Vitas Healthcare Corporation Atlantic

“Based on a review of Clinical Records (CR), Personnel Files (PF), agency policies, complaint log, interviews with complainant, the agency’s Patient Care Administrator (PCA) and National Patient Care Administrator (NPCA), the agency failed to ensure that all hospice care and services furnished to patients and their families must follow an individualized written plan of care established by the hospice interdisciplinary group in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver in accordance with the patient’s needs if any of them so desire for one (1) of three (3) clinical records reviewed. (CR#2). Findings include:A review of CR was conducted on 5/18/26 from 1 pm to 3 pm, 5/19/2026 from 12 pm to 4 pm, 5/20/2026 from 10 am to 3 pm, 5/27/2026 from 10 am and 6/2/2026 from 10 am.CR#2, SOC: 4/1/2026, Discharge Date: 4/26/2026, Inpatient Admission: 4/1/2026, Inpatient Discharge: 4/4/2026, Inpatient Re-admission:4/15/2026, CR review range: 4/1/2026 through 4/16/2026. CR#2 contains “Admission Order” which reads, “… Call bell at bed side at all times, check qs, Start Date: 4/1/2026; Colostomy care daily and PRN, Start Date: 4/1/2026;… Location of Care: VIPU… Admit frequency: N Assess x 1, SW or CH assess x 1 then N, SW, CH, HA and Vol. to visit PRN often as needed… Verbal Order Date: 4/1/2026…” signed by hospice MD on 5/19/2026.“RN - Initial Comprehensive Assessment Encounter – 04/01/2026” reads, “…Musculoskeletal – Data Collection: PPS: 20% Bed Bound… (Dependent for the following) Transferring, Dressing, Toileting/Continence, Ambulation/Mobility, Bathing, Taking Medications, Laundry, Telephone, Marketing, Preparing Meals, Light Housekeeping… (Minimal Assistance for the following) Feeding...”“RN – Updated Comprehensive assessment Encounter – 04/02/2026” reads, “…Musculoskeletal… #0121 (HA) Hospice Aide to perform Change Linens for patient every inpatient shift Start Date: 04/01/2026… #0136 (HA) Hospice Aide to administer Sponge Bath for patient every Inpatient shift Start Date: 04/01/2026… #0139 (HA) Hospice Aide to perform Dressing for patient inpatient Shift Start Date: 04/01/2026… #0142 (HA) Aide to administer Feeding Assistance for patient every inpatient shift Start Date: 04/01/2026…”A review of “VITAS VIPU INTERNAL (SHIFT) CHARTING” and Hospice Nurse Assessment documents revealed the following:There is no evidence that the agency provided change linen, feeding assistance and bed bath services on the following Inpatient shift: 4/1/2026 1:30 pm to 7:30 pm, 4/1/2026 7 pm to 4/2/2026 7:30 am, 4/2/2026 7 am to 7 pm, 4/2/2026 7 pm to 11 pm, 4/2/2026 11 pm to 4/3/2026 7 am, 4/3/2026 7 am to 7 pm, 4/3/2026 7 pm to 4/4/2026 7:30 am, 4/4/2026 7 am to 3:30 pm, 4/4/2026 3 pm to 7 pm, 4/15/2026 7 am 7:30 pm, 4/15/2026 7 pm to 4/16/2026 7:30 am.An interview with NPCA on 6/1/2026 at 3:15 pm confirmed the above findings.”

