control” Updated 8/22/2024- Pages 60-65 review gloving and hand hygiene revealed, Page 61, 4.) Remove gloves promptly after use, before touching non-contaminated items, environmental surfaces and before entering another patients room. Wash hands immediately to avoid transfer of micro-organisms. Don a new pair of gloves. (photographic evidence of policy obtained) Guidance published by the CDC revealed the following standard practice: 1. Require healthcare personnel to perform hand hygiene in accordance with CDC recommendations. 2. Use an alcohol-based hand rub or wash with soap and water for the following clinical indications: f. Immediately after glove removal Centers for Disease Control and Prevention. (n.d.). CDCs core infection prevention and control practices for safe healthcare delivery in all settings. Centers for Disease Control and Prevention. https://www.cdc.gov/infection-control/hcp/core-practices/index.html”

“Based on observation, staff interview, document review, and internet webpage review, the hospice provider failed to notify and seek approval from the Centers for Medicare and Medicaid Services (CMS) prior to operating inpatient hospice units and providing care to hospice patients in 7 inpatient hospice settings (inpatient units Community Suites at Community Health & Rehabilitation 3611 Transmitter Road Panama City, Florida, Sacred Heart Hospital 5151 North 9th Avenue Pensacola, Florida, West Florida Medical Center Hospital 8383 North Davis Highway Pensacola, Florida, Vitas Suites at Destination Health & Rehab 195 Mattie M. Kelly Boulevard Destin, Florida, Lake Wales 410 South 11th Street Lake Wales, Florida, Orlando Lutheran Towers 210 Lake Drive Orlando, Florida, and Solaris Healthcare 900 Imperial Golf Course Boulevard Naples, Florida. During an interview with the General Manager for Program 18 (Melbourne Location) on 10/30/24 at 3:26 PM, information was provided that indicated patients received Hospice services at an in-patient setting in a Skilled Nursing Facility (SNF) in Orlando, Florida at Orlando Lutheran Towers (OLT) located at 210 Lake Drive Orlando, Florida. During a tour on 10/31/2024 at 8:26 AM of OLT SNF facility confirmed a designated area with 8 Vitas Hospice Beds and a current census of 4. Review of the website for this facility confirmed the SNF had an 8 bed Vitas Unit for Hospice patients with around the clock care provided by Vitas. During an interview with the Patient Care Administrator on 10/28/2024 at 9:30 AM, information was provided that noted patients received Hospice services at an in-patient setting at AdventHealth Lake Wales Hospital located at 410 South 11th Street Lake Wales, Florida. During a tour on 10/29/20243 at 10:00 AM of the 2nd floor at AdventHealth Lake Wales Hospital revealed an 8-bed in-patient unit with a sign that showed they were Vitas Hospice Beds. Review of the website in a location search for Hospice in-patient units confirmed Vitas advertised they had an 8 bed Unit for Hospice patients with around the clock care at AdventHealth Lake Wales Hospital that noted hospice provided direct care to patients 24/7 in an in-patient setting. A contract was provided for review between Vitas Healthcare Corporation of Florida Hospice and the hospital with an original date of 04/27/21, the date the first patient was admitted. This was also confirmed during interview with the Senior Patient Care Administrator on 10/28/24 at approximately 10:30 AM, who stated Hospice staff provided direct care to the patients on this unit.. Observations on 10/29/24 at 10:45 AM, at West Florida Medical Center Hospital located at 8383 N Davis highway in Pensacola, Florida noted an in-patient unit designated for Vitas Hospice beds with a current patient census of 6. This in-patient setting was staffed with 3 Vitas Registered Nurses who were observed to provide direct care to the patients. Review of a signed memorandum of understanding for a Hospice direct shared inpatient unit at the West Florida Medical Center dated 4/30/24, indicated the hospital would make available space and beds on the 1st floor of the hospital for provision of inpatient services to Vitas patients. Review of the internet website for Vitas In-Patient Unit located in West Florida Medical Center confirmed the advertising of these designated in-patient beds as Vitas Hospice beds. Observations on 10/30/24 at 9:45 AM of the in-patient unit at Vitas Suites located at Destination Health & Rehab 195 Mattie M. Kelly Blvd. Destin, Florida were conducted and noted an inpatient setting designated for Vitas Hospice beds, staffed with two vitas Registered Nurses, 1 Vitas Licensed Practical Nurse, and 1 Vitas Certified Nursing Assistant. The census at this unit was eight patients and during this visit the nurses were observed to provide direct care to the patients on this unit. Review of a signed Vitas Healthcare corporation of Florida agreement for services in dedicated beds dated 3/29/24 indicated the agreement was entered into effect as of 3/1/24 by and between Vitas Healthcare corporation of Florida and Destin Senior Care LLC dba Destination Health and Rehab center located at 195 Mattie M. Kelly Blvd. Destin, Florida. Section 2.4 of the agreement stated facility shall provide Vitas with exclusive tenancy to certain beds during the term of the agreement. Vitas shall also have access able to admit Hospice patients into the Vitas patient rooms at any time 24/7. Review of the internet website for the Vitas In-Patient Unit located in the Destination Health and Rehab facility confirmed the advertising of these designated in-patient beds as Vitas Hospice beds. An interview with the Senior General Manager Registered Nurse was conducted on 10/29/24 at 2:13 PM. She indicated Vitas had four inpatient units in the Northwest Florida area that included the units in West Florida Hospital in Pensacola, Florida, an in-patient setting in Sacred Heart Hospital in Pensacola, Florida, the in-patient setting in Destination Health and Rehab facility in Destin, Florida and one at the Community Health and Rehab in Panama City, Florida. She stated the West Florida and Sacred Heart units were acquired by Vitas on 4/17/24, the Destin inpatient unit opened in July of 2024 by Vitas, and the Community Health and Rehab inpatient unit was opened by Vitas on 6/21/21. On 10/29/24 at 9:15 AM, the National Patient Care Administrator acknowledged the inpatient care unit was not listed on the Vitas license as the beds released and covered by Community Health and Rehabilitation Centers license. She also confirmed Vitas employees were staffing the unit. Observations were conducted at the inpatient Hospice unit located in the Community Health & Rehab Center located at 3611 Transmitter Road Panama City, Florida on 10/29/24 at 11:15 AM. The unit was staffed with Vitas Registered Nurse and one Vitas Licensed Practical Nurse. The current inpatient census was 4 patients. During the visit to this site the Vitas nurses were observed to provide direct care to those patients. Review of a signed contractual mutual agreement between Vitas Healthcare Corporation of Florida and Rehabilitation Center LLC dba Community Health and Rehabilitation Center dated 2/5/21 with a First Amendment to agreement for nursing facility inpatient and inpatient respite services indicated the facility would provide Vitas with exclusive tenancy to multiple rooms and Vitas would have access and be able to admit Hospice patients 24/7. Review of the internet website for the Vitas In-Patient Unit located in Community Health and Rehabilitation facility confirmed the advertising of these designated in-patient beds as Vitas Hospice beds. A telephone interview was conducted with the Vice President of Operations on 10/29/24 at 2:21 PM. She stated the bed count was under the hospital not under Vitas. She said that was how the memorandum of understanding was written because they leased the beds from the hospital. She verified the staff was provided by Vitas and care and services provided by Vitas. She stated this was why the units in Panama City and Destin were not added to their license. She was not able to state whether the locations were reported to CMS stating she would have to consult their legal counsel. An in person interview was conducted with the Vice President of Operations on 10/29/24 at 3:10 PM. When asked why they did not report the additional inpatient units to CMS, she stated the contractual relationship between the hospital and Vitas did not serve as multiple site locations. On 10/29/24, a review of a hospice brochure showed an inpatient unit located within a skilled nursing facility at 900 Imperial Golf Course Blvd. in Naples, Florida. Observations on 10/29/24 at 4:00 PM, of the inpatient unit with the Acting Director of Nursing noted a 12-bed in-patient unit located within the skilled nursing facility with a current census of 10 patients. On 10/29/24 at 4:30 PM, the Hospice Patient Care Administrator arrived on site and provided an Agreement with the skilled nursing facility dated 12/1/19. The agreement was signed by and between the Hospice Chief Executive Officer on 12/5/19 and the Skilled Nursing Facility Administrator on 12/2/19. On 10/29/24 at 5:00 PM, the Hospice Acting Director of Nursing noted she confirmed this hospice inpatient unit was always staffed by Hospice nurses and the 12 beds were dedicated to Hospice patients. She also verified a current census of 10 patients who currently received inpatient Hospice care at this location. On 10/31/24 during the exit conference with Vitas Administrative Staff, all of the above in-patient units/beds were discussed. The Vitas Hospice Administrator provided a copy of a license at that time with multiple in-patient units but did not have the units identified above on their license. A CMS 855 was not provided to demonstrate Vitas Hospice had notified and sought approval from CMS for the aforementioned in-patient units/beds.”

“Based on record review and interview, the Hospice failed to ensure 2 of 6 sampled patients (Patient #1 and #22) were free from neglect This affected Patient #1 who expressed suicidal ideation, and the Hospice failed to develop a Care Plan with appropriate interventions, or communicate the concerns for suicidal ideation between disciplines and care settings, which ended with a family member finding Patient #1 dead by fatal gunshot wound with a gun in his hand. This affected Patient #22 for whom the Hospice was notified by nursing home staff on 06/17/24 that she was found disoriented with pills nearby, but the Hospice did not implement any interventions to address the risk of patient overdose, and Patient #22 died on 06/20/24 after a suspected second overdose on 06/19/24. (L0517). The cumulative effect of these systemic problems resulted in Immediate jeopardy, a situation in which the noncompliance with Conditions of Participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient.”

“Based on record review and interview, the Hospice provider failed to update the comprehensive assessment for 1 of 6 sampled patients (Patient #1) to indicate newly identified needs. This affected Patient #1, who expressed suicidal ideation by firearm to a nurse in the Inpatient Unit on 07/04/24 but was discharged home on 07/05/24 without an update to his assessment or other communication to his home care team. Patient #1 was found by his family dead with a gunshot wound to his head and gun in hand on 07/13/24. (L0533). The cumulative effect of these systemic problems resulted in Immediate jeopardy, a situation in which the noncompliance with Conditions of Participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient.”

“Based on record review and interview, the Hospice provider failed to ensure care planning was updated with appropriate interventions to address the needs of 1 of 6 sampled patients (Patient #1). After Patient #1 made a suicidal statement in the Hospice inpatient unit, staff failed to update his Plan of Care with appropriate interventions, and he was sent home the next day. Several days later, Patient #1 was found by a family member dead with a fatal gunshot wound and gun in his hand. (L552). The Hospice failed to ensure after Patient #1 made a suicidal statement in the hospice inpatient unit on 07/04/24 and staff verified there was a gun in the home, that these concerns were communicated to the home team when he went home on 07/05/24. On 07/13/24 Patient #1 was found by a family member dead with a fatal gunshot wound and gun in his hand. (L554). The cumulative effect of these systemic problems resulted in Immediate jeopardy, a situation in which the noncompliance with Conditions of Participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient.”

“Based on interview and record review, the hospice provider failed to: Ensure services provided to patients residing in skilled nursing facility were appropriate to address their needs and were coordinated and effective to keep patients safe. (L765) These failures resulted in the hospice provider’s inability to ensure patients’ needs were met to keep patients in their care safe. This affected Patient #22 for whom the Hospice was notified by nursing home staff on 06/17/24 that she was found disoriented with pills nearby, but the Hospice did not implement any interventions to address the risk of patient overdose, and Patient #22 died on 06/20/24 after a suspected second overdose on 06/19/24. (L765)”

“The hospice must designate a physician to serve as Medical Director. The hospice provider failed to meet the requirement as the patient census was 14,635 at the time of the survey and the provider had 20 listed Medical Directors. Their Chief Medical Director was not aware of recent serious adverse patient events related to suicide for patients #1 and #22 and for patient #21 who attempted suicide. Based on interview and record review, the hospice provider failed to ensure a single individual filled the role as Medical Director and assumed overall responsibility for the medical component of the hospice patient care program. The cumulative effects of these systemic practices resulted in the hospice provider’s inability to ensure patients’ needs would be met. (L0669)”

“Based on review of the Hospice’s Policy and Procedure, record review and interview, the Hospice failed to provide effective symptom management for 1 of 3 sampled patients. This affected Patient #4 whose continuous care nurse at the bedside failed to administer the available medications as ordered and indicated to manage shortness of breath. The findings include: Review of the Hospice’s Standard titled, VS [Vitas Standard] Symptom Management, undated, documents “Symptoms should be care planned with outcomes, goals and interventions based on assessment findings and patient/family input” and “Symptoms with a high level of concern, a level of concern or severity greater than “5” may require immediate intervention” and “Interventions should include pharmacological and non-pharmacological approaches as appropriate based on scope of practice.” Review of the record reveals Patient #4 was admitted to the Hospice’s services on 01/16/24 with a terminal diagnosis. Patient #4s “;VITAS Chart Medication List/Signed Physician Orders List” documents an order for “;duoneb (ipratropium/albuterol sulfate) 0.5-3mg. (milligrams)/3 ampul-neb”, to empty one ampule into nebulizer and inhale by mouth every four hours as needed for shortness of breath. Patient #4s “;Continuous Care Shift Care Note-Nurse” by Licensed Practical Nurse, Staff O dated 08/05/24 for the start of shift at 8:00 AM documents, “;respiration shallow and labored”, a respiratory rate of 30 at 8:00 AM, and does not indicate when Patient #4 had their last nebulizer treatment; and at 08:30 AM “;respiration shallow labored @ [at] this time.” Patient #4s “Addendum Interdisciplinary Note” by Staff O dated 08/05/24 documents at 10:30 AM “;respiration labored @ (at) this time” on 4 liters oxygen via nasal cannula; that at 12:00 PM a nebulizer treatment was administered; at 2:30 PM “;respiration shallow and labored - period of shortness of breath noted” and the patient was on 4 liters oxygen via nasal cannula; at 4:00 PM “;shortness of breath with rest and exertion noted @ this time” on 4 liters oxygen via nasal cannula but no evidence of documentation of administration of medication or nebulizer treatment although it had been four hours since her last treatment; at 5:00 PM “;will continue to monitor pt [patient] for s/s [signs or symptoms] of resp [respiratory] distress” without evidence of documentation of whether Patient #4 did or did not have respiratory distress at that time; at 6:00 PM “;shortness of breath c [with] exertion and rest noted” and under pharmacological intervention [medications given] “;neb tx” [nebulizer treatment]. A “Focus Visit Note” by a Registered Nurse dated 08/06/24 for a visit start time of 10:20 AM documents Patient #4 was on continuous care for shortness of breath and “;Instructed PCG [primary caregiver] to administer meds [medications] as ordered/duoneb as ordered.” Patient #4s “;Continuous Care Shift Care Note-Nurse” by Staff O dated 08/06/24 for start of shift at 8:00 AM documents a respiratory rate of 30 at 8:00 AM and “;respiration shallow and labored” on 4 liters oxygen via nasal cannula and does not indicate when patient #4 had their last nebulizer treatment. Patient #4s “Addendum Interdisciplinary Note” by Staff O dated 08/06/24 documents at 12:00 PM “;shortness of breath c rest and exertion noted at this time” on 4 liters oxygen via nasal cannula and a nebulizer treatment was administered; at an illegible time before a 2:00 PM entry, “;respiration shallow and labored shortness of breath with rest and exertion” on 4 liters oxygen via nasal cannula and Ativan was administered; at 4:30 PM “;shortness of breath c rest and exertion noted @” but no evidence a nebulizer treatment was administered although it had been 4 hours since the last nebulizer treatment; and at 6:00 PM “;nebulizer treatment given for shortness of breath.” During telephonic interview on 08/29/24 at 3:17 PM, Staff O stated she gave Patient #4 a breathing treatment as often as she needed it following physician orders and that she documented every time she gave the patient a breathing treatment.”

