Every finding on record at 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.

Based on review of facility documents, staff interview, and review of CDC guidance, it was determined the facility failed to ensure adherence to nationally recognized infection control guidelines and acceptable standards of practice that seek to minimize the transmission of infectious diseases, including COVID-19. Findings include: The facility failed to ensure that: 1) a written respiratory protection program that includes fit testing, is developed and implemented; 2) staff adhere to the established COVID screening process, in accordance with facility policy; 3) physician documentation granting vaccination exemption includes information specifying which of the COVID-19 vaccines are clinically contraindicated and the recognized clinical reasons for the contraindications; 4) a policy and procedure regarding mandatory COVID-19 vaccination, that includes a process for requesting and granting medical and religious exemptions, is developed. (Cross refer to Tags 0578, 0579, and 0900).

Based on review of facility documents, staff interview, and review of facility policy and procedure, it was determined the facility failed to ensure employees perform daily COVID-19 screening, in accordance with facility policy. Findings include: Reference: Facility policy, "COVID-19 Pandemic March 11, 2020" states, "... 5. Office Screening A. All program locations including main office, satellite office, VIPU... will screen employees and visitors prior to allowing entry. B. Each employee and visitor shall be screened for temperature and respiratory symptoms prior to entering the location. C. A designated individual will ensure screening is accomplished and record the temperature and screening question answers into the respective log." Upon interview on 2/3/22 at 10:40 AM, Staff #1 stated that staff are required to complete daily COVID-19 screening prior to arriving for work. Staff #1 stated, "Staff complete screening through an electronic portal. They submit it before they come to work. The information goes to the PCAs (Patient Care Administrators)." At 11:00 AM, a request was made to Staff #3 and Staff #5 for the staffing schedule and completed daily COVID-19 screening logs for the IPU for the following dates: 12/20/22, 12/21/22, and 12/22/22. Review of the staffing schedule and the completed daily COVID-19 screening logs revealed the following: a. Staff #9 did not complete COVID-19 screening prior to working his/her shift on 12/20/22 and 12/22/22. b. Staff #10 did not complete COVID-19 screening prior to working his/her shift on 12/22/22. c. Staff #11 did not complete COVID-19 screening prior to working his/her shift on 12/21/22. d. Staff #12 did not complete COVID-19 screening prior to working his/her shift on 12/20/22, 12/21/22, and 12/22/22. e. Staff #13 did not complete COVID-19 screening prior to working his/her shift on 12/20/22. f. Staff #14 did not complete COVID-19 screening prior to working his/her shift on 12/21/22 and 12/22/22. g. Staff #15 did not complete COVID-19 screening prior to working his/her shift on 12/20/22 and 12/21/22. h. Staff #16 did not complete COVID-19 screening prior to working his/her shift on 12/20/22 and 12/22/22. Staff #2, Staff #3, and Staff #5 confirmed the above findings on 2/3/22 at 3:10 PM.

Based on review of CDC guidance, staff interviews, review of facility fit testing logs, and review of facility policy and procedure, it was determined the facility failed to ensure a written respiratory protection program that includes fit testing, is developed and implemented. Findings include: Reference #1: Centers for Disease Control and Prevention (CDC), Strategies for Optimizing the Supply of N95 Respirators, updated September 16, 2021, https://www.cdc.gov/coronavirus/2019-ncov/hcp/respirators-strategy/ states, "... Respirators, when required to protect HCP (healthcare professionals) from airborne contaminants such as some infectious agents, must be used in the context of a comprehensive, written respiratory protection program that meets the requirements of Occupational Safety and Health Administration (OSHA) Respiratory Protection standard. The program should include medical evaluations, training, and fit testing." Reference #2: Facility policy, "COVID-19 Pandemic March 11, 2020" states, "... 3. Fit Testing... A. The N95 mask utilized to care for patients with infectious diseases such as SARS-COVID19, Measles, Chickenpox, TB, and COVID-19 requires fit testing to ensure proper fit." On 2/3/22 at 10:30 AM, a request was made to Staff #1 for the fit testing logs for staff working on the Inpatient Unit (IPU). Review of the fit testing logs revealed seven (7) of thirty-one (31) employees were fit tested for N95 face masks. During a telephone interview at 1:20 PM, Staff #6 identified him/herself as the person responsible for conducting fit testing in the IPU. Staff #6 stated, "I wasn't able to get to everyone for fit testing. We care for COVID positive patients, but they are not aerosolizing. The patients are not on forced air, nebulizers, or suctioning. All staff caring for COVID positive patients wear N95s, even if they haven't been fit tested." At 10:45 AM, a request was made to Staff #3 and Staff #5 for the facility's written respiratory protection program. No written respiratory protection program was provided. At 2:50 PM, Staff #5 stated, "We don't have a policy for a respiratory protection program that is all encompassing."

