Vitas Healthcare Corporation Atlantic

“It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including the following medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (16%) clinical records reviewed, the hospice did not ensure that the written plan of care included the medical supplies necessary to meet the needs of the patient. Clinical Record 2: The patient elected hospice care on 10/10/2022 with the diagnosis of malignant neoplasm of the liver. The Registered Nurse (RN) documented that the patient was incontinent of bowel and bladder and that the agency provided adult briefs, pads, gloves, and wipes. The initial plan of care did not document the adult briefs, pads, gloves, and wipes necessary to meet the needs of the patient. Clinical Record 5: The patient elected hospice care on 01/26/2023 with the diagnosis of senile degeneration of the brain. The RN documented that the patient was incontinent of bowel and bladder and that the agency provided adult briefs, pads, gloves, and wipes. The initial plan of care did not document the adult briefs, pads, gloves and wipes necessary to meet the needs of the patient. During an interview and a joint review of clinical records on 04/23/2024, the Patient Care Administrator (PCA) confirmed that the initial plan of care did not include documentation of the medical supplies. No further information was provided.”

“It is required that a hospice aide provides services: ordered by the Interdisciplinary Group; included in the plan of care; permitted to be performed under state law and regulation; [and] consistent with the hospice aide training. This standard was not met as evidenced by clinical record review and interview. In 3 of 14 (21%) clinical records reviewed of patients who accepted Hospice Aide (HA) services, the agency did not ensure that the HA followed the plan of care. Clinical Record 5: The patient elected hospice care on 01/26/2023 with a diagnosis of senile degeneration of the brain. The HA plan of care dated 01/26/2023 assigned the HA the relevant task: shampoo every visit. The HA visit note dated 04/22/2023 documented that “shampoo not required this visit.” Clinical Record 9: The patient elected hospice care on 08/11/2023 with a diagnosis of cerebral atherosclerosis. The HA plan of care dated 08/11/2023 assigned the HA the relevant task: oral care every visit. The HA visit note dated 08/22/2023 documented that “oral care not required this visit.” Clinical Record 12: The patient elected hospice care on 03/04/2024 with a diagnosis of Parkinson disease. The HA plan of care dated 03/04/2024 assigned the HA the relevant task: oral care every visit. The HA visit note dated 04/03/2024 documented that “oral care not required this visit.” During an interview and a joint review of clinical records, the Patient Care Administrator confirmed that the aide did not follow the HA plan of care.”

“It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review and interview. In 3 of 14 (21%) clinical records reviewed of patients who accepted Hospice Aide (HA) services, the agency did not ensure that the HA followed the plan of care. Clinical Record 5: The patient elected hospice care on 01/26/2023 with a diagnosis of senile degeneration of the brain. The HA plan of care dated 01/26/2023 assigned the HA the relevant task: shampoo every visit. The HA visit note dated 04/22/2023 documented that “shampoo is not required this visit.” There was no documented evidence that the RN was notified of the task not being completed. Clinical Record 9: The patient elected hospice care on 08/11/2023 with a diagnosis of cerebral atherosclerosis. The HA plan of care dated 08/11/2023 assigned the HA the relevant task: oral care every visit. The HA visit note dated 08/22/2023 documented, “Oral care not required this visit.” There was no documented evidence that the RN was notified of the task not being completed. Clinical Record 12: The patient elected hospice care on 03/04/2024 with a diagnosis of Parkinson’s disease. The HA plan of care dated 03/04/2024 assigned the HA the relevant task: oral care every visit. The HA visit note dated 04/03/2024 assigned the HA the relevant task: “oral care not required this visit.” There was no documented evidence that the RN was notified of the task not being completed. During an interview and a joint review of clinical records, the Patient Care Administrator confirmed that the aide did not follow the HA plan of care.”

“It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary described in HCDT 40.I; and the patient’s record, if requested. This standard was not met as evidenced by clinical record review and interview. In 1 of 3 (33%) clinical records reviewed of patients transferred to a Medicare/Medicaid Certified Facility, the agency did not ensure that a discharge summary was sent to the receiving facility. Clinical Record 15: The patient elected hospice care on 08/31/2023 with the diagnosis of cerebral vascular disease. The patient was transferred to the hospital and revoked the hospice benefit on 09/14/2023 to seek aggressive treatment. The clinical record contained no documented evidence that a discharge summary was sent to the receiving hospital. There was a discharge summary completed. During an interview and a joint review of clinical records, the Patient Care Administrator (PCA) confirmed that the discharge summary was not forwarded to the receiving facility. No further information was provided.”