Every finding on record at Vitas Healthcare Corporation Atlantic

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 2 of 13 (15%) clinical records reviewed for patients who elected Hospice Aide (HA) services, the agency did not ensure that the HA received specific written patient care instructions regarding ambulation. Clinical Record 1: The patient elected hospice care on 08/02/2023. The initial comprehensive assessment completed by the Registered Nurse (RN) dated 08/02/2024 documented that the patient was using a "wheelchair to ambulate." The HA care plan dated 08/09/2023 documented by the RN assigned the HA the relevant tasks: "Ambulation... 1) Stand-by assist; 2) Wheelchair used; 3) One-person assist." The assigned tasks included multiple options for ambulation and did not provide the HA with clear instructions regarding the patient's "Ambulation," which was documented by the RN on 08/02/2024 as using a "wheelchair to ambulate." The HA documented "Ambulation...Wheelchair used” in the visit note dated 05/23/2024. During an interview and a joint record review on 06/13/2024, the Patient Care Administrator and Performance Improvement Specialist agreed that the options "Stand-by assist" and "One-person assist" assigned by the RN were incorrect for this patient who used a wheelchair. Clinical Record 8: The patient elected hospice care on 05/09/2023. The Skilled Nursing (SN) assessment dated 01/31/2024 documented that the patient was using "a walker to ambulate." The HA care plan dated 02/06/2024 documented by the RN assigned the HA the relevant tasks: "Ambulation...1) Independent; 2) Walker; and 3) "One-person assist." The assigned tasks included multiple options for ambulation and did not provide the HA with clear instructions regarding the patient's ambulation needs, which were documented by the SN on 01/31/2024 as using "a walker to ambulate." Additionally, the SN assessment documented that the patient was a "Pivot 1 person" for transfers. The RN assigned the HA the relevant tasks: "Transfer...1) Independent...Pivot 1 person." The assigned tasks included multiple options for transfers and did not provide the HA with clear instructions regarding the patient's transfers, which were documented by the SN on 01/31/2024 as "Pivot 1 person." The HA documented "Ambulation...Walker used...Transferred...Pivot 1 person" in the visit note dated 02/22/2024. During an interview and a joint record review on 06/13/2024, the Patient Care Administrator and Performance Improvement Specialist agreed that the options "Independent" and "One-person assist" for the "Ambulation" and "Independent" for the "Transfer" assigned by the RN were incorrect for this patient that used a walker and required “Pivot 1 person." The General Manager, National Patient Care Administrator, Patient Care Administrator, and Performance Improvement Specialist confirmed in an interview on 06/14/2024 that the RN had not provided the aide with patient-specific written care instructions and stated that the agency had already started a plan of correction pertaining to this issue.

Based on review of email, policy, the admission packet containing patient rights, clinical records (CR), and staff (EMP) interview, the agency failed to protect and promote the rights of the patient by not ensuring the patient received effective pain management and symptom control (L512), and for permitting non-agency staff who were not under the purview of the parent hospice to have access to the patient's clinical record (L516). This condition was not met as evidenced by the above non-compliance but did not result in an immediate jeopardy. Findings included: The parent agency located in Cranberry Township, Pennsylvania utilized an after-hours on-call system staffed by an out-of-state interdisciplinary group (IDG) and other personnel who assessed, evaluated, and triaged the agency's patients by accessing the patient's clinical record. This IDG was not under the control of the parent agency's governing body or considered to be staff associated with the independently certified agency. This out-of-state IDG and its supervisors, again who were also not part of the parent agency, were located across the country with some providing remote supervision (living in Florida and supervising call-center staff located in New Jersey). This system was the root-cause contributor to a process of care failure that left a patient without necessary comfort medications during end-of life.

Based on review of agency policy, clinical records (CR), and staff (EMP) interview, the agency failed to ensure the patient received effective pain management and symptom control for one (1) of three (3) discharged clinical records (CR1). Findings included: Note: Agency is located in Cranberry Township Pennsylvania Review of agency policy on April 26, 2023, at 10:40 a.m. showed, "Patient's Rights ... POLICY NUMBER 5:07 ... A copy of the patient bill of rights ... will be presented to the patient/family during the admission process." Review of admission packet provided to patients and families at the start of care on April 26, 2023, at 10:50 a.m. showed, "A patient has the right to: ... Receive effective pain management and symptom control from the hospice for conditions related to the terminal illness." Review of CR1 on April 26, 2023, at 10:40 a.m. revealed patient was admitted to routine home care on 2/15/2023 with a diagnosis of heart failure (chronic diastolic congestive heart failure). The medications Tramadol and Tylenol were ordered to be taken by mouth for pain and discomfort. The episode was unremarkable, and the patient had minimal complaints of pain. The patient resided in an assisted living facility. On 3/21/2023 at 5:38 p.m., the patient's family called after hours on-call stating the patient was in pain and not able to swallow medications. A local Vitas on-call nurse made a home visit at 7:35 p.m. and documented, "FS [facility staff] report pt [patient] not responding much, not swallowing, [decreased] appetite, taking sips of fluid. ... Unable to palpate radial pulse, [decreased] urine output. ... New order- Roxanol [comfort medication] 5mg SL [taken under the tongue] [as needed] for pain / sob [shortness of breath]." During the visit the RN obtained an order for Roxanol but the facility could not obtain the medication via its contracted pharmacy related to the time of day the orders were received. Interview with EMP2 on April 26, 2023, at 11:26 a.m. confirmed the patient's faciliy uses a "[local pharmacy]," and sometimes medications can also be obtained from local pharmacy via courier. EMP2 noted the patient's comfort pain medication Roxanol could not be obtained because the local pharmacies were closed, "could not find it at this time of night. We try to anticipate anything coming down the pike and should have been Roxanol already ordered. In this case it looks like it could have been ordered on 21st [3/21/2023]." The following "Telecare Call" logs for CR1 show how the agency utilized a remote call center with staff located out of state. For instance, these staff members can be located in New Jersey, Illinois, or Florida. Interviews with local human resource manager (EMP4), and EMP2 confirmed agency does not directly supervise these remote staff. The administrator and governing body from the Vitas parent location in Cranberry Township do not maintain personnel files for telecare staff, nor does it provide orientation or performance evaluations for these staff. The below transcript shows how this deficient practice caused a delay in care with the patient expiring without medications necessary for symptom management. Review of on-call "TELECARE CALL" logs on April 26, 2023, at 11:40 a.m. showed non-agency staff or staff who were not directly controlled or supervised by independently certified parent agency, assessed, and triaged the patient and obtained physician orders. The remainder of the patient's clinical record is summarized from the below Telecare entries. 