Vitas Healthcare Corporation Atlantic

“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 and interview. In 3 of 23 (13%) clinical records reviewed, the agency did not ensure that all medications were included in the drug profile. Clinical Record 10: The patient elected hospice care on 05/27/2024. On 05/27/2024, oxygen was ordered at 2 liters per nasal cannula, pro re nata/as needed (PRN) dyspnea. The drug profile dated 05/27/2024 did not include documentation of oxygen. Clinical Record 20: The patient elected hospice care on 01/23/2024. Oxygen was ordered at 2 liters per nasal cannula pro re nata/as needed (PRN) at the time of admission. The drug profile dated 01/23/2024 did not include documentation of oxygen. On 03/12/2024, the oxygen order was changed to 4 liters per nasal cannula, continuously. The drug profile did not include documentation of oxygen 4 liters per nasal cannula, continuously. Clinical Record 23: The patient elected hospice care on 02/02/2024. Oxygen was ordered at 2 liters per nasal cannula PRN on 02/02/2024. The drug profile did not include documentation of oxygen from 02/02/2024 through the patient’s discharge on 04/16/2024 During a joint clinical record review, the Patient Care Administrator confirmed that the drug profiles for records # 20, #10 and #23 did not contain documentation of oxygen and oxygen should have been included.”

“Based on a review of the agencys complaint log, staff interviews, and agency complaint policy, it was determined the agency failed to ensure to protect the patient and patient caregivers right to voice grievances and have those grievances investigated and a resolution reached with notification of the resolution made to the complainant for one (1) of one (1) clinical record in the survey sample (Clinical record for Patient #2). Findings: A review of the complaint log in the agency on April 03, 2024 revealed no complaints documented on Patient #2 in the survey sample. The log contained multiple complaints similar in nature to the complaint being investigated with allegations of missed visits from skilled nurses and hospice aides. The log failed to contain evidence this complaint was investigated, and the complaint was resolved. An interview with Staff Member #6 on April 03, 2024 at 9:00 am revealed that Patient #2s daughter made a complaint to this staff member regarding the hospices aide missed visits and directed the daughter to call the office or email the team leader (Staff Member #3). Staff Member #6 confirmed he/she did not write up the complaint. An interview with the Administrator on ­­­April 03, 2024 at 10:00 am revealed complaints are reported to the team manager who then reports it to performance improvement to start the process for follow up. An interview with the Team Manager, Staff Member #3 on April 03, 2024 at 10:30 am revealed there are no documented phone calls or email containing a complaint for (name redacted Patient #2). A review of the complaint policy provided titled “Service Comment Process” states in part: Service Comment Guidelines, A: All complaints and grievances received from a patient, patients family/guardian or the patient’s health care provider regarding treatment, care, or respect for the active, discharged, pending and/or not admitted patient’s will be recorded via the Service Comment Electronic System (SCES) and investigated in an expeditious method. The complaint/grievance investigation begins immediately by the (name of hospice agency-redacted) employee who witnesses/receives the service issue. Service comments will be reviewed by a Senior Manager in every program to assure appropriate and satisfactory follow-up.”