“Based on a review of agency’s complaint log, clinical record (CR), HME (home medical equipment) records, agency policies, and interviews with agency’s patient care administrator (PCA), NPCA (national PCA), General Manager, AVP HME IT Systems, Senior VP of Survey Readiness & Response, the Agency failed to ensure that the patient, where appropriate, as well as the family and/or other caregiver(s), receive instruction in the safe use of durable medical equipment and supplies. The hospice may use persons under contract to ensure patient and family instruction. The patient, family, and/or caregiver must be able to demonstrate the appropriate use of durable medical equipment to the satisfaction of the hospice staff for two (2) of four (4) clinical records reviewed (CR#2 and 3). Findings include:A review of agency’s policies was conducted on 2/25/2026 at 2 pm.A policy titled, “VMS Clinical Documentation Tracking” reads, “Purpose: …A clinical record containing past and current findings is maintained for each hospice patient. The clinical record must contain correct clinical information that is available to the patient’s attending physician and hospice staff. The clinical record may be maintained electronically… Considerations: 1. VITAS Policy 5:65 states: i. Documentation is to be available in the office no more than 7 calendar days after the care or services are provided… 3. Missing Documentation i. When documentation is identified as missing; first follow the process outlined in VS Late Entry…”A policy titled, “VS Medical Supplies and HME” reads, “…Considerations: The VITAS RN ensures that appropriate and adequate supplies are provided to the patient… General Instructions: … Programs contracted with VITAS HME should provide the tracking link to the patient and/or caregiver so they are able to monitor delivery status of HME after it’s been ordered…” A review of hospice plan of care for CRs (clinical record) and HME record was conducted on 2/3/26 starting at 12 pm, 2/6/26 starting at 10 am, 2/13/26 starting from 10 am, 2/20/26 starting from 12 pm, 2/23/26 starting from 10 am and 2/25/2026 starting from 8:30 am.CR#2, SOC (Start of Care): 11/8/25, D/C (discharge): 11/11/25:”History Report: 11/08/2025 - 11/11/2025” reads, six (6) HME orders “E CYLINDER, E CYLINDER CART, OXYGEN USP - E CYLINDER, CONCENTRATOR - 5 LPM, NEBULIZER COMPRESSOR, SUCTION RESPIRATORY MACHINE” started on 11/8/2025 and ended on 11/11/2025. However, there is no documentation that shows hospice provided above 6 HME to CR#2 from 11/8/2025 to 11/11/2025. CR#3, SOC: 11/22/25, D/C: 12/20/25:CR#3’s “History Report: 11/22/2025 – 12/20/2025” shows total of 14 HME orders which are “BED RAILS - HALF (PR), FRONT WHEEL WALKER - JUNIOR, E CYLINDER CART, OXYGEN USP – E CYLINDER, SING AWAY FOOTREST - HEMI SPAC, CONCENTRATOR - 5LPM, NEBULIZER COMPRESSOR, SUCTION RESPIRATORY MACHINE, PRESSURE RELIEF MATTRESS, E CYLINDER, OVER BED TABLE, COMMODE 3-IN-1, FULL ELECTRONIC HOME CARE BED LO, SHOWER CHAIR WITH BACK.” All 14 equipment orders started on 11/21/2025 and order ended on 12/20/2025. “Rental Contract 21070047804/1.00” reads, “Date: 12/23/2025; Customer Ref: (blank), Rental from: 12/23/2025 to (blank), Duration: Open-ended; Customer Billing Information: (CR#3 and CR#3’s address)... Customer Shopping Information: (CR#3 and CR#3’s address)...” Items for this rental contracts includes: BED RAILS - HALF (PR), FULL ELECTRONIC HOME CARE BED LOW, PRESSURE RELIEF MATTRESS, OVER BED TABLE, COMMODE 3-IN-1, SHOWER CHAIR WITH BACK, FRONT WHEEL WALKER - JUNIOR, SWING AWAY FOOTREST - HEMI SPACING (PR), E CYLINDER CART, CONCENTRATOR - 5LPM, E CYLINDER, NEBULIZER COMPRESSOR, SUCTION RESPIRATORY MACHINE.” The contract start date is on 12/23/2025 which is after the patient discharge date on 12/20/2025. 14 HME that are listed on this contract are 14 HME that were ordered on 11/21/2025, ended on 12/20/2025 (patient discharge date), dispense date of 11/21/2025. The contract reads, “...You are being asked to sign this form to document you are in receipt of this equipment and/or these services on this date from VITAS Healthcare. I am in receipt of this medical equipment intended only for use by this patient or me on this date. I have been instructed on the proper care, use and maintenance of this medical equipment and I have been instructed to contact VITAS Healthcare in the event of emergency, consultation or repair. I understand all of the medical equipment being provided to this patient or me is being provided on a rental basis and must be returned when this patient is no longer on service with VITAS Healthcare. I agree I am personally responsible for loss, theft, or damage to this medical equipment while in my care... By signing this contract, Customer confirms they have read and agreed with all Terms and Conditions. INDEMNIFICATION AGREEMENT, Renter shall assume the risks of and shall indemnify and hold lessor harmless...” The signature and name section is left blank.There is no documentation that shows hospice provided above 14 HME to CR#3 from 11/22/2025 to 12/20/2025. There is no documentation that shows hospice provided HME use education to CR#3 or CR#3’s caregiver.Interviews with NPCA on 2/25/2026 at 11:18 am and 2/27/2026 at 8:52 am confirmed above findings.”