3/21/2023 5:41 p.m., "called stating PCG feels [patient] won't make it. Caller states pt is not swallowing meds but complains of stomach pain. Expressed sympathy. Caller agreed to hold for a nurse." 3/21/2023 5:44 p.m., "Transferred to TRI [triage]." 3/21/2023 6:19 p.m., "Returned call to facility, spoke with [facility] med tech. States pt not responding much, not swallowing or eating/drinking which started yesterday. PT having pain - no comfort meds place. States if morphine is ordered they will need pre-filled syringes. State pt is declining. States [family] is aware. Pt states pain is all over. No SOB. CML [comfort medication list] reviewed, pt has PRN Tramadol and scheduled Tylenol but unable to swallow. Pt had PRN Ativan and Zofran today. Currently in bed with HOB elevated. Advised re-positioning with pillows for comfort. Will send nurse, nurse will call with eta and call back for any needs/changes. Agreed to plan, no further needs. Thanked." 3/21/2023 6:19 p.m., "TRANSFER TO DIS [dispatch]" 3/21/2023 6:24 p.m., "Read Receipt ... To: [EMP5 (Vitas RN)]" EMP5 arrived at 7:35 p.m. (almost 2 hours after Telecare call was first logged) completed the nursing visit at approximately 8:35 p.m. and obtained an order for comfort med Roxanol 5mg every 3 hours as needed. However, the agency was unable to obtain the Roxanol since local pharmacies did not carry this medication. 3/21/2023 11:23 p.m., "CONVERSATION ... [family] called to report pt. is in pain, doesn't have Morphine to give her ... ask for assistance. Agreed to hold for a nurse." No morphine is available and once again family calls Telecare again. The family is transferred to Telecare staff for assessment, evaluation, and planning. 3/21/2023 11:26 p.m., "TRANSFER TO TRI ... Triage nurse agreed to take call." 3/21/2023 11:37 p.m., "CONVERSATION ... Spoke with [family] who stated pt is still in a lot of pain. Caller states they cannot get the morphine till the morning, that no pharmacies were open for local fill. Caller states nurse tried to give Tramadol but even with applesauce pt was unable to swallow it. Reviewed cml [comfort medication list], pt currently has orders for Ativan. Caller states she forgot about that and pt is definitely anxious due to the pain. Advised pull was small and can be dissolved under the tongue if pt is not swallowing. Caller states she will reach out to nurse and have her give it. Advised will check back with her in 30 minutes to see if effective. Advised will also reach out to oncall nurse to see if she had any suggestions. Caller agreed to call back. CB number verified." 3/21/2023 11:49 p.m., "Spoke with [EMP5 (Vitas RN)] regarding above pt. OCN stated he/she called multiple pharmacies for Morphine and was unsuccessful. She states pt can no longer take pills. advised of above, she stated that [on-call physician] may order something rectally if Ativan not effective. Advised will f/u with [family] in 30 min, if Ativan not effective will call [on-call physician]." 3/22/2023 12:13 a.m., "PHYSICIAN CALLE[D] Called to advise of above. [On-call physician] reviewed pt chart while on phone with her. New orders received to increase Ativan to 0.5mg every 4 hours as needed for anxiety, and advised may give Tylenol ES 500mg tab 1 tab rectally every 4 hours as needed for pain. Read back verified." 3/22/2023 12:13 a.m., "FACILITY CALLED ... Called to advise of above. Advised of new orders from our on-call doctor to help control pt's pain for tonight. [ALF staff] advised he gave Ativan, and was going to check on her in 30 min. He states pt appeared to be in pain, calling out. Advised will fax new orders." 3/22/2023 12:26 a.m., "CARGIVER CALLE[D] ... Call back to advise of new orders and to check pt status." 3/22/2023 2:30 a.m., "CONVERSATION ... [ALF Med Tech] ... Caller is reporting that pt has expired. Family is bedside. Offer SW and Chap offered. Both declined. Caller not able to pronounce." 3/22/2023 2:38 a.m., "[Vitas] NURSE SENT." Per "REPORT OF DEATH" note, the registered nurse arrive onsite at facility at 3:15 a.m. and the patient was pronounced at 3:25 a.m. Patient expired 9 hours and 44 minutes after first call to Telecare staff without ever receiving necessary comfort medications. Interviews with EMP2, and EMP3 on April 26, 2023, at approximately 2 p.m. confirmed above findings-- patient never received Roxanol dose prior to expiring.

Based on review of email, policy, the admission packet containing patient rights, clinical records (CR), and staff (EMP) interview, the agency failed to ensure the patient's clinical record was kept confidential for one (1) of one (1) discharged clinical record who's on-call telecare transcripts were reviewed (CR1). The agency permitted non-agency staff who were not under the purview of the parent hospice to have access to the patient's clinical record. Findings included: Note: Agency is located in Cranberry Township Pennsylvania Review of admission packet on April 26, 2023, at 10:50 a.m. showed, "VITAS Healthcare 2009 Mackenzie Way, Ste. 110 Cranberry Township, PA 16066 ... NOTICE OF PRIVACY PRACTICES Original Effective Date: April 14, 2002 I. THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. ... III. HOW WE MAY USE AND DISCLOSE YOUR PHI [protected health information] ... To Provide Treatment. VITAS may use your PHI to coordinate care within VITAS and others involved in your care, such as your attending physician, members of the hospice interdisciplinary team and other healthcare professionals who have agreed to assist VITAS in coordinating care. For example, physicians involved in your care will need information about your symptoms in order to prescribe appropriate medications. VITAS also may disclose your PHI to individual or entities outside VITAS involved in your care including family members, clergy whom you have designated, pharmacists, suppliers of medical equipment, or other healthcare professionals VITAS uses to coordinate your care. ... Pennsylvania Patient's Bill of Rights and Responsibilities ... A patient has the right to: ... Have a confidential clinical record." There was nothing in the above privacy notice that the patient's PHI would be shared with a separate intranational interdisciplinary team. Review of CR1 on April 26, 2023, from 10:40 a.m. revealed patient was admitted to routine home care on 2/15/2023 with a diagnosis of heart failure (chronic diastolic congestive heart failure). The medications Tramadol and Tylenol were ordered to be taken by mouth for pain and discomfort. The episode was unremarkable, and the patient had minimal complaints of pain. The patient resided in an assisted living facility. On 3/21/2023 at 5:38 p.m., the patient's family called after hours on-call stating the patient was in pain and not able to swallow medications. A local Vitas on-call nurse made a home visit at 7:35 p.m. Review of on-call "TELECARE CALL" logs on April 26, 2023, at 11:40 a.m. showed non-agency "Telecare" interdisciplinary team members or staff who were not directly controlled or supervised by independently certified parent agency, assessed, and triaged the patient and obtained physician orders by accessing the patient's clinical record. For instance, these staff members can be located in New Jersey, Illinois, or Florida. The administrator and governing body from the Vitas parent location in Cranberry Township do not maintain personnel files for these telecare staff, nor does it provide orientation or performance evaluations for these staff. The below transcript shows how the agency permitted non-agency personnel access to the patient's clinical record. 