“Based on clinical record review, agency policy, select nursing facility documents, and staff interview, it was determined the agency failed to identify and address the initial comprehensive assessment of the physical and psychosocial needs related to the terminal illness to promote the hospice patient’s well-being, comfort, and dignity throughout the dying process. Specifically, the agency staff failed to identify current medications and skin integumentary issues in (2) of (11) clinical records reviewed. (Clinical records for Patient #2 and #9). Additionally, hospice staff failed to provide documentation of completion of an initial comprehensive assessment for one (1) of eleven (11) clinical records reviewed. (Clinical record for Patient #9). On April 02, 2024, the Administrator provided the Medical Facilities Inspector (MFI) with the procedures titled “;Documentation Procedures for RN (Registered Nurse) Initial Comprehensive Assessment, and Nursing Updated Assessment”. The procedure read in part: Complete and document patient assessment including as applicable-Head to toe assessment; patient personal medication list. The clinical record for Patient #2 was reviewed for the time period of September 30, 2023, to November 14 ,2023. The initial comprehensive assessment for Patient #2 was completed on October 02, 2023. The assessment failed to contain evidence of a current medication list. The hospices initial comprehensive assessment form contained a check box that was left blank and read as follows: Facility patient, reviewed facility records and received report from_______. The clinical record contained no documentation that the patients condition, assessment findings or current medications were discussed with facility staff on October 02, 2023 when the RN completed the initial assessment of the patient. On April 02,2024 at 11:10 AM an interview with the Administrator revealed the following hospice process for medication reconciliation for a patient residing in a facility: The hospice nurse compares the list of hospice medications with the list of facility medications to complete the medication profile. The Medical Director then reviews the list of medications. The Administrator also confirmed a head-to-toe should be performed during the initial comprehensive assessment. On April 02, 2024, at 11:12 am the MFI interviewed the RN (Staff Member #4) who performed the initial comprehensive assessment for Patient #2 on October 02, 2024. The interview revealed that Staff Member #4 could not find any nursing home staff to assist in locating a medication list for Patient #2 on October 02,2024. Staff Member #4 also stated that he/she should have pushed for the facility medication list harder. Staff Member #4 confirmed that a medication reconciliation was not conducted during the initial visit. The clinical record for Patient #2 failed to contain a current medication list. In addition, the initial comprehensive assessment for Patient #2 documentation revealed there were no concerns with the patients skin integrity. The wound care notes from the nursing home were reviewed and indicated that Patient #2 had a left heel wound acquired date of September 29, 2023, and a right heel wound acquired September 29, 2023 (1 day before the patients date of election of benefit with hospice). The initial assessment conducted on Patient #2 failed to identify skin integumentary issues despite documentation from the nursing home that the patient had pressure ulcers on admission to hospice services. The hospice nurse did document a left heel wound that was unstageable on November 3, 2023 (32 days later). The clinical record for Patient #9 was reviewed for the time period of October 23, 2023, to December 21, 2023. The clinical record for Patient #9 contained no documented evidence of an initial comprehensive assessment. The MFI requested the initial comprehensive assessment on April 09, 2024, at 9:20 am. The Administrator revealed the visit was done because it is in payroll but unable to find documentation of the visit. The MFI requested the assessment again on April 09,2024 at 3:00 PM and again on April 16, 2024. The hospice was unable to provide evidence of documentation of the assessment. The clinical record for Patient #9 failed to contain an initial comprehensive assessment. The Administrator acknowledged that the agency failed to document a complete and accurate comprehensive assessment during the initial nursing visit for the above noted patients on April 03, 2024, and April 09, 2024. The Administrator again acknowledged the above noted deficiencies during the exit conference on April 17, 2024.”

