Vitas Healthcare Corporation Midwest

“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 4 of 19 (21%) clinical records reviewed and home visits observed, the agency did not ensure that the comprehensive assessment included a medication profile that contained the patient’s current medications. Clinical Record 4/Home Visit 4: The patient elected hospice care on 03/29/2024. On 03/29/2024, the physician ordered, “monitor use and effectiveness of Aleve, Flexeril, Biofreeze, and heating pad. Biofreeze was not documented on the patient’s medication profile. During the home visit with the Social Worker (SW) [Personnel Record 4] on 06/19/2024, the patient reported that they prefer herbal remedies, and the hospice staff is aware. The patient reported that smoking “Mullein” (an herbal remedy used for asthma, bronchitis, pneumonia, colds, and cough) as needed for respiratory relief. A large glass jar with dried plant material labeled “Mullein” was on the table. The patient reported that Mullein is primarily for breathing but also helps with the digestive system. The patient reported taking Turmeric (a dietary supplement used for disorders of the skin, upper respiratory tract, joints, and digestive system) for inflammation. The patient stated that they held off on taking their pain medication, but that could change at any time as their pain was becoming worse. Mullein and Turmeric were not documented on the patient’s medication profile. There was no evidence that Biofreeze, Mullein, and Turmeric were reviewed with the patient’s medication regimen. The SW confirmed that the staff was aware that the patient prefers herbal remedies. The patient’s pain has increased over the last three (3) weeks, and the patient is aware that they may need to supplement herbal remedies soon. Clinical Record 9: The patient elected hospice care on 06/12/2023. A review of the clinical record revealed that the Registered Nurse (RN) plan of care review and updated comprehensive assessment dated 05/28/2024 documented, “Has started marijuana gummies.” The patient’s medication profile created on 05/06/2024 was not updated to document the marijuana gummies. There was no evidence that marijuana gummies were reviewed with the patient’s medication regimen. Clinical Record 10: The patient elected hospice care on 05/24/2024 with a history of chronic obstructive pulmonary disease (COPD) and lung cancer. The Skilled Nursing (SN) visit note dated 05/25/2024 documented, “Oxygen (O2) and breathing treatment available for patient and effective.” Oxygen was not documented on the patient’s medication profile. Clinical Record 14: The patient elected hospice care on 05/25/2024. The plan of care dated 05/25/2024 ordered: “Oxygen 2 liters (L) per nasal cannula (NC) as needed (PRN) for dyspnea. The medication profile dated 05/27/2024 and updated 06/17/2024 documented oxygen via nasal cannula as needed for dyspnea. The medication profile did not document a flow rate for the oxygen. During an interview and a joint clinical record review on 06/19/2024, the Patient Care Administrator confirmed that medications, supplements, herbal treatments, and oxygen were not included in the medication profiles.”

“It is required that the hospice ensures that each patient and the primary caregiver(s) receive education and training, provided by the hospice, as appropriate to their responsibilities for care as stated in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 9 (11%) clinical records reviewed, the agency did not ensure that the patient and the primary caregiver(s) received education and training. Clinical Record 1/Home Visit 1: The patient elected hospice care on 01/02/2024. The initial comprehensive assessment completed by the Registered Nurse (RN) on 01/02/2024 documented that the patient smoked. The plan of care ordered: “Oxygen 4 liters per minute (LPM) per nasal cannula (NC)” continuously with an oxygen concentrator. The plan of care dated 01/02/2024 did not include interventions related to the patient’s smoking and use of oxygen. The bi-weekly interdisciplinary group (IDG) notes dated through 06/12/2024 indicated that the patient continued to smoke. The plan of care did not include interventions or education after the initial visit related to safety concerns. During the home visit with the Registered Nurse (RN) [Personnel Record 1] on 06/18/2024, a single cigarette and lighter were observed on patient’s the bedside table. The house did not smell of cigarette smoke, and the patient’s daughter confirmed that the patient did not smoke in the home. The patient, who was alert and oriented, stated that they smoke outside and not around the oxygen. The patient stated that they do not stay outside too long because they cannot use oxygen. The patient had a sign on the front door that read “oxygen was in use.” The patient stated that the agency provided education and safety information at the initiation of care. The patient safety information was observed in the home with the home folder.”