3/21/2023 5:41 p.m., "called stating PCG feels [patient] won't make it. Caller states pt is not swallowing meds but complains of stomach pain. Expressed sympathy. Caller agreed to hold for a nurse." Call taken by TC1 (patient care coordinator) 3/21/2023 5:44 p.m., "Transferred to TRI [triage]." Call taken by TC1 3/21/2023 6:19 p.m., "Returned call to facility, spoke with [facility] med tech. States pt not responding much, not swallowing or eating/drinking which started yesterday. PT having pain - no comfort meds place. States if morphine is ordered they will need pre-filled syringes. State pt is declining. States [family] is aware. Pt states pain is all over. No SOB. CML [comfort medication list] reviewed, pt has PRN Tramadol and scheduled Tylenol but unable to swallow. Pt had PRN Ativan and Zofran today. Currently in bed with HOB elevated. Advised re-positioning with pillows for comfort. Will send nurse, nurse will call with eta and call back for any needs/changes. Agreed to plan, no further needs. Thanked." Call taken by TC2 (registered nurse) 3/21/2023 6:19 p.m., "TRANSFER TO DIS [dispatch]" Call taken by TC2 3/21/2023 6:24 p.m., "Read Receipt ... To: [EMP5 (Vitas RN)]" EMP5 arrived at 7:35 p.m. (almost 2 hours after Telecare call was first logged) completed the nursing visit at approximately 8:35 p.m. and obtained an order for comfort med Roxanol 5mg every 3 hours as needed. However, the agency was unable to obtain the Roxanol since local pharmacies did not carry this medication. The assisted living facility where patient was located only wanted to use its pharmacy. This is the only time an agency RN is with the patient. The remaining actions, assessments, and orders are performed remotely by Telecare (call center) staff who could be located in New Jersey or Chicago Illinois. 3/21/2023 11:23 p.m., "CONVERSATION ... [family] called to report pt. is in pain, doesn't have Morphine to give her ... ask for assistance. Agreed to hold for a nurse." Call taken by TC3 No morphine is available and once again family calls Telecare again. The patient is transferred to Telecare staff for assessment, evaluation, and planning. 3/21/2023 11:26 p.m., "TRANSFER TO TRI ... Triage nurse agreed to take call." Call taken by TC3 3/21/2023 11:37 p.m., "CONVERSATION ... Spoke with [family] who stated pt is still in a lot of pain. Caller states they cannot get the morphine till the morning, that no pharmacies were open for local fill. Caller states nurse tried to give Tramadol but even with applesauce pt was unable to swallow it. Reviewed cml [comfort medication list], pt currently has orders for Ativan. Caller states she forgot about that and pt is definitely anxious due to the pain. Advised pull was small and can be dissolved under the tongue if pt is not swallowing. Caller states she will reach out to nurse and have her give it. Advised will check back with her in 30 minutes to see if effective. Advised will also reach out to oncall nurse to see if she had any suggestions. Caller agreed to call back. CB number verified." Call taken by TC4 (licensed practical nurse) 3/21/2023 11:49 p.m., "Spoke with [EMP5 (Vitas RN)] regarding above pt. OCN stated he/she called multiple pharmacies for Morphine and was unsuccessful. She states pt can no longer take pills. advised of above, she stated that [on-call physician] may order something rectally if Ativan not effective. Advised will f/u with [family] in 30 min, if Ativan not effective will call [on-call physician]." Call taken by TC4 3/22/2023 12:13 a.m., "PHYSICIAN CALLE[D] Called to advise of above. [On-call physician] reviewed pt chart while on phone with her. New orders received to increase Ativan to 0.5mg every 4 hours as needed for anxiety, and advised may give Tylenol ES 500mg tab 1 tab rectally every 4 hours as needed for pain. Read back verified." Call taken by TC4 3/22/2023 12:13 a.m., "FACILITY CALLED ... Called to advise of above. Advised of new orders from our on-call doctor to help control pt's pain for tonight. [ALF staff] advised he gave Ativan, and was going to check on her in 30 min. He states pt appeared to be in pain, calling out. Advised will fax new orders." Call taken byTC4 3/22/2023 12:26 a.m., "CARGIVER CALLE[D] ... Call back to advise of new orders and to check pt status." Call taken by TC4 3/22/2023 2:30 a.m., "CONVERSATION ... [ALF Med Tech] ... Caller is reporting that pt has expired. Family is bedside. Offer SW and Chap offered. Both declined. Caller not able to pronounce." Call taken by TC5 (licensed practical nurse) 3/22/2023 2:38 a.m., "[Vitas] NURSE SENT." Per "REPORT OF DEATH" note, the registered nurse arrive onsite at facility at 3:15 a.m. and the patient was pronounced at 3:25 a.m. Review of parent agency's (Cranberry Township) organizational chart on April 26, 2023, at 12:57 a.m. showed agency administrator (EMP1/general manager) at the top. Telecare staff (TC) did not appear on the organizational chart. A review of personnel files of telecare staff listed above showed their orientation and/or performance evaluations were performed by staff who did not appear on the Parent agency's organizational chart. Review of a separate organizational chart for call center staff showed TC7 (vice president care connection center) at the top of the chart. TC7 has control of call center staff who supervise TC3, TC4, TC5, and their supervisors TC8, TC9, TC10, TC11. An email from EMP2 reviewed on May 1, 2023, at 11 a.m. showed that TC7 reports to the "Cincinnati office," and lives in Indiana. Review of email from EMP2, and "Telecare" personnel files on May 1, 2023, at 10 a.m. showed call center supervision does not occur at or from the Cranberry Township location but occurs at an intranational level as follows: TC1 (PCC) is located in Atlanta and was hired 3/27/2020. TC1's supervisor is TC8 who lives in Florida and remotely oversees the New Jersey (NJ) call center. TC1's orientation was completed by telecare trainers TC12 and TC14 both of whom are located in Florida. TC1's performance evaluation was completed by TC8 during April of 2023. TC2 (RN) is located in New Jersey and was hired 7/19/2021. TC2's supervisor is telecare team lead TC11 who lives in Connecticut (CT) and remotely oversees the NJ call center. TC2's orientation was completed by telecare trainer TC14 who is located in Florida. TC2's performance evaluation was completed by TC10 during April of 2023. TC10 lives in Connecticut and remotely oversees the NJ call center. TC3 (administrative) is located in Texas and was hired 2/13/2023. TC3's supervisor is TC18 located in Illinois. TC3's orientation was completed by telecare trainer TC16 located in Illinois. TC4 (LPN) is located in Illinois and was hired 3/28/2022. TC4's supervisor is TC11. TC4's orientation was completed by national patient care administrator TC24 located in Ohio. TC4's performance evaluation was completed during April of 2023 by TC11. TC5 (LPN) is located in Illinois and was also hired 3/28/2022. TC5's supervisor is telecare team lead TC9 whom lives in Illinois. TC5's orientation was completed by telecare trainers TC13 and TC14 both of whom are located in Florida. TC5's performance evaluation was completed during April 2023 by TC9. Review of agency policy on May 1, 2023, at 11 a.m. showed" "TITLE: JOB DESCRIPTION: CCC TELECARE LPN POLICY 9:98 POSITION SUMMARY The VITAS Telecare LPN is a member of the interdisciplinary team who is responsible for identifying the physical, psychological, social, and spiritual needs of those patients and families needing assistance during alternate hours. All clinical tasks for this supporting position will be performed under the collaboration and direction of the Telecare RN as needed. ... Provides clinical