Based on review of one (1) of seven (7) employee health files of staff granted COVID-19 vaccination exemptions, and staff interview, it was determined the facility failed to ensure: 1) physician documentation granting vaccination exemption includes information specifying which of the COVID-19 vaccines are clinically contraindicated and the recognized clinical reasons for the contraindications; 2) a policy and procedure regarding mandatory COVID-19 vaccination, that includes a process for requesting and granting medical and religious exemptions, is developed. Findings include: 1) Review of the facility's staff vaccination reports revealed Staff #8 was granted a medical exemption for receiving COVID-19 vaccination. Review of Staff #8's health file revealed physician documentation utilized to grant his/her medical exemption that stated, "Not a candidate for COVID vaccine." There was no additional information indicated. The physician documentation did not include information specifying which of the COVID-19 vaccines is clinically contraindicated for Staff #8, or the recognized clinical reasons for the contraindication. 2) During the entrance conference on 2/3/22 at 10:10 AM, a request was made to Staff #1 for the facility's policy regarding mandatory vaccinations. An additional request was made to Staff #3 and Staff #5 at 10:45 AM. At 1:45 PM, Staff #5 stated, "We are still working on a vaccination policy. It hasn't been completed yet." Staff #2, Staff #3, and Staff #5 confirmed the above findings on 2/3/22 at 3:10 PM.

Based on staff interviews, review of two (2) out of three (3) medical records (#14, #15), and review of facility policies and procedures, it was determined that the facility failed to ensure the initial comprehensive assessment includes appropriate details, and pain assessments are conducted for each individual patients' status and are complete. Finding include: Reference #1: Facility policy titled, "RN Initial Comprehensive Assessment ... General Instructions for each symptom category" states, " ... Use the "Describe" Column to document additional assessment information regarding that symptom ..." Reference #2: Facility policy titled, "RN Initial Comprehensive Assessment" states, " ... Pain ... Verbal/Non-Verbal Assessment - Caregiver input - ... caregiver can provide input for all other PQRST questions .... PQRST should be completed for both verbal and non-verbal or cognitively impaired patients. ... Each PQRST question below should be asked of the patient; or the caregiver if the patient is non-verbal or unable to answer. ..." 1. On 10/27 and 10/28/2021, a review of medical records was conducted with Staff #1 and Staff #3 and the following was revealed: a. In Medical Record #14 on 7/3/21, on the "RN-Initial Comprehensive Assessment" the nurse marked off "Paresis." There were no details related to the finding in the "Describe" section. b. In the "Cardiovascular" section the nurse marked off "current Edema." There were no details related to the finding in the "Describe" section. 2. In Medical Record #15 on 8/29/20, a "Pre-Admit Evaluation" was conducted and the nurse documented the patient has dementia. In section, "Ability to Communicate," noted, "Pt [patient] parrots back 1-4 word sentences. At times does not respond back." In section, "Source(s) of Information," the nurse documented the names of the patient's two(2) daughters and a caregiver-aide. On the "RN-Initial Comprehensive Assessment" under "Neurosensory" the patient was assessed with "confusion." a. In the "Pain" assessment section, the nurse documented the pain assessment was conducted by "Patient Visual" and marked off: "Assessed, no pain symptoms identified" and the "Verbal/Non-Verbal Assessment - Caregiver Input" was left blank. b. At 10:30 AM, Staff #3 confirmed at least one of the sections titled, "Description/Attempted" or "Behavior" should have been completed, and at 1:00 PM Staff #3 confirmed the "PQRST" section should have been completed. c. On the "RN-Initial Comprehensive Assessment" under "Neurosensory" the patient was assessed with current "confusion, Paresis, Agitation and Dementia Related Agitation." There was no details related to the finding in the "Describe" section. 3. On 10/28/2021 at 10:20 PM, Staff #1 and Staff #3 confirmed the above findings. N.J.A.C. 8:43C-7.2(a)