“Based on review of the Hospice’s Standard (in lieu of Policy and Procedure), patient record review and staff interview, the Hospice provider failed to ensure 2 of 6 sampled patients (Patient #1 and #22) were free from neglect. This affected Patient #1 who expressed suicidal ideation and the Hospice failed to develop care plan with appropriate interventions and/or referrals, and failed to communicate concerns for suicidal ideation between disciplines and care settings, which ended with a family member finding Patient #1 dead by gunshot wound to the head with gunpowder residue on his hands. This affected Patient #22 for whom Hospice staff was notified by nursing home staff on 06/17/24 that she was found disoriented with pills nearby after a return from a leave of absence, but the Hospice did not implement any interventions to address the risk of patient overdose, and Patient #22 died on 06/20/24 after a suspected second overdose on 06/19/24. The findings include: 2. Review of the medical record revealed patient #22, a 78-year-old female, was admitted to the hospice agency on 7/29/23 with terminal diagnosis of atherosclerotic heart disease and secondary diagnosis of heart failure. Review of the medical record dated 7/31/23 revealed a Registered Nurse (RN) completed the Initial Comprehensive Assessment that noted the patient was alert and oriented to person, place, situation and time. The patient reported a pain level of “;6” with care plan goal of “;3” or less. The assessment indicated the patient was on opioid type medications for sharp/shooting pain down her left leg and across her back. The patient stated, “;I just want to feel better, I have no quality of life”. The RN documented under psychosocial assessment no history of psychiatric illness/substance abuse or suicidal ideation. The RN documented the patient had history of depression since her son passed away in January from Corona Virus Disease. The Bachelor of Social Work (BSW) completed a Psychosocial Comprehensive Assessment on 8/1/23 and documented the patient denied concerns regarding suicidal ideation or substance abuse history and currently was in acceptance of her terminal illness, had depression and was coping appropriately. The plan moving forward was for SW (Social Worker) to meet with patient twice per month to provide support and education. The plan of care included symptom management regarding “;sense of control and ability to cope” and interventions to provide reassurance, educate regarding hospice services and provide support through being present. The SW assisted patient #22 with nursing home placement per note dated 2/26/24. The hospice RN note dated 6/15/24 revealed the nurse visited the patient at the nursing home. During the visit the patient opened her eyes when her name was called but fell asleep while talking. She then opened her eyes and said she felt “;wiped out.” The hospice RN did not collaborate with other hospice staff or with nursing home staff to determine the reason for the patient’s change in condition and why she was so lethargic. On 6/16/24 to 6/17/24, patient #22 went on a Leave of Absence (LOA) from the nursing home and obtained unknown drugs while on leave. The hospice agency did not ensure coordination of communication and were not notified of the patient’s leave. The hospice Licensed Practical Nurse (LPN) #LL visited the patient at the nursing home on 6/17/24 from 9 AM to 10:20 AM, and documented the patient was alert and calm. He wrote he was informed by nursing home staff the patient returned from LOA and was found in her room very disoriented. About 5-6 bottles of medications including Ativan and other narcotics were found in the patients room which the nursing home staff secured in a locked box. The hospice LPN did not initiate an incident report or collaborate with the nursing home staff to address why the resident brought the medications to the nursing home or which medications she may have taken. On 6/18/24 at 11:45 PM, the Telecare Call Action Log by hospice RN #ZZ showed the nursing home LPN called to report patient #22 was found 10 minutes ago foaming at the mouth and unresponsive. The patient had a pulse of 51 bpm [beats per minute]. The nursing home LPN stated she found a cup in the patients room with Ativan, Temazepam and Potassium pills. The LPN also reported the patient had history of self-harming behavior. The patient was sent to the hospital for possible overdose. At 12:45 AM, the “;Hospital called in stated that patient overdose, reason for the visit to hospital...” On 6/19/24 at 6:43 AM, Telecare Call note by hospice staff #BBB read, “;Facility nurse called in and stated patient came back from the hospital at 0400 (4 AM) but the patient’s condition is still bad...” On 6/19/24 hospice RN #MM visited the patient at the nursing home and documented a visit note at 10 AM. The noted indicated the patient was unresponsive, and foaming at the mouth. The patient was suctioned, and family notified of the situation. The family informed this situation has occurred many times...” On 6/20/24 RN #MM documented a visit at the nursing home from 8:45 AM to 9:55 AM. The note showed the patient had no response to stimuli and was clammy. The patient was not able to swallow, and all medications were discontinued except for comfort. On 6/20/24 at 10:35 AM, the hospice chaplain visited the patient at the nursing home and documented death at this time was imminent. She had decreased response to verbal and visual stimuli. The date and time of death according to the hospice Case Sheet was on 6/20/24 at 1:30 PM. On 8/27/24 at 12:43 PM, interview and concurrent record review was conducted with General Manager (GM) DD in person and other staff on the phone from program #78 including Senior Patient Care Administrator (PCA) #II, Performance Improvement Specialist (PIS) #JJ, and Associate GM #KK. The staff verified they did not have a General Manager for program #78 at this time. They explained this incident was suspected suicide as the patient was found with bottles of pills nearby. Hospice staff indicated they did not know what day she went on leave and thought that a friend brought her home, and that is how she obtained pills and brought them back to the nursing home. The Senior Patient Care Administrator verified she was responsible to ensure a thorough investigation and root cause analysis was done post incidents. She verified that hospice staff did not talk to the nursing home staff to find out exactly what happened. She said they did identify areas of opportunity for communication and education. They needed to educate the nursing home staff that hospice should have been notified immediately after drugs were confiscated from patient #22. She stated, “;the main thing that was lacking was our communication between facility staff and hospice staff. I think mainly being aware the patient went out of the facility so that we would have known when she came back, she was having a hard time adjusting to being at the facility”. The Senior Patient Care Administrator noted they needed to improve their communication with the nursing home staff and should have implemented measures to keep the patient safe. She acknowledged they had not revised the care plan after it was identified the patient brought in medications to the nursing home and was found disoriented. 1) The hospices Standard titled VS Responding to Abuse, Neglect and Financial Exploitation and Reporting of Crimes in the Long-Term Care Facility, dated 06/15/23 documents “;Neglect means failure to provide goods and services necessary to avoid physical harm or mental anguish. Review of the clinical record reveals Patient #1 was admitted to the Hospice for “;Routine Home Care” in February 2021 with no known history of depression or mental illness. An Interdisciplinary Plan of Care Revision/Physician Orders dated 07/01/24 documents, “;Transfer to IPU [Inpatient Unit] – [name of hospital] for SOB [shortness of breath] & cough. Pneumonia.” A Psychosocial Updated Comprehensive Assessment was completed by an unlicensed and unregistered Social Worker, Staff A on 07/03/24 who documented Patient #1 was lethargic but arousable, did not want nursing home placement but wanted to go home and was receptive to seek veteran benefits for aide services. This assessment did not document any signs of suicidality. Patient #1s Focus Visit by Staff A on 07/04/24 for 3:00 PM to 4:30 PM documents the Social Worker (SW) conducted a follow up visit after report from Registered Nurse, Staff B that “;patient said he wished he had a gun, he doesn’t want to live like this (bed bound)” and under interventions performed, “;SW provided PS [psychosocial] support/provide active empathetic listening/validation of feelings assess for suicidal ideation re: statements made to RN [name] when providing care SW called PCG [primary caregiver] to discuss safety re: statements of ideation + DC [discharge] planning” and Response to Care “;Patient presented AAOx2 [awake alert and oriented to person and place]; intermittent forgetfulness/confusion/receptive/engaged Pt [patient] advised “;I was just running my mouth; I would never do anythin_ I do not want to hurt my family I do not want to leave this as my legacy to my grandkids Pt denied plan/attempts of suicid_ son advise pt made similar statements since pt was 50 years old PCG advise_ gun in home in lock box away from pts reac_ PCG wants pt to return home.” This Focus Visit does not document communication or collaboration with any other staff although there is a place on the form to indicate collaboration with empty checkboxes for several disciplines. Review of Patient #1s inpatient nursing notes for 07/02/24, 07/03/24, 07/04/24, and 07/05/24 reveal no documentation that Patient #1 made any statements indicating suicidal intent or ideation while in the inpatient unit. An entry on Patient #1s Addendum: VIPU Shift Care Note for 07/05/24 at 7:35 PM documents “;Pt discharged home.” Review of Patient #1s physician notes for 07/02/24, 07/03/24, 07/04/24 reveal no documentation of awareness that Patient #1 made any statements indicating suicidal intent or ideation. There was no physician note for 07/05/24 and no order to send the patient home from the inpatient unit, as of the date of record review on 08/28/24. After inquiry on 08/28/24 to Patient Care Administrator, Staff C as to whether the physician ever gave an order for Patient #1 to go home from the Inpatient Unit on 07/05/24, Staff C reviewed the chart and on 08/29/24 at 10:18 AM confirmed she could not find such an order, stated she talked to the physician that morning and he confirmed he had given the order, so she wrote a late order for the discharge. Later that day, Staff C provided an Interdisciplinary Plan of Care Revision/Physician Orders documenting “;Late entry for 07/05/24 DC [discontinue] IPU Level of Care Resume Routine Home Care” with physician signature dated 08/29/24, and no evidence of any other orders or changes to the care plan. Review of Patient #1s Plan of Care Review dated 07/05/24 documents in the Psychosocial category “;S/W available” and in the Spiritual category “;Chaplain available” and gives no indication of any interventions or changes to the plan of care to address his suicidal statement in the inpatient unit. Review of the Nursing-Updated Comprehensive Assessment by Registered Nurse, Staff D dated 07/06/24 for a visit at 6:25 PM to 7:25 PM reveals no documentation or evidence of awareness of Patient #1s suicidal statement in the inpatient unit and no evidence of psychosocial assessment other than the words “;SW involved c [with] care.” Review of the Nursing-Updated Comprehensive Assessment dated 07/08/24 for a visit at 9:40 to 10:40 (no AM or PM) reveals no documentation or evidence of awareness of Patient #1s suicidal statement in the inpatient unit; the Psychosocial section documents a reported level of “;4”, care plan outcome “;maintain psych”, care plan goal “;2”; and on the next line a reported level of “;0”, care plan outcome “;0”, and care plan goal “;0”, followed by Interventions Performed “;assessed psych” and Response to Care “;SW involved in case”; and the Location of Care (Home) Environmental Safety section indicates by a mark in a checkbox “;Cluttered or unclean living area(s), the Care Plan Outcome “;maintained safety,” interventions “;assessed safety,” and Response to Care “;Educated PCG to keep pt belonging in reach.” A Supplemental Interdisciplinary Note for 07/08/24 by the Social Worker on the home team, Staff E documents phone contact to Patient #1s family member who reported the patient is stable and the nurse visit would be sufficient for now, Social Worker advised will be visiting the home the next day and the visit is important in case there are any needs, and the PCG asked her to call before arriving. A Supplemental Interdisciplinary Note for 07/09/24 by Staff E documents she called to confirm the visit, but the family member denied the visit and rescheduled it for 07/11/24. A Psychosocial Updated Comprehensive Assessment completed by Staff E for 07/11/24 at 12:30 PM to 1:30 PM indicates in the psychosocial section by marks in checkboxes: Emotional Affects/Behavioral Manifestations, Patient is a Veteran, and in comments that the patient was very happy with services provided, support to patient and caregiver, the caregiver confirmed patient is a veteran but wants to put benefits on hold for now. An Addendum Interdisciplinary Note dated 07/13/24 by a Chaplain documents she was notified the patient had died and visited the Patient #1s residence, that the family member stated “;I think he shot himself,” that the family member reported they went into the patient’s room that morning and found him in an odd position with the gun next to him, that the family called 911, and that the family member mentioned a nurse had reported to him Patient #1 had made the comment “;I wanna blow my head off” while he was at the Inpatient Unit. Review of the associated police report printed 08/27/24 at 1:00 PM revealed when police arrived to the home on 07/13/24, they found Patient #1 dead with a gunshot wound to his head, loaded firearm in his hand, and a presumptive test was positive for the presence of gunshot residue on Patient #1s right hand. The police report also documented the family member reported Patient #1 “;had made comments about shooting himself and so he hid his firearm in another drawer in the room.” During telephone interview on 08/27/24 at 2:35 PM, the inpatient Registered Nurse, Staff B reported Patient #1 stated to her in the hospice inpatient unit that he should have blown his brains before he came to this place, but when she asked what he meant by that, he then said it’s nothing and he was just frustrated; that when she asked if he had a gun at home he denied having one and said forget it, it’s nothing, that he was just frustrated and then he talked of what his life had been, his past accomplishments, and that now he’s here; that Staff B then told the Social Worker, Staff A what Patient #1 had said, and Staff A said she would go talk to him; that Staff B then told the Team Manager, who said she had to “;escalate this all the way up”; that Staff B called Patient #1s family member and told them what Patient #1 had said and asked if that seemed strange, to which the family member responded Patient #1 has been saying this for 35 years and it’s nothing; that Staff B asked the family member if there was a gun in the home, but the family member downplayed it, said it’s nothing, and asked when they are sending the patient home. During telephone interview on 08/27/24 at 2:55 PM, the inpatient Social Worker, Staff A stated she evaluated Patient #1 on 07/03/24, there were concerns for his loss of autonomy and she remembered he wanted to keep his urinary catheter in when he went home, which was an unusual request but maybe he did not want to burden the household with trips to the bathroom; that her focus was his weakness and need for support and they discussed veteran benefits to try to get him part-time help at home; that on 07/04/24 she was informed Patient #1 wanted to be discharged as soon as possible, she met with him early in the day and he talked of his life experiences and wanting to go home for the holiday with family; that after this Staff B reported he just made a statement that he wished he had a gun to make things go faster, so Staff A immediately texted the physician to put a hold on the discharge and talk when he gets in, and informing the physician the nurse verbalized Patient #1 had suicidal ideation and Staff A was going to go talk to Patient #1; that Staff A talked to Patient #1 about his statement that he wished he had a gun and he said Oh, no, it’s just words, and minimized it; that Staff A immediately asked Patient #1 if he ever attempted suicide before and if he had a plan, and he said he would never do that to his children or grandchildren; that Patient #1 talked about feeling depressed and his loss of autonomy and weakness; that Staff A then talked to Staff B about symptom management for his depression and moving him closer to the nurses station; that Staff A called the family member who said Patient #1 has been saying things like that since his first cardiac event at age 50, that there was a gun in the home but it was on the other side of the house in a locked box out of reach, and the family member denied feeling concerned about Patient #1s statement; that Staff A then talked to the Team Manager and Physician about Patient #1s statements and conversations, and the discharge was held, but Patient #1 ended up being discharged the following day while Staff A was not working; Staff A denied using, or the Hospice having, any formal suicide assessment or suicide screening tool; Staff A reported they used to contract for safety when a person was a suicide risk, but they stopped doing that at this Hospice; Staff A denied having a Social Work license or being a Registered Clinical Social Work Intern but reported she has a Masters in Social Work and has worked in the Hospice as a Social Worker seeing patients for the last nine years. During telephone interview on 08/28/24 at 11:31 AM, Registered Nurse, Staff D stated she remembered Patient #1 and had been seeing him weekly since January 2024 except when he was in the inpatient unit; that there was nothing concerning in her visits to indicate a Social Worker was needed; when asked about her nursing assessments in which she consistently documented for psychosocial a Reported Level of “;4” and a Care Plan Goal of “;0” and what this means, Staff D answered she was trained to put a “;4” and whether they were depressed or suicidal she would probably still put a “;4” but there are other things she would do, such as staying with them until they can find another intervention, call the doctor and social worker, start continuous care; Staff D stated since August she learned if there’s nothing wrong, she could put a “0” instead of a “;4”; Staff D stated “;Psychosocial is not something I focus on. I focus on medication management and, if there is something else, I let another team member know. I have not learned how to do a psychosocial assessment”; Staff D stated she received a report from the inpatient manager when Patient #1 was coming home that he would probably need a follow up visit that night and the next day, he had a urinary catheter and wanted to keep it in, was still very weak and had issues swallowing, but no mention he had made any suicidal statements; that if there had been anything about him feeling suicidal they would probably have kept him in the inpatient unit or she could have put him on continuous care at home, and that it “;would have changed everything”, but she was never informed of this; and that the Social Worker made a visit to Patient #1 right after her own on 07/11/24 to talk about veterans benefits. During telephone interview on 8/28/24 at 3:34 PM, Registered Clinical Social Work Intern, Staff E stated Patient #1 was assigned to her on a Monday or a Tuesday but the family member refused a visit until she saw him later that same week on Thursday, 07/11/24; that she believed this to be a routine new patient visit and denied awareness that he was not a new patient, that there was any concern for suicidality, or that he had been in the inpatient unit; that she and Patient #1 had a really good conversation with life review and he was joking around, talked about the future and was looking forward to their next visit; that she did not ask about firearms or suicidal ideation as part of that assessment; and that if she had known of his suicidal comment she would have changed her approach, that it “;would have been a completely different thing.””

“Based on interview, and record review, the hospice provider failed to ensure thorough and accurate admission suicide risk assessment was conducted for 1 of 4 patients reviewed for suicide attempt/committed, (#21). Patient #21 was admitted to hospice on 3/20/24 with terminal diagnosis of alcoholic cirrhosis of liver with ascites (fluid buildup in abdomen). Review of patient #21s medical record revealed a Psychosocial Initial Comprehensive Assessment completed by Master of Social Work (MSW) #RR on 3/21/24. The MSW assessed patient #21 as having a history of suicidal ideation or attempt but did not obtain any other pertinent information and left the description box blank. The MSW’s comments were as follows, “;Condition of pts [patients] home was found to be deplorable and smelled horrible. Pt reports emotional struggles and admits to recently starting back on alcohol...this was also confirmed by numerous beer cans/bottles located w/in (within) the apartment. SW advised pt that w/ her being able to walk and get around, she is going to have to clean the apartment as it poses as a safety hazard, especially if pt is wanting support services coming in. SW informed pt that by the time she returns she expect pt to have her kitchen area cleaned as a start and that there will be no beer cans around.” On 6/20/24 at 3:30 PM, MSW #RR documented she received a call from the Home Health Aide (HHA) related to concerns that patient not doing well and took bunch of muscle relaxant pills. The MSW called the Advance Practice Registered Nurse (APRN) who was near the patient’s home for a visit however, the HHA called 911 per the patient’s request. On 6/20/24 at 7:15 PM, Registered Nurse (RN) #SS documented making visit to the hospital and spoke to the hospital RN who said the patient was currently under Baker Act status. The hospital RN explained the patient came wielding a knife and possible overdose and will need to be observed for 24 to 48 hours. RN #SSs documentation revealed she found patient #21 at the hospital to be alert and oriented x3, going in/out of sleep and stated, “;is sorry, doesnt want to be in hospital, will never do this again, got medication from a friend.” The hospital RN reported the patient admitted she took unknown pills. On 8/27/24 at 10:23 AM, an interview and concurrent record review was conducted with General Manager (GM) #DD. Review of the provider Root Cause Analysis (RCA) for incident dated 6/20/24 and RCA meeting dated 7/24/24 greater than 1 month post event. Although the provider did not identify a root cause for the adverse event, the potential contributing factors listed were human/staff. GM #DD said, MSW#RR did not complete the Suicidal Ideation Risk Assessment for patient who was found to have history of suicidal ideation/attempt. She said she did not know why the MSW did not complete the required suicide risk assessment form. The GM did not know if education or anything was ever done with MSW #RR regarding not doing an appropriate assessment. Further review of the patient’s record with the GM revealed the MSW visited patient #21 a total of 19 times to get patient needed assistance with cleaning home, groceries and healthcare surrogate paperwork. The Nurses documented pain level ranging from 3-9 out of 10 and APRN #TT documented patient was taking less Oxycontin than ordered Ativan pill counts were okay. The GM did not explain why it took more than a month for them to do an RCA meeting and why root cause of the event was not identified. The GM did not explain what human/staff factors were and they did not specify why the MSW did not do a Suicidal Ideation Risk Assessment. On 8/27/24 at 11:15 AM, a telephone interview conducted with the APRN #TT, Patient Care Administrator (PCA) #UU, and PCA #VV who all worked for program #20 (1 of 16 programs). The APRN said that on 6/20/24 she went to the patient’s home for a visit after the HHA indicated the home was in disarray with pills strewn about and the patient did not know what pills or how many she took. The police and 911 were there when the APRN arrived and they transported the patient to the hospital where she was Baker Acted and discharged on 6/21/24. They said an incident report was completed after the hospital informed them this was a suicide attempt. They explained the team was educated post incident on suicide and depression and MSW #RR had 1:1 counseling post incident and was paired with another more experienced social services staff. On 8/28/24 at 4:05 PM, a telephone interview was conducted with MSW #RR. She verified she was MSW since 12/2023 and then started to work for hospice provider in 2/2024. She described patient #21 as having good and bad days, some days conversational and other days tired. The MSW verified she marked “;yes” regarding the question on Psychosocial Initial Comprehensive Assessment dated 3/21/24 which noted patient had history of suicidal ideation/attempt. MSW #RR said, if yes then I come up with plan of care on how we are going to move forward and ask if they have any current thoughts. She said she did not document or describe the history of suicidal thoughts or attempts as the question was yes/no. She explained she had never completed a Suicidal Ideation Assessment and said, she had not been informed that she needed to. MSW #RR acknowledged she worked with a Licensed Clinical Social Worker (LCSW) #QQ on 6/24/24 and had education as well. MSW #RR denied any discussion/education regarding adverse incidents or need to do a suicide risk assessment and did not have 1:1 education. The provider provided evidence of education conducted 6/24/24 for MSW #RR which contradicted interview conducted with her. The education agenda listed responding to suicidal ideations or suicide, suicide risk assessment and intervention, best practice suicide risk assessment and interventions, managing suicidal ideation or intent and psychosocial initial comprehensive assessment procedure. On 8/28/24 at 4:50 PM, GM #DD was asked several times from 8/27/24 to 8/28/24 to provide copy of the Suicide Ideation Risk Assessment form or policy and failed to provide requested documentation. The Job Descriptions: Social Worker revised 5/22/24, read, “;The social worker is that member of the core interdisciplinary group whose primary function is to perform and assessment of psychosocial symptoms of the patient and family, develop psychosocial outcomes for alleviating identified symptoms and help provide the psychoeducation, supportive counseling and casework interventions need to meet these outcomes.... Performs bio-psycho-social-spiritual assessment of patient/families....””

“Based on record review and interview, the Hospice provider failed to update the comprehensive assessment for 1 of 6 sampled patients to indicate newly identified needs. This affected Patient #1, who expressed suicidal ideation by firearm to a nurse in the inpatient unit on 07/04/24 but was discharged home on 07/05/24 without an update to his assessment or other communication to his home care team. Patient #1 was found by his family dead with a gunshot wound to his head and gun in hand on 07/13/24. The findings include: The VITAS Procedure titled Nursing Updated Comprehensive Assessment, dated 11/01/21, documents “documentation is expected to take place at the time of the visit or event” and under Symptom Category Completion, “Complete the assessment for each symptom category by -assessing patient for each symptom listed under each category -check off each current patient symptom, including: -currently care planned symptoms -new symptoms identified during this visit. -Use the “Other/Describe” space to elaborate on assessment and response to care, and additional symptom information, etc.” and “Document care plan activities -enter the reported level -this is the symptom severity score as reported by the primary symptom communication source” and “Evaluate the patient’s Response to Care (interventions provided)… anything that the patient specifically stated should be documented.” The VITAS Standard titled VS Responding to Suicidal Ideation or Suicide (Patient or Family), updated 6/12/19 documents during a visit if there is any indication that a patient or a family has suicidal intent or ideation, the team member should immediately notify the team manager or manager on-call and charge nurse (if in facility) and the team manager/manager on-call should call the VITAS social worker [SW] to visit immediately and assess (if SW will be safe) and “assessment to help determine plan of care or if additional resources required…” Review of the clinical record reveals Patient #1 was admitted to the hospice for “Routine Home Care” in February 2021 with no known history of depression or mental illness. An Interdisciplinary Plan of Care Revision/Physician Orders dated 07/01/24 documents “Transfer to IPU [Inpatient Unit] – [name of hospital] for SOB [shortness of breath] & cough. Pneumonia.” A Psychosocial Updated Comprehensive Assessment was completed by a Social Worker, Staff A on 07/03/24 who documented Patient #1 was lethargic but arousable, did not want nursing home placement but wanted to go home and was receptive to seek veteran benefits for aide services. This assessment did not document any signs of suicidality. Patient #1’s VIPU (Vitas) Inpatient Unit) Nursing Updated Comprehensive Assessment for 07/04/24 from 7:00 AM to 7:30 PM includes under Psychosocial, the circled words “emotional functioning,” checked boxes for “knowledge deficit” and “caregiver situation,” and the handwritten comment, “Emot. supp. prov. c gentle touch, kind consoling words & active listening. Update PCG via phone” and includes under Bereavement (Caregiver) the circled words “Emotional functioning” and handwritten note, “SW & chaplain available for extra support and comfort” and in the box for Comment/Shift Report, the handwritten note, “Provided multiple updates to PCG [name and phone number] at AM & PM via phone regarding pt’s current status, POC. SW updates PCG also. MD notified of pt’s C/O of difficulty swallowing & refusing to eat & pt’s claim of depression. Report given to oncoming shift.” Further review of this nursing note and the Addendum: VIPU Shift Care Note for the same date and time range reveals no evidence that the patient made a suicidal statement or any expressions of emotional distress. Patient #1’s Focus Visit by Staff A on 07/04/24 for 3:00 PM to 4:30 PM documents the Social Worker (SW) conducted a follow up visit after report from Registered Nurse, Staff B that “patient said he wished he had a gun, he doesn’t want to live like this (bed bound)” and under interventions performed, “SW provided PS [psychosocial] support/provide active empathetic listening/validation of feelings assess for suicidal ideation re: statements made to RN [name] when providing care SW called PCG [primary caregiver] to discuss safety re: statements of ideation + DC [discharge] planning” and Response to Care “Patient presented AAOx2 [awake alert and oriented to person and place]; intermittent forgetfulness/confusion/receptive/engaged Pt [patient] advised “I was just running my mouth; I would never do anythin_ I do not want to hurt my family I do not want to leave this as my legacy to my grandkids Pt denied plan/attempts of suicid_ son advise pt made similar statements since pt was 50 years old PCG advise_ gun in home in lock box away from pts reac_ PCG wants pt to return home.” This Focus Visit does not document communication or collaboration with any other staff although there is a place on the form to indicate collaboration with empty checkboxes for several disciplines. Review of Patient #1’s inpatient nursing notes for 07/02/24, 07/03/24, 07/04/24, and 07/05/24 reveal no documentation that Patient #1 made any statements indicating suicidal intent or ideation while in the inpatient unit. An entry on Patient #1’s Addendum: VIPU Shift Care Note for 07/05/24 at 7:35 PM documents “Pt discharged home.” Review of Patient #1’s physician notes for 07/02/24, 07/03/24, 07/04/24 reveal no documentation of awareness that Patient #1 made any statements indicating suicidal intent or ideation. There was no physician note for 07/05/24 and no order to send the patient home from the inpatient unit, as of the date of record review on 08/28/24. After inquiry on 08/28/24 to Patient Care Administrator, Staff C as to whether the physician ever gave an order for Patient #1 to go home from the Inpatient Unit on 07/05/24, Staff C reviewed the chart and on 08/29/24 at 10:18 AM confirmed she could not find such an order, stated she talked to the physician that morning and he confirmed he had given the order, so she wrote a late order for the discharge. Later that day, Staff C provided an Interdisciplinary Plan of Care Revision/Physician Orders documenting “Late entry for 07/05/24 DC [discontinue] IPU Level of Care Resume Routine Home Care” with physician signature dated 08/29/24, and no evidence of any other orders or changes to the care plan. Review of Patient #1’s Plan of Care Review dated 07/05/24 documents in the Psychosocial category “S/W available” and in the Spiritual category “Chaplain available” and gives no indication of any interventions or changes to the plan of care to address his suicidal statement in the inpatient unit. Review of the Nursing-Updated Comprehensive Assessment by Registered Nurse, Staff D dated 07/06/24 for a visit at 6:25 PM to 7:25 PM reveals no documentation or evidence of awareness of Patient #1’s suicidal statement in the inpatient unit and no evidence of psychosocial assessment other than the words “SW involved c [with] care.” Review of the Nursing-Updated Comprehensive Assessment dated 07/08/24 for a visit at 9:40 to 10:40 (no AM or PM) reveals no documentation or evidence of awareness of Patient #1’s suicidal statement in the inpatient unit; the Psychosocial section documents a reported level of “4”, care plan outcome “maintain psych”, care plan goal “2”; and on the next line a reported level of “0”, care plan outcome “0”, and care plan goal “0”, followed by Interventions Performed “assessed psych” and Response to Care “SW involved in case”; and the Location of Care (Home) Environmental Safety section indicates by a mark in a checkbox “Cluttered or unclean living area(s), the Care Plan Outcome “maintained safety,” interventions “assessed safety,” and Response to Care “Educated PCG to keep pt belonging in reach.” A Supplemental Interdisciplinary Note for 07/08/24 by the Social Worker on the home team, Staff E documents phone contact to Patient #1’s family member who reported the patient is stable and the nurse visit would be sufficient for now, Social Worker advised will be visiting the home the next day and the visit is important in case there are any needs, and the PCG asked her to call before arriving. A Supplemental Interdisciplinary Note for 07/09/24 by Staff E documents she called to confirm the visit, but the family member denied the visit and rescheduled it for 07/11/24. A Psychosocial Updated Comprehensive Assessment completed by Staff E for 07/11/24 at 12:30 PM to 1:30 PM indicates in the psychosocial section by marks in checkboxes: Emotional Affects/Behavioral Manifestations, Patient is a Veteran, and in comments that the patient was very happy with services provided, support to patient and caregiver, the caregiver confirmed patient is a veteran but wants to put benefits on hold for now. An Addendum Interdisciplinary Note dated 07/13/24 by a Chaplain documents she was notified the patient had died and visited the Patient #1’s residence, that the family member stated “I think he shot himself,” that the family member reported they went into the patient’s room that morning and found him in an odd position with the gun next to him, that the family called 911, and that the family member mentioned a nurse had reported to him Patient #1 had made the comment “I wanna blow my head off” while he was at the Inpatient Unit. Review of the associated police report printed 08/27/24 at 1:00 PM revealed when police arrived to the home on 07/13/24, they found Patient #1 dead with a gunshot wound to his head, loaded firearm in his hand, and a presumptive test was positive for the presence of gunshot residue on Patient #1’s right hand. The police report also documented the family member reported Patient #1 “had made comments about shooting himself and so he hid his firearm in another drawer in the room.” During telephone interview on 08/27/24 at 2:35 PM, the inpatient Registered Nurse, Staff B reported Patient #1 stated to her in the hospice inpatient unit that he should have blown his brains before he came to this place, but when she asked what he meant by that, he then said it’s nothing and he was just frustrated; that when she asked if he had a gun at home he denied having one and said forget it, it’s nothing, that he was just frustrated and then he talked of what his life had been, his past accomplishments, and that now he’s here; that Staff B then told the Social Worker, Staff A what Patient #1 had said, and Staff A said she would go talk to him; that Staff B then told the Team Manager, who said she had to “escalate this all the way up”; that Staff B called Patient #1’s family member and told them what Patient #1 had said and asked if that seemed strange, to which the family member responded Patient #1 has been saying this for 35 years and it’s nothing; that Staff B asked the family member if there was a gun in the home, but the family member downplayed it, said it’s nothing, and asked when they are sending the patient home. During telephone interview on 08/27/24 at 2:55 PM, the inpatient Social Worker, Staff A stated she evaluated Patient #1 on 07/03/24, there were concerns for his loss of autonomy and she remembered he wanted to keep his urinary catheter in when he went home, which was an unusual request but maybe he did not want to burden the household with trips to the bathroom; that her focus was his weakness and need for support and they discussed veteran benefits to try to get him part-time help at home; that on 07/04/24 she was informed Patient #1 wanted to be discharged as soon as possible, she met with him early in the day and he talked of his life experiences and wanting to go home for the holiday with family; that after this Staff B reported he just made a statement that he wished he had a gun to make things go faster, so Staff A immediately texted the physician to put a hold on the discharge and talk when he gets in, and informing the physician the nurse verbalized Patient #1 had suicidal ideation and Staff A was going to go talk to Patient #1; that Staff A talked to Patient #1 about his statement that he wished he had a gun and he said Oh, no, it’s just words, and minimized it; that Staff A immediately asked Patient #1 if he ever attempted suicide before and if he had a plan, and he said he would never do that to his children or grandchildren; that Patient #1 talked about feeling depressed and his loss of autonomy and weakness; that Staff A then talked to Staff B about symptom management for his depression and moving him closer to the nurses’ station; that Staff A called the family member who said Patient #1 has been saying things like that since his first cardiac event at age 50, that there was a gun in the home but it was on the other side of the house in a locked box out of reach, and the family member denied feeling concerned about Patient #1’s statement; that Staff A then talked to the Team Manager and Physician about Patient #1’s statements and conversations, and the discharge was held, but Patient #1 ended up being discharged the following day while Staff A was not working; Staff A denied using, or the Hospice having, any formal suicide assessment or suicide screening tool; Staff A reported they used to contract for safety when a person was a suicide risk, but they stopped doing that at this Hospice. During telephone interview on 08/28/24 at 11:31 AM, Registered Nurse, Staff D stated she remembered Patient #1 and had been seeing him weekly since January 2024 except when he was in the inpatient unit; that there was nothing concerning in her visits to indicate a Social Worker was needed; when asked about her nursing assessments in which she consistently documented for psychosocial a Reported Level of “4” and a Care Plan Goal of “0” and what this means, Staff D answered she was trained to put a “4” and whether they were depressed or suicidal she would probably still put a “4” but there are other things she would do, such as staying with them until they can find another intervention, call the doctor and social worker, start continuous care; Staff D stated since August she learned if there’s nothing wrong, she could put a ”0” instead of a “4”; Staff D stated “Psychosocial is not something I focus on. I focus on medication management and, if there is something else, I let another team member know. I have not learned how to do a psychosocial assessment”; Staff D stated she received a report from the inpatient manager when Patient #1 was coming home that he would probably need a follow up visit that night and the next day, he had a urinary catheter and wanted to keep it in, was still very weak and had issues swallowing, but no mention he had made any suicidal statements; that if there had been anything about him feeling suicidal they would probably have kept him in the inpatient unit or she could have put him on continuous care at home, and that it “would have changed everything”, but she was never informed of this; and that the Social Worker made a visit to Patient #1 right after her own on 07/11/24 to talk about veterans’ benefits. During telephone interview on 8/28/24 at 3:34 PM, Registered Clinical Social Work Intern, Staff E stated Patient #1 was assigned to her on a Monday or a Tuesday but the family member refused a visit until she saw him later that same week on Thursday, 07/11/24; that she believed this to be a routine new patient visit and denied awareness that he was not a new patient, that there was any concern for suicidality, or that he had been in the inpatient unit; that she and Patient #1 had a really good conversation with life review and he was joking around, talked about the future and was looking forward to their next visit; that she did not ask about firearms or suicidal ideation as part of that assessment; and that if she had known of his suicidal comment she would have changed her approach, that it “would have been a completely different thing.” During the interview on 8/29/24 at 12:39 PM General Manager, Staff H stated Patient #1’s event was discussed and corrective action was taken to educate the staff in the Broward program, but not throughout the Hospice.”

