Vitas Healthcare Corporation of Georgia

“Based on review of clinical records and staff interviews, it was determined that the Hospice failed to effectively provide appropriate interventions for pain symptom management of two patients (P) P1, P2 of six sample patients. Findings included: Review of document titled, “Patient Bill of Rights,” dated December 01, 2025, revealed the patient has the right to receive effective pain and symptom management for conditions related to terminal illness(es). The patient has the right to participate i the hospice voluntarily and sever the relationship with hospice at any time. Review of an on-call log dated 07/15/2026, revealed the family of P1 called to report P1 had not received Haldol and lorazepam (anxiety medications). The family reported P1 needed those medications. The agency informed the family of P1 that the medication would be delivered on 07/16/2026. Review of an on-call log dated 07/19/2026, at 5:58 PM, revealed family of P1 requested a nurse to assess P1 for symptoms of agitation and dyspnea (shortness of breath). An interview conducted on 08/05/2026, at 10:03 AM, with the family of P1, revealed the on-call nurse advised them via phone on 07/19/2026, to give Ativan 1 mg (milligram) and other medications.The family of P1 further stated they called again the same evening at 8:16 PM, again requesting a nurse and a chaplain as P1 continued to be agitated with dyspnea. According to the clinical record, a nurse arrived to assess P1 on 07/19/2026, at 8:50 PM. The family of P1 further reported he requested to transfer P1 to another hospice on 07/15/2026. The family member of P1 revealed it took five days to transfer. He stated he called the hospice agency to get the transfer documents sent to the receiving agency. During an interview on 08/06/2026, at 10:30 AM, the National Patient Care Administrator (NPCA) General Manager (GM) confirmed the agency failed to send a nurse to address symptoms and manage pain for P1. The GM was unable to give a reason as to why the hospice agency did not assist with the transfer/discharge as requested on 07/15/2026. The NPCA confirmed the transfer was not completed within 30 days per the hospice agency’s policy. Review of the on-call log revealed on 07/26/2026, at 10:04 AM, a nurse was called to visit P2. The medical doctor was called to prescribe a three regime (divide the total daily dose into three separate doses taken at different times throughout the day) of Ativan as P2 did not receive them from the delivery service. The on-call log revealed the family of P2 called at 5:40 PM to inquire about the arrival time of the nurse as P2 had become more agitated and needed assistance. The family called again on 07/26/2026, at 9:54 PM, requesting an update for the nurse visit. On 07/26/2026, at 10:03 PM, the family cancelled the nurse visit requesting a nurse visit in the morning 07/28/2026, as they were tired and did not want to wait any longer. An interview on 08/05/2026, at 12:13 PM, with the family of P2, who revealed that a nurse was scheduled to come on 07/26/2026, to manage agitation. The family of P2 stated they called several times to find out what time the nurse would arrive and was told by the on-call staff they didn’t know the nurse had not arrived.At 5:40 PM, the family of P2 informed the on-call staff they had not had a visit since 07/22/2026, and P2 was agitated and needed a nurse. The family of P2 confirmed that P2 received Ativan. The family of P2 stated P2 became comfortable around 9:00 PM, and they were tired of waiting for the nurse, so they cancelled the visit. The family requested to be seen the next day. An interview on 08/05/2026, at 2:10 PM, with the General Manager (GM), confirmed the agency failed to send a nurse to address symptoms and manage pain for P1 and P2. She was unable to give a reason as to why there were delays in nursing services.”