“Based on clinical record review, staff interview, and review of agency policy, it was determined the agency failed to ensure each patient’s comprehensive assessment included an accurate drug profile by conducting a review of all the patient’s prescription and over-the-counter drugs, herbal remedies, and other alternative treatments that could affect drug therapy in one (1) of (11) clinical records reviewed (Clinical record for Patient #2). Findings: On April 02,2024, the Administrator provided the MFI with the agency’s policy and procedures related to the content of the plan of care. The policy read in part: The content of the plan of care shall include drugs and treatments necessary to meet the needs of the patient; nursing visit pharmacological overview, chart medication list and review medications in the home. The clinical record for Patient #2 was reviewed for the time period of September 30, 2023, to November 14, 2023. The clinical record review indicated the initial comprehensive assessment dated October 02, 2023, contained three (3) medications ordered by the hospice for pain and symptom management that included: Roxanol, Ativan and Senna. These medications were documented as indicated for pain, dyspnea, anxiety, and treatment of constipation. No other routine medications were documented. The MFI (Medical Facilities Inspector) requested an active medication list with all medications prescribed for Patient #2. The Administrator was unable to provide an active medication list at the time of request on April 02, 2024. The Administrator contacted the nursing home where the patient resided and later on April 02, 2024, the Administrator provided the MFI with the nursing home’s active medication list for Patient #2 for the months of September 2023 through November 2023. The medications on the nursing homes list included: Guaifenesin, Bisacodyl, Linezolid, Potassium, MiraLAX, Hyoscyamine, Torsemide, Propranolol and Furosemide. None of these medications were included in the hospice medical record, despite Patient #2 receiving them in the facility. The hospices clinical record for Patient #2 failed to include an accurate/complete drug profile. On April 02, 2024, at 11:12 am the MFI interviewed the Registered Nurse (Staff Member #4) who performed the initial comprehensive assessment on October 02, 2024. The interview revealed Staff Member #4 could not find any nursing facility staff to assist in locating a facility medication list. A medication reconciliation was not conducted during the visit. The Administrator acknowledged the failure to include an accurate drug profile as part of the comprehensive assessments for Patient #2 during the exit conference on April 17, 2024.”

“Based on clinical record review, staff interview, agency procedures, and select nursing facility documents, it was determined the agency staff failed to update the hospice interdisciplinary group (IDG) with changes to each patients comprehensive assessment that have taken place since the initial assessment. Specifically, the agency staff failed to ensure current medications and/or skin integumentary issues were reported to the IDG to make accurate care planning decisions for one (1) of (11) clinical records in the survey sample (Clinical Record for Patient #2). Additionally, the hospice staff failed to make changes to the patients visit frequency regarding imminent death procedures to the IDG in one (1) of eleven (11) in the survey sample (Clinical Record for Patient #9). Findings The clinical record for Patient #2 was reviewed for the time period of September 30, 2023, to November 14, 2023. The initial comprehensive assessment on October 02, 2023, contained three medications ordered by the hospice for pain and symptom management. A review of the nursing home medication profile from September 30, 2023 to November 11, 2023 revealed medications given to the patient that included: Potassium, Tylenol, MiraLax, Bisacodyl, Levsin, Ondansetron, and Propranolol. These above noted medications were not documented on the hospice medication profile until November 11, 2023 (40 days later). The hospice staff failed to update the hospice IDG of the medication Patient #2 was receiving at the nursing facility, therefore the hospice had no knowledge of the patients medication regimen from September 30, 2023, to November 11, 2023. Also, the initial comprehensive assessment documented the skin integumentary was assessed and no concerns were identified. A review of nursing home records indicated the patient had wounds to the left and right heel and later buttocks wounds. The wound care notes from the nursing home read as follows: -October 04, 2023, left heel Length 3 cm Width 3 cm with a date wound acquired date of September 29, 2023 (1 day before the patients election of benefit with hospice); right heel Length 3 cm Width 3 cm with a date wound acquired date of September 29, 2023. -October 13, 2023, left heel left heel Length 3 cm Width 3 cm and right heel Length 3 cm Width 3 cm. -October 19, 2023, left heel left heel Length 6.5 cm Width 4 cm and right heel Length 3 cm Width 3 cm. -October 26, 2023, left heel left heel Length 6.5 cm Width 5 cm and right heel Length 3 cm Width 3 cm. -November 03, 2023, left upper buttocks Length 3.5 cm Width 0.30 cm with a date wound acquired date of November 03, 2023; left buttocks Length 3 cm Width 2 cm with a date wound acquired date of November 03, 2023; left heel Length 6 cm Width 5.5 cm with epithelium, fluid filled blister and worsening. -November 08, 2023, left buttocks Length 3.5 cm Width 1 cm unstageable and 100% slough; left upper buttocks Length 3 cm Width 0.5 cm unstageable and 100% slough; left heel Length 5 cm Width 4.8 cm with 25-49% eschar. The hospice staff failed to update the hospice IDG of the patients right heel wound and worsening left heel wound until October 31, 2024. The buttocks wounds were first ­­­documented on November 11, 2023, by the hospice nurse but not reported to the IDG, therefore the hospice IDG had no timely knowledge of the patients ongoing wound status. The clinical record for Patient #9 was reviewed for the time period of October 23, 2023, to December 21, 2023. On the IDG meeting of December 12, 2023, Staff Member #4 documented that Staff Member #10 had End of Life (EOL) plans in place. On April 10, 2024, the Administrator provided the Medical Facilities Inspector (MFI) with the agency’s procedures titled “;VS Imminence”. The procedure read in part: Once a patient has been identified as imminent, the IDG should assess and modify frequencies, if needed. A Registered Nurse (RN) should visit the patient daily until they die or are no longer imminent. The Social Worker (SW) should visit once imminence is identified and then adjust frequency based on assessment. On April 10, 2024 at 1:56 pm the MFI interviewed Staff Member #10 and revealed the EOL procedure included having daily visits from either the Social Worker and/or Registered Nurse. Staff Member #10 did not provide any further information regarding reporting to the IDG. Staff Member #4 attended the IDG meeting of December 12, 2023 and documented the Social Worker had EOL plans in place, however there were no documented daily visits to the Patient #9 until December 20, 2024 (8 days later). The hospice staff failed to update Patient # 9’s visit frequency after the IDG meeting of December 12, 2023. The above-noted deficiency was acknowledged during the record reviews with the Administrator on April 10, 2024, and again by the Administrator on April 17, 2024 during the exit conference.”