“Based on review of the agency’s policies/procedures, Clinical Record (CR), and an interview with the agency’s patient care administrator, the agency failed to ensure that comprehensive assessment must identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient’s well-being, comfort, and dignity throughout the dying process. The comprehensive assessment must take into consideration the following factors: (5) Severity of symptoms for one (1) of three (3) CR reviewed: CR#1. Findings included:A review of hospice agency’s policies was conducted on 9/26/25 at 3 pm.A policy titled, “VS Patient Rights” reads, “… General Instructions: 1. Patient Rights Notification. 1. VITAS patient are notified of their rights when consents are signed… 2. Rights of the Patient. 1. Patients will be treated with respect and courtesy… 3. Being transparent with information in language that is easily understood…3. Patients will receive effective pain management and symptom control for conditions related to the terminal illness… 4. Patients have right to be involved in developing their plan of care…2. Patients are vital to the care planning process and in making decisions regarding their care, treatment and services… 4. Staff provide care and services as specified in the plan of care… 9. Patients have the right to receive information about the services covered under the hospice benefit… 10. Patients have the right to receive information about the scope of services that the Hospice will provide and the specific limitations on those services. 1. Patients receive information during the admission process… 3. Voicing Grievances: 1. Inform patients and caregivers of how to reach VITAS with concerns or complaints. 1. Ensure patient and caregivers know how to reach VITAS 24 hours/day 7 days/week. 2. Ensure patients and caregivers have access to program phone number. 3. Ensure patients have received Share Your Experience information with toll free VITAS phone number 800.582.9533… 4. Allegations of Patient Rights Violations: 1. Many suspected violations of patient rights by anyone furnishing services on behalf of VITAS (e.g., staff, volunteer, agency) must be immediately reported to the TM. 1. Mistreatment, 2. Neglect,… 2. TM will notify PCA and GM, 3. Immediate investigation will occur to determine appropriate next steps.”A policy titled, “VS Symptom Management” reads, “…GENERAL INSTRUCTIONS: … Assessment: Patient should be asked about or observed for pain every visit. Pain should be assessed using the verbal or non-verbal behavioral scale. PQRST (Palliation and provocation, Quality, Radiation, Severity, Temporal) should be completed even if the pain is managed. Wounds are assessed by nursing staff each visit; And at least every 7 days an RN (Registered Nurse) assessment that includes visualization, measurement and a complete description of the wound. All physical, psychosocial, and spiritual symptoms should be assessed at each visit by all of the disciplines visiting…”A policy titled, “VS Care Planning” reads, “The Hospice must designate an interdisciplinary group or groups as specified in paragraph (a) of this section which, in consultation with the patient’s attending physician, must prepare a written plan of care for each patient. The plan of care must specify the hospice care and services necessary to meet the patients and family’s specific needs identified in the comprehensive assessment as such needs relate to the terminal illness and related conditions. 3. Standard: approach to service delivery – a. The Hospice must designate an interdisciplinary group or groups composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of those Hospice patients and families facing terminal illness and bereavement. Interdisciplinary group members must provide the care and services offered by the Hospice, and the group, in its entirety, must supervise the care and services. The Hospice must designate a registered nurse that is a member of the interdisciplinary group to provide the coordination of care and to ensure continuous assessment of each patient’s and the family’s needs and implementation of the interdisciplinary plan of care… Consideration: … d. Appropriate, through assessment is the key to good care planning. i. Each care plan is only as good as the assessment is based on…”A review of Clinical Records (CR) was conducted on 9/26/25 from 12 pm. CR#1, SOC (Start of Care): 6/27/25,CR#1 did not receive a comprehensive wound assessment with measurements from admission on 6/27/25 until 7/26/25, a gap of 29 days. The initial registered nurse assessment on 6/27/25 documented sacral wound but did not include required comprehensive wound assessment with measurements, staging, or photographic documentation. Multiple shifts charting entries from 6/28/25 through 8/2/25 contained no documentation of wound assessment despite physician orders for dressing change every 3 days.“RECAPITULATION OF STAY (DISCHARGE SUMMARY)” from CR#1’s previous Skilled Nursing Facility reads, “…1. Recapitulation of Stay… 1a. Most Recent Admission: 6/9/25, 1b. Discharge Date: 6/26/25, … 1e. Reason for Discharge: resident will be transferring over to inpatient hospice… 2. Nursing: …4. Wound Care Recommendations Post Discharge: Cleanse sacrum with nss, apply zinc oxide, apply foam dressing daily and prn… 4. Nutrition: … 8. Nutrition Summary: Poor PO intake, discharge on hospice care…”“RN – Initial Comprehensive Assessment Encounter – 06/27/2025” did not contain documentation that a complete wound assessment was completed for the scrum wound.