“Based on record review and staff and family interviews, it was determined the agency failed to comply with the State Regulation of the nursing services one-hour response time when there is notification by a patient or family member of a patient experiencing a crisis or change in condition. Findings included: Review of document titled, “Patient Bill of Rights,” dated December 01, 2025, revealed the patient has the right to receive effective pain and symptom management for conditions related to terminal illness(es). Review of on-call log dated 07/15/2026, revealed family members of P1 called to report P1 had not received Haldol and lorazepam (anxiety medications). The family reported P1 needed those medications. The agency informed the family of P1 that the medication would be delivered on 07/16/2026. Review of the on-call log dated 07/19/2026, revealed the family of P2 called the agency at 6:04 AM to request a nurse to make an onsite visit as P2 had expired. The family member informed the on-call service that 911 had been called as well because she didn’t know what to do. The on-call log revealed the nurse arrived at 9:00 AM. Review of on-call log dated 07/19/2026, at 5:58 PM, revealed family of P1 requested a nurse to assess P1 for symptoms of agitation and dyspnea (shortness of breath). During an interview on 08/05/2026, at 12:13 PM, with the family of P2 who stated that she called the agency at 6:04 AM to have nurse come out as P2 had expired. She stated she also called 911 because she didn’t know what to do. She stated the nurse arrived at 9:00 AM. During an interview on 08/05/2026, 10:03 AM, with family of P1, revealed she requested a nurse on 07/19/2026, at 5:58 PM, as P1 was experiencing dyspnea and agitation. The family of P1 was told to administer Ativan 1 mg (milligram). The family of P1 stated P1 continued to experience dyspnea and agitation. At 8:16 PM, a nurse was again requested. The nurse made a visit at 9:00 PM. Review of the on-call log revealed on 07/26/2026, at 10:04 AM, a nurse was called to visit P2. The medical doctor was called to prescribe a three regime (divide the total daily dose into three separate doses taken at different times throughout the day of Ativan as P2 did not receive them from the delivery. The on-call log revealed the family of P2 called at 5:40 PM to inquire about the arrival time of the nurse as P2 had become more agitated and needed assistance. The family called again on 07/26/2026, at 9:54 PM, requesting an update for the nurse’s visit. On 07/26/2026, at 10:03 PM, the family cancelled the nurse visit requesting a nurse visit in the morning 07/28/2026, as they were tired and did not want to wait any longer. The family of P2 confirmed that she called the agency at 6:04 AM to have a nurse come out as P2 had expired. She stated she also called 911 because she didn’t know what to do. She indicated the nurse arrived at 9:00 AM. An interview on 08/06/2026, with the General Manager and National Patient Care Administrator (NPCA), it was confirmed the hospice agency was unaware of the one-hour response time to manage symptoms, pain and change in patient condition.”

“Based on record review, and family and staff interviews, the agency failed to promote the rights of the patient to receive effective pain management and symptom control from the hospice for conditions related to the terminal illness of two of six sampled patients (P) (P1, P2). Findings include: Review of document titled, “Patient Bill of Rights,” dated December 01, 2025, revealed the patient has the right to receive effective pain and symptom management for conditions related to terminal illness(es). Review of on-call notes dated 07/19/2026, revealed family of P1 requested a nurse at 5:58 PM as P1 was experiencing dyspnea (shortness of breath) and agitation. The family of P1 was told to administer Ativan 1mg (milligram) (anti-anxiety medication). The on-call log revealed the hospice agency did not send a nurse for an onsite visit. The family of P1 revealed P1 continued to experience dyspnea and agitation. At 8:16 PM, a nurse was again requested. The nurse made a visit at 9:00 PM. Review of the on-call log revealed on 07/26/2026, at 10:04 AM, a nurse was called to visit P2. The medical doctor was called to prescribe a three regime (divide the total daily dose into three separate doses taken at different times throughout the day) of Ativan as P2 did not receive them from the delivery. The on-call log revealed the family of P2 called at 5:40 PM, to inquire about the arrival time of the nurse as P2 had become more agitated and needed assistance. The family called again on 07/26/2026, at 9:54 PM, requesting an update for the nurse’s visit. On 07/26/2026, at 10:03 PM, the family cancelled the nurse visit requesting a nurse visit in the morning 07/28/2026, as they were tired and did not want to wait any longer. An interview conducted on 08/05/2026, at 12:13 PM, with the family of P2, who revealed that a nurse was scheduled to come on 07/26/2026, to manage agitation. The family of P2 stated they called several times to find out what time the nurse would arrive and was told by the on-call service they didn’t know the nurse had not arrived. At 5:40 PM, the family of P2 informed the on-call service they had not had a visit since 07/22/2026, and P2 was agitated and needed a nurse. The family of P2 confirmed Ativan (anti-anxiety medication) was received. The family of P2 indicated P2 became comfortable around 9:00 PM, and they were tired of waiting for the nurse, so they cancelled the visit. The family requested to be seen the next day. An interview with the General Manager on 08/05/2026, at 3:33 PM, confirmed the hospice agency was unaware of the one-hour response time of notification to manage symptoms, pain and crisis and failed to send a nurse to address a crisis and manage signs and symptoms.”