“Based on a review of clinical records and staff interview, it was determined the agency failed to ensure their staff documented providing care according to the patient’s plan of care for two (2) of (11) clinical records in the survey sample (Clinical record for Patient #s 3 and 9). Findings: The clinical record for Patient #3 was reviewed for the time period of July 07, 2023 to September 03, 2023. The plan of care contained a physician’s order for the Skilled Nurse to visit two times a week from July 13, 2023 to July 20, 2023. The clinical record contained documentation of zero (0) Skilled Nurse visits for the above noted week. The clinical record for Patient #9 was reviewed for the time period of October 23, 2023 to December 21, 2023. The plan of care contained a physician’s order for the Skilled Nurse to visit two times a week from December 06, 2023 to December 13, 2023. The clinical record contained documentation of zero (0) Skilled Nurse visits for the above noted week. On April 09, 2024 at 10:00 am the MFI (Medical Facilities Inspector) conducted an interview with the Administrator regarding the missed Skilled Nurse visits for the above Patients. The Administrator did not comment on Patient #3 but revealed there was a Skilled Nurse visit for Patient #9 on December 11, 2023 but was unable to locate it. The clinical record failed to contain documented evidence of notification to the patient’s physician of the missed Skilled Nurse visits. The lack of staff not providing evidence of care according to the patient’s plan of care during the clinical record review was acknowledged by the Administrator and during the exit conference conducted in the agency on April 17, 2024.”

“Based on review of clinical records and staff interview, it was determined the agency failed to ensure that Hospice Aide supervisory visits were conducted by a Registered Nurse no less frequently than every 14 days to evaluate the services provided by the Hospice Aide for two (2) of eight (8) clinical records reviewed of patient’s receiving Hospice Aide services for whom Hospice Aide supervisory visits were applicable (Clinical record for Patient # 4). Findings: The clinical record of Patient #4 was reviewed for the time period of August 03, 2023 to September 25, 2023. The plan of care contained physician orders for Hospice Aide services beginning with the first visit as documented on August 11, 2023. The clinical record contained documentation of Hospice Aide visits as per plan of care. The first documented Hospice Aide supervisory visit was on August 16, 2023 with the next Hospice Aide supervisory visit on September 05, 2023 (20 days in between visits). On April 3, 2024 at 11:10 am the Administrator acknowledged the past due Hospice Aide supervisory visit during the clinical record review for Patient #4.”