“Based on interview, and record review, the hospice agency failed to ensure an individualized care plan for patient with history of suicidal ideation and or attempt was initiated and implemented for 1 of 4 sampled patients, (#21). Findings: Patient #21 was admitted to hospice on 3/20/24 with terminal diagnosis of alcoholic cirrhosis of liver with ascites (fluid buildup in your abdomen). Review of patient #21s medical record revealed a Psychosocial Initial Comprehensive Assessment completed by Master of Social Work (MSW) #RR on 3/21/24. The MSW assessed patient #21 as having a history of suicidal ideation or attempt however did not obtain any other pertinent information and left the description box blank for this subject matter. The MSW comments were as follows, “;Condition of pts [patients] home was found to be deplorable and smelled horrible. Pt reports emotional struggles and admits to recently starting back on alcohol...this was also confirmed by numerous beer cans/bottles located in the apartment. SW advised pt that w/(with) her being able to walk and get around, she is going to have to clean the apartment as it poses as a safety hazard, especially if pt is wanting support services coming in. SW informed pt that by the time she returns she expect pt to have her kitchen area cleaned as a start and that there will be no beer cans around.” MSW #RR initiated plan of care (POC) dated 3/21/24 for symptom of emotional stability and to provide empathy and active listing, facilitate positive coping strategies, weekly visits and assess depression. The POC for alcoholism also included assess patient ability to comply with drug contract and maintain sobriety. The MSW failed to initiate POC regarding history of suicidal ideation/attempts or if any current thoughts of suicide plan. On 6/20/24 at 3:30 PM, MSW #RR documented she received a call from the Home Health Aide (HHA) related to concerns that patient not doing well and took bunch of muscle relaxer medications. The MSW called the Advance Practice Registered Nurse (APRN) who was close to the patient’s home to conduct visit however, the HHA had called 911 per the patient request. On 6/20/24 at 7:15 PM, Registered Nurse (RN) #SS documented making visit to the hospital and spoke to the hospital RN who said the patient was currently under Baker Act status, wielding a knife, possible overdose and will be observed for 24 to 48 hours. RN #SSs documentation revealed she found patient #21 at the hospital to be alert and oriented, going in/out of sleep and stated, “;is sorry, doesnt want to be in hospital, will never do this again, got medication from a friend”. Hospital RN reported patient admitted to the doctor that she took unknown pills. On 8/28/24 at 4:05 PM, a telephone interview conducted with MSW #RR, verified she had been MSW since 12/2023 and started to work for hospice provider in February of 2024. She described patient #21 as having good and bad days, some days conversive and other days tired. MSW verified she did mark “;yes” regarding the question on Psychosocial Initial Comprehensive Assessment dated 3/21/24 which asked if patient had history of suicidal ideation/attempt. MSW #RR said, if yes, then I come up with plan of care on how we are going to move forward and ask if they have any current thoughts. MSW #RR was asked about doing Suicidal Ideation Assessment and she said, she has never filled out that type of form or been informed that she needed to. MSW #RR verified she started to work with Licensed Clinical Social Worker (LCSW) #QQ on about 6/24/24 and had education as well. MSW #RR explained the education was done at their Interdisciplinary group meeting which included the RN, Team Manager, and the HHA. MSW #RR denied any discussion/education regarding adverse incidents or suicide risk assessment and interventions. The provider showed evidence of education conducted 6/24/24 for MSW #RR which contradicted interview conducted with the MSW. The education agenda listed responding to suicidal ideations or suicide, suicide risk assessment and intervention, best practice suicide risk assessment and interventions, managing suicidal ideation or intent and psychosocial initial comprehensive assessment procedure. On 8/28/24 at 4:50 PM, General Manager #DD verified plan of care was never initiated for patient #21 regarding suicidal ideation/risk. The Job Descriptions for RN (Registered Nurse) revised 8/23/23, read, “;RN is a member of the interdisciplinary team who works together to meet the physical, medical, psychosocial, emotional...needs of hospice patients and families.... Coordinates all service delivers including review of entries in the record...Professionally manages/coordinates the hospice plan of care....” The Job Descriptions: Social Worker revised 5/22/24, read, “;The social worker is that member of the core interdisciplinary group whose primary function is to perform and an assessment of psychosocial symptoms of the patient and family.... Job responsibilities 1. Participates in the preparation, evaluation and execution of the interdisciplinary plan of care to assure that the highest psychosocial care is provided to patient/families and that continuity and comprehensiveness of care are accomplished....””

“Based on record review and interview, the Hospice provider failed to ensure care planning was updated with appropriate interventions to address the needs of 1 of 6 sampled patients (Patient #1). After Patient #1 made a suicidal statement in the Hospice inpatient unit, staff failed to update his Plan of Care with appropriate interventions, and he was sent home the next day. Several days later, Patient #1 was found by a family member dead with a fatal gunshot wound and gun in his hand. The findings include: The VITAS patient information packet documents, “What differentiates VITAS from other hospices is our ability and commitment to adjust care based on each patient’s current needs. As an illness changes and evolves, the individualized care plan we have created will change and evolve, too. That is why VITAS is available 24/7 (including evenings, weekends, and holidays) for consultations, evaluations, admission to Hospice, patient/caregiver support, and solutions that support patients who have complex needs.”The VITAS Standard titled VS Care Planning, updated 06/19/18 documents, “The core IDG must collaborate on all care planning... Collaboration includes communication of assessment findings, severity findings above ideal score or goal, and identification of new symptoms to Core IDG members and attending physician... Collaboration and Communication Examples by role: ... -SW -Changes in POC -Suicidal thoughts (immediate notification required).”The VITAS Standard titled VS Responding to Suicidal Ideation or Suicide (Patient or Family), updated 6/12/19 documents, “During a visit if there is any indication that a patient or a family has suicidal intent or ideation, the team member should: …ii. immediately notify (make verbal contact) the team manager or manager on-call ii. Notify charge nurse (if in facility)” and “The team manager/manager on-call should i. call the VITAS social worker [SW] to visit immediately and assess (if SW will be safe) and 1. assessment to help determine plan of care or if additional resources required ii. Call the PCA and GM immediately iii. Notify the attending physician and Hospice medical director iv. Notify the other team members.”Review of the clinical record reveals Patient #1 was admitted to the hospice for “Routine Home Care” in February 2021 with no known history of depression or mental illness. An Interdisciplinary Plan of Care Revision/Physician Orders dated 07/01/24 documents “Transfer to IPU [Inpatient Unit] – [name of hospital] for SOB [shortness of breath] & cough. Pneumonia.” A Psychosocial Updated Comprehensive Assessment was completed by Social Worker, Staff A on 07/03/24 and did not document any signs of suicidality. Patient #1’s Focus Visit by Staff A on 07/04/24 for 3:00 PM to 4:30 PM documents the Social Worker (SW) conducted a follow up visit after report from Registered Nurse, Staff B that “patient said he wished he had a gun, he doesn’t want to live like this (bed bound)” and under interventions performed, “SW provided PS [psychosocial] support/provide active empathetic listening/validation of feelings assess for suicidal ideation re: statements made to RN [name] when providing care SW called PCG [primary caregiver] to discuss safety re: statements of ideation + DC [discharge] planning” and Response to Care “Patient presented AAOx2 [awake alert and oriented to person and place]; intermittent forgetfulness/confusion/receptive/engaged Pt [patient] advised “I was just running my mouth; I would never do anythin_ I do not want to hurt my family I do not want to leave this as my legacy to my grandkids Pt denied plan/attempts of suicid_ son advise pt made similar statements since pt was 50 years old PCG advise_ gun in home in lock box away from pts reac_ PCG wants pt to return home.” This Focus Visit does not document communication or collaboration with any other staff although there is a place on the form to indicate collaboration with empty checkboxes for several disciplines. Review of Patient #1’s inpatient nursing notes for 07/02/24, 07/03/24, 07/04/24, and 07/05/24 reveal no documentation that Patient #1 made any statements indicating suicidal intent or ideation while in the inpatient unit. An entry on Patient #1’s Addendum: VIPU Shift Care Note for 07/05/24 at 7:35 PM documents “Pt discharged home.” Review of Patient #1’s physician notes for 07/02/24, 07/03/24, 07/04/24 reveal no documentation of awareness that Patient #1 made any statements indicating suicidal intent or ideation. There was no physician note for 07/05/24. On 08/29/24, Staff C provided an Interdisciplinary Plan of Care Revision/Physician Orders documenting “Late entry for 07/05/24 DC [discontinue] IPU Level of Care Resume Routine Home Care” with physician signature dated 08/29/24, and no evidence of any other orders or changes to the care plan. Review of Patient #1’s Plan of Care Review dated 07/05/24 documents in the Psychosocial category “S/W available” and in the Spiritual category “Chaplain available” and gives no indication of any interventions or changes to the plan of care to address his suicidal statement in the inpatient unit. Review of the Nursing-Updated Comprehensive Assessment by Registered Nurse, Staff D dated 07/06/24 for a visit at 6:25 PM to 7:25 PM reveals no documentation or evidence of awareness of Patient #1’s suicidal statement in the inpatient unit and no evidence of psychosocial assessment other than the words “SW involved c [with] care.” Review of the Nursing-Updated Comprehensive Assessment dated 07/08/24 for a visit at 9:40 to 10:40 (no AM or PM) reveals no documentation or evidence of awareness of Patient #1’s suicidal statement in the inpatient unit; the Psychosocial section documents a reported level of “4”, care plan outcome “maintain psych”, care plan goal “2”; and on the next line a reported level of “0”, care plan outcome “0”, and care plan goal “0”, followed by Interventions Performed “assessed psych” and Response to Care “SW involved in case”; and the Location of Care (Home) Environmental Safety section indicates by a mark in a checkbox “Cluttered or unclean living area(s), the Care Plan Outcome “maintained safety,” interventions “assessed safety,” and Response to Care “Educated PCG to keep pt belonging in reach.” Supplemental Interdisciplinary Notes for 07/08/24 and 07/09/24 by the Social Worker on the home team, Staff E document phone contacts to Patient #1’s family member to arrange a visit, but the family member denied the visit until 07/11/24. A Psychosocial Updated Comprehensive Assessment completed by Staff E for 07/11/24 at 12:30 PM to 1:30 PM indicates in the Psychosocial section by marks in checkboxes: Emotional Affects/Behavioral Manifestations, Patient is a Veteran, and in comments that the patient was very happy with services provided, support to patient and caregiver, the caregiver confirmed patient is a veteran but wants to put benefits on hold for now. There was no indication that Patient #1 had recently made suicidal statements, of suicide risk assessment or follow up pertaining to suicidality. An Addendum Interdisciplinary Note dated 07/13/24 by a Chaplain documents she was notified the patient had died and the family member reported they found him with the gun next to him. Review of the associated police report printed 08/27/24 at 1:00 PM revealed when police arrived to the home on 07/13/24, they found Patient #1 dead with a gunshot wound, loaded firearm in his hand, and a presumptive test was positive for the presence of gunshot residue on Patient #1’s right hand. The police report also documented the family member reported Patient #1 “had made comments about shooting himself and so he hid his firearm in another drawer in the room.” During telephone interview on 08/27/24 at 2:35 PM, the inpatient Registered Nurse, Staff B reported Patient #1 stated to her in the hospice inpatient unit that he should have blown his brains before he came to this place, but when she asked what he meant by that, he then said it’s nothing and he was just frustrated; that when she asked if he had a gun at home he denied having one and said forget it, it’s nothing, that he was just frustrated and then he talked of what his life had been, his past accomplishments, and that now he’s here; that Staff B then told the Social Worker, Staff A what Patient #1 had said, and Staff A said she would go talk to him; that Staff B then told the Team Manager, who said she had to “escalate this all the way up”; that Staff B called Patient #1’s family member and told them what Patient #1 had said and asked if that seemed strange, to which the family member responded Patient #1 has been saying this for 35 years and it’s nothing; that Staff B asked the family member if there was a gun in the home, but the family member downplayed it, said it’s nothing, and asked when they are sending the patient home. During telephone interview on 08/27/24 at 2:55 PM, the inpatient Social Worker, Staff A stated she evaluated Patient #1 on 07/03/24, there were concerns for his loss of autonomy and she remembered he wanted to keep his urinary catheter in when he went home, which was an unusual request but maybe he did not want to burden the household with trips to the bathroom; that her focus was his weakness and need for support and they discussed veteran benefits to try to get him part-time help at home; that on 07/04/24 she was informed Patient #1 wanted to be discharged as soon as possible, she met with him early in the day and he talked of his life experiences and wanting to go home for the holiday with family; that after this Staff B reported he just made a statement that he wished he had a gun to make things go faster, so Staff A immediately texted the physician to put a hold on the discharge and talk when he gets in, and informing the physician the nurse verbalized Patient #1 had suicidal ideation and Staff A was going to go talk to Patient #1; that Staff A talked to Patient #1 about his statement that he wished he had a gun and he said Oh, no, it’s just words, and minimized it; that Staff A immediately asked Patient #1 if he ever attempted suicide before and if he had a plan, and he said he would never do that to his children or grandchildren; that Patient #1 talked about feeling depressed and his loss of autonomy and weakness; that Staff A then talked to Staff B about symptom management for his depression and moving him closer to the nurses’ station; that Staff A called the family member who said Patient #1 has been saying things like that since his first cardiac event at age 50, that there was a gun in the home but it was on the other side of the house in a locked box out of reach, and the family member denied feeling concerned about Patient #1’s statement; that Staff A then talked to the Team Manager and Physician about Patient #1’s statements and conversations, and the discharge was held, but Patient #1 ended up being discharged the following day while Staff A was not working; Staff A denied using, or the Hospice having, any formal suicide assessment or suicide screening tool; Staff A reported they used to contract for safety when a person was a suicide risk, but they stopped doing that at this Hospice. During telephone interview on 08/28/24 at 11:31 AM, Registered Nurse, Staff D stated she remembered Patient #1 and had been seeing him weekly since January 2024 except when he was in the inpatient unit; that there was nothing concerning in her visits to indicate a Social Worker was needed; when asked about her nursing assessments in which she consistently documented for psychosocial a Reported Level of “4” and a Care Plan Goal of “0” and what this means, Staff D answered she was trained to put a “4” and whether they were depressed or suicidal she would probably still put a “4” but there are other things she would do, such as staying with them until they can find another intervention, call the doctor and social worker, start continuous care; Staff D stated since August she learned if there’s nothing wrong, she could put a ”0” instead of a “4”; Staff D stated “Psychosocial is not something I focus on. I focus on medication management and, if there is something else, I let another team member know. I have not learned how to do a psychosocial assessment”; Staff D stated she received a report from the inpatient manager when Patient #1 was coming home that he would probably need a follow up visit that night and the next day, he had a urinary catheter and wanted to keep it in, was still very weak and had issues swallowing, but no mention he had made any suicidal statements; that if there had been anything about him feeling suicidal they would probably have kept him in the inpatient unit or she could have put him on continuous care at home, and that it “would have changed everything”, but she was never informed of this; and that the Social Worker made a visit to Patient #1 right after her own on 07/11/24 to talk about veterans’ benefits. During telephone interview on 8/28/24 at 3:34 PM, Registered Clinical Social Work Intern, Staff E stated Patient #1 was assigned to her on a Monday or a Tuesday but the family member refused a visit until she saw him later that same week on Thursday, 07/11/24; that she believed this to be a routine new patient visit and denied awareness that he was not a new patient, that there was any concern for suicidality, or that he had been in the inpatient unit; that she and Patient #1 had a really good conversation with life review and he was joking around, talked about the future and was looking forward to their next visit; that she did not ask about firearms or suicidal ideation as part of that assessment; and that if she had known of his suicidal comment she would have changed her approach, that it “would have been a completely different thing.””