“It is required that each patient’s individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review, observation, and interview. In 2 of 19 (11%) clinical records reviewed, the agency did not ensure that individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 1/Home Visit 1: The patient elected hospice care on 01/02/2024. The initial comprehensive assessment completed by the Registered Nurse (RN) on 01/02/2024 documented that the patient smoked. The plan of care ordered: “Oxygen 4 liters per minute (LPM) per nasal cannula (NC)” continuously with an oxygen concentrator. The plan of care dated 01/02/2024 did not include interventions related to the patient’s smoking and use of oxygen. The bi-weekly interdisciplinary group (IDG) notes dated through 06/12/2024 indicated that the patient continued to smoke. The plan of care did not include interventions or education after the initial visit related to safety concerns. During the home visit with the Registered Nurse (RN) [Personnel Record 1] on 06/18/2024, a single cigarette and lighter were observed on the patient’s bedside table. The house did not smell of cigarette smoke, and the patient’s daughter confirmed that the patient did not smoke in the home. The patient, who was alert and oriented, stated that they smoke outside and not around the oxygen. The patient stated that they do not stay outside too long because they cannot use the oxygen. The patient had a sign on the front door that “oxygen was in use.” The patient stated that the agency provided education and safety information at the initiation of care. The patient safety information was observed in the home with the home folder. Clinical Record 9: The patient elected hospice care on 06/12/2023. A review of the clinical record revealed that the Registered Nurse (RN) plan of care review and updated comprehensive assessment dated 05/28/2024 documented, “Has started marijuana gummies.” The plan of care was not updated to include goals or interventions related to the patient’s use of marijuana gummies. During an interview on 06/17/2024, the Patient Care Administrator confirmed that the plan of care did not include interventions related to the patient’s continued smoking.”

“It is required that each patient’s individualized written plan of care: includes all services necessary for the palliation and management of the terminal illness, including the following: drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, interview, and observation. In 1 of 19 (5%) clinical records reviewed the agency did not ensure that the individualized written plan of care included the patient’s drugs and treatments. Clinical Record 4/Home Visit 4: The patient elected hospice care on 03/29/2024. On 03/29/2024, the physician ordered, “monitor use and effectiveness of Aleve, Flexeril, Biofreeze, and heating pad. Biofreeze was not documented on the patient’s plan of care. During the home visit on 06/19/2024, the patient reported that they prefer herbal remedies, and the hospice staff is aware. The patient reported that they smoke “Mullein” (an herbal remedy used for asthma, bronchitis, pneumonia, colds, cough) as needed for respiratory relief. The patient reported taking Turmeric (a dietary supplement used for disorders of the skin, upper respiratory tract, joints, and digestive system) for inflammation. Mullein and Turmeric were not documented on the patient’s plan of care. The SW confirmed that the staff was aware that the patient prefers herbal remedies. During an interview on 06/19/2024, the National Patient Care Administrator and Patient Care Administrator confirmed that the care plans did not include the use of herbal remedies and dietary supplements.”

“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 2 of 12 (17%) clinical records reviewed, the agency did not ensure that the Hospice Aide (HA) received written patient care instructions specific to the patient’s needs. Clinical Record 5: The patient elected hospice care on 07/13/2023. On 07/20/2023 Hospice aide services were added to the plan of care and the HA care plan was documented. A Hoyer lift was added to the patient’s plan of care on 09/28/2023. The HA care plan was not updated to include the use of the Hoyer lift during personal care. The HA documented that the caregivers used the Hoyer lift for transfers. The HA visit notes documented that the HA did not transfer the patient from the bed during personal care. On 06/12/2024, oxygen was ordered. The HA care plan was not updated to include the patient’s use of oxygen during personal care. Clinical Record 19: The patient elected hospice on 01/15/2024 with a history of epilepsy and seizures. The HA care plan documented by RN on 01/17/2024 did not document seizure precautions. During an interview on 06/19/2024, the Patient Care Administrator confirmed that the HA care plans did not include the requirements and stated, “I understand completely.””