“LPN – Updated Comprehensive Assessment Encounter – 06/28/2025” did not include the sacrum wound assessment.“LPN – Focus Encounter – 06/28/2025” did not include the sacrum wound assessment.“LPN – Updated Comprehensive Assessment Encounter – 06/29/2025” did not include the sacrum wound assessment.“RN – Updated Comprehensive Assessment Encounter – 06/30/2025” did not include the sacrum wound assessment.“RN – Focus Encounter – 06/30/2025” did not include the sacrum wound assessment.“RN – Updated Comprehensive Assessment Encounter – 07/01/2025” did not include the sacrum wound assessment.“RN – Updated Comprehensive Assessment Encounter – 07/02/2025” did not include the sacrum wound assessment.“RN – Focus Encounter – 07/02/2025” did not include the sacrum wound assessment.“RN – Updated Comprehensive Assessment Encounter – 07/03/2025” did not include the sacrum wound assessment.“RN – Updated Comprehensive Assessment Encounter – 07/04/2025” did not include the sacrum wound assessment.“RN – Updated Comprehensive Assessment Encounter – 07/05/2025” did not include the sacrum wound assessment.“RN – Updated Comprehensive Assessment Encounter – 07/06/2025” did not include the sacrum wound assessment.“LPN – Updated Comprehensive Assessment Encounter – 07/07/2025” did not include the sacrum wound assessment.“RN – Updated Comprehensive Assessment Encounter – 07/08/2025” did not include the sacrum wound assessment.“RN – Updated Comprehensive Assessment Encounter – 07/09/2025” did not include the sacrum wound assessment.“LPN – Updated Comprehensive Assessment Encounter – 07/10/2025” did not include the sacrum wound assessment.“LPN – Updated Comprehensive Assessment Encounter – 07/11/2025” did not include the sacrum wound assessment.“RN – Updated Comprehensive Assessment Encounter – 07/12/2025” did not include the sacrum wound assessment.“LPN – Updated Comprehensive Assessment Encounter – 07/13/2025” did not include the sacrum wound assessment.“LPN – Focus Encounter – 07/14/2025” reads, “…Physician Order Needs: Medications – FLAGYL (METRONIDAZOLE) 500 MG TABLET (take 1 tablet (=500mg) crushed to sacrum & cover with Mepilex drs (dressing)& change every 3 days & pen), Start Date: 7/14/25… Other Orders: Cleanse sacrum with NSS and cover with mepilex/Comparable dressing every 3 days and PRN, Start Date: 6/27/25, End Date: 7/14/25… Elaborations: Pt (patient) with unstageable sacral pressure ulcer order for Flagyl 500mg crushed and apply in wound & cover with mepilex & change q (every) 3 days & prn order obtained bu Dr. (hopsice MD).” There was no further note regarding assessment of the sacrum wound.“Physician Order – Focus” reads, “…Oher Orders Cleanse sacrum with NSS and cover with mepilex/Comparable dressing every 3 days and PRN, … Start Date: 6/27/25, End Date: 7/14/25…” and was signed by hospice MD on 7/17/25.“RN – Updated Comprehensive Assessment Encounter – 07/15/2025” did not include the sacrum wound assessment.“LPN – Updated Comprehensive Assessment Encounter – 07/16/2025” did not include the sacrum wound assessment.“LPN – Updated Comprehensive Assessment Encounter – 07/17/2025” did not include the sacrum wound assessment.“RN – Updated Comprehensive Assessment Encounter – 07/19/2025” did not include the sacrum wound assessment.“RN – Updated Comprehensive Assessment Encounter – 07/20/2025” did not include the sacrum wound assessment.“LPN – Updated Comprehensive Assessment Encounter – 07/21/2025” did not include the sacrum wound assessment.“LPN – Updated Comprehensive Assessment Encounter – 07/22/2025” did not include the sacrum wound assessment. “RN – Updated Comprehensive Assessment Encounter – 07/23/2025” did not include the sacrum wound assessment.“LPN – Updated Comprehensive Assessment Encounter – 07/24/2025” reads, “Integumentary… Other Order: … Cleanse L (left) heel with Wound Cleanser then apply mepilex drs & change q 5 days & prn, Start Date: 7/24/25… Elaborations: Pt with Left heel unstageable pressure ulcer cleansed with wound cleanser then applied mepilex dressing & change q5days & prn…” There was no further note regarding assessment of the left heel wound or the scrum wound.“Physician Order – Updated Comprehensive Assessment” reads, “… Other Order Cleanse L heel with wound cleanser then apply mepilex drs & change q 5 days & prn,… Start Date: 7/24/25...” and was signed by hospice MD on 7/28/25.A document titled, “LPN – Updated Comprehensive Assessment Encounter – 07/25/2025” showed no documentation that wound assessment was completed for scrum or L heel wound.“RN – Updated Comprehensive Assessment Encounter – 07/26/2025” did not contain documentation that wound measurement was completed for L heel wound.“RN – Updated Comprehensive Assessment Encounter – 07/27/2025” did not contain documentation that wound measurement was completed for L heel wound.An interview with agency’s patient care administrator on 9/26/25 at 3:50 pm confirmed the above findings.”

