Every finding on record at Vitas Healthcare Corporation

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by a review of clinical records. In 5 of 13 (38%) records, the agency failed to ensure that the spiritual assessment was completed no later than 5 calendar days after the election of hospice care. Clinical Record 1: The patient was admitted on 12/16/22. The chaplain documented the initial spiritual assessment visit on 12/23/22, 7 days after the election of hospice care. No documentation was found to support the delay. Clinical Record 2: The patient was admitted on 12/2/22. The social worker documented the initial psychosocial assessment visit on 12/8/22, 6 days after the election of hospice care. No documentation was found to support the delay. Clinical Record 5: The patient was admitted on 11/14/22. The chaplain documented the initial spiritual assessment visit on 12/1/22, 16 days after the election of hospice care. In addition, the social worker documented the initial psychosocial assessment visit on 11/28/22, 14 days after the election of hospice care. There was no documentation found to support the delay of either assessment. Clinical Record 6: The patient was admitted on 8/5/22. The chaplain documented the initial spiritual assessment visit on 8/15/22, 10 days after the election of hospice care. There was no documentation found to support the delay. Clinical Record 13: The patient was admitted on 9/6/22. The social worker documented the initial psychosocial assessment visit on 9/29/22, 23 days after the election of hospice care. There was no documentation found to support the delay.

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. This standard was not met as evidenced by a review of clinical records. In 1 of 13 (8%) records, the agency did not ensure that all medications ordered were included on the medication profile. Clinical Record 1: The patient was admitted 12/16/22 with a diagnosis of cerebral atherosclerosis. Oxygen 2L prn (pro re nata/as needed) was ordered at admission on 12/16/22. Oxygen 2Lprn was not documented on the medication profile.

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 a review of clinical records. In 1 of 13 (8%) records, the agency did not ensure that problems identified had documented goals and interventions with respect to the use of Oxygen. Clinical Record 1: The patient was admitted 12/16/22 with a diagnosis of cerebral atherosclerosis. Oxygen 2L prn (pro re nata/as needed) was ordered at admission on 12/16/22. There were no goals or interventions noted in the plan of care with respect to Oxygen usage or safety.