assessment and intervention utilizing the nursing process, VITAS Palliative Care Guide, and Triage Protocols. Coordinates all service delivery after hours including patient and family education, dispatching of interdisciplinary visits, and coordination of services with external vendors and resources as needed. Provides support and collaboration with Telecare staff to ensure favorable patient outcomes. Provides bereavement support to families. Documents interactions with patients, families, contacts, and vendors in the patient record to include the assessment, plan of care, caller agreement to the plan, any actions and interventions and the resolution of each patient/family interaction." "TITLE: JOB DESCRIPTION:CCC TELECARE RN POLICY 9:101 NUMBER: 1 of 3 POSITION SUMMARY The VITAS Telecare RN is a member of the interdisciplinary team who is the pivotal person responsible for identifying the physical, psychological, social, and spiritual needs of those patients and families needing assistance after normal business hours. He or she initiates appropriate interventions to the patients and families by utilizing the nursing process, the VITAS Palliative Care Guide, and Telecare Protocols during alternate hours. ESSENTIAL DUTIES & RESPONSIBILITIES All duties and responsibilities are to be performed in accordance with VITASs policies, procedures, guidelines, contractual commitments and governmental regulations. Provides clinical assessment and intervention utilizing the nursing process, VITAS Palliative Care Guide, and Triage Protocols. Serves as the patient and family advocate by communicating with the attending physicians, long term care facility staff, case managers, and others external to VITAS as necessary. Provides collaboration with LPN/LVNs. Coordinates all service delivery after hours including patient and family education, dispatching of interdisciplinary visits, and coordination of services with external vendors and resources as needed. Provides support and collaboration with Telecare staff to ensure favorable patient outcomes. Provides bereavement support to families. Documents interactions with patients, families, contacts, and vendors in the patient record to include the assessment, plan of care, caller agreement to the plan, any actions and interventions and the resolution of each patient/family interaction. Reviews all entries in the record made by Telecare LPN/LVNs and Patient Care Coordinators and ensures compliance with documentation Standards. Participates in the orientation of new team members as assigned by the supervising manager. Attends regularly scheduled in-services, staff meetings, and educational conferences. Develops and achieves professional growth goals and objectives, and reviews with supervising manager on a monthly basis. Seeks certification in the specialty of hospice nursing when qualified to do so. Instructs and documents appropriate use of medications, home medical equipment and supplies." "Position Description Position Title: CCC Patient Care Coordinator ... Reports To: Telecare Team Leader (Clinical / Non-Clinical) Dept: Care Connection Center POSITION SUMMARY The VITAS Healthcare Patient Care Coordinator is a member of the interdisciplinary team who effectively processes calls, answers general questions, provides information, and transfers calls to triage nurses when appropriate during alternate hours." Interviews with local human resource manager (EMP4) on April 26, 2023, at approximately 12 p.m. confirmed agency does not directly supervise these remote staff.

Based on review of agency policy, email, clinical records (CR), and staff (EMP) interview, the agency failed to ensure the interdisciplinary group (IDG) maintained responsibility for directing, coordinating, and supervising the care and services provided for one (1) of three (3) discharged clinical records reviewed (CR1). Findings included: Note: Agency is located in Cranberry Township Pennsylvania Per email from EMP2, reviewed on May 2, 2023, at 10:30 a.m. and sent on May 1, 2023, at 3 p.m., the agency maintains two interdisciplinary groups. Teams 631 and 632. These members meet at least weekly at the parent location in Cranberry Township. Review of CR1 on April 26, 2023, at 10:40 a.m. revealed patient was admitted to routine home care on 2/15/2023 with a diagnosis of heart failure (chronic diastolic congestive heart failure). The medications Tramadol and Tylenol were ordered to be taken by mouth for pain and discomfort. The episode was unremarkable, and the patient had minimal complaints of pain. The patient resided in an assisted living facility. On 3/21/2023 at 5:38 p.m., the patient's family called after hours on-call stating the patient was in pain and not able to swallow medications. A local Vitas on-call nurse made a home visit at 7:35 p.m. and documented, "FS [facility staff] report pt [patient] not responding much, not swallowing, [decreased] appetite, taking sips of fluid. ... Unable to palpate radial pulse, [decreased] urine output. ... New order- Roxanol [comfort medication] 5mg SL [taken under the tongue] [as needed] for pain / sob [shortness of breath]." During the visit the RN obtained an order for Roxanol but the facility could not obtain the medication via its contracted pharmacy related to the time of day the orders were received. Interview with EMP2 on April 26, 2023, at 11:26 a.m. confirmed the patient's facility uses a "[local pharmacy]," and sometimes medications can also be obtained from local pharmacy via courier. EMP2 noted the patient's comfort pain medication Roxanol could not be obtained because the local pharmacies were closed, "could not find it at this time of night. We try to anticipate anything coming down the pike and should have been Roxanol already ordered. In this case it looks like it could have been ordered on 21st [3/21/2023]." The following "Telecare Call" logs show how the agency utilized remote call center staff located out of state. For instance, these staff members can be located in New Jersey, Illinois, or Florida. Interviews with local human resource manager (EMP4), and EMP2 confirmed agency does not directly supervise these remote staff. The administrator and governing body from the Vitas parent location in Cranberry Township do not maintain personnel files for telecare staff, nor does it provide orientation or performance evaluations for these staff. The below transcript shows how this deficient practice cause a delay in care with the patient expiring without medications necessary for symptom management. Review of on-call "TELECARE CALL" logs on April 26, 2023, at 11:40 a.m. showed non-agency staff or staff who were not directly controlled or supervised by independently certified parent agency, assessed, and triaged the patient and obtained physician orders. The remainder of the patient's clinical record is summarized from the below Telecare entries. 