“Based on review of the agency’s policies/procedures, Clinical Record (CR), and an interview with the agency’s patient care administrator, the agency failed to ensure that the care and services are provided in accordance with the plan of care for one (1) of three (3) CR reviewed: CR#1. Findings included:A review of hospice agency’s policies was conducted on 9/26/25 at 3 pm.A policy titled, “VS Symptom Management” reads, “…GENERAL INSTRUCTIONS: … Assessment: Patient should be asked about or observed for pain every visit. Pain should be assessed using the verbal or non-verbal behavioral scale. PQRST (Palliation and provocation, Quality, Radiation, Severity, Temporal) should be completed even if the pain is managed. Wounds are assessed by nursing staff each visit; And at least every 7 days an RN (Registered Nurse) assessment that includes visualization, measurement and a complete description of the wound. All physical, psychosocial, and spiritual symptoms should be assessed at each visit by all of the disciplines visiting…”A policy titled, “VS Care Planning” reads, “The Hospice must designate an interdisciplinary group or groups as specified in paragraph (a) of this section which, in consultation with the patient’s attending physician, must prepare a written plan of care for each patient. The plan of care must specify the hospice care and services necessary to meet the patients and family’s specific needs identified in the comprehensive assessment as such needs relate to the terminal illness and related conditions. 3. Standard: approach to service delivery – a. The Hospice must designate an interdisciplinary group or groups composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of those Hospice patients and families facing terminal illness and bereavement. Interdisciplinary group members must provide the care and services offered by the Hospice, and the group, in its entirety, must supervise the care and services. The Hospice must designate a registered nurse that is a member of the interdisciplinary group to provide the coordination of care and to ensure continuous assessment of each patient’s and the family’s needs and implementation of the interdisciplinary plan of care…3) Standard: Coordination of services: The hospice must develop and maintain a system of communication and integration, in accordance with the hospice’s own policies and procedures, to a) Ensure that the interdisciplinary group maintains responsibility for directing, coordinating, and supervising the care and services provided. b) Ensure that the care and services are provided in accordance with the plan of care. c) Ensure that the care and services provided are based on all assessments of the patient and family needs... Consideration: … d. Appropriate, through assessment is the key to good care planning. i. Each care plan is only as good as the assessment is based on… Coordination of Services: 1. The Core IDG must coordinate all services provided to patient directly or via contract. 2. Coordination is accomplished by: i. Care planning based on assessment which identifies needed interventions. 1. Ensuring care planned interventions are provided directly or via contract. 2. Ensuring contractors provide care according to the POC (plan of care)... 5. Documenting care planned interventions provided...”A review of Clinical Records (CR) was conducted on 9/26/25 from 12 pm. “Physician Order – Initial Comprehensive Assessment” reads, “… Other Orders Cleans sacrum with NSS (normal sterile saline) and cover with mepilex/Comparable dressing every 3 days and PRN… Start Date: 6/27/25… ” this order was signed by hospice MD on 7/17/25.“RN – Initial Comprehensive Assessment Encounter – 06/27/2025” did not contain documentation that the sacrum wound assessment or treatment was performed.“LPN – Updated Comprehensive Assessment Encounter – 06/28/2025” did not contain documentation that the sacrum wound assessment or treatment was performed.“LPN – Focus Encounter – 06/28/2025” did not contain documentation that the sacrum wound assessment or treatment was performed.“LPN – Updated Comprehensive Assessment Encounter – 06/29/2025” did not contain documentation that the sacrum wound assessment or treatment was performed.“RN – Updated Comprehensive Assessment Encounter – 06/30/2025” did not contain documentation that the sacrum wound assessment or treatment was performed.“RN – Focus Encounter – 06/30/2025” did not contain documentation that the sacrum wound assessment or treatment was performed.“RN – Updated Comprehensive Assessment Encounter – 07/01/2025” did not contain documentation that the sacrum wound assessment or treatment was performed.“RN – Updated Comprehensive Assessment Encounter – 07/02/2025” did not contain documentation that the sacrum wound assessment or treatment was performed.“RN – Focus Encounter – 07/02/2025” did not contain documentation that the sacrum wound assessment or treatment was performed.“RN – Updated Comprehensive Assessment Encounter – 07/03/2025” did not contain documentation that the sacrum wound assessment or treatment was performed.“RN – Updated Comprehensive Assessment Encounter – 07/04/2025” did not contain documentation that the sacrum wound assessment or treatment was performed.“RN – Updated Comprehensive Assessment Encounter – 07/05/2025” did not contain documentation that the sacrum wound assessment or treatment was performed.“RN – Updated Comprehensive Assessment Encounter – 07/06/2025” did not contain documentation that the sacrum wound assessment or treatment was performed.“LPN – Updated Comprehensive Assessment Encounter – 07/07/2025” did not contain documentation that the sacrum wound assessment or treatment was performed.“RN – Updated Comprehensive Assessment Encounter – 07/08/2025” did not contain documentation that the sacrum wound assessment or treatment was performed.“RN – Updated Comprehensive Assessment Encounter – 07/09/2025” did not contain documentation that the sacrum wound assessment or treatment was performed.“LPN – Updated Comprehensive Assessment Encounter – 07/10/2025” did not contain documentation that the sacrum wound assessment or treatment was performed.“LPN – Updated Comprehensive Assessment Encounter – 07/11/2025” did not contain documentation that the sacrum wound assessment or treatment was performed.