“Based on staff interview, clinical record review, and document review, it was determined the hospice agency failed to communicate with a SNF (Skilled Nursing Facility)/NF (Nursing Facility) and document such communication to ensure that the needs of the patient are addressed 24 hours a day. Specifically, the hospice staff failed to communicate with the SNF/NF regarding the patients routine nursing home medication list to be reviewed with the hospices Medical Director for one (1) of two (2) SNF/NF contracts reviewed in the survey sample (Contract #1). Findings: On April 15, 2024 at 2 pm, the Administrator provided the MFIs (Medical Facilities Inspector) Contract #1 where Patient #2 previously resided. Contract #1 read in part as follows: Communications Concerning Hospice Patient. The parties will communicate pertinent information with each other either verbally or in the Hospice Patients record at least weekly and/or at each hospice patient visit to ensure the needs of each Hospice Plan Care are addressed and met 24 hours per day. Documentation of such communication shall be included in the Hospice Patients medical record. (Hospice Agency name redacted) shall provide hospice services to the Hospice Patient which services include but are not limited to medical direction and management of the hospice patient, drugs, all as necessary for the palliation of pain and symptoms associated with and necessary for the care the Hospice Residents terminal illness and related conditions. On April 02, 2024, at 11:12 am the MFI interviewed the RN (Staff Member #4) who performed the initial comprehensive assessment for Patient #2 on October 02, 2024. The interview revealed that Staff Member #4 could not find any nursing facility staff to assist in locating a medication list for Patient # 2 on October 02, 2023. Staff Member #4 also stated that he/she should have pushed for the facility medication list harder. Staff Member #4 confirmed that a medication reconciliation was not conducted during the initial visit. The SNF/NF medication reconciliation was not documented on the hospice medication profile until November 11, 2023 (40 days later) whereas, the hospice Medical Director then determined which medications were related and not related to the patients terminal illness. The clinical record for Patient #2 failed to contain a current medication list due to lack of communication on the hospices behalf.”

“Based on document review and an interview, it was determined the hospice agency failed to establish and maintain in consultation with the Skilled Nursing Facility (SNF)/Nursing Facility (NF) a coordinated plan of care for hospice services. Specifically, the hospice agency failed to provide the SNF/NF the hospices plan of care for Patient #2 for one (1) of two (2) SNF/NF contracts reviewed in the survey sample (Contract #1). Findings: The Administrator provided the MFIs (Medical Facilities Inspector) a SNF/NF contract on April 15, 2024, at 2:00 p.m. where Patient #2 previously resided. Contract #1 read in part as follows: Plan of Care and Interdisciplinary Team: (Hospice agency name redacted) shall establish, modify as appropriate, and provide the facility with a copy of, a Hospice Plan of Care for Hospice patient, and shall designate an interdisciplinary team for Hospice Patient. On April 12, 2024, at 12 p.m., the MFI interviewed the Administrator who revealed coordination of care is done at the SNF/NF by looking at the facilities plan of care; however the facilities plan of care was not located in the clinical record. On April 12, 2024, at 12:19 p.m., the MFI interviewed the Nursing Home Administrator who confirmed the record for Patient #2 did not contain a hospice plan of care. The hospice agency failed to update the SNF/NF with the hospices plan of care.”