3/21/2023 5:41 p.m., "called stating PCG feels [patient] won't make it. Caller states pt is not swallowing meds but complains of stomach pain. Expressed sympathy. Caller agreed to hold for a nurse." Call taken by TC1 (patient care coordinator) 3/21/2023 5:44 p.m., "Transferred to TRI [triage]." Call taken by TC1 3/21/2023 6:19 p.m., "Returned call to facility, spoke with [facility] med tech. States pt not responding much, not swallowing or eating/drinking which started yesterday. PT having pain - no comfort meds place. States if morphine is ordered they will need pre-filled syringes. State pt is declining. States [family] is aware. Pt states pain is all over. No SOB. CML [comfort medication list] reviewed, pt has PRN Tramadol and scheduled Tylenol but unable to swallow. Pt had PRN Ativan and Zofran today. Currently in bed with HOB elevated. Advised re-positioning with pillows for comfort. Will send nurse, nurse will call with eta and call back for any needs/changes. Agreed to plan, no further needs. Thanked." Call taken by TC2 (registered nurse) 3/21/2023 6:19 p.m., "TRANSFER TO DIS [dispatch]" Call taken by TC2 3/21/2023 6:24 p.m., "Read Receipt ... To: [EMP5 (Vitas RN)]" EMP5 arrived at 7:35 p.m. (almost 2 hours after Telecare call was first logged) completed the nursing visit at approximately 8:35 p.m. and obtained an order for comfort med Roxanol 5mg every 3 hours as needed. However, the agency was unable to obtain the Roxanol since local pharmacies did not carry this medication. The assisted living facility where patient was located only wanted to use its pharmacy. This is the only time an agency RN is with the patient. The remaining actions, assessments, and orders are performed remotely by Telecare (call center) staff who could be located in New Jersey or Chicago Illinois. 3/21/2023 11:23 p.m., "CONVERSATION ... [family] called to report pt. is in pain, doesn't have Morphine to give her ... ask for assistance. Agreed to hold for a nurse." Call taken by TC3 No morphine is available and once again family calls Telecare again. The patient is transferred to Telecare staff for assessment, evaluation, and planning. 3/21/2023 11:26 p.m., "TRANSFER TO TRI ... Triage nurse agreed to take call." Call taken by TC3 3/21/2023 11:37 p.m., "CONVERSATION ... Spoke with [family] who stated pt is still in a lot of pain. Caller states they cannot get the morphine till the morning, that no pharmacies were open for local fill. Caller states nurse tried to give Tramadol but even with applesauce pt was unable to swallow it. Reviewed cml [comfort medication list], pt currently has orders for Ativan. Caller states she forgot about that and pt is definitely anxious due to the pain. Advised pull was small and can be dissolved under the tongue if pt is not swallowing. Caller states she will reach out to nurse and have her give it. Advised will check back with her in 30 minutes to see if effective. Advised will also reach out to oncall nurse to see if she had any suggestions. Caller agreed to call back. CB number verified." Call taken by TC4 (licensed practical nurse) 3/21/2023 11:49 p.m., "Spoke with [EMP5 (Vitas RN)] regarding above pt. OCN stated he/she called multiple pharmacies for Morphine and was unsuccessful. She states pt can no longer take pills. advised of above, she stated that [on-call physician] may order something rectally if Ativan not effective. Advised will f/u with [family] in 30 min, if Ativan not effective will call [on-call physician]." Call taken by TC4 3/22/2023 12:13 a.m., "PHYSICIAN CALLE[D] Called to advise of above. [On-call physician] reviewed pt chart while on phone with her. New orders received to increase Ativan to 0.5mg every 4 hours as needed for anxiety, and advised may give Tylenol ES 500mg tab 1 tab rectally every 4 hours as needed for pain. Read back verified." Call taken by TC4 3/22/2023 12:13 a.m., "FACILITY CALLED ... Called to advise of above. Advised of new orders from our on-call doctor to help control pt's pain for tonight. [ALF staff] advised he gave Ativan, and was going to check on her in 30 min. He states pt appeared to be in pain, calling out. Advised will fax new orders." Call taken byTC4 3/22/2023 12:26 a.m., "CARGIVER CALLE[D] ... Call back to advise of new orders and to check pt status." Call taken by TC4 3/22/2023 2:30 a.m., "CONVERSATION ... [ALF Med Tech] ... Caller is reporting that pt has expired. Family is bedside. Offer SW and Chap offered. Both declined. Caller not able to pronounce." Call taken by TC5 (licensed practical nurse) 3/22/2023 2:38 a.m., "[Vitas] NURSE SENT." Per "REPORT OF DEATH" note, the registered nurse arrive onsite at facility at 3:15 a.m. and the patient was pronounced at 3:25 a.m. Patient expired 9 hours and 44 minutes after first call to Telecare staff without ever receiving necessary comfort medications. Review of parent agency's (Cranberry Township) organizational chart on April 26, 2023, at 12:57 a.m. showed agency administrator (EMP1/general manager) at the top. Telecare staff (TC) did not appear on the organizational chart. A review of personnel files of telecare staff listed above showed their orientation and/or performance evaluations were performed by staff who did not appear on the Parent agency's organizational chart. Review of a separate organizational chart for call center staff showed TC7 (vice president care connection center) at the top of the chart. TC7 has control of call center staff who supervise TC3, TC4, TC5, and their supervisors TC8, TC9, TC10, TC11. An email from EMP2 reviewed on May 1, 2023, at 11 a.m. showed that TC7 reports to the "Cincinnati office," and lives in Indiana. Review of email from EMP2, and "Telecare" personnel files on May 1, 2023, at 10 a.m. showed call center supervision does not occur at or from the Cranberry Township location but occurs at an intranational level as follows: TC1 (PCC) is located in Atlanta and was hired 3/27/2020. TC1's supervisor is TC8 who lives in Florida and remotely oversees the New Jersey (NJ) call center. TC1's orientation was completed by telecare trainers TC12 and TC14 both of whom are located in Florida. TC1's performance evaluation was completed by TC8 during April of 2023. TC2 (RN) is located in New Jersey and was hired 7/19/2021. TC2's supervisor is telecare team lead TC11 who lives in Connecticut (CT) and remotely oversees the NJ call center. TC2's orientation was completed by telecare trainer TC14 who is located in Florida. TC2's performance evaluation was completed by TC10 during April of 2023. TC10 lives in Connecticut and remotely oversees the NJ call center. TC3 (administrative) is located in Texas and was hired 2/13/2023. TC3's supervisor is TC18 located in Illinois. TC3's orientation was completed by telecare trainer TC16 located in Illinois. TC4 (LPN) is located in Illinois and was hired 3/28/2022. TC4's supervisor is TC11. TC4's orientation was completed by national patient care administrator TC24 located in Ohio. TC4's performance evaluation was completed during April of 2023 by TC11. TC5 (LPN) is located in Illinois and was also hired 3/28/2022. TC5's supervisor is telecare team lead TC9 whom lives in Illinois. TC5's orientation was completed by telecare trainers TC13 and TC14 both of whom are located in Florida. TC5's performance evaluation was completed during April 2023 by TC9. Review of agency policy on May 1, 2023, at 11 a.m. showed: "TITLE: JOB DESCRIPTION: CCC TELECARE LPN POLICY 9:98 POSITION SUMMARY The VITAS Telecare LPN is a member of the interdisciplinary team who is responsible for identifying the physical, psychological, social, and spiritual needs of those patients and families needing assistance during alternate hours. All clinical tasks for this supporting position will be performed under the collaboration and direction of the Telecare RN as needed. ... Provides clinical assessment and intervention utilizing the nursing process, VITAS Palliative Care Guide, and Triage Protocols. Coordinates all service delivery after hours including patient and family education, dispatching of interdisciplinary visits, and coordination of services with external vendors and resources as needed. Provides support and collaboration with Telecare staff to ensure favorable patient outcomes. Provides bereavement support to families. Documents interactions with patients, families, contacts, and vendors in the patient record to include the assessment, plan of care, caller agreement to the plan, any actions and interventions and the resolution of each patient/family interaction." "TITLE: JOB DESCRIPTION: CCC TELECARE RN POLICY 9:101 NUMBER: 1 of 3 POSITION SUMMARY The VITAS Telecare RN