“RN – Updated Comprehensive Assessment Encounter – 07/12/2025” did not contain documentation that the sacrum wound assessment or treatment was performed.“LPN – Updated Comprehensive Assessment Encounter – 07/13/2025” did not contain documentation that the sacrum wound assessment or treatment was performed.“LPN – Focus Encounter – 07/14/2025” reads, “…Physician Order Needs: Medications – FLAGYL (METRONIDAZOLE) 500 MG TABLET (take 1 tablet (=500mg) crushed to sacrum & cover with Mepilex drs (dressing)& change every 3 days & pen), Start Date: 7/14/25… Other Orders: Cleanse sacrum with NSS and cover with mepilex/Comparable dressing every 3 days and PRN, Start Date: 6/27/25, End Date: 7/14/25… Elaborations: Pt (patient) with unstageable sacral pressure ulcer order for Flagyl 500mg crushed and apply in wound & cover with mepilex & change q (every) 3 days & prn order obtained bu (hospice MD).” There was no documentation that the sacrum wound assessment or treatment was performed.“Physician Order – Focus” reads, “…Oher Orders Cleanse sacrum with NSS and cover with mepilex/Comparable dressing every 3 days and PRN, … Start Date: 6/27/25, End Date: 7/14/25…” and was signed by hospice MD on 7/17/25.“RN – Updated Comprehensive Assessment Encounter – 07/15/2025” did not contain documentation that the sacrum wound assessment or treatment was performed.“LPN – Updated Comprehensive Assessment Encounter – 07/16/2025” did not contain documentation that the sacrum wound assessment or treatment was performed.“LPN – Updated Comprehensive Assessment Encounter – 07/17/2025” did not contain documentation that the sacrum wound assessment or treatment was performed.“RN – Updated Comprehensive Assessment Encounter – 07/19/2025” did not contain documentation that the sacrum wound assessment was performed.“RN – Updated Comprehensive Assessment Encounter – 07/20/2025” did not contain documentation that the sacrum wound assessment was performed.“LPN – Updated Comprehensive Assessment Encounter – 07/21/2025” reads, did not contain documentation that the sacrum wound assessment was performed.“LPN – Updated Comprehensive Assessment Encounter – 07/22/2025” did not contain documentation that the sacrum wound assessment was performed. “RN – Updated Comprehensive Assessment Encounter – 07/23/2025” did not contain documentation that the sacrum wound assessment was performed.“LPN – Updated Comprehensive Assessment Encounter – 07/24/2025” reads, “Integumentary… Other Order: … Cleanse L heel with Wound Cleanser then apply mepilex drs & change q 5 days & prn, Start Date: 7/24/25… Elaborations: Pt with Left heel unstageable pressure ulcer cleansed with wound cleanser then applied mepilex dressing & change q5days & prn…” There was no further note regarding assessment of the left heel wound or the scrum wound.“Physician Order – Updated Comprehensive Assessment” reads, “… Other Order Cleanse L heel with wound cleanser then apply mepilex drs & change q 5 days & prn,… Start Date: 7/24/25...” and was signed by hospice MD on 7/28/25.“LPN – Updated Comprehensive Assessment Encounter – 07/25/2025” does not contain documentation showing that wound care for L heel was provided. There was no documentation showing that wound assessment was completed for scrum or L heel wound.“RN – Updated Comprehensive Assessment Encounter – 07/26/2025” does not contain documentation that wound assessment or treatment was completed for L heel wound.“RN – Updated Comprehensive Assessment Encounter – 07/27/2025” does not contain documentation that wound assessment or treatment was completed for L heel wound.“Physician Order – Updated Comprehensive Assessment” reads, “…Other Orders Cleanse Sacrum with NSS and cover with Netflix comparable dressing every three days and the PRN… start date: 6/27/25… other orders cleanse sacrum with wound cleanser then crush Flagyl 500mg tab and place in wound & cover with mepilex dressing change Q3 days & prn… start date 7/14/25…” This order was signed by hospice MD on 7/17/25.“RN – Updated Comprehensive Assessment Encounter – 07/28/2025” does not contain documentation that wound assessment or treatment was completed for L heel wound.“RN – Updated Comprehensive Assessment Encounter – 07/29/2025” does not contain documentation that wound assessment or treatment was completed for L heel wound.“LPN – Updated Comprehensive Assessment Encounter – 07/30/2025” does not contain documentation that wound assessment or treatment was completed for L heel wound.“LPN – Updated Comprehensive Assessment Encounter – 07/31/2025” does not contain documentation that wound assessment or treatment was completed for L heel wound.“RN – Updated Comprehensive Assessment Encounter – 08/01/2025” does not contain documentation that assessment was completed for L heel wound.“RN – Updated Comprehensive Assessment Encounter – 08/02/2025” does not contain documentation that wound assessment or treatment was completed for L heel wound.Plan of Care Review on 7/17/25 reads, “…Integumentary – Unstageable on sacrum drsg (dressing) change Q3D/PRN…”“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 6/28/25 from 7 am to 3 pm does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 6/28/25 from 3 pm to 7:30 pm does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 6/28/25-6/29/25 from 11pm to 7 am does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 6/27/25 time: 7:30 pm, new note started/VIPU Shift Start Time: 7 am does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 6/29/25 from 7 am to 3 pm does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 6/29/25 from 3 pm to 11 pm does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 6/29/25 – 6/20/25 from 11 pm to 7:30 am does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 6/30/25 from 7 am to 7 pm does not contain documentation that wound assessment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 6/30/25 – 7/1/25 from 7 pm to 7:30 am does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/1/25 from 7 am to 3:30 pm does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/1/25 from 3 pm to 11 pm does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/1/25 – 7/2/25 from 11 pm to 7:30 am does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/2/25 from 7 am to 12 pm does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/2/25 shift start time: unknown, shift end time: 7 pm