“Based on record review, review of policy and procedure, and family and staff interviews, it was determined the agency failed to be responsible for the day-to-day operation of the hospice agency. Specifically, the agency failed to comply with the State Regulation of the nursing services one-hour response time when there was notification by a patient or family member of a patient experiencing a crisis, change in condition or death for two of six sampled patients (P) (P1 and P2); failed to ensure that drugs were made routinely available on a 24-hour basis, 7 days a week, for one of six sampled Ps (P1); and failed to complete and provide the receiving facility of a transferred patient with a copy of the hospice agency’s discharge summary for one of six sampled Ps (P1). Findings included: Review of “Governance Policies: Governing Body” last revised 2/23/16, revealed:PolicyThe governing Body assumes full legal responsibility for the management of the hospice, the provision of all hospice services, its fiscal operation and continuous quality assessment and performance improvement. It also implements and monitors policies that govern the program’s total operation in compliance with all federal and state hospice regulations and accreditation standards. Review of the “Interdisciplinary Team Policies Administrative On-Call” with last revised date 1/15/02, revealed:PolicyTo provide a high quality of hospice care directed by a physician and supervised by a registered nurse 24 hours a day, 7 days a week.ObjectiveTo provide safe continuity of hospice care for the patient and family 24 hours a day, 7 days a week adhering to the state and federal rules and regulations for hospice programs. Review of “Interdisciplinary Team Policies Discharge from Hospice” with last revise date 6/23/2011, revealed:PolicyVitas will facilitate continuity of care and transfer to another health provider, according to the patient/family choice.ObjectiveTo facilitate the transfer of the patient’s care to others.ProcedureA registered nurse will coordinate with the patient/family and the attending physician the discharge plan of care.Discharge Planning3. If the care of the patient is transferred to another Medicare/ Medicaid-certified facility, Vitas will forward to the receiving facility, a copy of the hospice discharge summary; and the patient’s clinical record, if requested.Discharge SummaryWill be completed on all live discharges and filed in the medical record no later than 30 days after the patient is discharged. Review of the on-call log dated 07/15/2026, revealed Haldol and Ativan (antianxiety medications) were unavailable for P1 when family member requested, they were needed. P1 was without medication until the medications were delivered the next day on 07/16/2026. The on-call log confirmed the hospice agency failed to meet the one-hour response time of being notified that P1 was experiencing a crisis. Review of clinical records revealed the agency failed to complete a transfer/discharge summary for P1 upon transfer to another hospice. The clinical records revealed the transfer was requested on 07/15/2026 and was initiated on 07/20/2026. During an interview on 08/05/2026, at 11:00 AM, with the family of P1, it was confirmed that P1 did not have medications readily available to treat signs and symptoms related to her illness on 07/15/2026. Review of the on-call log dated 07/19/2026, revealed family of P1 requested a nurse at 5:58 PM, as P1 was experiencing dyspnea (shortness of breath) and agitation. The family of P1 was told by the triage nurse to administer Ativan 1 mg (milligram). The hospice agency did not send a nurse for an onsite visit to assess effectiveness. The on-call log does not reveal a follow up call to the family. The family of P1 stated P1 continued to experience dyspnea and agitation. At 8:16 PM, a nurse was again requested. The nurse made a visit at 9:00 PM. An interview on 08/05/2026, at 10:03 AM, the family member of P1 stated he requested to transfer to another hospice on 07/15/2026. The family member of P1 stated it took five days to transfer. He stated he called the hospice agency to get the transfer documents sent to the receiving agency to initiate the transfer. An interview conducted on 08/05/2026, at 12:13 PM, with the family of P2, who revealed that a nurse was scheduled to come on 07/26/2026, to manage agitation. The family of P2 indicated they called several times to find out what time the nurse would arrive and was told by