is a member of the interdisciplinary team who is the pivotal person responsible for identifying the physical, psychological, social, and spiritual needs of those patients and families needing assistance after normal business hours. He or she initiates appropriate interventions to the patients and families by utilizing the nursing process, the VITAS Palliative Care Guide, and Telecare Protocols during alternate hours. ESSENTIAL DUTIES & RESPONSIBILITIES All duties and responsibilities are to be performed in accordance with VITASs policies, procedures, guidelines, contractual commitments and governmental regulations. Provides clinical assessment and intervention utilizing the nursing process, VITAS Palliative Care Guide, and Triage Protocols. Serves as the patient and family advocate by communicating with the attending physicians, long term care facility staff, case managers, and others external to VITAS as necessary. Provides collaboration with LPN/LVNs. Coordinates all service delivery after hours including patient and family education, dispatching of interdisciplinary visits, and coordination of services with external vendors and resources as needed. Provides support and collaboration with Telecare staff to ensure favorable patient outcomes. Provides bereavement support to families. Documents interactions with patients, families, contacts, and vendors in the patient record to include the assessment, plan of care, caller agreement to the plan, any actions and interventions and the resolution of each patient/family interaction. Reviews all entries in the record made by Telecare LPN/LVNs and Patient Care Coordinators and ensures compliance with documentation Standards. Participates in the orientation of new team members as assigned by the supervising manager. Attends regularly scheduled in-services, staff meetings, and educational conferences. Develops and achieves professional growth goals and objectives, and reviews with supervising manager on a monthly basis. Seeks certification in the specialty of hospice nursing when qualified to do so. Instructs and documents appropriate use of medications, home medical equipment and supplies." "Position Description Position Title: CCC Patient Care Coordinator ... Reports To: Telecare Team Leader (Clinical / Non-Clinical) Dept: Care Connection Center POSITION SUMMARY The VITAS Healthcare Patient Care Coordinator is a member of the interdisciplinary team who effectively processes calls, answers general questions, provides information, and transfers calls to triage nurses when appropriate during alternate hours." Review of on-call "TELECARE CALL" logs on April 26, 2023, at 11:40 a.m. showed non-agency staff or staff who were not directly controlled or supervised by independently certified parent agency, assessed, and triaged the patient and obtained physician orders. The remainder of the patient's clinical record is summarized from the below Telecare entries. "INTERDISCIPLINARY TEAM POLICIES ADMINISTRATIVE ON-CALL ... 5:39 ... POLICY To provide a high quality of hospice care directed by a physician and supervised by a registered nurse 24 hours a day, 7 days a week. OBJECTIVE(S) To provide safe continuity of hospice care for the patient and family 24 hours a day, 7 days a week adhering to the state and federal rules and regulations for hospice programs. PROCEDURE(S) ... 2. Problems of a serious nature related to ... hospice services will be referred to the team manager/patient care administrator on-call who may contact the general manager [EMP1/administrator]." "Resolution for Meeting of the Governing Body Health Regulatory Approvals November 16, 2022 APPROVAL OF INTERDISCIPLINARY GROUP ... NOW, THEREFORE, BE IT RESOLVED, that the governing body of the following programs confirms and approves the appointment of the persons set forth in the list presented to this meeting, to the interdisciplinary group for the respective hospice programs ... Pittsburgh Pennsylvania [Cranberry Township parent location] ... [EMP20] Medical director [EMP2] Nurse [EMP18] Social Worker [EMP19] Chaplain." Interview with EMP2 on April 26, 2023, at 11:26 a.m. and review of email from EMP2 on May 2, 2023, at 3 p.m. confirmed above findings, and that EMP1 (adminstrator) is also part of the governing body.

Based on review of agency policy, clinical records (CR), and staff (EMP) interview, the hospice failed to analyze aspects of performance in order to assess processes of care, hospice services, and operations. The agency permitted an out-of- state interdisciplinary group (IDG) located at various on-call centers to triage the hospice's patients to determine if the patient's needs warranted further investigation by the parent hospice located in Cranberry township. This group was remotely supervised remotely by personnel located accross the country and not directly controlled by the independently certified hospice (parent). This practice contributed to process of care failure related to palliative outcomes (pain control) for one (1) of three (3) discharged clinical records (CR1). Findings included: Note: Agency is located in Cranberry Township Pennsylvania Review of agency policy on April 28, 2023, at 1:40 p.m. showed: "GOVERNING BODY ... The governing body assumes full legal responsibility for the management of the hospice, the provision of all hospice services ... PROCEDURE(S) ... 2. Appoint the members of the interdisciplinary group ("IDG") ... to participate in the establishment of policies governing the day-to-day provision of hospice care and services, to include a. A doctor of medicine or osteopathy b. A registered nurse c. A social worker d. A chaplain or other counselor. 3. Adopt and revise, as needed, policies that govern the operation and administration of the organization. These policies are available to patients/families or their agents upon request." "PROFESSIONAL MANAGEMENT OF THE HOSPICE PATIENT ... PROCEDURE(S) 1. The organizational structure in each office will follow the reporting order defined in the job descriptions and organizational chart for VITAS." Review of CR1 on April 26, 2023, at 10:40 a.m. revealed patient was admitted to routine home care on 2/15/2023 with a diagnosis of heart failure (chronic diastolic congestive heart failure). The medications Tramadol and Tylenol were ordered to be taken by mouth for pain and discomfort. The episode was unremarkable, and the patient had minimal complaints of pain. The patient resided in an assisted living facility. On 3/21/2023 at 5:38 p.m., the patient's family called after hours on-call stating the patient was in pain and not able to swallow medications. A local Vitas on-call nurse made a home visit at 7:35 p.m. and documented, "FS [facility staff] report pt [patient] not responding much, not swallowing, [decreased] appetite, taking sips of fluid. ... Unable to palpate radial pulse, [decreased] urine output. ... New order- Roxanol [comfort medication] 5mg SL [taken under the tongue] [as needed] for pain / sob [shortness of breath]." During the visit the RN obtained an order for Roxanol but the facility could not obtain the medication via its contracted pharmacy related to the time of day the orders were received. Interview with EMP2 on April 26, 2023, at 11:26 a.m. confirmed the patient's facility uses a "[local pharmacy]," and sometimes medications can also be obtained from local pharmacy via courier. EMP2 noted the patient's comfort pain medication Roxanol could not be obtained because the local pharmacies were closed, "could not find it at this time of night. We try to anticipate anything coming down the pike and should have been Roxanol already ordered. In this case it looks like it could have been ordered on 21st [3/21/2023]." The following "Telecare Call" logs show how the agency utilized remote call center staff located out of state. For instance, these staff members can be located in New Jersey, Illinois, or Florida. Interviews with local human resource manager (EMP4), and EMP2 confirmed agency does not directly supervise these remote staff. The administrator and governing body from the Vitas parent location in Cranberry Township do not maintain personnel files for telecare staff, nor does it provide orientation or performance evaluations for these staff. The below transcript shows how this deficient practice cause a delay in care with the patient expiring without medications necessary for symptom management. Review of on-call "TELECARE CALL" logs on April 26, 2023, at 11:40 a.m. showed non-agency staff or staff who were not directly controlled or supervised by independently certified parent agency, assessed, and triaged the patient and obtained physician orders. The remainder of the patient's clinical record is summarized from the below Telecare entries. 