“Based on observations at a SNF (Skilled Nursing Facility) /NF (Nursing Facility) and staff interview, it was determined the hospice staff failed to provide the SNF/NF with names and contact information for hospice personnel involved in hospice care of each patient and the instructions on how to access the hospices 24-hour on-call system for two (2) of the four (4) patients visited (Patient #s 13 and 15). Additionally, the hospice staff failed to provide evidence of on-going communication regarding the hospices specific medication information to each patient for four (4) of four (4) patients visited (Patient #s: 12, 13, 14 and 15). Findings: On April 16, 2024 at 1:18 pm, the MFIs (Medical Facilities Inspectors) visited a SNF/NF with Staff Members #3 and #11. The SNF/NF charts for Patients #12 and #14 had a sticker attached to outside of the chart with the hospices name, instructions and contact number except for Patients #13 and #15. Staff Member #3 instructed Staff Member #11 to place the hospice sticker on the front of Patients #13 and #15 chart. Staff Member #11 revealed he/she did not know where to get the hospice stickers from and Staff Member #3 advised these were at the hospice office and should have some with him/her on hand. The hospice failed to provide the SNF/NF with the hospice contact information for the hospice patients. During the SNF/NF chart reviews it was noted that all the patients reviewed (Patient #s: 12, 13, 14, and 15) had hospice medication lists dated for April 16, 2024 and did not include a medication list prior to this date. The patients noted below were on services with hospice for more than 2 weeks as follows: -Patient #12 with a hospice election of benefit of July 19, 2023. -Patient #13 with a hospice election of benefit of March 19, 2024. -Patient #14 with a hospice election of benefit of September 11, 2023. -Patient #15 with a hospice election of benefit of May 11, 2023. The hospice failed to provide the SNF/NF with on-going communication regarding the hospices specific medication information for each patient.”

“Based on staff interview and document review, it was determined the hospice staff failed to provide orientation and training to SNF (Skilled Nursing Facility)/NF (Nursing Facility) staff furnishing care to hospice patients in the hospice philosophy, hospice policy and procedures regarding methods of comfort, pain control, symptom management, as well as death and dying and individual responses to death, patient rights, appropriate forms, and record keeping requirements. Specifically, the hospice staff failed to coordinate specific orientation curriculum for two (2) of two (2) SNF/NF contracts reviewed in the survey sample (Contract #s 1 and #2). Findings: The Administrator provided the MFIs (Medical Facilities Inspector) two (2) SNF/NF contracts (Contracts #1 and #2) on April 15, 2024 at 2 pm where Patient #2 and #9 previously resided. Both contracts read in part as follows: Training. (Hospice agency name redacted) shall provide orientation and in-service training on its policies and procedures to Facility Personal as (Hospice agency name redacted) deems appropriate and document the description of the training and the names of those giving the training. On April 16, 2024 at 10:10 am the Administrator revealed Contract #1 did not have any orientation or training due to the SNF/NF was offered but declined the hospices offer. The Administrator did not provide any documentation of the SNF/NF declination for Contract #1. In addition, the Administrator provided the MFIs with an email from the hospices Director of Market Development with a dated 12-month summary of education completed at the SNF/NF for Contract #2. The email contained the following information: -June 13, 2023-Attend care plan for (patient name redacted)-nursing -June 20, 2023-Hospice basics and benefits with OT/PT (Occupational Therapy/Physical Therapy) -November 15, 2023-Hospice basics and benefits with nursing -November 20, 2023-Family night coordination with Social Work presenting to families -February 23, 2024-Meeting with Social Work to review ALZ/DEM (Alzheimers and Dementia) eligibility -April 17, 2024-Review eligibility with OT/PT The above noted email outline did not provide evidence of specific hospice orientation but with benefits/eligibility for billing purposes. The hospice failed to provide evidence of orientation curriculum to meet the CFR 42 418.12(f) elements for SNF/NF.”

“Based on personnel file review and staff interview, it was determined the agency failed to obtain a criminal background check in accordance with Virginia State requirements for one (1) of one (1) personnel file reviewed (Staff Member #: 4). Findings: According to Virginia State Hospice licensure regulation 12VAC5-391-110, the criminal record report shall be obtained directly from the Virginia Department of State Police within 30 days of employment. Staff Member #4 with a documented date of hire of June 15, 2021 failed to contain a criminal record check obtained from the Virginia State Police (VSP) within 30 days for hire. During the personnel file review conducted on April 08, 2024 the Administrator acknowledged the lack of a criminal background report from the Virginia State Police on the above noted personnel file.”