does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/2/25 from 7 pm to 11 pm does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/2/25 – 7/3/25 from 11pm to 7 am does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/3/25 from 3 pm to 11 pm does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/4/25 time: 7 am (does not specify 7 am was start or end of shift time) does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/4/25 – 7/5/25 shift start time: 7 pm, shift end time: unknown does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/5/25 from 7 am to 3:30 pm does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/5/25 from 3 pm to 11 pm does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/5/25 – 7/6/25 from 11 pm to 7 am does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/6/25 from 7am to 3 pm does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/6/25 – 7/7/25 from 11 pm to 7 am does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/7/25 from 7 am to 7 pm shows reposition at 8 am and again at illegible time. There is no documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/7/25 – 7/8/25 from 7 pm to 7 am does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/8/25 from 7 am to 7:30 pm does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/8/25 – 7/9/25 from 7 pm to 7:30 am does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/9/25 from 3 pm to 11 pm does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/9/25 – 7/10/25 from unknown time to 7 am does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/10/25 from 3 pm to 7 pm does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/10/25 – 7/11/25 from 7 pm to 7:30 am does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/11/25 from unknown time to 3 pm does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/11/25 from 3 pm to 11 pm does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/11/25 – 7/12/25 from 11 pm to 7 am does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/12/25 from 7 am to 7:30 pm does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/12/25 – 7/13/25 from 7 pm to 7:30 am does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/13/25 from 7 am to 3 pm does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/13/25 from 3 pm to 11 pm does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/13/25 – 7/14/25 from 11 pm to 7:30 am does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/14/25 from 3 pm to 11 pm does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/14/25 – 7/15/25 from 11 pm to 7:30 am does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/15/25 from 3 pm to 11 pm does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/15/25 – 7/16/25 from 11 pm to 7:30 am does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/16/25 from 7 am to 3 pm does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/16/25 from 3 pm to 11 pm does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/16/25 from unknown time to 11 pm does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/16/25 – 7/17/25 from unknown time to 7 am does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/17/25 from 7 am to 3 pm does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/17/25 from unknown time to 3 pm does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/17/25 from 3 pm to 11 pm does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/17/25 – 7/18/25 from 11 pm to 7:30 am does not contain documentation that wound assessment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/18/25 from 7 am to 7 pm does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/18/25 from 7 pm to 11 pm does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/18/25 – 7/19/25 from 11 pm to 7 am does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/19/25 – 7/20/25 from 11 pm to 7:30 am does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/20/25 from 3 pm to 11 pm does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/21/25 from 7 am to 7 pm does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/21/25 – 7/22/25 from 7 pm to 7:30 am does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/22/25 from 7 am to 7 pm does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/22/25 to 7/23/25 from 7 pm to 7:30 am does not contain documentation that wound assessment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/23/25 – 7/24/25 from 7 pm to 7:30 am does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/24/25 from 3 pm to 11 pm does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/24/25 to 7/25/25 from 11 pm to 7 am does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/25/25 from 3 pm to 11:30 pm does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/25/25 – 7/26/25 from 11 pm to 7 am does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/26/25 from 3 pm to 7:30 pm does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/26/25 – 7/27/25 from 7 pm to 7:30 am does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/27/25 from 3 pm to 11 pm does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/27/25 – 7/28/25 from 11 pm to 7:30 pm does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/28/25 from 7 am to 7 pm does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/27/25 – 7/28/25 from 11 pm to 7:30 pm does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/28/25 – 7/29/25 from 7 pm to 7:30 am does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/29/25 from 3 pm to 11 pm does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/29/25 from 11 pm to 7 am does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/30/25 from 7 am to 7 pm does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/30/25 from 7 pm to 7:30 am does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/31/25 from 7 am to 7 pm does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/28/25 – 7/29/25 from 7 pm to 7:30 am does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 8/1/25 from 3 pm to 11 pm does not contain documentation that wound assessment or treatment was performed.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 8/1/25 – 8/2/25 from 11 pm to 7:30 am does not contain documentation that wound assessment or treatment was performed.An interview with agency’s patient care administrator on 9/26/25 at 3:50 pm confirmed the above findings.”

