Vitas Healthcare Corporation of Illinois

“It is required that the hospice Interdisciplinary Group, in consultation with the individual’s attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (11%) clinical records reviewed, the hospice did not ensure that a comprehensive assessment was completed no later than five (5) calendar days after the election of hospice care. Clinical Record 6: The patient elected the hospice benefit on 01/02/2024 with a diagnosis of unspecified severe protein-calorie malnutrition. The Social Worker (SW) documented a psychosocial/ spiritual initial comprehensive assessment on 01/04/2023. The SW documented all assessment categories as “unable to assess, patient caregiver unavailable.” There was no documented evidence of follow-up to this visit until 01/17/2024, when the Chaplain visited the patient and documented the interventions of “active listening, life review, and prayer.” During a joint clinical record review, the Patient Care Administrator confirmed that the comprehensive assessment was completed late. Clinical Record 19: The patient elected the hospice benefit on 02/27/2024 with a diagnosis of malignant neoplasm of colon. The SW comprehensive assessment was documented on 03/04/2024, six days outstanding. A clinical record review revealed no documented reason why the assessment was completed after five (5) calendar days. During a joint clinical record review, the Patient Care Administrator confirmed that the comprehensive assessment was completed late.”

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current: prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; [and] other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: the effectiveness of drug therapy; drug side effects; actual or potential drug interactions; duplicate drug therapy; [and] drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review, interview, and observation. In 3 of 19 (16%) clinical records reviewed and home visits observed, the agency did not ensure that the drug profile was updated when new medication was added or changes were made to existing medication. Clinical Record 1/Home Visit 2: The patient elected hospice care on 12/27/2023 and resided in an assisted living facility (ALF). During the home visit with the Chaplain [Personnel Record 6] on 4/10/2024, a review of the hospice medication profile and the ALF medication revealed the patient was taking Eliquis 5 mg one (1) tablet by mouth twice a day and Atorvastatin 40 mg one (1) tablet by mouth at night. Eliquis and Atorvastatin were not documented on the hospice medication profile. These medications were confirmed with the ALF staff. The hospice medication profile documented Tylenol 325 mg take two (2) tablets by mouth every 6 hours as needed for pain, K-Dur 20 MEQ take one (1) tablet by mouth twice a day for low potassium, Senna S 8.6/50mg take one (1) tablet by mouth every day, and Ativan 0.5mg take one (1) tablet by mouth every 6 hours as need for anxiety/agitation. These medications were not documented on the ALF medication profile. Clinical Record 2/Home Visit 1: The patient elected hospice care on 01/13/2021 and resided in a memory care facility (MCF). During the home visit on 04/10/2024, a review of the MCF medication profile revealed that the patient was taking Ipratropium-Albuterol Solution 0.5-2.5(3) MG/3 ML, inhale orally every 4 hours as needed or shortness of breath or wheezing via nebulizer and Loperamide HCI capsule 2 mg take one (1) capsule by mouth as needed for diarrhea after each loose stool. The facility staff confirmed these medications. These medications were not documented on the hospice medication profile. Clinical Record 3/Home Visit 3: The patient elected hospice care on 10/28/2022. During the home visit with the Registered Nurse (RN) Case Manager [Personnel Record 7] on 4/10/2024, a review of the skilled nursing (SNF) medication profile and interview with the SNF staff confirmed that the patient was using Brimonidine drops 0.15% one (1) drop both eyes twice a day, Protonix 40 mg take one (1) tablet once a day, and Artificial tears 1-0.3% one (1) drop in both eyes twice a day. Brimonidine drops, Protonix, and Artificial tears were not documented on the hospice medication profile.”

“It is required that each patient’s individualized written plan of care includes a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (20%) clinical records reviewed, the hospice did not ensure that the plan of care included a detailed statement of the scope and frequency of services to meet specific patient and family needs. Clinical Record 1: The patient elected the hospice benefit on 12/27/2024 with a diagnosis of cerebrovascular disease. An order was written by the physician on 01/04/2024 for Physical Therapy (PT) to evaluate and treat. PT documented visits on 01/23/2024, 02/07/2024, and 02/18/2024. The plan of care dated 12/27/2024 did not include documentation of PT services and the frequency of services to be provided. During a joint review of the clinical record and interview, the Patient Care Administrator confirmed PT was missing from the plan of care. Clinical Record 11: The patient elected the hospice benefit on 02/17/2024 with a diagnosis of chronic obstructive pulmonary disease. Respiratory Therapy (RT) documented an evaluation visit on 02/21/2024 and a visit on 02/26/2024. The plan of care dated 02/17/2024 did not include documentation of RT services and the frequency of services to be provided. This was confirmed in an interview and a joint clinical record review with the Patient Care Administrator.”

“It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services are noted in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 3 (33%) clinical records reviewed of patients that received volunteer services, the hospice did not ensure that the plan of care included the visit frequency. Clinical Record 3: The patient elected the hospice benefit on 10/28/2022 with a diagnosis of cerebral atherosclerosis. Volunteer services were accepted on 10/18/2023. Volunteer visits were documented on 11/03/2023, 11/18/2023, 12/19/2023, 12/23/2023, and 02/28/2024. The frequency of visits for volunteer services was not documented in the plan of care. During a joint review of the clinical record with the Patient Care Administrator, no frequency statement was found in the plan of care.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. Each patient’s record includes, at a minimum, physician orders. This standard was not met as evidenced by clinical record review and interview. In 2 of 3 (67%) clinical records reviewed of patients receiving respiratory therapy, the hospice did not ensure that the patient’s record included a physician’s order for respiratory therapy services. Clinical Record 17: The patient elected the hospice benefit on 12/01/2023 with a diagnosis of Chronic Obstructive Pulmonary Disease. There were visits documented by a Respiratory Therapist (RT) dated 12/11/2023 and 12/20/2023. A clinical record review revealed no evidence of a documented physician order for RT services. During an interview and a joint review of the clinical record, the Patient Care Administrator confirmed there was no physician’s order for the RT visits. Clinical Record 18: The patient elected the hospice benefit on 11/20/2023 with a diagnosis of heart disease unspecified. There were visits documented by a RT dated 11/27/2023 and 12/04/2023. A review of the clinical record revealed no evidence of a documented physician order for RT services. During an interview and a joint review of the clinical record, the Patient Care Administrator confirmed there was no physician’s order for the RT visits.”