“It is required that a hospice aide provides services: ordered by the Interdisciplinary Group. This standard was not met as evidenced by clinical record review and interview. In 1 of 12 (8%) clinical records reviewed of patients that received Hospice Aide (HA) services, the agency did not ensure that the HA provided the services ordered by the interdisciplinary group. Clinical Record 1: The plan of care dated 02/08/2024 ordered HA services “1 x week.” The patient’s diagnosis was documented as chronic pulmonary disease. No HA visits were provided for the weeks of 03/07/2024, 04/25/2024, and 05/25/2024. A review of the clinical record revealed the HA note dated 03/07/2024 documenting, “Called patient CG to inform them that I will not provide services on 03/08/2024.” There was no documented evidence of communication with the physician. There were no documented missed visits for the weeks of 04/25/2024 and 05/25/2024. During an interview on 06/17/2024, the Patient Care Administrator (PCA) confirmed that there was no notification to the physician related to missed visits and stated, “We are really struggling with staffing.””

“It is required that a hospice aide provides services: included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 3 of 12 (25%) clinical records reviewed of patients that accepted Hospice Aide (HA) services, the agency did not ensure that the HA provided services included in the plan of care (POC). Clinical Record 3: The patient elected hospice care on 12/20/2023 and resided in a skilled nursing facility (SNF). The patient’s diagnosis was documented as chronic pulmonary disease (COPD). The HA care plan dated 05/08/2024 assigned the HA the relevant task: weigh the patient every month. The HA visit notes dated 05/09/2024, 05/21/2024, 05/24/2024, 05/28/2024, 05/30/2024, 06/04/2024, 06/06/2024 and 06/13/2024 documented “not performed/not required this visit” for the assigned task to weigh the patient monthly. There was no evidence that the HA weighed the patient monthly as assigned. A review of the clinical record revealed a weight was obtained at the time of recertification. The HA did not obtain that weight. Clinical Record 4: The patient elected hospice care on 03/29/2024. The patient’s diagnosis was documented as neoplasm of pancreas. The HA care plan documented on 04/23/2024 assigned the HA the relevant task: weigh the patient every month. The HA visit notes dated 05/01/2024, 05/03/2024, 05/06/2024, 05/08/2024, 05/13/2024, 05/15/2024, 05/20/2024, 05/24/2024, 05/27/2024, 06/03/2024, 06/05/2024, 06/07/2024, 06/10/2024, 06/12/2024, 06/14/2024, and 06/17/2024 documented “not performed/not required this visit” for the assigned task to weigh the patient monthly. There was no evidence that the HA weighed the patient monthly as assigned. A review of the clinical record revealed a weight was obtained at the time of recertification. The HA did not obtain that weight. Clinical Record 9: The patient elected hospice care on 06/12/2023. The patient’s diagnosis was documented as neoplasm of the bladder. The HA care plan documented on 06/17/2024 assigned the HA the relevant task “Infection Control -Universal Precautions.” The HA visit note dated 06/17/2024 documented “Infection Control - Universal Precautions... Not performed/Not required.” Clinical Record 12: The patient elected hospice care on 05/08/2024. The patient’s diagnosis was documented as end stage renal disease. The HA care plan documented on 05/10/2024 assigned the HA the relevant task: weigh the patient every month. The HA visit notes dated 05/14/2024, 05/21/2024, 05/28/2024, 06/03/2024, 06/10/2024, 06/14/2024, and 06/18/2024 documented “not performed/not required this visit” for the assigned task to weigh the patient monthly. There was no evidence that the HA weighed the patient monthly as assigned. A review of the clinical record revealed a weight was obtained at the time of recertification. The HA did not obtain that weight. During an interview and a joint record review on 06/18/2024, the Regional Patient Care Director agreed with the findings related to HA documentation.”