“Based on record review and interview, the Hospice failed to ensure concerns were communicated between disciplines and care settings for 1 of 6 sampled patients. The Hospice failed to ensure after Patient #1 made a suicidal statement in the hospice inpatient unit on 07/04/24 and staff verified there was a gun in the home, that these concerns were communicated to the home team when he went home on 07/05/24. On 07/13/24 Patient #1 was found by a family member dead with a fatal gunshot wound and gun in his hand. The findings include: The VITAS patient information booklet documents, “What differentiates VITAS from other hospices is our ability and commitment to adjust care based on each patient’s current needs. As an illness changes and evolves, the individualized care plan we have created will change and evolve, too” and “The VITAS interdisciplinary team works in partnership with the patient, family, and caregiver(s) to provide Hospice care and services. Each team includes a team manager, nurse, physician, social worker, chaplain, hospice aide, and volunteer. They work individually and together on each patient’s behalf, providing a personal care plan that includes physical, emotional, and spiritual support to live each day to the fullest.” The VITAS Standard titled VS Responding to Suicidal Ideation or Suicide (Patient or Family), updated 6/12/19 documents, “;During a visit if there is any indication that a patient or a family has suicidal intent or ideation, the team member should: ...ii. immediately notify (make verbal contact) the team manager or manager on-call ii. Notify charge nurse (if in facility)” and “;The team manager/manager on-call should i. call the VITAS social worker [SW] to visit immediately and assess (if SW will be safe) and 1. assessment to help determine plan of care or if additional resources required ii. Call the PCA and GM immediately iii. Notify the attending physician and Hospice medical director iv. Notify the other team members.” Review of the clinical record reveals Patient #1 was admitted to the hospice for “;Routine Home Care” in February 2021 with no known history of depression or mental illness. An Interdisciplinary Plan of Care Revision/Physician Orders dated 07/01/24 documents “;Transfer to IPU [Inpatient Unit] – [name of hospital] for SOB [shortness of breath] & cough. Pneumonia.” A Psychosocial Updated Comprehensive Assessment was completed by Social Worker, Staff A on 07/03/24 and did not document any signs of suicidality. Patient #1s Focus Visit by Staff A on 07/04/24 for 3:00 PM to 4:30 PM documents the Social Worker (SW) conducted a follow up visit after report from Registered Nurse, Staff B that “;patient said he wished he had a gun, he doesn’t want to live like this (bed bound)” and under interventions performed, “;SW provided PS [psychosocial] support/provide active empathetic listening/validation of feelings assess for suicidal ideation re: statements made to RN [name] when providing care SW called PCG [primary caregiver] to discuss safety re: statements of ideation + DC [discharge] planning” and Response to Care “;Patient presented AAOx2 [awake alert and oriented to person and place]; intermittent forgetfulness/confusion/receptive/engaged Pt [patient] advised “;I was just running my mouth; I would never do anythin_ I do not want to hurt my family I do not want to leave this as my legacy to my grandkids Pt denied plan/attempts of suicid_ son advise pt made similar statements since pt was 50 years old PCG advise_ gun in home in lock box away from pts reac_ PCG wants pt to return home.” [sic] This Focus Visit does not document communication or collaboration with any other staff although there is a place on the form to indicate collaboration with empty checkboxes for several disciplines. Review of Patient #1s inpatient nursing notes for 07/02/24, 07/03/24, 07/04/24, and 07/05/24 reveal no documentation that Patient #1 made any statements indicating suicidal intent or ideation while in the inpatient unit. An entry on Patient #1s Addendum: VIPU Shift Care Note for 07/05/24 at 7:35 PM documents “;Pt discharged home.” Review of Patient #1s physician notes for 07/02/24, 07/03/24, 07/04/24 reveal no documentation of awareness that Patient #1 made any statements indicating suicidal intent or ideation. There was no physician note for 07/05/24 and no order to send the patient home from the inpatient unit, as of the date of record review on 08/28/24. After inquiry on 08/28/24 to Patient Care Administrator, Staff C as to whether the physician ever gave an order for Patient #1 to go home from the Inpatient Unit on 07/05/24, Staff C reviewed the chart and on 08/29/24 at 10:18 AM confirmed she could not find such an order, stated she talked to the physician that morning and he confirmed he had given the order, so she wrote a late order for the discharge. Later that day, Staff C provided an Interdisciplinary Plan of Care Revision/Physician Orders documenting “;Late entry for 07/05/24 DC [discontinue] IPU Level of Care Resume Routine Home Care” with physician signature dated 08/29/24, and no evidence of any other orders or changes to the care plan. Review of Patient #1s Plan of Care Review dated 07/05/24 documents in the Psychosocial category “;S/W available” and in the Spiritual category “;Chaplain available” and gives no indication of any interventions or changes to the plan of care to address his suicidal statement in the inpatient unit. Review of the Nursing-Updated Comprehensive Assessment by Registered Nurse, Staff D dated 07/06/24 for a visit at 6:25 PM to 7:25 PM reveals no documentation or evidence of awareness of Patient #1s suicidal statement in the inpatient unit and no evidence of psychosocial assessment other than the words “;SW involved c [with] care.” Review of the Nursing-Updated Comprehensive Assessment dated 07/08/24 for a visit at 9:40 to 10:40 (no AM or PM) reveals no documentation or evidence of awareness of Patient #1s suicidal statement in the inpatient unit; the Psychosocial section documents a reported level of “;4”, care plan outcome “;maintain psych”, care plan goal “;2”; Interventions Performed “;assessed psych” and Response to Care “;SW involved in case”; Environmental Safety section indicates by a mark in a checkbox “;Cluttered or unclean living area(s), the Care Plan Outcome “;maintained safety,” interventions “;assessed safety,” and Response to Care “;Educated PCG to keep pt [patient]belonging in reach.” Supplemental Interdisciplinary Notes for 07/08/24 and 07/09/24 by the Social Worker on the home team, Staff E document phone contacts to Patient #1s family member to arrange a visit, but the family member denied the visit until 07/11/24. A Psychosocial Updated Comprehensive Assessment completed by Staff E for 07/11/24 at 12:30 PM to 1:30 PM indicates in the Psychosocial section by marks in checkboxes: Emotional Affects/Behavioral Manifestations, Patient is a Veteran, and in comments that the patient was very happy with services provided, support to patient and caregiver, the caregiver confirmed patient is a veteran but wants to put benefits on hold for now. There was no evidence in this documentation that Patient #1 had recently made suicidal statements, of suicide risk assessment or follow up pertaining to suicidality. An Addendum Interdisciplinary Note dated 07/13/24 by a Chaplain documents she was notified the patient had died and the family member reported they found him with the gun next to him. Review of the associated police report printed 08/27/24 at 1:00 PM revealed when police arrived to the home on 07/13/24, they found Patient #1 dead with a gunshot wound, loaded firearm in his hand, and a presumptive test was positive for the presence of gunshot residue on Patient #1s right hand. The police report also documented the family member reported Patient #1 “;had made comments about shooting himself and so he hid his firearm in another drawer in the room.” During telephone interview on 08/27/24 at 2:35 PM, the inpatient Registered Nurse, Staff B reported Patient #1 stated to her in the hospice inpatient unit that he should have blown his brains before he came to this place, but when she asked what he meant by that, he then said it’s nothing and he was just frustrated; that when she asked if he had a gun at home he denied having one and said forget it, it’s nothing, that he was just frustrated and then he talked of what his life had been, his past accomplishments, and that now he’s here; that Staff B then told the Social Worker, Staff A what Patient #1 had said, and Staff A said she would go talk to him; that Staff B then told the Team Manager, who said she had to “;escalate this all the way up”; that Staff B called Patient #1s family member and told them what Patient #1 had said and asked if that seemed strange, to which the family member responded Patient #1 has been saying this for 35 years and it’s nothing; that Staff B asked the family member if there was a gun in the home, but the family member downplayed it, said it’s nothing, and asked when they are sending the patient home. During telephone interview on 08/27/24 at 2:55 PM, the inpatient Social Worker, Staff A stated she evaluated Patient #1 on 07/03/24 and there were concerns for his loss of autonomy; that her focus was his weakness and need for support and they discussed healthcare benefits to try to get him help at home; that on 07/04/24 she was informed Patient #1 wanted to be discharged as soon as possible, she met with him early in the day and he wanted to go home for the holiday with family; that after this Staff B reported he just made a statement that he wished he had a gun to make things go faster, so Staff A immediately texted informing the physician the nurse verbalized Patient #1 had suicidal ideation; that Staff A talked to Patient #1 about his statement that he wished he had a gun and he said Oh, no, it’s just words, and minimized it; that Staff A immediately asked Patient #1 if he ever attempted suicide before and if he had a plan, and he said he would never do that to his children or grandchildren; that Patient #1 talked about feeling depressed and his loss of autonomy and weakness; that Staff A then talked to Staff B about symptom management for his depression and moving him closer to the nurses station; that Staff A called the family member who said Patient #1 has been saying things like that since his first cardiac event at age 50, that there was a gun in the home but it was on the other side of the house in a locked box out of reach, and the family member denied feeling concerned about Patient #1s statement; that Staff A then talked to the Team Manager and Physician about Patient #1s statements and conversations, and the discharge was held, but Patient #1 ended up being discharged the following day while Staff A was not working. During telephone interview on 08/28/24 at 11:31 AM, Registered Nurse, Staff D stated she remembered Patient #1 and had been seeing him weekly since January 2024 except when he was in the inpatient unit; that there was nothing concerning in her visits to indicate a Social Worker was needed; Staff D stated she received a report from the inpatient team manager when Patient #1 was coming home that he would probably need a follow up visit that night and the next day, he had a urinary catheter and wanted to keep it in, was still very weak and had issues swallowing, but no mention he had made any suicidal statements; that if there had been anything about him feeling suicidal they would probably have kept him in the inpatient unit or she could have put him on continuous care at home, and that it “;would have changed everything”, but she was never informed of this; and that the Social Worker made a visit to Patient #1 right after her own visit on 07/11/24 to talk about healthcare resources. During telephone interview on 8/28/24 at 3:34 PM, Registered Clinical Social Work Intern, Staff E stated Patient #1 was assigned to her on a Monday or a Tuesday but the family member refused a visit until she saw him later that same week on Thursday, 07/11/24; that she believed this to be a routine new patient visit and denied awareness that he was not a new patient, that there was any concern for suicidality, or that he had been in the inpatient unit; that she and Patient #1 had a really good conversation with life review and he was joking around, talked about the future and was looking forward to their next visit; that she did not ask about firearms or suicidal ideation as part of that assessment; and that if she had known of his suicidal comment she would have changed her approach, that it “;would have been a completely different thing.””

“Based on interview and record review, the hospice provider failed to track and analyze adverse patient events and initiate preventive measures to address patient suicide for 2 of 4 patients reviewed for suicide, (#22, #1). 2. The VITAS Management Standard titled VMS Root Cause Analysis, revised 03/12/19 documents the Purpose, “;418.58, (c), (2) Performance Improvement activities must track adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the Hospice”; under General Instructions, “;The General Manager and the Patient Care Administrator will be responsible for implementation of the corrective action plan”; within Instructions for Completion of Root Cause Analysis and Action Plan Development, “;...a Root Cause = a finding related to a process or system that VITAS has the potential to redesign to reduce future risk of reoccurrence.” This Standard does not specify any means by which to implement corrective actions throughout the Hospice since the persons with responsibility for implementation of any corrective action plans are the General Manager and the Patient Care Administrator, whose positions are at the Program levels and they do not have authority over the Hospice. On 07/04/24 Patient #1 made a statement of suicidal ideation by firearm to a nurse in the inpatient unit. Patient #1 was then assessed for suicidal ideation by a Social Worker who was not qualified to practice clinical social work as defined in 491.003(8) F.S. and 491.012 F.S. Refer to L594. Patient #1 was sent home the following day, 07/05/24, without communication of his suicidal statement and that family confirmed there was a gun in the home to the home team. Refer to L554. Patient #1s care plan was not revised to address his psychosocial and emotional needs as evidenced by his expression of suicidal ideation. Refer to L552. Another Social Worker visited Patient #1 on 07/11/24 for what she believed to be a routine new patient assessment and identified no concerns for suicidality. On 07/13/24 Patient #1 was found by his family dead. Review of the associated police report printed 08/27/24 at 1:00 PM revealed when police arrived, they found Patient #1 dead with a gunshot wound to his head, loaded firearm in his hand, and a presumptive test was positive for the presence of gunshot residue on his right hand. During interview on 08/29/24 at 12:39 General Manager, Staff H stated each program within the Hospice has their own QAPI program and QAPI team with representatives from the disciplines and corrective actions are carried out within each program; that Patient #1s event was discussed and corrective action was to do education with staff, which they did for Broward; that the Broward, Treasure Coast, and Palm Beach programs each have their own QAPI and track their own data, do their own corrective actions; that they have quarterly regional meetings for these 3 programs to compare findings and national leadership may attend any of these meetings, and that the minutes from all these meetings are sent to the national corporate QAPI team, which is the next level up. There is no unified Florida QAPI program. 1. Review of the medical record revealed patient #22, a 78-year-old female, was admitted to the hospice agency on 7/29/23. The hospice Case Sheet indicated her terminal diagnosis was atherosclerotic heart disease with secondary diagnosis of heart failure. Review of the medical record dated 7/31/23 revealed a Registered Nurse (RN) completed the Initial Comprehensive Assessment that noted the patient was alert and oriented to person, place, situation and time. The patient reported a pain level of “;6” with care plan goal of “;3” or less. The assessment indicated the patient was on opioid type medications for sharp/shooting pain down her left leg and across her back. The patient stated, “;I just want to feel better, I have no quality of life”. The RN documented under psychosocial assessment no history of psychiatric illness/substance abuse or suicidal ideation. The RN documented the patient had history of depression since her son passed away in January from Covid. The Bachelor of Social Work (BSW) completed a Psychosocial Comprehensive Assessment on 8/1/23 and documented the patient denied concerns regarding suicidal ideation or substance abuse history and was in acceptance of her terminal illness, had depression and was coping appropriately. The plan was for SW (Social Worker) to meet with patient twice per month to provide support and education. The plan of care included symptom management regarding “;sense of control and ability to cope,” and interventions to provide reassurance, educate regarding hospice services and provide support through being present. The SW assisted patient #22 with nursing home placement per note dated 2/26/24. The RN note dated 6/15/24 showed the patient was visited by nurse at the nursing home for routine visit and read, “;Pt [patient] opened eyes when name called and said she felt [wipe out] then fell asleep while talking. When touched said [ouch] when asked to level her pain when not being touched fell asleep”. The RN reviewed her medications for effectiveness and noted the patient had 4+ pitting tight edema bilateral lower extremities. There was no collaboration with the RN, SW, Chaplain, Physician, Facility Staff or caregiver checked. On 6/16/24-6/17/24, patient #22 went LOA (Leave of Absence) from the nursing home and obtained unknown drugs. The nursing home staff did not immediately notify hospice staff of the incident until the hospice staff visited the patient at the nursing home. The Licensed Practical Nurse (LPN) #LL documented routine visit note dated 6/17/24 from 9 AM to 10:20 AM which read, “;Pt [patient] sitting on side of bed, alert, calm”. He performed patient assessment and documented response to care, “;FS [Facility staff] report pt went LOA and was found in room very disoriented. Bottle of Lorazepam and another med [medication] found in Pt (patient) possession after further inspection 5-6 bottles of meds found including narcotics. All meds in...locked in lock box of facility. Pt edu [educated on not self-medication as facility controls meds. To prevent double dosing”. The note indicated the LPN collaborated with the RN. On 6/18/24 at 11:45 PM, the Telecare Call Action Log conversation note read, “;Facility LPN- called to report that patient is foaming at the mouth and unresponsive. LPN reports the patient still has a pulse of 51 bpm [beats per minute]. Patient was seen earlier today, appeared lethargic. Patient was found laying in bed 10 minutes ago. Facility staff also found a cup in patients s room with Ativan, Temazepam and Potassium pills. LPN reported that patient has Hx [history] of self-harming behavior...Advised LPN to elevate head of bed, place patient in side laying position and continue to trend VS [vital signs]. Advised LPN that hospice nurse will be sent out and will call with ETA [estimated time of arrival] ...” note was documented by hospice RN #ZZ. On 6/18/24 at 11:47 PM, hospice RN #ZZ documented, “;Please send to evaluate patient who was found unresponsive and foaming at the moth with pulse of 51 bpm. Possible overdose on medication. Cup of pills found next to patient”. On 6/19/24 at 12:45 AM, the Telecare Call Conversation Note documented by hospice staff #AAA read, “;Hospital called and stated that pt overdose, reason for the visit to hospital...” On 6/19/24 from 2:30 AM to 3:35 AM, RN #PP visited the patient at the hospital after being informed by the facility staff the patient was found unresponsive and foaming at the mouth with multiple pills at the foot of the bed. The RN note indicated the hospital emergency room MD (medical doctor) was not sure if patient overdosed on pills. The hospice RN made arrangements with transport for patient to return to facility. On 6/19/24 at 6:43 AM, Telecare Call note by hospice staff #BBB read, “;Facility nursed called in and stated pt came back from hospital at 0400 from the hospital but the patients condition is still bad...” On 6/19/24 at 6:54 AM, Telecare Call note by LPN #CCC read, “;facility nurse stating that patient arrived back to facility she is not doing well. States she is totally unresponsive, using accessory muscle to breath, oxygen on currently, crackles bilaterally and he doesnt know that the POC [plan of care] is. Advised to continue to monitor, elevate HOB [head of bed], oxygen on and will send nurse to assess...” On 6/19/24 RN #MM documented a visit note at 10 AM “;Pt on telecare ...found unresponsive, pills on her bed. Pt foaming at mouth sent to [hospital]. Pt returned, -at visit-pt unresponsive. Foaming at mouth, suctioned. FS [facility staff] requesting for drug screen-state to ask facility Dr.- FS agreed. Family notified of situation-stated this situation has occurred many times...” On 6/20/24 RN #MM documented visit at the nursing home from 8:45 AM to 9:55 AM, that the patient had no response to stimuli and was clammy. The patient was not able to swallow, and all medications were discontinued except for comfort. On 6/20/24 at 10:35 AM, documentation noted the hospice chaplain visited patient #22 at the nursing home and death at this time was imminent. She had decreased response to verbal and visual stimuli. Her date and time of death according to the hospice Case Sheet was on 6/20/24 at 1:30 PM. On 8/27/24 at 12:43, interview and concurrent record review was conducted with General Manager (GM) DD in person and other staff on the phone from program #78 included Senior Patient Care Administrator (PCA) #II, Performance Improvement Specialist (PIS) #JJ, and Associate GM #KK. The staff verified they did not have a GM for program #78 at this time. The staff on the phone explained that patient #22 was found with pill bottles at the end of her bed at the facility and they suspected suicide. Hospice staff indicated they did not know what day she went on leave from the nursing home and thought a friend brought her home, and that is how she obtained pills and brought them back to the nursing home. From 8/26/24 to 8/28/24, the hospice General Manager (GM) #DD was asked to provide any documentation to show that patient #22 had history of drug abuse, abuse of prescription medications or taking her medications excessively or inappropriately. The hospice staff did not provide any care plans or documentation to that effect. PCA #II verified she was the person responsible for ensuring a root cause analysis (RCA) was done post incidents and a thorough investigation was conducted. She verified hospice staff did not talk to the nursing home staff to find out exactly what happened. They determined the root cause was not within their scope of control without doing a thorough investigation. PCA #II said they did identify areas of opportunity for communication and education. They said they needed to educate the nursing home staff to notify the hospice agency immediately when they confiscated the drugs from the patient. PCA #II stated, “;the main thing that was lacking was our communication between nursing home staff and hospice staff. I think mainly being aware the patient went out of the facility so that we would have known when she came back, she was having a hard time adjusting to being at the facility.” PCA #II verified their RCA showed they needed to improve their communication between the nursing home staff and hospice staff. They had not contacted the nursing home administration regarding their need to improve communication with them. On 8/28/24 at 12:24 PM, in an interview with GM #DD and the National PCA #CC verified they did not have any evidence of education being done with the Interdisciplinary Team which was the team responsible for the holistic care of the hospice beneficiary. They explained the RCA was late because the PCA working at that time left quickly and therefore was put on the back burner. PCA #CC verified that LPN #LL who conducted the visit on 6/17/24 and noted she had 5-6 bottles of medications per nursing home staff. They stated the LPN should have filled out an incident report. “;We know the patient overdosed 2 days later.” They could not provide any evidence that LPN #LL did an incident report or that post incident, any communication with the nursing home administration regarding the incident or follow was ever done. They added that when a PCA was out on leave, a GM or another PCA will step in to assist and they did not know why this incident was dropped and why no investigation was completed. It was noted the Hospice Root Cause Analysis (RCA) meeting for incident dated 6/19/24 was delayed for over 2 months until 8/22/24. The incident date should have been on or about 6/16/24 to 6/17/24 when LPN LL and RN #MM failed to initiate an incident report. As part of the RCA, the hospice failed to do a thorough investigation and did not speak with the nursing home facility staff as to why they did not contact hospice on 6/16/24 or 6/17/24 when patient #22 went on leave and returned with 5-6 bottles of pills. LPN #LL who visited the patient on 6/17/24 failed to find out from the patient what happened, what pills she had taken or why. LPN #LL reported to the hospice RN #MM who also failed to initiate an incident report. On 8/28/24 during interviews with Hospice Program #78 staff, Senior PCA #II, PIS #JJ, GM #KK all confirmed they did not communicate with any of the facility staff as part of their investigation or post incident corrective measures. The hospice provider failed to investigate on 6/17/24 when they became aware patient #22 had 5-6 bottles of pills at her bedside including Opioids and Benzodiazepines. The education they provided to their program 78 staff was not adequate and did not include immediate incident reporting education. The national QAPI staff and Chief Medical Director were not aware of any recent program concerns regarding recent suicides/attempts/suspected attempts pertaining to any of their 16 specific programs and 53 multiple locations. On 8/28/24 hospice staff provided survey team evidence of education on 8/28/24 with approximately 186 staff. Team Agenda for Team 863 read, “;Education Focus for: Hospice Aid Team Meeting Takeaway Think for HAs-Dehydration”. Other Announcements and Education included Focus Areas, “;Education on documentation with contact with facilities after death or any difficult situations with patient or family. Reviewed importance of performing head to toe assessment with each and every visit to note any changes or concerns”. Hospice also provided the list of participants names which was approximately 186 staff and meeting summary dated 8/28/24 with start time of 2:16 PM and end time of 3:09 PM, read, “;Meeting is MANDATORY PLEASE ATTEND Education on communication with facilities”. The education was not specific to concerns surrounding patient #22s serious adverse event and did not include the need for immediate incident reporting, reporting unusual occurrences to the Team Manager with an hour, or the specific concerns regarding communication with nursing home staff that should have been done to address concerns identified with patient #22. Hospice could not show evidence that staff were instructed on timely RCA, conducting more thorough serious adverse event investigations and appropriate/timely follow up conducted post investigations at all 16 programs/53 multiple locations to ensure safety of the hospice patients throughout the agency. On 8/28/24 in phone interviews conducted with the Chief Medical Director, it was noted he was not aware of any recent patient suicides/attempts by hospice patients #1, #20, #21, #22, nor was the Director of Operations and Performance and the QAPI Compliance Advocate #FF. The QAPI staff denied being aware of the recent statement of deficiencies from complaint survey conducted on 7/3/24 that resulted in 3 federal conditions of participation and 4 federal standard level deficiencies. The QAPI staff indicated no involvement in addressing the plan of corrections across their 16 programs and 53 locations they were responsible for. The hospices Internal Reporting policy read, “;Purpose...Develop, implement, and maintain an effective, ongoing, hospice-wide data driven quality assessment and performance improvement program...Performance improvement activities must track adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospice. What: 1. Patient/Family/Visitor Incidents...3. Medication Adverse Event...Considerations 5. All incidents involving employees, patients and families should be report immediately to the employees s manager including...b. Medication...a. Medication Adverse Events.... General Instructions a. Patient/Family/Visitor Incidents a) All patient/Family/Visitor incidents will be reported and documented i) Report to employee manager within one hour of knowledge of incident....” The hospices Management Standard (VMS) Serious Adverse Event/Sentinel Event, dated 2022 read, “;Purpose...must measure, analyze, and track quality indicators, including adverse patient events...Serous Adverse Event (Sentinel Event)- and unexpected occurrence involving unanticipated death or serious physical or psychological injury, or the risk thereof. Serous injury specifically includes loss of limb or major permanent loss of function not related to the patients illness or underlying condition. The phrase [or the risk thereof] includes any process variation for which a recurrence wound carry a significant chance of serious adverse outcome. Serious adverse events may include but are not limited to: 1. Suicide of patient, family member or caregiver including volunteers 2. Significant adverse drug reaction 3. Significant medication error...9. Any other serious event that leadership determines the need for intense analysis to improve performance. 3. Serous Adverse Events (Sentinel Events) require completion of a Root Cause Analysis to precent the likelihood of similar occurrence in the future....” The VMS Root Cause Analysis Purpose...Performance Improvement activities must track adverse patient events, analyze their causes, and implement preventive actions and mechanism that include feedback and learning throughout the hospice. What: Perform a Root Cause Analysis (RCA) for every Serous Adverse Event in order to prevent or reduce the likelihood of similar occurrence in the future....3. Anytime a Root Cause Analysis I completed; notify applicable corporate staff by sending a copy of the completed RCA, all coordinating Incident Report(s)....4. A root Cause Analysis is done to find out what happened, why it happened, and what to do to prevent it from happening again.... Facts will be rigorously reviewed to be certain that all avenues have been exhausted.... The General Manager and Patient Care Administrator will be responsible for implementation of the corrective action plan. The Performance Improvement Specialist/designee will be responsible to notify the General Manager and Patient Care Administrator of any undesirable or unexpected outcomes. Upon completion of the Root Cause Analysis/Action Plan Form...A brief summary of Serous Adverse Events (Sentinel Events) and the related RCA/Action Plan will be reported on quarterly basis at the AQAP/IDG meeting....””