A. Based on on review of one (1) out of two (2) medical record (#19), staff interviews, and review of policy and procedure, it was determined that the facility failed to ensure that the updated Comprehensive Assessment identifies changes that have occurred and the patient's response. Findings include: Reference: Facility policy titled: "Psychosocial/Spiritual Updated Comprehensive Assessment" states, "... Symptom Category Completion ... Outcomes, interventions and response to care ... Document the interventions provided under "Interventions Performed" ... Notification (who regarding what) Document who you notified and what your notified them about. .... Comment/Shift Report - Use this are [sic] to document any additional information, elaboration, ..." 1. On 10/28/2021, a review Patient #19's "Psychosocial/Spiritual Updated Comprehensive Assessment" conducted by Staff #26, a social worker, on 4/6/21, was reviewed with Staff #1 and Staff #3. In the system assessment sections, the following was documented: a. Section: "Neurological" - "Interventions Performed: increase sleep." b. Section: "Genitourinary" - "Interventions Performed: incontinent." c. Section: "Gastrointestinal" - "Interventions Performed: Poor appetite." d. The ""Notification" and the "Comment/Shift Report" sections were left blank. 2. At 11:20 AM, Staff #1 and Staff #3 confirmed the documentation for "Interventions Performed" did not indicate interventions performed. The "Notification" and "Comment/Shift Report" section should have been noted with issues identified and those needs communicated to the Case Manager or Registered Nurse (RN). N.J.A.C. 8:42C-6.3(a) B. Based on medical record review, review of facility policy and procedure, and staff interview, it was determined that the facility failed to ensure that wound assessments, interventions, and response to interventions were performed per physicians order in one (1) out of one (1) medical records reviewed (#4) of a patient with a wound. Findings include: Reference #1: Facility policy titled: "Interdisciplinary Team Policies", states: "... Updated Comprehensive Assessment -To identify changes that have taken place since the initial assessment and includes information on the patients progress toward desired outcomes, as well as a reassessment of the patients response to care..... All significant findings identified during assessments and updated assessments will be documented in the patient's record....." Reference #2: Procedure, titled: "Procedure for Documentation RN [Registered Nurse] Initial Comprehensive Assessment" states: "...General Instructions for each symptom category... Document care plan activities... -Provide the care planned interventions -Document the interventions provided under "Interventions Performed" -Evaluate the patient's Response to Care (interventions provided) -Document the response to care under the "Response to Care" column... -If an intervention is not performed, the reason for not performing the intervention should be documented under response to care...". 1. Patient #4 had an initial certification date of 6/24/2021 to the hospice agency. The following was identified during a review of the medical record: a. An "Interdisciplinary Plan of Care Revision/Physician Orders" dated for 7/27/2021 identified: "Outcome: Minimize or prevent surgical site infection ... abdominal surgical site irritation redness will reside ... Discipline [checked off box] N (Nursing) ... Interventions: Abdominal surgical site redness/irritation to skin will resolve ... Apply Neosporin to abdominal catheter site BID [twice a day] for redness/irritation ..." The next two (2) nursing visits conducted on 8/3/2021 and 8/10/2021 lacked documentation of wound assessment and interventions provided per physician's orders. b. An "Interdisciplinary Plan of Care Revision/Physician Orders" dated for 8/17/2021 identified: "Outcome: wound will heal without infection ... Discipline [checked of box] N (nursing) assess pt [patient] wound during visit. Wound care ... per MD [medical doctor] order ..." c. A second "Interdisciplinary Plan of Care Revision/Physician Orders" dated for 8/17/2021 identified: " ...cleanse rt [right] hand wound with NS [normal saline] pat dry apply medhoney cover with dry dressing daily. Cleanse rt knee wound with NS pat dry apply medhoney cover with dry dressing daily." The next nursing visit was conducted on 8/19/2021 and lacked documentation of wound assessment and interventions provided per physician's orders. 2. An interview with Staff #3 on 10/27/2021 at 11:50 AM confirmed the above findings and stated: "With each nursing visit all body systems should be assessed; If an issue is identified, then there should be an intervention; If there is an intervention, then there should be a response to care."