“It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 3 of 12 (25%) clinical records reviewed of patients that accepted Hospice Aide (HA) services, the agency did not ensure that the HA provided services included in the plan of care (POC). Clinical Record 3: The patient elected hospice care on 12/20/2023 and resided in a skilled nursing facility (SNF). The patient’s diagnosis was documented as chronic pulmonary disease. The HA care plan dated 05/08/2024 assigned the HA the relevant task: weigh the patient every month. The HA visit notes dated 05/09/2024, 05/21/2024, 05/24/2024, 05/28/2024, 05/30/2024, 06/04/2024, 06/06/2024 and 06/13/2024 documented “not performed/not required this visit” for the assigned task to weigh the patient monthly. There was no evidence that the HA weighed the patient monthly as assigned. A review of the clinical record revealed a weight was obtained at the time of recertification. The HA did not obtain that weight.The clinical record contained no documentation that the Registered Nurse (RN) was notified that the task was not completed. Clinical Record 4: The patient elected hospice care on 03/29/2024. The patient’s diagnosis was documented as neoplasm of pancreas. The HA care plan documented on 04/23/2024 assigned the HA the relevant task: weigh the patient every month. The HA visit notes dated 05/01/2024, 05/03/2024, 05/06/2024, 05/08/2024, 05/13/2024, 05/15/2024, 05/20/2024, 05/24/2024, 05/27/2024, 06/03/2024, 06/05/2024, 06/07/2024, 06/10/2024, 06/12/2024, 06/14/2024, and 06/17/2024 documented “not performed/not required this visit” for the assigned task to weigh the patient monthly. There was no evidence that the HA weighed the patient monthly as assigned. A review of the clinical record revealed a weight was obtained at the time of recertification. The HA did not obtain that weight. The clinical record contained no documentation that the RN was notified that the task was not completed. Clinical Record 12: The patient elected hospice care on 05/08/2024. The patient’s diagnosis was documented as end stage renal disease. The HA care plan documented on 05/10/2024 assigned the HA the relevant task: weigh the patient every month. The HA visit notes dated 05/14/2024, 05/21/2024, 05/28/2024, 06/03/2024, 06/10/2024, 06/14/2024, and 06/18/2024 documented “not performed/not required this visit” for the assigned task to weigh the patient monthly. There was no evidence that the HA weighed the patient monthly as assigned. A review of the clinical record revealed a weight was obtained at the time of recertification. The HA did not obtain that weight. The clinical record contained no documentation that the RN was notified that the task was not completed as assigned. During an interview and a joint record review on 06/18/2024, the Regional Patient Care Director agreed with the findings related to HA documentation.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. 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 19 (11%) clinical records reviewed, the agency did not ensure that the patient’s clinical record contained physician orders for all care and treatment. Clinical Record 5: The patient elected hospice care on 07/13/2023. The updated comprehensive assessment completed by the Skilled Nurse (SN) on 08/16/2023 documented, “Genitourinary system...patient has a pic wick [sic] system in place.” A review of the clinical record revealed no physician orders for a “PureWick” or “pic wick” system. Clinical Record 10: The patient elected hospice care on 05/24/2024 with a history of chronic obstructive pulmonary disease (COPD) and a diagnosis of lung cancer. The Skilled Nursing (SN) visit note dated 05/25/2024 documented, “Oxygen (O2) and breathing treatment available for patient and effective.” The initial plan of care documented an oxygen concentrator with medical equipment and supplies. The plan of care did not include orders for the administration of oxygen. During an interview and a joint record review on 06/17/2024, the Patient Care Administrator confirmed that there was no order for Clinical Record #1 for a pure wick system and no physician order for oxygen administration on Clinical Record #10.”