“Based on record review and staff interview, the Hospice failed to ensure an Administrator is responsible for the day-to-day operations. The findings include: Review of the Hospices Senior Operations Leadership, Executive Organizational chart, dated August 2024 reveals 4 Vice-Presidents of Operations, including Staff M, report to Staff I who is over South Florida and Georgia; and 3 Vice-Presidents of Operations report to Staff N who is over North Florida; and that Staff I and Staff N, as well as other SVPOs, “EVPs”, and “SVPs” report to the President/Chief Operating Officer of VITAS; and that the multiple locations of the Hospice do not report to the Administrator of Melbourne but to 2 different Administrators. During interview on 08/29/24 at 12:39 PM General Manager, Staff H reported the Broward, Palm Beach and Treasure Coast programs report to Vice-President of Operations (VPO), Staff M and there are multiple VPOs in Florida. During further interview on 08/29/24 at 10:57 AM, Staff M explained Staff M reports to Senior Vice-President of Operations, Staff I who is over the South Florida programs; that Senior Vice-President of Operations, Staff N is over the North Florida programs including Melbourne; that the 2 Senior VPOs, Staff I and Staff N report to the President/Chief Operating Officer who is over the entire company nationally; that there is no one person over Florida and the programs in Florida do not report to Melbourne, which holds the Medicare certification. During telephone interview on 08/29/24 at 2:08 PM Senior Vice-President of Operations, Staff I stated he and Senior Vice-President of Operations, Staff N report directly to the President/Chief Operating Officer who is over the national company.”

“Based on record review and staff interview, the Hospice failed to ensure its multiple locations function as part of one Hospice. The findings include: . Review of the Hospices Senior Operations Leadership, Executive Organizational chart dated August 2024 reveals 4 Vice-Presidents of Operations, including Staff M, report to Staff I who is over South Florida and Georgia; and 3 Vice-Presidents of Operations report to Staff N who is over North Florida; and that Staff I and Staff N, as well as other SVPOs, “EVPs”, and “SVPs” report to the President/Chief Operating Officer of VITAS; that the reporting structure is not to the certified provider in Melbourne but along 2 different lines of administrative authority to an entity (corporate) outside the hospice. During interview on 08/29/24 at 10:10 PM General Manager, Staff H reported the Broward, Palm Beach and Treasure Coast programs report to Vice-President of Operations (VPO), Staff M and there are multiple VPOs in Florida. During further interview on 08/29/24 at 10:57 AM, Staff H explained Staff M reports to Senior Vice-President of Operations, Staff I who is over the South Florida programs whereas Senior Vice-President of Operations, Staff N is over the North Florida programs including Melbourne; that the 2 Senior VPOs, Staff I and Staff N report to the President/Chief Operating Officer who is over the entire company nationally; that there is no one person over Florida and the programs in Florida do not report to Melbourne, which holds the Medicare certification. During further interview on 08/29/24 at 12:39 PM, Staff H reported corrective actions are conducted at the program level and each program has their own QAPI and no one program is over the others. During telephone interview on 08/29/24 at 2:08 PM Senior Vice-President of Operations, Staff I stated he and Senior Vice-President of Operations, Staff N report directly to the President/Chief Operating Officer who is over “;National.””

“Based on record review and staff interview, the Hospice failed to ensure the multiple locations of the hospice report to the Melbourne location. The findings include: During interview on 08/29/24 at 12:39 PM General Manager, Staff H reported the Broward, Palm Beach and Treasure Coast programs report to Vice-President of Operations (VPO), Staff M and there are multiple VPOs in Florida. During further interview on 08/29/24 at 10:57 AM, Staff M explained Staff M reports to Senior Vice-President of Operations, Staff I who is over the South Florida programs; that Senior Vice-President of Operations, Staff N is over the North Florida programs including Melbourne; that the 2 Senior VPOs, Staff I and Staff N report to the President/Chief Operating Officer who is over the entire company nationally; that there is no one person over Florida and the programs in Florida do not report to Melbourne, which holds the Medicare certification. During telephone interview on 08/29/24 at 2:08 PM Senior Vice-President of Operations, Staff I stated he and Senior Vice-President of Operations, Staff N report directly to the President/Chief Operating Officer who is over “;National.” Review of the Hospices Senior Operations Leadership, Executive Organizational chart dated August 2024 reveals 4 Vice-Presidents of Operations, including Staff M, report to Staff I who is over South Florida and Georgia; and 3 Vice-Presidents of Operations report to Staff N who is over North Florida; and that Staff I and Staff N, as well as other SVPOs, “EVPs”, and “SVPs” report to the President/Chief Operating Officer of VITAS; that the reporting structure is not to the certified provider in Melbourne but to an authority outside the hospice; and therefore there is no mechanism for the hospice to manage all of its locations.”

“Based on staff interview and record review, the Hospice failed to maintain operational control over all of its locations and therefore is unable to monitor and manage the services at its multiple locations. The findings include: During interview on 08/29/24 at 12:39 PM General Manager, Staff H reported the Broward, Palm Beach and Treasure Coast programs report to Vice-President of Operations (VPO), Staff M and there are multiple VPOs in Florida. During further interview on 08/29/24 at 10:57 AM, Staff M explained Staff M reports to Senior Vice-President of Operations, Staff I who is over the South Florida programs; that Senior Vice-President of Operations, Staff N is over the North Florida programs including Melbourne; that the 2 Senior VPOs, Staff I and Staff N report to the President/Chief Operating Officer who is over the entire company nationally; that the location that has the certification has no authority over the multiple locations; and that the only common authority all of the multiple locations report to is “national,” the corporate entity outside of the Hospice. During telephone interview on 08/29/24 at 2:08 PM Senior Vice-President of Operations, Staff I stated he and Senior Vice-President of Operations, Staff N report directly to the President/Chief Operating Officer who is over “;national.” Review of the Hospices Senior Operations Leadership, Executive Organizational chart dated August 2024 reveals 4 Vice-Presidents of Operations, including Staff M, report to Staff I who is over South Florida and Georgia; and 3 Vice-Presidents of Operations report to Staff N who is over North Florida; and that Staff I and Staff N, as well as other SVPOs, “EVPs”, and “SVPs” report to the President/Chief Operating Officer of VITAS; that the reporting structure is not to the certified provider in Melbourne but to an authority outside the hospice; and therefore there is no mechanism for the hospice to manage all of its locations.”

“Based on interview, and record review, the provider failed to ensure a single individual filled the role as medical director and assumed overall responsibility for the medical component of the hospices patient care program. Information provided by the hospice provider from 8/26/24 to 8/28/24 revealed the provider had a total of 20 medical directors employed. There were 16 medical directors, 3 regional medical directors and 1 chief medical director. As of 8/26/24 the patient census was 14,736 under a single Medicare Provider Number (CCN#) 101545. The CMS Certification number (CCN) replaces the term Medicare Provider Number, Medicare Identification Number. Information provided by the hospice provider on 8/26/24 showed provider had 16 programs throughout Florida with 53 multiple locations. Addresses for 53 locations revealed 3 licensed offices which were in Boynton Beach, Miami Lakes and Melbourne. The Boynton office had 7 multiple locations and 1 inpatient facility, Miami Lakes had 6 multiple locations, and 1 inpatient facility and Melbourne had 2 inpatient facilities and 33 multiple locations. Review of 4 of 20 Medical Directors records and Department of Health Licensing information revealed the Chief Medical Director address of record was Maitland, Regional Medical Director #AA’s address was Cocoa Beach, Medical Director #XX address was in Panama City and Medical Director #YY address was in Jacksonville. The Regional Medical Director #AAs Medical Doctor license had address of Record in Cocoa Beach, and she also had Controlled Substance Registration Certificate with different hospice provider in Titusville. On 8/26/24 at 1:40 PM, the Senior Vice President (VP) of Operations #BB explained the medical director was the Chief Medical Officer and he was responsible for nearly 15,000 patients. She noted they also had 3 Regional Medical Directors under supervision of the Chief Medical Officer. The Senior VP of Operations provided documentation that listed 16 medical directors, 3 regional medical directors and 1 chief medical director. On 8/28/24 at 2:29 PM, Regional Medical Director #AA verified she was not the lead Medical Director and explained there were 3 Regional Medical Directors in Florida., 5 Regional Medical Directors across the country and they currently had 2 vacancies. Regional Medical Director #AA said she covered North Florida and South Alabama and served in a supportive role for patients and staff in those areas. The Sr. VP of Operations #BB was present during the interview and added the Regional Medical Director #AA assisted if one of the other Medical Directors was on leave, assisted with interviews for Medical Director vacancies, and supervised the program Medical Directors. On 8/28/24 at 3:20 PM, a telephone interview was conducted with the Chief Medical Director/Officer. He explained the Regional Medical Directors reported directly to him and he worked with the Chief Nursing Officer to coordinate care with Medical Directors to ensure care was consistent. He said most of the policies and procedures were nursing driven and he provided oversight and input regarding policies. He had Teams call with the Regional Medical Directors every other week to discuss any concerns with medical management, patient care issues and discussed each program. He said he participated virtually in all 16 programs QAPI (Quality Assurance Performance Improvement) meetings and attended QAPI meetings quarterly. When asked about adverse events and his role in the investigation and interventions post investigation, he stated the regional Patient Care Administrators (PCA) would contact him if needed. He stated that they discussed suicides during their last call but it was not part of any recent re-education plan. The Chief Medical Director/Officer was not aware of patient #1 who committed suicide on 7/13/24, patient #20 who committed suicide on 8/17/24, patient #21 who attempted suicide on 6/20/24, patient #22 who had suspected attempted suicide/overdose which resulted in emergency room visit on 6/19/24 and subsequently died on 6/20/24. Review of the Regional Medical Director’s job description dated 8/7/18, read, “;Responsible for participation in leadership to and oversight of physicians in the interdisciplinary delivery of hospice care, consistent with applicable standards of hospice medical care....Responsible for the oversight and direction of the medical aspect of their assigned hospice programs...Essential duties and responsibilities- All duties and responsibilities are to be performed in accordance with...governmental regulations...Advise in recruitment and selection of program medical directors...Participate in assuring that program medical directors have appropriate competencies...participate in yearly evaluation of the program medical directors they work with. Establish and maintain direct communication with program medical directors as assigned by the Chief Medical Officer. Consult with and advise these program medical directors regarding certification and recertification standards.... Oversee and mentor program medical directors...Assist each program medical director...Assist in professional development of program medical directors...Assist and guild program medical directors....” Review of the Chief Medical Director job description effective 6/1/18, read, “;Responsible for the leadership, and oversight of physician practices in the interdisciplinary delivery of hospice care consistent with applicable standards of hospice medical care...Responsible for the oversight and direction of the medical aspect of hospice care program, the credentialing process, the establishment of patient care protocols....Essential duties and responsibilities....Oversees the regional medical directors...Ensures all clinical programs are in compliance....””

“Based on interview, and record review, the hospice provider failed to obtain pertinent information, revise the plan of care and collaborate with their interdisciplinary group to ensure patient safety for 1 of 4 patients, reviewed for suicide, (#22). Review of Vitas Healthcare Corporation of Florida agreement with the nursing facility for inpatient and inpatient respited services dated 2/15/19, read, “;Vitas desires to provide hospice services to resident of the facility in coordination with the management and staff of the facility....Vitas retains professional management responsibility for all hospice services furnished in accordance with each hospice patients plan of care and retains sole responsibility for the assessment....Facility personnel are responsible for administration of prescribed therapies, including therapies determined appropriate by Vitas and delineated in the hospice plan of care....2.1.3. Coordination, supervision, and evaluation of services. Vitas will coordinate supervise and evaluate deliver of services provided to a hospice patient hereunder in the following manner: 2.2.3.1 Vitas will promote open and frequent communication, in person, by phone, or fax, or in writing between Vitas and facility staff concerning the hospice plan of care and hospice patients needs...Vitas shall be responsible for ensuring that any changes or revision to the hospice plan of care are communicated and coordinated with facility staff...A hospice representative shall be available 24 hours per day, 7 days a week for consultation with facility concerning the hospice patients hospice plan of care.... Facility shall be responsible for ...Communicating to designated Vitas personnel and changes in the hospice patients condition...Vitas shall be responsible for...Ensuring that care provided by the facility is in conformance with hospice plan of care.... Communication. The parties will communicate pertinent information with each other either verbally or in the residential hospice patients record...a significant change in resident hospice patients physical, mental...the appearance of clinical complications which suggest the need to alter the hospice patients plan of care... Review of the medical record revealed patient #22, a 78-year-old female, was admitted to hospice agency on 7/29/23 with terminal diagnosis of atherosclerotic heart disease and secondary diagnosis of heart failure. The Bachelor of Social Work (BSW) did her Psychosocial Comprehensive Assessment on 8/1/23 and documented patient denied concerns regarding suicidal ideation or substance abuse history and was in acceptance of her terminal illness, had depression and was coping appropriately. The plan moving forward was for SW (Social Worker) to meet with patient twice per month to provide support and education. The plan of care included symptom management regarding “;sense of control and ability to cope” and interventions to provide reassurance, educate regarding hospice services and provide support through being present. The SW assisted patient #22 with nursing home placement per note dated 2/26/24. The hospice RN note dated 6/15/24, revealed during the visit the patient opened her eyes when her name was called but fell asleep while talking. She then opened her eyes and said she felt “;wiped out.” On 6/16/24 to 6/17/24, patient #22 went on Leave of Absence (LOA) from the nursing home and obtained unknown drugs. The nursing home staff failed to immediately notify hospice staff. The hospice Licensed Practical Nurse (LPN) #LL visited the patient at the nursing home on 6/17/24 from 9 AM to 10:20 AM, and documented the patient was alert and calm. He wrote he was informed by nursing home staff the patient returned from LOA and was found in room very disoriented. About 5-6 bottles of medications including Ativan and other narcotics were found in the patients room which the nursing home secured in locked box. On 6/18/24 at 11:45 PM, the Telecare Call Action Log by hospice RN #ZZ showed the nursing home LPN called to report patient #22 was found 10 minutes ago foaming at the mouth and unresponsive. The patient had a pulse of 51 bpm [beats per minute]. Facility LPN stated she found a cup in patients room with Ativan, Temazepam and Potassium pills. LPN also reported the patient had history of self-harming behavior. The patient was sent to the hospital for possible overdose. At 12:45 AM, the “;Hospital called in stated that patient overdose, reason for the visit to hospital...” On 6/19/24 at 6:43 AM, a Telecare Call note by hospice staff #BBB read, “;Facility nursed called in and stated pt came back from hospital at 0400 (4 AM) from the hospital but the patient’s condition is still bad...” On 6/19/24, hospice RN #MM visited the patient at the nursing home and documented a visit note at 10 AM. The noted indicated the patient was unresponsive, foaming at the mouth. The patient was suctioned and family notified of situation. The family informed this situation has occurred many times...” On 6/20/24, RN #MM documented visit at the nursing home from 8:45 AM to 9:55 AM, the patient had no response to stimuli and was clammy. The patient was not able to swallow, and all medications were discontinued except for comfort. On 6/20/24 at 10:35 AM, the hospice chaplain visited the patient at the nursing home and noted death was imminent. She had decreased response to verbal and visual stimuli. The date of time of death according to the hospice Case Sheet was on 6/20/24 at 1:30 PM. On 8/27/24 at 12:43, interview and concurrent record review was conducted with General Manager (GM) DD in person and other staff on phone from program #78 included Senior Patient Care Administrator (PCA) #II, Performance Improvement Specialist (PIS) #JJ, and Associate GM #KK. The staff verified they did not have a GM for program #78 at this time. They explained this incident was suspected suicide as the patient was found with bottles of pills nearby. Hospice staff indicated they did not know what day she went LOA and thought that a friend brought her home, and that is how she obtained pills and brought them back to the nursing home. PCA #II verified she was responsible to ensure a thorough investigation and root cause analysis was done post incidents. She verified that hospice staff did not talk to the nursing home staff to find out exactly what happened. PCA #II said they identified areas of opportunity for communication and education. They needed to educate the nursing home staff that hospice should have been notified immediately after drugs were confiscated from patient #22. PCA #II stated, “;the main thing that was lacking was our communication between facility staff and hospice staff. I think mainly being aware that the patient went out of the facility so that we would have known when she came back, she was having a hard time adjusting to being at the facility”. PCA #II verified their RCA showed they needed to improve their communication with the nursing home staff. PCA #II acknowledged they had not contacted the nursing home administration to implement any education plan. On 8/27/24 at 12:43 PM, the Senior Patient Care Administrator verified they needed to improve their communication with the nursing home and acknowledged they had not revised the plan of care after it was identified the patient brought in medications to the nursing home and was found to be disoriented. On 8/28/24 at 12:24 PM, during an interview with GM #DD and the National PCA #CC, they verified they did not have any evidence of any education provided to the Interdisciplinary Group (IDG) which was the team responsible for the holistic care of patients. On 8/28/24 during interviews with Hospice Program #78 staff Senior PCA #II, PIS #JJ, and GM #KK, they all confirmed they did not communicate with any of the nursing home staff as part of their investigation or post incident corrective measures.”

“Based on interview and record review, the hospice agency failed to honor the right to comfort during the dying process by ensuring end-of-life symptoms were evaluated and treated in a timely manner; and failed to promote the right to expression and resolution of grievances regarding care and services, for 1 of 4 patients reviewed for Patient Rights, out of a total sample of 4 patients, (#1). The cumulative effect of these systemic deficient practices resulted in unnecessary, preventable pain and suffering for patient #1 over a 21-hour period after he was discharged home from the hospital, and impeded investigation and resolution of consequential grievances. Cross reference L 505 and L 512.”

“Based on interview and record review, the hospice agency failed to effectively organize, manage, and administer its resources to ensure all necessary hospice care and services were provided for 1 of 4 patients reviewed for Patient Rights, out of a total sample of 4 patients, (#1); and failed to ensure reliable after-hours services were available to meet the needs of all hospice patients and their representatives. The cumulative effect of these systemic deficient practices resulted in unnecessary, preventable pain and suffering for patient #1, and placed all patients who experienced emergencies or distressing symptoms after regular business hours at risk. Cross Reference L 650 and L 653.”