3/21/2023 5:41 p.m., "called stating PCG feels [patient] won't make it. Caller states pt is not swallowing meds but complains of stomach pain. Expressed sympathy. Caller agreed to hold for a nurse." Call taken by TC1 (patient care coordinator) 3/21/2023 5:44 p.m., "Transferred to TRI [triage]." Call taken by TC1 3/21/2023 6:19 p.m., "Returned call to facility, spoke with [facility] med tech. States pt not responding much, not swallowing or eating/drinking which started yesterday. PT having pain - no comfort meds place. States if morphine is ordered they will need pre-filled syringes. State pt is declining. States [family] is aware. Pt states pain is all over. No SOB. CML [comfort medication list] reviewed, pt has PRN Tramadol and scheduled Tylenol but unable to swallow. Pt had PRN Ativan and Zofran today. Currently in bed with HOB elevated. Advised re-positioning with pillows for comfort. Will send nurse, nurse will call with eta and call back for any needs/changes. Agreed to plan, no further needs. Thanked." Call taken by TC2 (registered nurse) 3/21/2023 6:19 p.m., "TRANSFER TO DIS [dispatch]" Call taken by TC2 3/21/2023 6:24 p.m., "Read Receipt ... To: [EMP5 (Vitas RN)]" EMP5 arrived at 7:35 p.m. (almost 2 hours after Telecare call was first logged) completed the nursing visit at approximately 8:35 p.m. and obtained an order for comfort med Roxanol 5mg every 3 hours as needed. However, the agency was unable to obtain the Roxanol since local pharmacies did not carry this medication. The assisted living facility where patient was located only wanted to use its pharmacy. This is the only time an agency RN is with the patient. The remaining actions, assessments, and orders are performed remotely by Telecare (call center) staff who could be located in New Jersey or Chicago Illinois. 3/21/2023 11:23 p.m., "CONVERSATION ... [family] called to report pt. is in pain, doesn't have Morphine to give her ... ask for assistance. Agreed to hold for a nurse." Call taken by TC3 No morphine is available and once again family calls Telecare again. The patient is transferred to Telecare staff for assessment, evaluation, and planning. 3/21/2023 11:26 p.m., "TRANSFER TO TRI ... Triage nurse agreed to take call." Call taken by TC3 3/21/2023 11:37 p.m., "CONVERSATION ... Spoke with [family] who stated pt is still in a lot of pain. Caller states they cannot get the morphine till the morning, that no pharmacies were open for local fill. Caller states nurse tried to give Tramadol but even with applesauce pt was unable to swallow it. Reviewed cml [comfort medication list], pt currently has orders for Ativan. Caller states she forgot about that and pt is definitely anxious due to the pain. Advised pull was small and can be dissolved under the tongue if pt is not swallowing. Caller states she will reach out to nurse and have her give it. Advised will check back with her in 30 minutes to see if effective. Advised will also reach out to oncall nurse to see if she had any suggestions. Caller agreed to call back. CB number verified." Call taken by TC4 (licensed practical nurse) 3/21/2023 11:49 p.m., "Spoke with [EMP5 (Vitas RN)] regarding above pt. OCN stated he/she called multiple pharmacies for Morphine and was unsuccessful. She states pt can no longer take pills. advised of above, she stated that [on-call physician] may order something rectally if Ativan not effective. Advised will f/u with [family] in 30 min, if Ativan not effective will call [on-call physician]." Call taken by TC4 3/22/2023 12:13 a.m., "PHYSICIAN CALLE[D] Called to advise of above. [On-call physician] reviewed pt chart while on phone with her. New orders received to increase Ativan to 0.5mg every 4 hours as needed for anxiety, and advised may give Tylenol ES 500mg tab 1 tab rectally every 4 hours as needed for pain. Read back verified." Call taken by TC4 3/22/2023 12:13 a.m., "FACILITY CALLED ... Called to advise of above. Advised of new orders from our on-call doctor to help control pt's pain for tonight. [ALF staff] advised he gave Ativan, and was going to check on her in 30 min. He states pt appeared to be in pain, calling out. Advised will fax new orders." Call taken byTC4 3/22/2023 12:26 a.m., "CARGIVER CALLE[D] ... Call back to advise of new orders and to check pt status." Call taken by TC4 3/22/2023 2:30 a.m., "CONVERSATION ... [ALF Med Tech] ... Caller is reporting that pt has expired. Family is bedside. Offer SW and Chap offered. Both declined. Caller not able to pronounce." Call taken by TC5 (licensed practical nurse) 3/22/2023 2:38 a.m., "[Vitas] NURSE SENT." Per "REPORT OF DEATH" note, the registered nurse arrive onsite at facility at 3:15 a.m. and the patient was pronounced at 3:25 a.m. Review of parent agency's (Cranberry Township) organizational chart on April 26, 2023, at 12:57 a.m. showed agency administrator (EMP1/general manager) at the top. Telecare staff (TC) did not appear on the organizational chart. A review of personnel files of telecare staff listed above showed their orientation and/or performance evaluations were performed by staff who did not appear on the Parent agency's organizational chart. Review of a separate organizational chart for call center staff showed TC7 (vice president care connection center) at the top of the chart. TC7 has control of call center staff who supervise TC3, TC4, TC5, and their supervisors TC8, TC9, TC10, TC11. An email from EMP2 reviewed on May 1, 2023, at 11 a.m. showed that TC7 reports to the "Cincinnati office," and lives in Indiana. Review of email from EMP2, and "Telecare" personnel files on May 1, 2023, at 10 a.m. showed call center supervision does not occur at or from the Cranberry Township location but occurs at an intranational level as follows: TC1 (PCC) is located in Atlanta and was hired 3/27/2020. TC1's supervisor is TC8 who lives in Florida and remotely oversees the New Jersey (NJ) call center. TC1's orientation was completed by telecare trainers TC12 and TC14 both of whom are located in Florida. TC1's performance evaluation was completed by TC8 during April of 2023. TC2 (RN) is located in New Jersey and was hired 7/19/2021. TC2's supervisor is telecare team lead TC11 who lives in Connecticut (CT) and remotely oversees the NJ call center. TC2's orientation was completed by telecare trainer TC14 who is located in Florida. TC2's performance evaluation was completed by TC10 during April of 2023. TC10 lives in Connecticut and remotely oversees the NJ call center. TC3 (administrative) is located in Texas and was hired 2/13/2023. TC3's supervisor is TC18 located in Illinois. TC3's orientation was completed by telecare trainer TC16 located in Illinois. TC4 (LPN) is located in Illinois and was hired 3/28/2022. TC4's supervisor is TC11. TC4's orientation was completed