the on-call service they didn’t know the nurse had not arrived. At 5:40 PM, the family of P2 informed the on-call service they had not had a visit since 07/22/2026, and her father was agitated and needed a nurse. The family of P2 confirmed the P2 received Ativan The family of P2 received a three-day supply of Ativan and stated P2 became comfortable around 9:00 PM, and they were tired of waiting for the nurse, so they cancelled the visit. The family requested to be seen the next day. Review of the on-call log dated 07/29/2026, confirmed the family of P2 placed a call on 07/29/2026, at 6:04 AM, to the on-call service for the hospice agency, to notify them that P2 had expired. The on-call log confirmed the family of P2 called 911. The on-call log revealed the nurse from the hospice agency came at 9:00 AM to pronounce the death of P2. An interview conducted on 08/06/2026, at 2:00 PM, with Registered Nurse (RN) AA, the nurse dispatched to pronounce the death of P2, revealed she was not dispatched from the on-call service. She confirmed she received a call from the Emergency Medical Service and she responded promptly. In an interview on 08/06/202,6 at 2:30 PM, the General Manager confirmed the agency failed to send a nurse to address a crisis and manage signs and symptoms for P1 and P2. The General Manager confirmed the agency failed to send a nurse to address a change in condition for P2 within the one-hour notification time. The General Manager recalled the family member of P1 calling about transferring but was unable to give the actual date. The General Manager confirmed the hospice agency failed to initiate a transfer request timely and complete the discharge summary within 30 days per the hospice agency’s policy.”

“Based on record review and family and staff interviews, the hospice agency failed to ensure that nursing services, physician services, and drugs and biologicals were made routinely available on a 24-hour basis, 7 days a week, for one of six sampled patients (P) (P1). Findings included: Review of the on-call log, dated 07/15/2026, revealed Haldol and Ativan (anti-anxiety medications) were unavailable for P1 when family member requested, they were needed. P1 was without medication until the medications were delivered the next day on 07/16/2026. An interview conducted on 08/05/2026, at 10:03 AM, with the family of P1, revealed P1 did not have Haldol and Ativan when needed for agitation and dyspnea. An interview with the General Manager on 08/05/2026, at 2:00 PM, confirmed the hospice agency failed to ensure that prescribed medications were made available to P1.”

“Based on record review, review of policy and procedures, andstaff interviews, it was determined the agency failed to provide the receiving facility with a copy of the hospice discharge summary for one of six sampled patients (P) (P1).. Findings included: Review of the policy titled, “Interdisciplinary Team Policies Discharge from Hospice,” with last revise date 6/23/2011 revealed:PolicyVitas will facilitate continuity of care and transfer to another health provider, according to the patient/family choice.ObjectiveTo facilitate the transfer of the patient’s care to others.ProcedureA registered nurse will coordinate with the patient/family and the attending physician the discharge plan of care.Discharge Planning3. If the care of the patient is transferred to another Medicare/ Medicaid-certified facility, Vitas will forward to the receiving facility, a copy of the hospice discharge summary; and the patient’s clinical record, if requested.Discharge Summary1. Will be completed on all live discharges and filed in the medical record no later than 30 days after the patient is discharged. Review of clinical documents in the agency’s electronic medical record failed to reveal a discharge summary for P1. An interview conducted on 08/05/2026, at 3:33 PM, with the National Patient Care Administrator (NPCA), confirmed there was no discharge summary completed for P1.On 08/06/2026, at 10:30 AM, the NPCA produced a discharge summary titled, POC Conflict Report, dated 07/20/2026. The NPCA confirmed the discharge was a late entry into the agency’s electronic medical record and noted to be entered and completed on 08/05/2026. Review of faxed documents sent on 07/20/2026 to the receiving agency, revealed the discharge summary for P1 was not sent over at the time of transfer. The hospice agency failed to complete a discharge summary within 30 days per the hospice agency policy.”

