Vitas Healthcare of Texas LP

“It is required that the hospice inpatient facility has documented and dated written reports of Life Safety Code fire drills at varied times on all shifts. This standard was not met as evidenced by document review and interview. A review of the fire drill logs revealed the agency did not ensure compliance with the National Fire Protection Act (NFPA) section 18/19.7.1.6 which stated in part, “Fire drills conducted at unexpected times under varying conditions, at least quarterly, on each shift.” Document 6: (Agency name) “Management Standard: Fire” (no date) stated in part, “Fire drills are held quarterly at unexpected times under varying conditions, held during each shift.” The agency’s fire drill logs for 2023: first quarter, documented fire drills were held on February at 1400 and March at 1330, and for the fourth quarter a documented fire drill was held on December at 1640. There were no documented fire drills for the second shift for these quarters. During a joint review of the fire drill logs on 05/30/2024, the In-patient Unit (IPU) Team Manager reported that those were the only drills documented on the logs kept in the unit. On 06/05/2024, prior to the exit, the Patient Care Administrator (PCA) confirmed that there were no additional documented fire drills. The PCA confirmed that the IPU had two shifts (8 am to 8 pm and 8 pm to 8 am). Review of the fire drill logs revealed the agency did not ensure compliance with the National Fire Protection Act (NFPA) section 18/19.7.1.6 which stated, “Fire drills conducted at unexpected times under varying conditions, at least quarterly, on each shift.””

“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, document review, and interview. The agency document “Pharmacy Process” (no date) stated in relevant parts, “Each nursing updated comprehensive assessment visit begins with a review of the patient’s plan of care which includes current medications...the chart medication list should be reviewed during each patient visit and during IDG (interdisciplinary group) to ensure it is up to date including active and discontinued medications.” In 1 of 30 (3%) clinical records reviewed, the agency did not ensure that the comprehensive assessment included a review of the patient’s current medications. Clinical Record 20: The patient elected the hospice benefit on 04/18/2024 with a diagnosis of cerebral atherosclerosis. On 04/18/2024, the physician ordered: “Cefuroxime Axetil (Ceftin) 500 milligrams give one (1) tablet by mouth twice a day for UTI (urinary tract infection) until 04/27/2024.” A clinical record review on 05/30/2024 revealed that the current drug profile documented, “Ceftin 500 milligrams give one tablet by mouth twice a day for UTI.” The drug profile was not updated to reflect that the Ceftin was to be discontinued as of 04/27/2024. On 06/05/2024, the Patient Care Administrator (PCA) confirmed that when the medication was entered into the system, the nurse did not add the stop date and missed this during the medication reconciliations. The PCA reported that confirmation was obtained from the hospice pharmacy that this antibiotic was only “profiled” by the hospice but was not dispensed as the patient already had the medication at the time of admission, thus the patient received and administered the correct number of pills.”

“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 1 of 21 (5%) clinical records reviewed in which Hospice Aide (HA) services were accepted, the agency did not ensure that the Registered Nurse (RN) provided the Hospice Aide specific written patient care instructions. Clinical Record 16: The patient elected hospice care on 11/07/2022 with a diagnosis of Parkinson’s disease and dementia. A clinical record review revealed a physician order for continuous oxygen at 3 liters via nasal cannula effective 04/17/2024. A comprehensive nursing assessment dated 05/29/2024 documented that the patient remained on continuous oxygen. The HA care plans, effective from 04/17/2024 to the present, did not instruct the HA on oxygen precautions and provide the HA with instructions regarding the patient’s use of oxygen during personal care. During an interview on 06/04/2024, the Patient Care Administrator (PCA) confirmed that the HA care plan should have included the information on the oxygen.”