Every finding on record at Vitas Healthcare Corporation Atlantic

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.

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 clinical record review and interview. In 2 of 32 (6%) clinical records reviewed revealed that the agency did not ensure that the initial comprehensive assessment was completed within five days after the election of hospice care. Clinical Record 1: The patient was admitted on 8/8/23. The social work assessment was completed on 8/15/23 and the Spiritual assessment was done on 8/16/23. There was no documented evidence that the patient or family declined the visit or requested that this visit be rescheduled. Clinical Record 27: The patient was admitted on 9/1/23. The spiritual assessment was completed on 9/7/23. There was no documented evidence that the patient or family declined the visit or requested that this visit be rescheduled.

It is required that each patient’s individualized written plan of care: a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. This standard was not met as evidenced by clinical record review. In 1 of 32 (3%) clinical records reviewed, the agency did not ensure that a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs was included in the plan of care. Clinical Record 1: The initial plan of care dated 8/8/23 did not document a detailed statement of the scope and frequency of services necessary to meet the patient and family needs. There were no visit frequencies documented for any disciplines visiting the patient.

It is required that medical social services are provided: based on a psychosocial assessment, according to the patient’s and family’s needs and acceptance of these services, per the plan of care, and under the direction of a physician. The psychosocial assessment addresses: 1. The patient’s and the family’s adjustment to the terminal illness; 2. The social and emotional factors related to the terminal illness; 3. The presence or absence of adequate coping mechanisms; 4. Family dynamics and communication patterns; 5. Financial resources and any constraints; 6. The caregiver’s ability to function effectively; 7. Obstacles and risk factors that may affect compliance with the plan of care; 8. Family support systems to facilitate coping with end-of-life issues. The psychosocial assessment is revised as new information is acquired and as progress toward goals is made. This standard was not met as evidenced by clinical record review and interview. In 1 of 32 (3%) clinical records reviewed, the agency did not ensure that the social work assessment addressed all of the items listed in the standard. Clinical Record 24: The patient was admitted on 9/29/23. Upon review of the social work assessment dated 10/2/23, it was found that the assessment did not contain some information that is required to be addressed in a social work assessment. There was no evidence found on the assessment that the patient's and family's adjustment to the terminal illness or family dynamics and communication patterns were addressed. The social worker documented on the assessment that there were no problems with the family's adjustment to the terminal illness and also documented that there were no problems with communication as well as no problems with family support systems. During a patient visit on 10/11/23, the family expressed that had not adjusted to the terminal illness and there was a language barrier with the patient. There was also a lack of family support systems to facilitate coping with end-of-life issues. None of these issues were addressed in the social work assessment.