“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, document review, and interview. Agency policy entitled “Initial and Comprehensive Assessment” (dated 06/06/2024), stated in part, “Initial Assessment (RN)... as soon as possible but no greater than forty-eight hours after the effective date of the hospice election... In the event of the rare circumstance that the patient or caregiver refuses the RN Initial Comprehensive Assessment or the Psychosocial/Spiritual Initial Comprehensive Assessment within the regulatory required timeframe, then it should be documented clearly in the medical record that the visit was postponed per the requires of the patient or caregiver and the hospice physician is aware of the delay ...Initial Comprehensive Assessment (RN) consists of RN-Initial Comprehensive Assessment ... The RN may be the only discipline completing the Initial Comprehensive Assessment under certain conditions such as ... refusal of assessment visits by other disciplines by the patient/family, IDG determination that additional assessment is not necessary based on discussion/collaboration with RN following the RN Initial Comprehensive Assessment .. “ In 1 of 19 (6%) clinical records reviewed, the agency did not ensure that the Interdisciplinary Group completed the initial comprehensive assessment within five (5) calendar days after the patient’s election of hospice care. Clinical Record 11: The patient elected the hospice benefit on 11/14/2023. The initial psychosocial assessment was completed by the social worker (SW) on 11/22/2023, eight (8) days after the patient’s election of hospice care. The late initial comprehensive assessments were confirmed during a joint record review and interview with the Team Manager and the National Patient Care Administrator.”

“It is required that hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG in collaboration with the attending physician (if any); the patient or patient representative if any of them so desire; [and] the primary caregiver in accordance with the patient’s needs if any of them so desire. This standard was not met, as evidenced by clinical record review, document review, and interview. Agency policy “Frequency” (dated 08/15/2023) read in part, “Frequency is based on the IDG/patient care plan week and starts the day after team meeting ... A patient or family may choose to decline or re-schedule a visit. Document the declination and reason if known in the clinical record. Communicate the declination with the IDG as appropriate to determine if a change in the POC is warranted. Attempted visits do not count towards frequency. Every effort should be made to reschedule the visit during the same IDG/Care Plan week. Documentation should reflect visit attempts and efforts to reschedule...If a patient accepts SW or Chaplain ... once the assessment is completed ... document the ongoing visit frequency for the assigned discipline/clinician ... “ In 8 of 19 (42%) clinical records reviewed, the agency did not ensure that care and services furnished to patients and their families followed the plan of care (POC) established by the hospice interdisciplinary group. Clinical Record 1: The patient elected the hospice benefit on 04/03/2024 with the diagnosis of chronic obstructive pulmonary disease (COPD). The patient’s team meetings occurred on 04/24/2024, 05/08/2024, 05/22/2024, and 06/05/2024. The POC for the benefit period dated 04/03/2024 to 07/02/2024 ordered Skilled Nursing (SN) services twice (2) times for the week of 05/09/2024 and one (1) time a week for the week of 05/16/2024. A review of the clinical record revealed one (1) SN visit was documented on 05/13/2024 for the week of 05/09/2024, and no SN visits were documented for the week of 05/16/2024. A clinical record review revealed no evidence of documented missed visits or communication with the physician to change the SN visit frequency. Clinical Record 3: The patient elected the hospice benefit on 02/26/2024 with a diagnosis of severe protein-calorie malnutrition. The patient’s team meetings occurred on 04/17/2024, 05/01/2024, 05/14/2024, and 05/28/2024. The POC for the benefit period dated 02/26/2024 to 05/25/2024 ordered SN services one (1) time a week for the week of 03/27/2024, three (3) times a week for the week of 04/26/2024, and four (4) times a week for the week of 05/01/2024. A review of the clinical record revealed there was no documented SN visit for the week of 03/27/2024, one (1) SN visit documented for the week of 04/25/2024, and two (2) SN visits documented (05/02/2024 and 05/07/2024) for the week of 05/01/2024. A clinical record review revealed no evidence of documented missed visits or communication with the physician to change the SN visit frequency. Clinical Record 5: The patient elected the hospice benefit