“Based on interview and record review, the hospice agency failed to promote the right to verbalize grievances and seek resolution regarding communication and care concerns by patient representatives for 1 of 4 patients reviewed for Patient Rights, out of a total sample of 4 patients, (#1). Review of the medical record revealed patient #1, a 78-year-old male, was admitted to the hospice agency on 10/17/23. The Case Sheet indicated his terminal diagnosis was lung cancer and his secondary diagnoses included cancers of the prostate, brain, and bone, seizures, and atherosclerotic heart disease. Patient #1 died at home on 12/07/23. Review of an entry on a popular online platform used by the public to rate businesses revealed a negative review of the hospice agency. The review, dated 6/19/24, described the concerns of patient #1s son regarding the hospice agencys failure to provide essential care and services to meet his fathers needs and lack of appropriate responses to his grievances. The document indicated patient #1 was in the hospital from 12/02/23 to 12/03/23 and his physicians determined he was actively dying. The son noted the hospital Social Worker (SW) contacted the hospice agency regarding discharge home on 12/03/23, and the hospice agency verified his father was already an active patient since October 2023. The review showed the hospice Call Center was aware of patient #1s scheduled discharge home and promised a nurse would visit at approximately 6:00 PM. The son indicated the nurse did not show up as arranged, and family members called the hospice agency repeatedly from 12/03/24 at 7:00 PM to 12/04/24 at 4:00 AM. The review revealed a nurse arrived on 12/04/23 at about 6:30 AM but she was unable to obtain an order for pain medication from the on-call physician, who instructed her to reach out to the Team Physician after change of shift at 8:00 AM. The son indicated the nurse eventually obtained physician orders and he was able to pick up the medications at the pharmacy in the afternoon, almost 24 hours after his fathers discharge from the hospital. The review read, “;We, mom, brother, and I stressed the displeasure of their response or the lack of. The [name of hospice agency] Chaplain arrived later that evening around [6:00 PM], and again we expressed our displeasure in their care for a Decorated Veteran.” The son summarized the negative experiences as a lack of urgency to address patient #1s pain and suffering for almost 24 hours, and unresponsiveness to requests regarding Veteran-specific services and the death certificate. On 7/02/24 at 10:00 AM, in a telephone interview with patient #1s son, he validated the information in the above review. He emphasized that he clearly and repeatedly expressed his discontent and concerns related to the events surrounding his fathers return home from the hospital to multiple hospice staff. The son explained the hospice agency neither followed through on essential matters nor attempted to address his concerns until after the negative online review was posted. Review of an Addendum Interdisciplinary Note dated 12/04/23 revealed Registered Nurse (RN) E was the on-call nurse who visited patient #1s home at about 6:30 AM. RN Es note indicated the family members expressed dissatisfaction with the hospice agencys services. She wrote, “;. . .everyone was frustrated and not happy with [name of hospice agency]” due to the 12-hour wait for a nurse to arrive and the delay in obtaining appropriate medication. RN E described the family as emotional and desperate due to the circumstances. The note indicated patient #1s family was dissatisfied with the on-call physicians decision to defer additional medication orders to the Team Physician after change of shift. RN E noted the patients son became emotional and started to cry as he asked why his father had to wait for almost 12 hours without access to medication. The document revealed RN E called Team Manager (TM) C at 2:26 PM to report on the visit. The document indicated RN E listened to the family members as they aired their concerns throughout the entire visit until she left the home eight hours later at approximately 2:30 PM. The note read, “;. . .family were sighing with discontent, will have everything documented, so the Team and Telecare will follow up.” Review of Patient Chart Comments revealed a note dated 12/04/23 at 12:26 PM that read, “;Call received from the [Veterans Affairs hospital] advising family was complaining that patient is not doing well and need pain meds.” TM C was out of the office and the message was relayed to another TM. A note dated 12/04/23 at 5:21 PM, revealed TM C contacted patient #1s son and he informed her of concerns related to no comfort medications or a nurse in the home for his father. Review of an Addendum Interdisciplinary Note dated 12/05/23 revealed the Chaplain visited patient #1s home. The document indicated the patients son complained to the Chaplain about the gap in staffing and absence of medication for his father when he was discharged home from the hospital. The note revealed the Chaplain referred the sons concerns to the TM, SW, and RN Case Manager. Review of a Supplemental Interdisciplinary Note dated 12/12/23 revealed the hospice SW contacted patient #1s son following his fathers death. The SW indicated the son requested assistance with his fathers death certificate, which she discussed with a Patient Care Administrator (PCA) and a TM. The document read, “;SW stated the issue was being looked into and someone will follow up.” On 7/02/24 at 9:32 AM, the hospice SW recalled she visited patient #1s home after he returned home. She stated the patients wife recounted the events surrounding her husbands discharge home from the hospital. The SW said, “;She was very bothered about him not getting his medication. I also believe she mentioned that there was a delay in the nurse arriving. . .I dont recall mentioning it to the Team Manager. The SW stated she did not know about the negative online review before today, and she did not remember the familys concerns being discussed in team meetings. She confirmed she was not interviewed during investigation of the grievance in June 2024. On 7/02/24 at 10:59 AM, PCA B confirmed the purpose of the service comment log was to record grievances and concerns expressed by patients and/or caregivers. She validated TM C was made aware of the familys concerns and should have brought the issues to her assigned PCA. PCA B stated the expectation was either TM C or the PCA would have initiated a service comment to initiate an investigation which would involve communication with the family. She said, “;I cannot dispute that we did not adhere to process.” On 7/02/23 at 3:35 PM, TM C acknowledged she was made aware of concerns regarding patient #1, but she did not initiate a service comment as she felt she addressed and resolved the sons concerns quickly and appropriately. TM C stated she was new to her position at the time of the events and would definitely have mentioned the concerns to her teams PCA. She acknowledged the sons frustration related to the gaps in care was understandable. On 7/03/24 at 12:37 PM, the Senior General Manager (GM) validated all employees were expected to report any patient or family concerns, grievances, or any occurrences outside of the normal process of operations to their managers. The Senior GM was informed multiple staff documented and verbalized awareness of the familys dissatisfaction and legitimate concerns at the time patient #1 experienced significant delay in receiving care, services, and medication in December 2023. She confirmed she was not aware of the issues before the negative online review as no staff member recorded a service comment. On 7/03/24 at 2:35 PM, PCA A validated RN Es visit note, which included details regarding the obstacles and delays in the provision of care for patient #1 and the concerns verbalized by his family, was transmitted by email to a group of seven TMs. PCA A verified any TM who read RN Es note should have identified the concerns as significant and initiated the service comment process. Review of the hospice agencys Service Comment log revealed a grievance regarding patient #1 was received on 6/19/24. The Service Comment Form revealed the concern was categorized as timeliness and response time related to medication shortage and after-hours/weekend issues. The document showed PCA B contacted patient #1s son the day after the negative review of the hospice agency appeared online. PCA B noted the son explained his concerns and stated he was “;. . .unhappy it took a review before we addressed the issues.” Review of the hospice agencys policy for Internal Reporting (undated) revealed all complaints and grievances made by patients or their representatives regarding treatment or care would be recorded in the Service Comment Electronic System and promptly investigated. The document indicated the process was for any staff member who received a grievance to notify his/her manager and report the complaint. The Service Comment would be documented either electronically or on a paper form, and the complainant would be contacted within 24 hours.”

“Based on interview and record review, the hospice agency failed to ensure effective and timely management of pain and distressing symptoms related to a terminal condition for 1 of 4 patients reviewed for Patient Rights, out of a total sample of 4 patients, (#1). Review of the medical record revealed patient #1, a 78-year-old male, was admitted to the hospice agency on 10/17/23. The Case Sheet indicated his terminal diagnosis was lung cancer and his secondary diagnoses included seizures, atherosclerotic heart disease, and cancers of the prostate, brain, and bone, The medical record revealed patient #1 was hospitalized on 12/02/23 and returned home on 12/03/23, where he died on 12/07/23. Review of the hospice agencys Telecare Call log revealed communication between the hospital Social Worker (SW), patient #1s family, and the hospice agency on 12/03/23, prior to his discharge home from the hospital. The document indicated the hospital SW contacted the hospice call center on 12/03/23 at 2:32 PM regarding patient #1s impending discharge and his care needs. The log showed the hospice agencys Manager on Call, Registered Nurse (RN) H, called the hospital SW on 12/03/23 at 3:50 PM to finalize the patients discharge plans. RN H noted patient #1s family decided to hold off on starting antibiotic therapy as they did not want anything to delay his return home that afternoon. RN H wrote, “;Family would like [patient] to be comfortable at home.” The Telecare Call log revealed on 12/03/23 at 6:09 PM, patient #1s wife notified the hospice agency that her husband was on the way home from the hospital and they needed a nurse to visit the home. The document was updated at 6:19 PM by a triage nurse to show the visit request was upgraded to a Priority 1 or P1 level which indicated it was the highest priority level. The note read, “;Nurse visit needed for Tuck in Visit. Wife just called. Patient is on their way home now. Requesting a nurse visit for Tuck In. Dispatch requested.” The Telecare Call log revealed on 12/04/23 at 4:54 AM, an on-call nurse, RN E, contacted the hospice agency call center staff and stated she received a message regarding a visit, but it was blank. The call center provided her with patient #1s name, address, and phone number. Review of an Addendum to Interdisciplinary Note dated 12/04/23 revealed RN E called patient #1s home at 5:00 AM and spoke with his wife, who confirmed they still wanted a nursing visit. The note indicated on RN Es arrival, the family members expressed frustration and discontent with the hospice agencys services. They informed RN E that a hospice nurse was supposed to visit soon after patient #1 arrived home the previous evening. The family members explained they attempted to give the patient Morphine Sulfate liquid, but he choked on the medications as he could no longer swallow. RN E noted the family informed her the patient needed to receive medication by an alternate route, including an anti-seizure drug. The document revealed RN E contacted the on-call physician at approximately 7:30 AM and received an order to administer the Morphine Sulfate liquid that was currently available in the home and have the regular interdisciplinary team follow up during the day. The note indicated the family was not satisfied with the on-call doctors order to administer the medication that choked the patient or that they had to wait until day shift staff were available. The document read, “;. . .son became so emotional, verbalizing why the patient has to wait for almost 12 hours with nothing. . .” RN E documented that she was eventually able to communicate with the Team Physician at 9:00 AM. She obtained a physician order for Morphine Sulfate 20 milligrams (mg) / milliliter (ml) for pain, give 10 mg, a highly concentrated form of the drug that could be administered and absorbed sublingually (SL) or under the tongue rather than swallowed. The physician also ordered medications to treat patient #1s end-of-life symptoms including Ativan 0.5mg SL for agitation, Levsin 0.125 mg SL for excessive secretions, Tylenol 650 mg rectally for fever, and Keppra 500 mg rectally for seizure prevention. The Team Physician authorized Continuous Care for pain management and RN E followed up with the team regarding the need to schedule nursing staff 24 hours daily to monitor and treat patient #1s unmanaged symptoms in the home. RN E called in the medications to a community pharmacy and confirmed patient #1s son would pick them up when ready. A Nursing-Updated Comprehensive Assessment dated 12/04/23 showed RN Es assessment findings of patient #1. She noted he moaned and grimaced with movement and had a pain level of 6 on a 0 to 10 scale. RN E recorded the patients level of neurosensory distress as 8/10 with confusion and agitation. Patient #1 exhibited signs and symptoms of respiratory distress at the level 8/10, as he had shortness of breath and a new onset cough with swallowing. The document read, “;Patient is showing signs of decline. Family not happy with [name of hospice agency], has to wait for 12 hours before they can get pain medication or order for patient unable to swallow. . .” Review of the above Nursing-Updated Comprehensive Assessment and Addendum to Interdisciplinary Note revealed RN E left patients #1s home on 12/04/23 at approximately 2:30 PM. The documents showed as of that time, approximately 20 hours after his arrival home from the hospital, patient #1 had not received any medication for his symptoms of pain, anxiety, and respiratory distress. Review of the medical record revealed a Nurse Practitioner Face-To-Face Encounter progress note dated 12/04/23. The document indicated Advanced Practice Registered Nurse (APRN) G visited and assessed patient #1 from 3:25 PM to 4:30 PM for symptoms of pain and shortness of breath. The noted described the patient as “;a chronically ill-appearing, white male patient in acute distress.” APRN G noted patient #1 grimaced, frowned, and had shortness of breath at rest during her assessment. She documented, “;The patient is presenting with possible active process of dying and their main goal is for the patient to have comfort and a peaceful transition at home [surrounded] by his loved ones.” Upon her arrival, APRN G administered a dose of concentrated Morphine Sulfate 10mg SL, 0.5 ml of liquid, due to patient #1s pain and shortness of breath. Review of a Nursing-Updated Comprehensive Assessment dated 12/04/23 revealed patient #1s RN Case Manager (CM) arrived at his home at 3:35 PM, soon after APRN G. The note indicated the patient required Continuous Care for symptoms of fever, agitation, and pain, but there was no Continuous Care staff available yet. On 7/02/24 at 10:00 AM, in a telephone interview with patient #1s son, he explained on the morning of 12/03/23, hospital staff informed the family his father was entering the actively dying stage. He recalled the family was united in the decision to get his father home, where he could die in peace and comfort. The son explained the primary focus was to keep his father comfortable. He recalled his father was transported home on 12/03/24 at about 6:30 PM but was not seen by the hospice nurse on arrival as promised. Patient #1s son said, “;My dad was in bed suffering. He was alert enough to hear himself gurgling. He was short of breath and in pain. You could see the distress in his face. He was grunting.” The son explained his father suffered pain levels between 7 and 10 on a 0 to 10 scale throughout the night. He confirmed RN E arrived at about 6:00 AM, approximately 12 hours after his father arrived home, but she was unable to get physician orders for comfort medications, including the correct concentration of Morphine Sulfate, from the on-call physician. He explained RN E managed to obtain orders from the Team Physician after the change of shift, but the medications were not ready for pick up until mid-afternoon, just before the RN CM arrived. On 7/03/24 at 11:06 AM, the Team Physician confirmed she received report from an on-call nurse on 12/04/23 regarding patient #1s status, symptoms, and needs. She explained the patients symptoms were typical of the dying process and her orders reflected necessary medications to manage the symptoms. The Team Physician validated her expectation was staff would follow processes to ensure medications were either available in the home or accessible in a timely manner. On 7/03/24 at 3:24 PM, APRN G recalled the Team Physician asked her to visit patient #1 due to a change in condition and the need for pain management. She reviewed her schedule and stated she received the visit order on 12/04/23 at 10:56 AM. APRN G stated when she arrived at the home, the patients son was very angry and disappointed that his father came home on hospice services and did not receive the care he deserved. APRN G explained on her arrival, patient #1 was in severe distress. She stated he had apnea, he was moaning, and he had shortness of breath at rest. APRN G explained she medicated patient #1 with the SL Morphine Sulfate 20 mg/ml solution that was at the bedside. She was informed the patient had not received any medication prior to the dose she administered during the 21 hours since he arrived home. APRN G stated the SL Morphine Sulfate was effective and patient #1 appeared comfortable when she left the home an hour later. She acknowledged the goal of hospice services was to ensure comfort at the end of life, but patient #1 when she arrived. On 7/02/24 at 11:30 AM and 12:26 PM, Patient Care Administrator (PCA) B provided patient #1s Medication List which showed an admission physician order dated 10/17/23 for Morphine Sulfate 10 mg/5 ml oral solution. There was another order dated 10/19/23 for Morphine Sulfate 20 mg/ml SL solution. PCA B was informed patient #1s son reported his father was unable to swallow 5 ml of the Morphine Sulfate oral solution for the required 10 mg dose, and there was no other Morphine in the home. PCA B obtained medication delivery records from the pharmacy that showed the Morphine Sulfate 20 mg/ml was never delivered to patient #1. She stated the drug was ordered and profiled by the pharmacy in recognition that the patient might need it, but it was never activated. PCA B explained this was standard procedure on admission to make it easier to acquire the medication since there was already an order. PCA B validated the purpose was to prevent patients waiting for long periods of time for medications. She stated she was not sure why this order was not called in to the pharmacy when hospice staff were informed patient #1 was returning home from the hospital. Review of the hospice agencys policy for Patient Rights (undated) revealed patients had the right to receive effective pain management and symptom control. Review of the hospice agencys Admission Booklet (undated) revealed the hospice agency would provide comfort care including pain and symptom management. The document read, “;The care we provide focuses on relieving the symptoms of the illness, controlling pain, reducing anxiety and improving quality of life.””

“Based on interview and record review, the hospice agencys Quality Assurance and Performance Improvement (QAPI) program failed to effectively utilize the grievance process and monitor medical records to ensure end-of life experiences met the goals of patients and caregivers and reflected the standards of the hospice agency for 1 of 4 patients reviewed for Patient Rights, out of a total sample of 4 patients, (#1). Review of the medical record revealed patient #1, a 78-year-old male, was admitted to the hospice agency on 10/17/23. The Case Sheet indicated his terminal diagnosis was lung cancer and his secondary diagnoses included cancers of the prostate, brain, and bone, seizures, and atherosclerotic heart disease. On 7/02/24 at 10:00 AM, in a telephone interview with patient #1s son, he stated the hospice agency was made aware of his fathers planned discharge from the hospital, and they promised to send a nurse to assess his needs when he arrived home. He explained his father arrived home on 12/03/23 at approximately 6:30 PM but suffered without medications and nursing care throughout the next 12 hours until a nurse arrived at approximately 6:00 AM. Patient #1s son recalled the nurse eventually obtained physician orders, but the medications were not ready for pick up until mid-afternoon, 21 hours after he arrived home. He confirmed he expressed his concerns regarding the delay in care and services for his father to multiple staff, but the hospice agency did not reach out to him until he posted a negative online review. On 7/02/23 at 3:35 PM, Team Manager (TM) C confirmed she spoke to patient #1s son on 12/04/23 and he informed her there were no comfort medications and no nurse in the home when his father arrived from the hospital the previous night. TM C stated she did not document his concerns as a service comment. She explained, “;Every problem he presented, I followed up to ensure he received answers and care.” TM C acknowledged that although she dealt with immediate issues as presented by the patients son, without a service comment, the QAPI process was not implemented and there was no investigation to discover the root cause of the events. On 7/03/24 at 12:15 PM, in a telephone interview, the Performance Improvement (PI) Specialist explained her QAPI program responsibilities included data entry from service comments or grievances, consumer survey results regarding their hospice experience, and incident reports. She explained she pulled reports from the agencys reporting program and reviewed the data monthly. The PI Specialist explained she ran reports from the service comment log and then submitted the data in the QAPI Update Report (QUR) for review by upper management. She stated if she noted a significant trend or became aware of a serious occurrence, she would inform her managers. She was informed grievances made by patient #1s son in December 2023 were not recorded on a service comment form. She stated she only became aware of the concerns during the current State Survey Agency investigation, when she was asked to print the service comment created by Patient Care Administrator (PCA) B in June 2024, in response to a negative online review by patient #1s son. When asked if she read the service comments, the PI Specialist said, “;No, not the ones I dont put in myself.” She explained service comments were organized in categories for the QUR and there was not a single person who reviewed them all for content. She stated a PCA signed off on each service comment, but she acknowledged that process did not ensure the QAPI program would identify trends within categories that might not trigger on a broader report. The PI Specialist verified service comments were an important method of identifying problem areas that required a Performance Improvement Plan (PIP). She was informed multiple staff documented the concerns expressed by patient #1s son within the medical record but the notes did not trigger a service comment or investigation or (PIP). The PI Specialist stated to her knowledge, the hospice agency did not have a process in place to ensure charts were reviewed after patients expired, to determine if care and services were provided and all their needs were met according to the plan of care. On 7/03/24 at 12:37 PM, the Senior General Manager (GM) verified she was not aware of the concerns related to a delay in care and services for patient #1 or grievances expressed by his family until she was informed of the online review. The Senior GM acknowledged since staff did not record the concerns on a service comment, the issues were not addressed by the QAPI process. She confirmed the hospice agency did not perform a root cause analysis to identify causative factors including possible system or process failures that could have contributed to patient #1s experience. Review of the hospice agencys policy on Quality Assessment and Performance Improvement (undated) revealed the purpose to develop, implement, and maintain an effective and on-going performance improvement program that tracked events, analyzed causes, and implemented appropriate preventative measures. The hospice agencys policy for the QAPI Update Report (QUR) Process, dated 2/14/23, revealed the monthly report would provide consistent communication on QAP issues with the agencys parent and branch programs. The policy read, “;The report facilitates the identification of significant findings, including potential trends, and the need for further investigation and monitoring.” The QUR involved results of root cause analyses and determination of necessary resources. The document indicated the PI Specialist was responsible for scheduling monthly meetings to discuss significant findings and sending the report to designated members of administration.”

“Based on interview and record review, the hospice agency failed to provide care and services that prioritized comfort during the dying process, according to the goals of 1of 4 patients reviewed for Patient Rights, (#1), and all patients who received services from the hospice agency. Review of the hospice agencys Admission Booklet (undated) revealed the hospice agency would provide comfort care including pain and symptom management to enhance the quality of life for patients diagnosed with terminal conditions. The document indicated the patient and family input was fundamental in determining goals and care needs and the hospice agencys interdisciplinary team would create and implement a person-centered plan of care that reflected those needs. On 7/02/24 at 10:00 AM, in a telephone interview with patient #1s son, he explained his father selected hospice services in October 2023 as his cancer diagnoses were not responding to aggressive therapies. He stated after an overnight hospitalization in December 2023, hospital staff informed the family his father was entering the stage of actively dying. He recalled the family was united in the decision to get his father home, where he could die in peace and comfort. The son emphasized the primary focus was to keep his father comfortable. Patient #1s son stated instead of ensuring his fathers comfort at the end of his life, the hospice agency contributed to his suffering as he waited 12 hours for a nurse, then waited approximately another nine hours to obtain comfort medications. Review of patient #1s medical record revealed a Nursing-Updated Comprehensive Assessment dated 12/04/23 that showed when patient #1 was assessed by a hospice nurse, he exhibited signs and symptoms of pain, agitation, and respiratory distress. The document indicated the patients family was upset as the patient had to wait 12 hours for a nursing visit and he did not have appropriate pain medication in the home. The nursing notes showed the patient did not receive medication to manage his pain and respiratory distress until 12/04/23 at 3:30 PM, approximately 21 hours after his arrival home from the hospital. On 7/03/24 at 11:06 AM, the Team Physician stated her expectation was that hospice staff would follow established processes to ensure comfort medications were either available in the home or accessible in a timely manner. She explained good collaboration between hospice nurses, physicians, patients, and family was necessary to promote optimal outcomes for the patient. The Team Physician acknowledged it was not acceptable if patient #1 waited almost 24 hours for medication while he experienced pain and other unmanaged symptoms. On 7/03/24 at 3:24 PM, Advanced Practice Registered Nurse (APRN) G confirmed she visited patient #1s home on 12/04/23 at 3:25 PM. She recalled the patients son was very angry and disappointed that his father returned home from the hospital on hospice services but did not receive the care the family felt he deserved. APRN G explained the goal of hospice care was to ensure comfort at the end of life and confirmed patient #1 was not comfortable when she arrived at his home. On 7/03//24 at 4:49 PM, Patient Care Administrator (PCA) I reviewed after-hours staffing for 12/03/23 to 12/04/23. She stated during the overnight shift, there was a total of three on-call nurses available, two Registered Nurses (RNs) and one Licensed Practical Nurse (LPN). She reviewed the Telecare Call log and dispatch information and confirmed patient #1s nursing visit was upgraded from a P2 to a P1, or high priority visit, on 12/03/23 at 6:19 PM. PCA I acknowledged the patients P1 visit was already pending for almost one hour when one of the RNs began her shift at 7:00 PM, and still was not assigned almost six hours later when the LPN and RN E arrived for the midnight shift. PCA I explained the Telecare dispatchers should have assigned the RN who arrived at 7:00 PM to visit patient #1, and if there were other P1 visit requests, the patient should have been seen before the P2 visits were assigned. PCA I confirmed P2 visits were completed while patient #1 waited for a nurse. She stated the Telecare manager was responsible for tracking visits, and if a request was unattended in the queue for an hour or two, it should be sent back to the triage nurse for re-evaluation. PCA I explained her expectation was the Telecare triage nurse would reach out to the patient or family to offer a telehealth video call in the meantime to address to assess symptoms and re-prioritize visits if indicated. PCA I was informed there was no offer of a Telehealth visit and no efforts by Telecare nurses or non-clinical staff to reach out to patient #1s family during the 12-hour wait for the nursing visit. She was informed patient #1 had sublingual Morphine Sulfate profiled on his medication list, but the order was not called in until after RN spoke to the Team Physician on 12/04/23 at 9:00 AM. PCA I said, “;If there is an active script then it can be called in to a pharmacy by the triage nurse. The on-call nurse would not have to visit before that was done.” She verified the family could have picked up and administered the drug to maintain the patients comfort.”