“Based on review of the agency’s policies/procedures, Clinical Record (CR), and an interview with the agency’s patient care administrator, the hospice failed to ensure all entries must be legible, clear, complete, and appropriately authenticated and dated in accordance with hospice policy and currently accepted standards of practice for one (1) of three (3) CR reviewed: CR#1. Findings included:A review of Clinical Records (CR) was conducted on 9/26/25 from 12 pm. CR#1, SOC (Start of Care): 6/27/25,“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on following shifts contained illegible clinician handwritings: 8/1/25 7 am to 3 pm, 7/29/25 time 7 am, 7/27/25 7 am to 3 pm, 7/26/25 7 am to 3 pm, 7/25/25 7 am to 3 pm, 7/24/25 7 am to 3 pm, 7/20/25 – 7/21/25 11 pm to 7 am, 7/20/25 7 am to 3 pm,7/16/25 – 7/17/25 11 pm to 7 am,7/15/15 7 am to 3 pm, 7/14/25 7 am to 3 pm, 7/11/25 7 am to 3 pm, 7/10/25 – 7/11/25 7 pm to 7:30 am, 7/10/15 7 am to 3 pm, 7/9/25 – 7/10/25 11 pm to 7 am, 7/9/25 7 am to 3 pm, 7/3/25 7 am to 3 pm, 7/2/25 (many handwritings indicate time; however, surveyor unable to understand start to end shift time).“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/2/25 from 7 pm to 11 pm reads, “POC intervention Performed: (left blank).” There is no clinician’s initial or signature of which nurse was assigned for CR#1 in this shift.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/8/25 from 7 am to 7:30 pm reads, “POC intervention Performed: (left blank).” There is no clinician’s initial or signature of which nurse was assigned for CR#1 in this shift.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/8/25 – 7/9/25 from 7 pm to 7:30 am shows reposition at unknown time and brief changed at unknown time.” There is no clinician’s initial or signature of which nurse was assigned for CR#1 in this shift.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/10/25 from 3 pm to 7 pm reads, “POC intervention Performed: (left blank).” There is no clinician’s initial or signature of which nurse was assigned for CR#1 in this shift.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/13/25 from 7 am to 3 pm reads, “POC intervention Performed: (left blank).” There is no clinician’s initial or signature of which nurse was assigned for CR#1 in this shift.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/13/25 from 3 pm to 11 pm. There is no clinician’s initial or signature of which nurse was assigned for CR#1 in this shift.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/16/25 from 7 am to 3 pm reads, “POC intervention Performed: (left blank).” There is no clinician’s initial or signature of which nurse was assigned for CR#1 in this shift.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/24/25 from 3 pm to 11 pm reads, “POC intervention Performed: (left blank).” There is no clinician’s initial or signature of which nurse was assigned for CR#1 in this shift.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/25/25 – 7/26/25 from 11 pm to 7 am reads, “POC intervention Performed: (left blank).” There is no clinician’s initial or signature of which nurse was assigned for CR#1 in this shift.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/26/25 – 7/27/25 from 7 pm to 7:30 am shows wound care (unknown location) was provided at 6:10 am.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/27/25 from 3 pm to 11 pm reads, “POC intervention Performed: (left blank).” There is no clinician’s initial or signature of which nurse was assigned for CR#1 in this shift.“VITAS CC OR VIPU INTERVAL (SHIFT) CHARTING” on 7/27/25 – 7/28/25 from 11 pm to 7:30 pm shows incontinence care and reposition at unknown time. There is no clinician’s initial or signature of which nurse was assigned for CR#1 in this shift.An interview with agency’s patient care administrator on 9/26/25 at 3:50 pm confirmed the above findings.”