on 02/14/2024 with a diagnosis of cerebral atherosclerosis. The patient team meetings occurred on 04/03/2024, 04/17/2024, 05/01/2024, 05/15/2024, and 05/29/2024. The POC for the benefit period dated 02/14/2024 to 05/13/2024 ordered SN services four (4) times a week for the week of 04/25/2024. A clinical record review revealed two SN visits (04/29/2024 and 04/30/2024) documented for the week of 04/25/2024. For the benefit period dated 05/14/2024 to 08/12/2024, the POC ordered SN services five (5) times a week for the week of 05/02/2024. One SN visit was documented on 05/07/2024. For the week of 06/06/2024, the POC ordered SN service two (2) times a week. There were no nurse visits documented from 06/06/2024 to 06/12/2024. A clinical record review revealed no evidence of documented missed visits or communication with the physician to change the SN visit frequency. Clinical Record 6: The patient elected the hospice benefit on 02/02/2024 with a diagnosis of congestive heart failure. The patient’s team meetings occurred on 04/03/2024, 04/17/2024, 05/01/2024, 05/15/2024, and 05/29/2024. The POC for the benefit period dated 05/02/2024 to 07/31/2024 ordered SN services three (3) times a week for the week of 05/02/2024. There were no SN visits documented for the week of 05/02/2024 to 05/08/2024. For the week of 05/09/2024, the POC ordered SN visits seven (7) times a week and Chaplain visits one (1) time weekly. A clinical record review revealed two (2) SN visits documented (05/09/2024 and 05/15/2024), and no Chaplain visit from 05/09/2024 to 05/15/2024. The Social Worker (SW) documented one (1) visit on 05/22/2024. For the week of 05/16/2024, the POC did not order a SW visit. For the week of 05/23/2024, the POC ordered SN services twice (2) weekly. No SN visits were documented from 05/23/2024 to 05/29/2024. A clinical record review revealed no evidence of documented missed visits or communication with the physician to change the SN, Chaplain, or SW visit frequency. Clinical Record 7: The patient elected the hospice benefit on 01/19/2024 with a diagnosis of Parkinson’s. The patient’s team meetings occurred on 03/27/2024, 04/10/2024, 04/24/2024, 05/08/2024, and 05/22/2024. The POC for the benefit periods 03/19/2024 to 05/18/2024 ordered seven (7) SN visits for the week of 04/25/2024. Two (2) SN visits were documented (04/25/2024 and 04/30/2024) for the week of 04/25/2024. The POC for the benefit period dated 05/19/2024 to 07/17/2024 ordered one (1) SN visit for the week of 05/16/2024. No SN visit was documented from 05/16/2024 to 05/22/2024. One SW visit was documented on 05/14/2024. There were no POC orders for SW services for the week of 05/09/2024. A clinical record review revealed no evidence of documented missed visits or communication with the physician to change the SN and SW visit frequency. Clinical Record 8: The patient elected the hospice benefit on 04/15/2024 with the diagnosis of malignant neoplasm of the brain. The patient’s team meetings occurred on 04/24/2024, 05/08/2024, 05/22/2024, and 06/05/2024. The POC for the benefit period dated 04/15/2024 to 07/14/2024 ordered SN services two (2) times a week for the week of 05/09/2024. One SN visit was documented for the week of 05/09/2024. A clinical record review revealed no evidence of a documented missed visit or communication with the physician to change the SN visit frequency. Clinical Record 9: The patient elected the hospice benefit on 02/29/2024 with the diagnosis of Alzheimer’s. The patient’s team meetings occurred on 04/18/2024, 05/02/2024, 05/16/2024, and 05/30/2024. The POC for the benefit period 02/29/2024 to 5/29/2024 ordered SN services two times weekly for the week of 05/03/2024. One SN was documented on 05/08/2024 for the week of 05/03/2024. A clinical record review revealed no evidence of a documented missed visit or communication with the physician to change the SN visit frequency. Clinical Record 13: The patient elected the hospice benefit on 11/14/2023 with the diagnosis of cerebral atherosclerosis. The patient’s team meetings occurred on 04/10/2024, 04/24/2024, 05/08/2024, and 05/22/2024. The POC for the benefit period 04/12/2024 to 06/11/2024 ordered SN services two (2) times a week for the week of 05/16/2024. One SN was documented on 05/21/2024. A clinical record review revealed no evidence of a documented missed visit or communication with the physician to change the SN visit frequency. Additionally, one Social Worker (SW) visit was documented on 05/20/2024. The POC did not include an order for the SW visit. During a joint record review and interview on 06/28/2024, the Team Manager and the National Patient Care Administrator confirmed the missed visit and extra visit findings and that all available documentation for the patient visits was provided.”