“Based on interview and record review, the hospice agency failed to ensure nursing and physician services were available 24 hours daily and 7 days weekly to promptly address changes in condition and unmanaged symptoms for 1 of 4 patients reviewed for Patient Rights, (#1), and all patients who received services from the hospice agency. Review of the hospice agencys Admission Booklet (undated) revealed the care provided to hospice patients would focus on the management of symptoms associated with a terminal illness such as controlling pain and reducing anxiety. The booklet indicated a hospice nurse was available 24 hours daily and 365 days a year. The document instructed patients and families to utilize the telephone number provided to speak with an after-hours Telecare nurse regarding urgent situations or any concerns. “;A nurse is always just a phone call away to answer questions, provide support or make an unscheduled visit, depending on your needs.” On 7/02/24 at 10:00 AM, in a telephone interview with patient #1s son, he explained his father returned home on 12/03/23 after an overnight hospital stay. He stated the hospital SW and his mother communicated with after-hours staff at the hospice agencys call center regarding his fathers discharge plans and needs when he arrived home. The son stated the hospice agency assured them a nurse would visit the home at about 6:00 PM to assess his father and ensure he was comfortable. Patient #1s son stated the hospice nurse did not show up as promised and after waiting for about an hour the family members repeatedly called the hospice on-call staff regarding a nurse visit and the need for pain medication as their father could no longer swallow the medication he had in the home. He said, “;We kept getting the on-call people who said they dont have anything on him, and he doesnt exist in their system.” The patients son stated he unsuccessfully tried to explain that his father had been on hospice services since October 2023. He recalled a nurse arrived at the home on 12/04/23 at about 6:30 AM and informed them she was there to register his father for hospice service. The son stated the nurse called the on-call physician for orders for comfort medications, but the on-call physician said, “;It is shift change. I dont have time to deal with this right now.” He recalled the nurse finally got medication orders from another physician and he was able to pick up the drugs at the pharmacy at about 3:00 PM that afternoon. Review of the hospice agencys Telecare Call log revealed communication between the hospital Social Worker (SW), patient #1s family, and the hospice agency on 12/03/23, prior to his discharge home from the hospital. The document indicated the hospital SW contacted the hospice call center on 12/03/23 at 2:32 PM regarding patient #1s impending discharge and his care needs. The Telecare Call log revealed on 12/03/23 at 6:09 PM, patient #1s wife notified the hospice agency that her husband was on the way home from the hospital and they needed a nurse to visit the home. The document was updated at 6:19 PM by a triage nurse to show the visit request was upgraded to a Priority 1 or P1 level which indicated it was the highest priority level. The note read, “;Nurse visit needed for Tuck in Visit. Wife just called. Patient is on their way home now. Requesting a nurse visit for Tuck In. Dispatch requested.” The Telecare Call log revealed on 12/04/23 at 4:54 AM, an on-call nurse, RN E, contacted the hospice agency call center staff and stated she received a message regarding a visit, but it was blank. The call center provided her with patient #1s name, address, and phone number. Review of an Addendum to Interdisciplinary Note dated 12/04/23 revealed Registered Nurse (RN) E received a visit request via her cell phone five times, but each entry was blank, without any information from Telecare. She noted she attempted to retrieve the information from the scheduling application and the documents application, but neither source was available. Next, RN E emailed the dispatcher and then followed up with a phone call. She was informed the dispatcher was on break, so she told the Patient Care Coordinator (PCC) about the issues retrieving the visit information. The PCC emailed the dispatcher and eventually RN E received patient #1s address and phone number. The dispatcher did not get back to RN E with any additional information, so she called the telephone number at 5:00 AM and patient #1s wife told her they still wanted a visit. The document revealed RN E contacted the on-call physician at approximately 7:30 AM and received an order to administer the Morphine Sulfate liquid that was currently available in the home and have the regular interdisciplinary team follow up during the day. The note indicated the family was not satisfied with the on-call doctors order to administer the medication that choked the patient or that they had to wait until day shift staff were available. RN E documented that she called the team at 8:14 AM and was eventually able to communicate with the Team Physician at 9:00 AM. She obtained a physician order for the appropriate concentration of Morphine Sulfate pain and other medications for end-of-life symptom management and began the process of calling pharmacies to determine availability of the drugs. The note read, “;The son [name of son] apologized that its not me that they are upset at, but the people around who failed to do their job. . .because they failed their mission.” On 7/02/24 at 10:35 AM and 10:59 AM, Patient Care Administrator (PCA) B stated there was no evidence patient #1s family called several times throughout the nightshift as they waited for a nurse to show up. She explained nurses should have access to the documents application where they can retrieve face sheets, progress notes, and medication lists. She was informed RN Es note indicated those systems were not accessible on 12/04/23 when she attempted to access her assigned visit. PCA B explained the electronic medical record system might be down for scheduled updates on Sundays, but to her knowledge there was a back up system and tickets could also be entered manually. On 7/02/23 at 2:29 PM, the hospice agencys Director of Customer Service explained Telecare triage nurses and on-call nurses had access to the same electronic medical record system from which they retrieved all necessary patient information. She stated Telecare staff were expected to follow the process and open a ticket to document every call they received. The Director of Customer Service reviewed the Telecare Call log for 12/03/23 to 12/04/23 and confirmed after patient #1s visit was upgraded to a P1, the next entry at 10:08 PM, about four hours later, indicated the dispatcher remained aware of the need for a visit for patient #1. She said, “;It looks like there was a bit of a delay. It was a substantial gap in time.” She acknowledged the Team Manager on call was not made aware of the delay until 11:33 PM. The Director of Customer Service stated her records showed RN E was paged on 12/04/23 at 2:25 AM, approximately eight hours after the initial after-hours nursing visit was scheduled. She confirmed RN contacted telecare staff at 4:54 AM for information regarding the visit. The Director of Customer Service acknowledged there was definitely a significant delay in providing the nursing visit and she was never made aware of any of the issues reported by RN E. She validated Telecares ability to maintain communication with nurses, patients, or family members was essential to the provision of care. She said, “;That is what makes us available 24/7, to send out not only nurses, but Social Workers, Chaplain, and anyone or anything to meet the patients needs.” On 7/03/24 at 11:06 AM, the Team Physician confirmed she gave orders for comfort medications for patient #1 when she was contacted by the nurse on 12/04/23 at 9:00 AM. She stated if she were on call and a nurse reported a patient had unmanaged symptoms, she would immediately order comfort medications, even if it was at the change of shift, and instruct the nurse to have the team follow up. The Team Physician stated any physician would have given order based on the nurses assessment and the patients needs. On 7/03/24 at 1:15 PM, in a telephone interview, RN H, the Night Supervisor, stated on 12/03/23 at about 2:00 PM, she communicated with the hospital Social Worker and was made aware patient #1 would be discharged home. She acknowledged the nursing visit was escalated to a P1 level after the patients wife called at about 6:00 PM. RN H verified when the dispatcher for the next shift came on, she was informed at 11:33 PM that the visit was still pending. RN H said, “;It is a concern that four and a half hours later the visit was still pending. Most of the time it is a staffing issue.” She stated nurses attempted to visit the patients as soon as possible, but it might take up to five hours. RN H stated all nurses out on visits and unfortunately, at that time, there was probably no nurse available. Review of the hospice agencys policy for Telecare, dated 2/17/21, revealed the services was responsible for triaging patients needs, dispatching staff, and providing telephonic patient care. The document indicated Telecare staff would document all initial calls and forward calls that are clinical in nature to a triage nurse. The policy indicated the triage nurse would determine the priority level of a visit depending on the needs of the patient or family. The document included instruction for a P1 level visit. “;Dispatch the visit within one hour of completing the phone assessment.” The policy indicated the on-call nurse would document the purpose of the visit based on Telecare information, assess the patient, and “;contact the appropriate physician to report a change in the patients condition, and to obtain any necessary orders.””

“Based on review of the Hospice’s Standards of Care, record review and interview, the Plans of Care for 3 of 4 sampled patients failed to include all services, treatments and supplies or appliances necessary for their care (Patient #1, #2 and #5). The findings included: 1) The hospices Standards of Care titled VS Care Planning, provided by Patient Care Administrator, Staff A in lieu of Policies and Procedures, updated 05/16/23, documents “;The plan of care must specify the hospice care and services necessary to meet the patient and family-specific needs identified in the comprehensive assessment as such needs relate to the terminal illness and related conditions” and “;...content of the plan of care: Best practices... Covered supplies – supplies covered on the hospice plan of care should be documented on the POC (Plan Of Care).” (Parenthesis added.) The hospices Standards of Care titled, “VS Plan Of Care Revision/Physician Order,” as of 7/29/20, provided by Staff A in lieu of Policies and Procedures documents, “;Standard: Plan of care. All hospice care services furnished to patients and their families must follow an individualized written plan of care...” and “;Content of the plan of care ... The plan of care must reflect patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions” and “;ALL orders are documented, including those that are not related to the primary hospice diagnosis, or as well as those related to the primary diagnosis. ... all orders include: ...-Supplies -Treatments -Physician specialty consults...” and, under “;Non-Pharmacological Orders to Achieve Expected Outcomes” “;... Document non-pharmalogical orders, such as: ...-Treatments -Dressing changes -Foley catheters -Tube feeding -Etc.” Review of Patient #1s record reveals the patient was admitted to hospice care on 07/10/21 and had a diagnosis requiring hospice services. Patient #1s Plan of Care Review dated 07/18/23 documents under “Response to Care & Updates to Comprehensive Assessment,” for the Plan of Care Category “;Gastrointestinal” that the patient’s appetite was poor, the patient ate less than 25% of each meal and included no interventions or nutritional supplements to address this. During a telephonic interview on 03/11/24 beginning at 4:11 PM, Registered Nurse, Staff F stated Patient #1 needed a case of Ensure (a brand of nutritional supplement) weekly that was supposed to be provided by the hospice since the patient was not eating at least 25% of their meals and Ensure was the primary source of nutrition. Review of the “Hospices Supply Order Record,” for Patient #1 reveals 5 cases of Ensure (24 items per case) were ordered and delivered for Patient #1 between 07/17/23 and 08/21/23. Further review of the “Hospices Supply Order Record” reveals multiple orders for skin protectant creams, moist wipes, incontinence briefs and pull-ups, shampoos, lotions, absorbent underpads, and gloves for Patient #1 between 07/03/23 and 09/14/23 although these items were not documented to be provided by the Hospice or as necessary for care on Patient #1s “Plan of Care Reviews” dated 07/18/23, 08/01/23, 08/29/23, 09/12/23, and 09/26/23. Patient #1s “Report of Death” reveals the patient died on 09/29/23. 2) Review of Patient #2s record reveals the patient was admitted to Hospice care on 11/28/23 and had a diagnosis requiring Hospice services. Patient #2s “Pre-Admit Evaluation” documents the patient had a Stage IV Sacral pressure ulcer. (Stage IV pressure ulcers are a type of pressure ulcers with extensive tissue damage that may affect muscle, tendons or bone). “Patient #2s “Admission Orders/Hospice Certification/Initial Plan of Care” dated 11/28/23 documents orders for medications, diet, and durable medical equipment needed for the patient’s care but does not include directions for wound care, who was to perform wound care and how often, or document any wound care supplies or disposable supplies needed for Patient #2s care. Patient #2s “Initial General Plan of Care/Interdisciplinary Care Plan,” dated 11/28/23 includes the outcome (goal) for Patient #2 to be free of pain/SOB (Shortness of Breath)/agitation but does not include the wound care to be provided. Patient #2s RN (Registered Nurse)-“Initial Comprehensive Assessment” dated 11/30/23 documents, “;Stage IV wound in the sacrum” without documentation of wound care orders or method and products used. Patient #2s Interdisciplinary Plan Of Care Revision, dated 11/30/23 includes to assess wound and skin each visit, to provide wound care as ordered by the physician, and to train the caregiver on signs and symptoms of infection and proper wound care treatment; but no evidence of documentation of directions for the frequency, method, or products to be used for wound care or of supplies needed. Patient #2s Plan of Care Reviews, dated 12/03/23, 12/20/23, and 01/03/24 also included no evidence of documentation of directions for the frequency, method or products to be used for wound care or of supplies needed. Patient #2s wound specialists “Consultation Note,” dated 12/08/23 documents the patient was to have wound care to the sacral wound daily and to the left buttock wound three times a week with Saline, Calcium Alginate (type of dressing), and dry dressings. Patient #2s next nurse visit was documented on 12/11/23 with wound care performed, although the products and method used were not documented. There was no evidence of documentation of an update to the Plan of Care to incorporate the new wound care regimen. Patient #2 was not visited for wound care again until the “Wound Specialist’s Visit Note,” dated 12/15/23 that documents the sacral/coccyx wound was worsening; directions for daily wound care to the sacral/coccyx wound with wound cleanser, Calcium Alginate packing, and a dry dressing; and directions for 3 times weekly wound care to the left buttock with wound cleanser, Calcium Alginate, and a dry dressing. There was no evidence of documentation of an update to the Plan of Care to incorporate this wound care regimen. Patient #2s next nurse visit was documented on 12/18/23 with interventions performed, “;monitor for worsening of wound, turn/reposition Q (every) 2 hours” and no evidence of documentation that wound care was completed. There was no evidence of documentation that Patient #2 was visited again until the “Wound Specialist’s Visit Note,” dated 12/22/23 which reveals the sacral/coccyx and left buttock wounds were both worsening or deteriorating and new directions for care of both wounds: for the nurse to cleanse with Dakins (type of wound cleansing) ¼ strength solution, Calcium Alginate to the wound bed, and cover with dry dressing three times weekly. There was no evidence of documentation of an update to the Plan of Care to incorporate the new wound care regimen. Patient #2s next nurse visit was documented on 12/25/23 with “Interventions performed” that include, “;Perform wound care” without a description of what was done, the products used, and the visit follow up plan documents to continue the current Plan of Care and does not document a new nurse visit frequency or the new wound care regimen. Patient #2s next nurse visit note was documented on 01/01/24 with wound care that was already done, and the RN was “;unable to assist and produce wound care,” although there was no evidence of documentation that the caregiver was ever taught how to do wound care or provided the materials to be used. “A Focus Visit Plan of Care Revision,” dated 01/01/24 documents wound care per “;POC Revision/Physician Order”, to monitor “;Wound to sacral”, but no evidence of documentation of directions for wound care and no “POC Revision/Physician Order” was found in the patient’s clinical record with orders for wound care. “A Nursing-Updated Comprehensive Assessment,” dated 01/03/24 documents a sacral Stage II (partially skin deep) wound but includes no evidence wound care was performed. Patient #2s next nurse visit note, dated 01/04/24 documents, “;Wound care sacrum”, interventions performed “;monitor wound”, with no description of what was done for wound care. Patient #2s next nurse visit dated 01/08 does not document wound care methods or products used. Patient #2s physician’s order dated 01/10/24 includes to obtain wound care consult for dressing information and nurse to assess wound and perform wound care with no frequency documented. The “Wound Specialists Visit Note,” dated 01/10/24 documents the sacral/coccyx and left buttock wounds were both deteriorating, that there were signs of infection of the sacral/coccyx wound, and directions for care of both wounds: for the nurse to cleanse with Dakins ¼ strength solution, Calcium Alginate to the wound bed, and cover with dry dressing three times weekly. Patient #2s nurse visit note, dated 01/11/24 documents, “;open pressure on ... (Patient #2’s) coccyx”, that the wound was cleaned with Normal Saline, Medihoney (wound dressing) was applied and foam dressing on top of wound, although these products were not ordered, and there is no evidence of documentation of any care of the left buttock wound. This was Patient #2s last nursing visit before the patient’s death on 01/14/24. A Plan of Care Revision dated 01/17/24 describes Patient #2 as alert but not oriented, the plan to continue Oxygen as needed and teach the family pain management and does not document the patient’s death 3 days before, although a Social Worker documented completing the “Death Visit” on 01/14/24 and a Chaplain documented bereavement contact with the family on 01/16/24. Review of the “Hospices Supply Order Record,” for Patient #2 between 12/12/23 and 01/10/24 reveals supply orders for wound cleanser, bordered foam dressings, highly absorbent gelling fiber (indicated for heavily draining wounds) dressings, oil emulsion (petrolatum and oil) absorbent dressing strips, Iodoflex pads (antimicrobial impregnated gauze), and Iodoform packing strips; but no Dakins ¼ strength solution or Calcium Alginate, as recommended by the wound specialist who was consulted for wound care. During telephonic interview on 03/11/24 beginning at 4:11 PM, Registered Nurse, Staff F stated Patient #2 needed wound care by the Hospice nurse 3 times weekly but was not seen 3 times weekly. During interview on 03/11/24 at 2:13 PM, when Patient Care Administrator, Staff A and Patient Care Administrator, Staff G were asked if Patient #2 had physician’s orders for wound care and wound care supplies, Staff A was unable to provide further orders but explained Registered Nurse, Staff F and Registered Nurse, Staff H who had been involved in Patient #2s care were no longer from employed by the Hospice. Further review of the record reveals Staff F and Staff H were not the nurses who documented Patient #2s “Admission Orders” on 11/28/23, the “Initial Comprehensive Assessment and Plan Of Care Revisions” with a visit on 11/30/23, the “Plan Of Care Review” on 12/03/23, or nurse visits on 01/01/24, 01/11/24 and that these were done by 4 different nurses other than Staff F and Staff H. 3) Review of Patient #5s record reveals the patient was re-admitted to Hospice care on 11/04/23 with a diagnosis requiring Hospice services and the patient’s “;Admission Orders/Hospice Certification/Initial Plan of Care” include continuous Oxygen at 4 liters per minute and no orders or documentation of the patient having a PleurX catheter (chest tube to drain fluid) or of care and supplies needed to maintain the chest tube and the patients respiratory status. Review of the “Hospices Supply Order Record,” for Patient #5 between 10/25/23 and 01/11/24 reveals supply orders for 500 ml (milliliter) Pleurx drainage catheter kits beginning with one kit on 10/25/23, during the patient’s previous time on Hospice service and 5 to 6 kits ordered and delivered nearly weekly until 01/11/24. Review of Patient #5s “Interdisciplinary Plan of Care Revisions,” dated 11/6/23 reveals they address fall risk and pain and do not include orders or interventions to address care and/or drainage of the chest tube to prevent fluid accumulation. Patient #5s “Plan of Care Review,” dated 11/8/23 includes for the “Integumentary (Skin)” category “;Left side chest tube, provide care”, however the “Respiratory” category has no evidence of documentation of the presence of the chest tube or of the use or non-use of Oxygen as ordered, and documents “;no s/s (signs/symptoms) of respiratory distress.” Patient #5s “Plan of Care Review, “dated 11/15/23 documents for the “Musculoskeletal” and “Integumentary” categories “;left side PleurX drain, care provided” and in the “Respiratory” category that the patient is on room air and no dyspnea (shortness of breath) noted. Patient #5’s “Plan of Care Review,” dated 11/29/23 documents in the “Respiratory” category that the patient is on room air and uses Oxygen as needed, and in the “Integumentary” category. “;Skin intact, PleurX drain in left side.” Patient #5s “Plan of Care Review, “dated 12/13/23 documents in the “Respiratory” category that the patient is on 2 liters of Oxygen as needed and in the “Integumentary” category, “;Skin intact, PleurX drain in left side.” Patient #5s “Plan of Care Review,” dated 12/27/23 documents in the “Respiratory” category that the patient is on 2 liters of Oxygen as needed for shortness of breath and in the “Integumentary” category, “;Skin intact, PleurX drain left site dry and intact.” Patient #5s “Interdisciplinary Plan of Care Revisions,” dated 01/01/24 documents to monitor PleurX drain, and does not direct any care to be provided to the chest tube site to prevent infection or supplies needed. Patient #5s “Plan of Care Review,” dated 01/10/24 documents in the “Respiratory” category that the patient is on 2 liters Oxygen as needed for shortness of breath and in the “Integumentary” category “;PleurX drain left side dry intact.” During an interview on 03/13/24 at 10:40 AM, Patient Care Administrator, Staff A stated supplies needed are not on the Plans of Care.”

“Based on record review and interview, the Hospice failed to follow their standards of care to ensure the plan of care was reviewed and updated by the interdisciplinary group at least every 15 days for two of four sampled patients (Patient #2 and Patient #4). The findings included: 1) Review of the Hospice’s Standard of Care, provided in lieu of Policies and Procedures. titled, Care Planning, updated 05/16/23, documents under Standard, Review of the Plan of Care, “;The hospice interdisciplinary group (in collaboration with the individuals attending physician, if any) must review, revise and document the individualized plan as frequently as the patients condition requires, but no less frequently than every 15 days. A revised plan of care must include information from the patients updated comprehensive assessment and must note the patients progress toward outcomes and goals specified in the plan of care.” Review of Patient #2s record reveals the patient was admitted for Hospice services on 11/28/23, had an “Interdisciplinary Care Plan/Initial General Plan of Care,” dated 11/28/23, an “Initial Bereavement Plan of Care,” dated 11/30/23, and “Interdisciplinary Care Plan/Initial EOL (End Of Life) POC (Plan Of Care),” dated 11/30/23. Further record review reveals Patient #2 had “Plan Of Care Reviews” dated 12/20/23, 01/03/24, and 01/17/24. Patient #2s “Florida Death Record” documents that the patient died on 01/14/24 at 1:00 PM. Patient #2s “Plan Of Care Review,” dated 01/17/24 documents the patient was alert but not oriented, had an unstageable sacral wound, used Oxygen as needed, and nursing would teach the family about pain management. During an interview on 03/13/24 at 11:35 AM, Patient Care Administrator, Staff A was asked whether Patient #2 had any “Plan of Care Reviews” by the InterDisciplinaryGroup (IDG) between 11/28/23 and 12/20/23. During further interview on 03/13/24 at 11:45 AM, Staff A stated they are missing Patient #2s Plan of Care Review for “;12/3.” On 03/13/24 at 2:00 PM, Staff A provided a “Plan of Care Review” for Patient #2, dated 12/03/23 and signed only by a nurse, Staff B and no other IDG members. Further review reveals 12/03/23 is a Sunday and review of the IDG calendar reveals IDG meetings are held only on weekdays, specifically 3 weekdays a week, as confirmed with Staff A during an interview on 03/12/24 at 2:45 PM. Staff A could provide no evidence of a “Plan of Care Review” by the IDG for Patient #2 between 12/03/23 and 12/20/23. During interview on 03/13/24 at 11:45 AM, Staff A was asked about Patient #2s “Plan of Care Review,” dated 01/17/24, 3 days after Patient #2 died, and Staff A explained they review patients for bereavement needs at the IDG meeting following their death, but could not explain why the team members signed off on continuing the current “Plan of Care” without any of them documenting that the patient died, including the Chaplain, Staff C, who documented elsewhere a bereavement contact with the family on 01/16/24, the day before that meeting. 2) Review of the record for Patient #4 reveals the patient was admitted to Hospice services on 12/21/23, the “Admission Orders/ Hospice Certification/Initial Plan of Care” is dated 12/21/23, and further review reveals Patient #4 died on 01/14/24. Continued review of the record reveals no evidence of an IDG meeting with a “Plan Of Care Review” until 01/17/24. Review of the “Plan Of Care Review,” dated 01/17/24 reveals no change to the visit frequency and the “Plan of Care” that it was signed by a Registered Nurse; Chaplain, Staff C; and Social Worker, Staff E, although Patient #4 died on 01/14/24. During the interview on 03/13/24 at 1:36 PM, Patient Care Administrator, Staff D was asked about any evidence of an IDG meeting with “Plan of Care Review” between Patient #4s admission on 12/21/23 and 01/17/24. Staff D was unable to provide evidence of a “Plan of Care Review” within 15 days of the initial “Plan of Care” on 12/21/23, or before 01/17/24. During a telephonic interview with the Chaplain, Staff C on 03/13/24 at 2:57 PM, he stated in the IDG meeting they go over the patients who died in the previous 2 weeks as well as discuss current patients, and confirmed he contacted the families of Patient #2 and #4 with condolences before that meeting but could not explain signing for continuing their “Plans of Care” as he denied remembering doing this. During a telephonic interview on 03/13/24 with the Social Worker, Staff E who signed “Plan Of Care Revisions” on 01/17/24 for Patient #2 and #4, both three days after their deaths, she reported they discuss new patients in the next IDG after their admission, even if it is the next day, and go over deaths in the prior 2 weeks to the IDG meeting; was unable to explain the missing “Plan of Care Reviews” after admissions; and stated that although sometimes mistakes happen, their communication is “;spot on.””