Based on review of three (3) medical records (#1, #16, and #17), staff interviews, and review of facility documents, it was determined that the facility failed to implement Nursing Services in accordance with the Plan of Care for two (2) of three (3) patients (#1, #17). Findings include: Reference: Facility document titled, "VS Team Visit Schedules" states, " ... . Purpose: ... . The hospice must organize, manage, and administer its resources to provide the hospice care and services to patients, caregivers, and families necessary for the palliation and management of the terminal illness and related conditions. What: ... 5. Visits not completed per the POC [Plan of Care]. ... . III. Missed Visits: 1. If a visit is inadvertently missed documentation should support measures taken to meet patient needs. 2. Reschedule with the patient/family and ensure their agreement with the change. a) The visit schedule reflects visit frequency which is based on the patient care plan week; therefore, another visit should be scheduled to meet the frequency based on the POC. b) Core IDG[Interdisciplinary Group]members (RN [Registered Nurse], SW [Social Worker], Chaplain, and Physician) always remain involved in the hospice POC even if the patient or family has declined their visits. ... ." 1. On 10/28/2021, a medical record review was conducted and facilitated by Staff #4 and Staff #9. Upon Medical Record review, the following was noted: a. The Plan of Care of Patient #1 for the period of 8/22/21 through 11/20/21 was reviewed. (i) The document titled, "VITAS Plan of Care File; Visit Frequency Grid" indicates that 10/5/21 Planned Nurse visits are two times per week. The form was signed by the Physician. (ii) The twice per week frequency was not met for the Nurse Visits for the week of 10/6/21. There was one Nurse Visit on 10/7/21. There were no other Nursing visits that week. (iii) There was no documentation in the medical record identifying the missed visit or the action taken. (iv) The above was confirmed by Staff #4. b. The Plan of Care of Patient #17 for the period 9/29/21 through 12/28/21 was reviewed. (i) The document titled, "VITAS Plan of Care File; Visit Frequency Grid" indicates that 10/6/21 Planned Nurse visits are one time per week. The form was signed by the Physician. (ii) The once per week frequency was not met for the Nurse Visits for the week of 10/13/21. There was no Nurse Visit conducted this week. (iii) There was no documentation in the medical record identifying the missed visit or the action taken. (iv) The above was confirmed by Staff #9. 2. On 10/28/21 at 11:30 AM, Staff #4 stated that any time a visit is missed, and any action taken, the documentation should reflect in the patient medical record in a Focus Visit Note or in the Updated Comprehensive Assessment Note. 3. The above was additionally reviewed with and confirmed by Staff #3. N.J.A.C. 8:42C-5.1(b)7

Based on observation in two (2) of two (2) hospice home visits (Patient #1, Patient #17), staff interviews, and review of facility documents, it was determined that the Hospice Agency failed to ensure that their established screening protocol is implemented to prevent the transmission of COVID-19. Findings include: Reference: Facility document titled, "VS COVID 19 Pandemic March 11, 2020, National Emergency March 13, 2020-TBD" states, " ... . What: ... . 6. Screening. ... . Who: Vitas direct patient care staff such as Nurse, SW [Social Worker], Chaplain, HA [Hospice Aide], Volunteer, Therapist, and Physician. ... . 6. Screening. a. Screening questions: i. Does the patient or someone in the home have an active COVID-19 infection (been diagnosed in the last fourteen (14) days or still has symptoms)? ... . ii. Is the patient or someone in the home currently in isolation for potential COVID-19 exposure (e.g. awaiting results of COVID test, traveled from high risk area, known prolonged exposure with COVID patient, etc. ... )? ... . iii. Is the patient or others who will be present at the appointment or visit showing signs of respiratory illness (sneezing, coughing, congestion, and/or new onset shortness of breath) or have a fever of 100.0 or greater? ... . b. The visit staff shall contact the patient /bedside caregiver prior to each visit .... . i. Confirm the visit and ensure you have the appropriate PPE [Personal Protective Equipment] before visiting. ii. Ask respiratory screening questions (above). ... ." 1. On 10/25/2021 at 1:05 PM, a Hospice Home visit was conducted for Patient #1 and the following was observed and confirmed: a. Staff #10 arrived at the home and entered the home to conduct his/her visit. Surveyor and Staff entered the home together. The patient's spouse was also in the home. b. Upon the conclusion of the visit, Staff #10 was interviewed about the agency required COVID-19 screening protocols. (i) Staff #10 stated that the clinicians are not routinely performing COVID-19 screenings of the patient/family. The screening occurs at the time of admission. Some clinicians may choose to screen prior to or during their visits, but it is not required. c. Staff #10 confirmed that he/she did not perform any COVID-19 screening prior to his/her Hospice visit. 2. On 10/27/2021 at 2:30 PM, a Hospice Home Visit was conducted for Patient #17 and the following was observed and confirmed: a. Staff #13 and Staff #14 arrived at the home and entered the home to conduct their visit. Surveyor and staff entered together. There was one family member in the home as well. (i) Staff #13 asked the patient and family the above COVID-19 screening questions upon arrival once inside the home. b. Upon conclusion of the visit, Staff #13 and Staff #14 were interviewed about the agency required COVID-19 screening protocols. (i) Staff #13 stated that he/she performs the COVID-19 screening questions when he/she does his/her assessment. (ii) Staff #14 stated that he/she performs the COVID-19 questions the day before his/her visit when he/she confirms the appointment with the patient/family. 3. The above was reviewed with Staff #1 on 10/28/2021. Staff #1 stated that COVID screening questionnaire is to be done by the clinicians right before they enter the patient home. N.J.A.C. 8:42C-10.2(b)3