“It is required that the Interdisciplinary Group, in collaboration with the individual’s attending physician (if any), reviews, revises, and documents the individualized care plan as frequently as the patient’s condition requires, but no less frequently than every 15 calendar days. This standard was not met as evidenced by clinical record review, document review and interview. Agency policy “IDG POC Meeting” (dated 02/15/2023) read in part, “Each patient shall be reviewed at least every 15 days ... Bi-weekly review of each patient POC ... Discussion and Plan of Care Review (POCR) ... ensure Plans of Care are updated including a review an update of each patient’s visit frequency. The physician-ordered frequency changes per the POC ... Regulatory Documentation ... IDG Agenda/Attendance indicating attendees and their participation in the patient review and discussion; indicates patients discussed during the IDG meeting... POC Review form should be completed as documentation of the IDG discussion...” In 3 of 19 (16%) clinical records reviewed, the agency did not ensure that the Interdisciplinary Group (IDG) reviewed, revised, and documented the patient’s care plan no less frequently than every 15 calendar days. Clinical Record 3: The patient elected the hospice benefit on 02/26/2024 with the diagnosis of protein-calorie malnutrition. A review of the clinical record revealed no documented Plan of Care Review/Interdisciplinary Group Meetings from 03/27/2024 through 04/17/2024, with 21 days outstanding. Clinical Record 5: The patient elected the hospice benefit on 02/14/2024 with the diagnosis of cerebral atherosclerosis. A review of the clinical record revealed no documented Plan of Care Review/Interdisciplinary Group Meetings from 02/21/2024 to 03/20/2024, with 28 days outstanding. Clinical Record 18: The patient elected the hospice benefit on 12/21/2023 with the diagnosis of cerebral atherosclerosis. A review of the clinical record revealed no documented Plan of Care Review/Interdisciplinary Group Meetings from 12/21/2023 to 01/17/2024, with 27 days outstanding. During a joint record review and interview on 06/28/2024, the Team Manager and the National Patient Care Administrator confirmed the missing Plan of Care Reviews/Interdisciplinary Group Meetings and that all available patient documentation had been provided including all Team Meeting Agendas with team members present and patients presented with the collaboration of the attending physician.”

“It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to: assess the quality of care and services provided by the hospice aide; [and] ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 3 of 12 (25%) clinical records reviewed in which Hospice Aide (HA) services were accepted, the agency did not ensure that the Registered Nurse (RN) documented supervision of the Hospice Aide no less frequently than every 14 days. Clinical Record 6: The patient elected the hospice benefit on 02/02/2024. The plans of care (POC) for the benefit periods dated 02/02/2024 to 05/01/2024 and 05/02/2024 to 07/31/2024, ordered HA services twice (2) times a week. A review of the clinical record revealed no documented RN supervision of the HA from 03/21/2024 to 04/29/2024, with 39 days outstanding. Clinical Record 8: The patient elected the hospice benefit on 04/15/2024. The POC for the benefit period 04/15/2024 to 07/14/2024, ordered HA services twice (2) times a week. The first HA visit was documented on 04/26/2024. A review of the clinical record revealed no documented RN supervision of the HA from 05/09/2024 to 05/24/2024, with 15 days outstanding, and 05/24/2024 to 06/21/2024, with 28 days outstanding. Clinical Record 9: The patient elected the hospice benefit on 02/29/2024. The POC for the benefit period 02/29/2024 to 05/29/2024, ordered HA services three (3) times a week. A review of the clinical record revealed no RN documented supervision of the HA from 03/21/2024 to 04/10/2024, with 20 days outstanding, and 04/23/2024 to 05/08/2024, with 15 days outstanding. During a joint clinical record review and interview on 06/28/2024, the Team Manager confirmed the gaps in HA supervision.”