“Based on record review and interview, the Hospice failed to coordinate care with all disciplines for 1 of 4 sampled patients as evidenced by Patient #2 who the Hospice consulted for wound care but did not obtain and follow directions for this wound care, resulting in recommended treatments not being followed (Patient #2). The findings included: Review of Patient #2s record reveals the patient was admitted to Hospice care on 11/28/23 and had a diagnosis requiring Hospice services. Patient #2s “Pre-Admit Evaluation” documents the patient had a Stage IV Sacral pressure ulcer. (Stage IV pressure ulcers are a type of pressure ulcers with extensive tissue damage that may affect muscle, tendons or bone). Patient #2s “Admission Orders/Hospice Certification/Initial Plan of Care,” dated 11/28/23 documents orders for medications, diet, and durable medical equipment needed for the patient’s care but does not include directions for wound care, who was to perform wound care and how often, or document any wound care supplies or other disposable supplies needed for Patient #2s care. Patient #2s “Initial General Plan of Care/Interdisciplinary Care Plan,” dated 11/28/23 includes the outcome (goal) for Patient #2 to be free of pain/SOB (Shortness of Breath)/agitation but also does not include the wound care to be provided. Patient #2s “Plan of Care Review,” dated 12/03/23 included no evidence of directions for the frequency, method or products to be used for wound care or of supplies needed. A “Physician Order” for “;Wound Eval (Evaluation)” that documented it was related to the Hospice diagnosis was dated 12/06/23. However, review of the record reveals no evidence of wound consultation notes. During an interview on 03/12/24 at 9:54 AM, Patient Care Administrator, Staff A stated the “Wound Specialists” orders and consultation notes were not in the record, but she would ask the doctors office to send them. On 03/12/24 at 12:50 PM, Staff A provided Patient #2s “Wound Specialists” “Consultation Note,” dated 12/08/23 that she stated was obtained from the physicians office per the surveyors request; but was unable to explain why they were not in Patient #2s record and why the hospice did not have them to direct the patient’s care. After inquiry on 03/13/24 at 11:51 AM for any additional wound care consultation notes, additional notes were provided by Staff A on 03/13/24 at 12:40 PM. The “Wound Specialists Consultation Note,” dated 12/08/23 documents Patient #2 was to have wound care to the sacral wound daily and to the left buttock wound three times a week with Saline, Calcium Alginate (wound dressing), and dry dressings. However, Patient #2s next nurse visit was documented on 12/11/23 with wound care performed, although the products and method used were not documented. There was no evidence of documentation Patient #2 was visited again until the “Wound Specialists Visit Note,” dated 12/15/23 that documents the sacral/coccyx wound was worsening; directions for daily wound care to the sacral/coccyx wound with wound cleanser, Calcium Alginate packing, and a dry dressing; and directions for 3 times weekly wound care to the left buttock with wound cleanser, Calcium Alginate, and a dry dressing. Patient #2s next nurse visit was documented on 12/18/23 with interventions performed, “;monitor for worsening of wound, turn/reposition Q (every) 2 hours” and no evidence of documentation that wound care was completed. Patient #2s “Plan of Care Review,” dated 12/20/23 included no evidence of documented directions for the frequency, method or products to be used for wound care or of supplies needed. There was no evidence of documentation Patient #2 was seen for wound care after 12/18/23 until the “Wound Specialists Visit Note,” dated 12/22/23 which documents the sacral/coccyx and left buttock wounds were both worsening or deteriorating and new directions for care of both wounds: for the nurse to cleanse with Dakins (type of wound cleansing) ¼ strength solution, Calcium Alginate to the wound bed, and cover with dry dressing three times weekly. Patient #2s next nurse visit note dated 12/25/23 includes Interventions performed, “;Perform wound care,” without description of what was done, products used, and “Response to Care” to increase visit frequency for wound care; however, the visit follow up plan documents continue current plan of care and does not document a new nurse visit frequency, or the wound care regimen directed by the “Wound Specialist.” Patient #2s next nurse visit note was dated 7 days later, on 01/01/24, and documents per the primary caregiver, wound care was already done and the RN was “;unable to assist and produce wound care”, although there was no evidence the caregiver was ever taught how to do wound care or provided the materials directed to be used for wound care, and there was no evidence of documentation that the nurse asked the caregiver how they did wound care or what products they used. “A Focus Visit Plan of Care Revision,” dated 01/01/24 documents wound care per “POC (Plan of Care) Revision/Physician Order,” to monitor “;Wound to sacral”, does not include a second wound to the left buttock, and no evidence of directions for wound care. Patient #2s “Plan of Care Review,” dated 01/03/24 also included no evidence of directions for the frequency, method or products to be used for wound care or of supplies needed. A “Nursing-Updated Comprehensive Assessment,” dated 01/03/24 documents a sacral stage II (partially skin deep) wound with surrounding edema (swelling), erythema (redness), the presence of exudate (discharge from wound); interventions performed to monitor for worsening of wound, turn/reposition every 2 hours; and response to care, “;initially wound unstageable”; but does not document whether wound care was performed, describe the wound bed or exudate, or whether the wound was healing, deteriorating, or the same, and does not document any care of the left buttock wound. Patient #2s next nurse visit note, dated 01/04/24 documents, “;Wound care sacrum,” interventions performed “;monitor wound”, that there was no improvement noted, no description of what was done for wound care, and does not document any care of the left buttock wound. Patient #2s next nurse visit dated 01/08/24 also does not document wound care methods or products used or the presence or care of the left buttock wound. Patient #2s “Physician Order, dated 01/10/24 includes to obtain wound care consult for dressing information and nurse to assess wound and perform wound care (but does not specify a frequency). The “Wound Specialists Visit Note,” dated 01/10/24 indicates the sacral/coccyx and left buttock wounds were both deteriorating, that there were signs of infection of the sacral/coccyx wound, and directions for care of both wounds: for the nurse to cleanse with Dakins ¼ strength solution, Calcium Alginate to the wound bed, and cover with dry dressing three times weekly. Patient #2s nurse visit note, dated 01/11/24 documents “;open pressure on her coccyx”, that the wound was cleaned with normal saline, Medihoney (wound dressing) was applied and foam dressing on top of wound, although these products were not ordered, and does not document any care of the left buttock wound. This was Patient #2s last nursing visit before the patient’s death on 01/14/24. Review of the “Hospices Supply Order Record” for Patient #2 between 12/12/23 and 01/10/24 reveals supply orders for wound cleanser, bordered foam dressings, highly absorbent gelling fiber (indicated for heavily draining wounds) dressings, oil emulsion (petrolatum and oil) absorbent dressing strips, Iodoflex pads (antimicrobial impregnated gauze), and iodoform packing strips; but no Dakins ¼ strength solution or calcium alginate, as recommended by the “Wound Specialist,” who was consulted for wound care. During telephonic interview on 03/13/24 at 11:58 AM, “Wound Specialist” APRN (Advanced Practice Registered Nurse) stated the hospice nurse was supposed to do Patient #2s wound care 3 times weekly; that the initial direction for daily wound care for Wound 1 was in error and she meant 3 times weekly for both wounds, which was corrected in later notes; and that she printed and left the wound care note with the patient in the home chart with each visit and faxed it to the hospice. During interview on 03/11/24 at 2:13 PM, when Patient Care Administrator, Staff A and Patient Care Administrator, Staff G were asked if Patient #2 had physician’s orders for wound care and wound care supplies, Staff A was unable to provide further orders but explained Registered Nurse, Staff F and Registered Nurse, Staff H who had been involved in Patient #2s care were no longer employed by the hospice. Further review of the record reveals Staff F and Staff H were not the nurses who did Patient #2s Admission Orders on 11/28/23, the “Initial Comprehensive Assessment and Plan Of Care Revisions” with a visit on 11/30/23, the “Plan Of Care Review” on 12/03/23, or nurse visits on 01/01/24, 01/11/24, but that these were done by 4 different nurses other than Staff F and Staff H.”

“Based on record review and interview, the hospice failed to maintain a complete clinical record for 3 of 4 sampled patients; Patient #1, whose record did not include provision of nutritional supplements; Patient #2, whose record did not include wound assessments, specialist consult notes, wound care orders with frequencies, directions, and supplies to be used; and Patient #5, whose record did not include assessments of chest tube patency and drainage with monitoring for signs of infection, directions for chest tube care and maintenance, or related supplies needed for care. The findings included: 1) Review of Patient #1s record reveals the patient was admitted to hospice care on 07/10/21 and had a diagnosis requiring Hospice services. Patient #1s “Plan of Care Review,” dated 07/18/23 documents the patient’s appetite was poor, and the patient ate less than 25% of each meal but includes no interventions or nutritional supplements. Further review of the “Plan of Care Review” form reveals a single line that documents, “;Plan of Care Review & Plan for Next 2 Weeks” (includes pharmacological and non-pharmacological interventions)” but provides no space for such documentation before the next line with the heading, “;Response to Care & Updates to Comprehensive Assessment.” Supplies needed for Patient #1s daily care were not included on the patient’s “Plans of Care.” During a telephonic interview on 03/11/24 beginning at 4:11 PM, Registered Nurse, Staff F stated a case of Ensure (nutritional supplement) was supposed to be provided by the hospice to Patient #1 every week since the patient was not eating at least 25% of their meals and it was the patient’s main source of nutrition. Review of the “Hospices Supply Oder Record,” for Patient #1 reveals 5 cases of Ensure, with 24 supplements per case, were ordered and delivered to the hospice for Patient #1 nearly weekly between 07/17/23 and 08/21/23. Further review of the “Hospices Supply Order Record reveals multiple orders for skin protectant creams, moist wipes, incontinence briefs and pull-ups, shampoos, lotions, absorbent underpads, and gloves for Patient #1 between 07/03/23 and 09/14/23 although these items were not documented to be provided by the Hospice or as necessary for the patient’s care. Patient #1s “Plan of Care Reviews,” are dated 07/18/23, 08/01/23, 08/29/23, 09/12/23, and 09/26/23. Patient #1s Report of Death reveals the patient died on 09/29/23. 2) Review of Patient #2s record reveals the patient was admitted to Hospice care on 11/28/23 and had a diagnosis requiring Hospice services. Patient #2s” Pre-Admit Evaluation” documents the patient had a Stage IV sacral pressure ulcer. (Stage IV pressure ulcers are a type of pressure ulcers with extensive tissue damage that may affect muscle, tendons or bone.) Patient #2s “Admission Orders/Hospice Certification/Initial Plan of Care,” dated 11/28/23 documents orders for medications, diet, and durable medical equipment needed for the patient’s care but does not include directions for wound care, who was to perform wound care and how often, or indicate any wound care supplies or disposable supplies needed for Patient #2s care. Patient #2s “Initial General Plan of Care/Interdisciplinary Care Plan,” dated 11/28/23 includes the outcome (goal) for Patient #2 to be free of pain/SOB (shortness of breath)/agitation but does not include wound care. Patient #2s “Plan of Care Review,” dated 12/03/23 includes no directions for the frequency, method or products for wound care and does not include other supplies needed. A “Physician Order for “;Wound Eval” (evaluation by a wound specialist) dated 12/06/23 documents that it was related to the hospice diagnosis. However, review of the record reveals no evidence of documentation of “Wound Consultants notes.” During an interview on 03/12/24 at 9:54 AM, Patient Care Administrator, Staff A confirmed after her own review, the “Wound Specialists Orders” and “Consultation Notes” were not in the patient’s record or at the hospice and stated she would request the doctors office to send them. On 03/12/24 at 12:50 PM, Staff A provided Patient #2s “Wound Specialist Consultation Note,” with directions for wound care dated 12/08/23, which she explained was obtained from the physicians office that same day per the surveyors request; but was unable to explain why this was not in Patient #2s record or how the hospice could direct wound care without it. After further inquiry on 03/13/24 at 11:51 AM for any additional “Wound Care Consultation Notes,” additional notes were provided by Staff A on 03/13/24 at 12:40 PM. The “Wound Specialists Consultation Note,” dated 12/08/23 documents Patient #2 was to have wound care to the Stage IV sacral pressure wound daily and to the Stage III left buttock wound three times a week with Saline, Calcium Alginate (wound dressing), and dry dressings. (Stage III pressure ulcers involve full-thickness skin loss potentially extending into the subcutaneous tissue layer.) Patient #2s”Nurse Visit Note,” for 12/11/23 documents wound care was performed, but not the products and methods used or description and measurements of the wounds. The “Wound Specialists Visit Note” for 12/15/23 documents the sacral/coccyx wound was worsening; directions for daily wound care to the sacral/coccyx wound with wound cleanser, Calcium Alginate packing, and a dry dressing; and directions for 3 times weekly wound care to the left buttock with wound cleanser, Calcium Alginate, and a dry dressing. Patient #2s “Nurse Visit Note” for 12/18/23 documents the interventions performed “;monitor for worsening of wound, turn/reposition Q2 (every 2) hours” and no evidence of documentation that wound care was completed or description of the wound. Patient #2s “Plan of Care Review,” dated 12/20/23 includes no evidence of documentation of directions for the frequency, method or products to be used for wound care or of supplies needed for the patient’s care and does not document the healing status of the wound. Patient #2s “Wound Specialists Visit Note” for 12/22/23 documents the sacral/coccyx and left buttock wounds were both worsening or deteriorating and new directions for care of both wounds: for the nurse to cleanse with Dakins (wound cleanser) ¼ strength solution, Calcium Alginate to the wound bed, and cover with dry dressing three times weekly. Patient #2s next nurse visit note documented on 12/25/23 includes Interventions performed “;Perform wound care”, without description of what was done and products used, no evidence of documentation of the description or measurements of the wound, and the “;response to care” to increase visit frequency for wound care; however, the “Visit Follow Up Plan” documents to continue current plan of care and does not document a new nurse visit frequency or the wound care regimen directed by the “Wound Specialist.” Patient #2s “Nurse Visit Note” for 01/01/24 documents that per the primary caregiver, wound care was already done and the RN was “;unable to assist and produce wound care”, although there was no evidence of documentation that the caregiver was ever taught how to do wound care or provided materials to be used for wound care, there was no evidence of documentation that the nurse asked the caregiver what they did or what products they used, and no evidence the dressing was observed. A “Focus Visit Plan of Care Revision,” dated 01/01/24 documents wound care per “POC (Plan of Care) Revision/Physician Order,” documents to monitor “;Wound to sacral”, but no evidence of documentation of directions for wound care and the record does not include a “POC Revision/Physician Order” for wound care as referenced. Patient #2s “Plan of Care Review,” dated 01/03/24 includes no evidence of documentation of directions for the frequency, method or products to be used for wound care or of supplies needed for the patient’s care. A “Nursing-Updated Comprehensive Assessment,” dated 01/03/24 documents a sacral Stage II wound (Stage II or 2 means limited to partial skin thickness) with surrounding edema (swelling) and erythema (redness), exudate (discharge from wound), “;Yes”; “;interventions performed” to monitor for worsening of wound, turn/reposition every 2 hours; and response to care “;initially pt (patient) wound unstageable”; but does not document whether wound care was performed, appearance of the wound bed or discharge or wound measurements. Patient #2s “Nurse Visit Note,” for 01/04/24 documents, “;Wound care sacrum”, interventions performed “;monitor wound”, that there was no improvement noted, but contains no further description of the wounds, no indication of care to the left buttock wound, or what was done for wound care. Patient #2s “Nurse Visit Note,” for 01/08/24 documents a sacral Stage II wound with surrounding edema and erythema, presence of exudate, “;interventions performed” to monitor for worsening of wound, turn/reposition every 2 hours; and response to care “;initially pt wound unstageable”; but does not document whether wound care was performed, appearance of the wound bed, wound measurements, or describe exudate. Patient #2s “Physician Order,” dated 01/10/24 includes to obtain “Wound Care Consultation” for dressing information and nurse to assess wound and perform wound care but does not specify a frequency or wound care regimen. The “Wound Specialists Visit Note,” dated 01/10/24 documents the sacral/coccyx and left buttock wounds were both deteriorating, that there were signs of infection of the sacral/coccyx wound, and directions for care of both wounds: for the nurse to cleanse with Dakins ¼ strength solution, Calcium Alginate to the wound bed, and cover with dry dressing three times weekly. Patient #2s “Nurse Visit Note” for 01/11/24 documents, “;open pressure on her coccyx”, that the wound was cleansed with Normal Saline, Medihoney (wound dressing) was applied and foam dressing on top of wound, although these products were not ordered, and does not document any care of the left buttock wound. This was Patient #2s last nursing visit before the patient’s death on 01/14/24. Review of Patient #2s “Nurse Visit Notes” or “Plan of Care Reviews” reveal no evidence of documentation to include measurements or wound bed description by which to objectively determine wound progress. Although the “Wound Specialists Consultation Notes” included assessments with measurements of the wounds, these were not included in the patient’s record and had to be requested by the surveyor and obtained from the physician office, approximately 3 months after the patient’s discharge. During a telephonic interview on 03/13/24 at 11:58 AM, Wound Specialist APRN (Advanced Practice Registered Nurse) stated she printed and left the wound care notes with the patient in the home record with each visit and also faxed them to the hospice. Review of the “Hospices Supply Order record for Patient #2 between 12/12/23 and 01/10/24 reveals supply orders for wound cleanser, bordered foam dressings, highly absorbent gelling fiber (indicated for heavily draining wounds) dressings, oil emulsion (petrolatum and oil) absorbent dressing strips, Iodoflex pads (antimicrobial impregnated gauze), and Iodoform packing strips, of which all but the first 2 items were not included in the patient’s wound care directions, as well as incontinence briefs, underpads, shampoos, skin lotions, barrier creams, gloves, and Ensure supplements; but no Dakins ¼ strength solution or Calcium Alginate as specified by the “Wound Specialist who was consulted for wound care. There was no evidence of documentation that these supplies were included in the patient’s record or care plan and the record of supplies had to be obtained from the supply ordering system upon surveyors request. 3) Review of Patient #5s record reveals the patient was re-admitted to Hospice care on 11/04/23 with a diagnosis requiring Hospice services and the patient’s “;Admission Orders/Hospice Certification/Initial Plan of Care” include continuous Oxygen at 4 liters per minute and no evidence of documentation of orders of the patient having a PleurX catheter (chest tube to drain fluid), of care and supplies needed to maintain the chest tube, Oxygen tubing and nasal cannula, or supplies needed for routine care and hygiene. Review of the “Hospices Supply Order Record” for Patient #5 between 10/25/23 and 01/11/24 reveals supply orders for 500 ml (milliliter) Pleurx drainage catheter kits beginning with one kit on 10/25/23 (during the patient’s previous time on hospice service) and 5 to 6 kits ordered and delivered nearly weekly until 01/11/24, as well as for moist wipes, incontinence briefs, underpads, shampoos, skin protectant, and lotions. Review of Patient #5s “Interdisciplinary Plan of Care Revisions,” dated 11/6/23 reveals they document fall risk and pain and do not include orders or interventions to address care and/or drainage of the chest tube to prevent fluid accumulation. Patient #5s “Plan of Care Review,” dated 11/8/23 includes for the “Integumentary” (Skin) category, “;Left side chest tube, provide care”; however, the “Respiratory” category has no documentation of the presence of the chest tube or of the patient’s use or non-use of Oxygen as ordered, and documents “;no s/s (signs/symptoms) of respiratory distress.” Patient #5s “Plan of Care Review,” dated 11/15/23 documents for the “Musculoskeletal “and “Integumentary” categories, “;left side PleurX drain, care provided” and in the “Respiratory” category that the patient is on room air and no dyspnea (shortness of breath) noted. No evidence of documentation of an order was found to discontinue continuous Oxygen at 4 liters per minute or change Oxygen to “;as needed.” Patient #5s “Plan of Care Review,” dated 11/29/23 documents in the “Respiratory” category that the patient is on room air and uses Oxygen as needed, and in the “Integumentary” category, “;Skin intact, PleurX drain in left side.” Patient #5s “Plan of Care Review,” dated 12/13/23 documents in the “Respiratory” category that the patient is on 2 liters Oxygen as needed and in the “Integumentary” category, “;Skin intact, PleurX drain in left side.” Patient #5s “Plan of Care Review,” dated 12/27/23 documents in the “Respiratory” category that the patient is on 2 liters Oxygen as needed for shortness of breath and in the “Integumentary” category, “;Skin intact, PleurX drain left site dry and intact.” Patient #5s “Interdisciplinary Plan of Care Revision,” dated 01/01/24 documents to monitor PleurX drain, and does not direct any care to be provided to the chest tube site to prevent infection, how to manage drainage, or specify the supplies needed. Patient #5s “Plan of Care Review,” dated 01/10/24 documents in the “Respiratory” category that the patient is on 2 liters Oxygen as needed for shortness of breath and in the “Integumentary” category, “;PleurX drain left side dry intact.” There was no documentation in Patient #5s record of orders for care and drainage of the chest tube, who was to drain the tube and when, or how often to change the drainage bottle, or assessment of drainage, such as changes in volume or consistency or complications warranting further intervention, or of other supplies needed for the patient’s routine care. During an interview on 03/13/24 at 10:40 AM, Patient Care Administrator, Staff A stated supplies needed are not documented on the Plans of Care; that nurse visit notes have a box where they can list items delivered; that the Hospice Aides also take supplies to patients but may not document that; and that there would be record of the nurses supply orders in the ordering system, but there might not be any record of items delivered to the patient.”