by national patient care administrator TC24 located in Ohio. TC4's performance evaluation was completed during April of 2023 by TC11. TC5 (LPN) is located in Illinois and was also hired 3/28/2022. TC5's supervisor is telecare team lead TC9 whom lives in Illinois. TC5's orientation was completed by telecare trainers TC13 and TC14 both of whom are located in Florida. TC5's performance evaluation was completed during April 2023 by TC9. Review of agency policy on May 1, 2023, at 11 a.m. showed" "TITLE: JOB DESCRIPTION: CCC TELECARE LPN POLICY 9:98 POSITION SUMMARY The VITAS Telecare LPN is a member of the interdisciplinary team who is responsible for identifying the physical, psychological, social, and spiritual needs of those patients and families needing assistance during alternate hours. All clinical tasks for this supporting position will be performed under the collaboration and direction of the Telecare RN as needed. ... Provides clinical assessment and intervention utilizing the nursing process, VITAS Palliative Care Guide, and Triage Protocols. Coordinates all service delivery after hours including patient and family education, dispatching of interdisciplinary visits, and coordination of services with external vendors and resources as needed. Provides support and collaboration with Telecare staff to ensure favorable patient outcomes. Provides bereavement support to families. Documents interactions with patients, families, contacts, and vendors in the patient record to include the assessment, plan of care, caller agreement to the plan, any actions and interventions and the resolution of each patient/family interaction." "TITLE: JOB DESCRIPTION:CCC TELECARE RN POLICY 9:101 NUMBER: 1 of 3 POSITION SUMMARY The VITAS Telecare RN is a member of the interdisciplinary team who is the pivotal person responsible for identifying the physical, psychological, social, and spiritual needs of those patients and families needing assistance after normal business hours. He or she initiates appropriate interventions to the patients and families by utilizing the nursing process, the VITAS Palliative Care Guide, and Telecare Protocols during alternate hours. ESSENTIAL DUTIES & RESPONSIBILITIES All duties and responsibilities are to be performed in accordance with VITASs policies, procedures, guidelines, contractual commitments and governmental regulations. Provides clinical assessment and intervention utilizing the nursing process, VITAS Palliative Care Guide, and Triage Protocols. Serves as the patient and family advocate by communicating with the attending physicians, long term care facility staff, case managers, and others external to VITAS as necessary. Provides collaboration with LPN/LVNs. Coordinates all service delivery after hours including patient and family education, dispatching of interdisciplinary visits, and coordination of services with external vendors and resources as needed. Provides support and collaboration with Telecare staff to ensure favorable patient outcomes. Provides bereavement support to families. Documents interactions with patients, families, contacts, and vendors in the patient record to include the assessment, plan of care, caller agreement to the plan, any actions and interventions and the resolution of each patient/family interaction. Reviews all entries in the record made by Telecare LPN/LVNs and Patient Care Coordinators and ensures compliance with documentation Standards. Participates in the orientation of new team members as assigned by the supervising manager. Attends regularly scheduled in-services, staff meetings, and educational conferences. Develops and achieves professional growth goals and objectives, and reviews with supervising manager on a monthly basis. Seeks certification in the specialty of hospice nursing when qualified to do so. Instructs and documents appropriate use of medications, home medical equipment and supplies." "Position Description Position Title: CCC Patient Care Coordinator ... Reports To: Telecare Team Leader (Clinical / Non-Clinical) Dept: Care Connection Center POSITION SUMMARY The VITAS Healthcare Patient Care Coordinator is a member of the interdisciplinary team who effectively processes calls, answers general questions, provides information, and transfers calls to triage nurses when appropriate during alternate hours." "INTERDISCIPLINARY TEAM POLICIES ADMINISTRATIVE ON-CALL ... 5:39 ... POLICY To provide a high quality of hospice care directed by a physician and supervised by a registered nurse 24 hours a day, 7 days a week. OBJECTIVE(S) To provide safe continuity of hospice care for the patient and family 24 hours a day, 7 days a week adhering to the state and federal rules and regulations for hospice programs. PROCEDURE(S) ... 2. Problems of a serious nature related to ... hospice services will be referred to the team manager/patient care administrator on-call who may contact the general manager [EMP1/administrator]." "Resolution for Meeting of the Governing Body Health Regulatory Approvals November 16, 2022 APPROVAL OF INTERDISCIPLINARY GROUP ... NOW, THEREFORE, BE IT RESOLVED, that the governing body of the following programs confirms and approves the appointment of the persons set forth in the list presented to this meeting, to the interdisciplinary group for the respective hospice programs ... Pittsburgh Pennsylvania [Cranberry Township parent location] ... [EMP20] Medical director [EMP2] Nurse [EMP18] Social Worker [EMP19] Chaplain." Interviews with EMP2, and EMP3 on April 26, 2023, at approximately 2 p.m., and review of email from EMP2 on May 2, 2023, at 3 p.m. confirmed above findings, and that EMP1 (administrator) is also part of the governing body.

Based on review of agency policy, clinical records (CR), and staff (EMP) interview, the hospice failed to routinely and substantially provide nursing services directly by hospice employees (L591). This condition was not met as evidenced by the above non-compliance but did not result in an immediate jeopardy. Findings included: Note: Agency is located in Cranberry Township Pennsylvania Review of CR1 on April 26, 2023, at 10:40 a.m. revealed patient was admitted to routine home care on 2/15/2023 with a diagnosis of heart failure (chronic diastolic congestive heart failure). On 3/21/2023 at 5:38 p.m., the patient's family called after hours on-call stating the patient was in pain and not able to swallow medications. The following "Telecare Call" logs for CR1 show how the hospice failed to routinely and substantially provide nursing services directly by hospice employees. The "Telecare" episode transcripts began on 3/21/2023 at 5:41 p.m. and lasted until 3/22/2023 at 2:38 a.m. for a total time of 8 hours and 57 minutes. During this time the agency RN (EMP5) conducted a home visit that lasted one hour. EMP5 also received a phone call from telecare staff on 3/21/2023 at 11:49 p.m. No other services rendered directly by hospice staff until hospice nurse arrived onsite at 3:15 a.m. to pronounce the patient at 3:23 a.m. The majority of the episode was handled by remote call center staff located out of state. For instance, these staff members can be located in New Jersey, Illinois, or Florida. "TELECARE CALL" logs reviewed on April 26, 2023, at 11:40 a.m. 3/21/2023 5:41 p.m., "called stating PCG feels [patient] won't make it. Caller states pt is not swallowing meds but complains of stomach pain. Expressed sympathy. Caller agreed to hold for a nurse." 3/21/2023 5:44 p.m., "Transferred to TRI [triage]." 3/21/2023 6:19 p.m., "Returned call to facility, spoke with [facility] med tech. States pt not responding much, not swallowing or eating/drinking which started yesterday. PT having pain - no comfort meds place. States if morphine is ordered they will need pre-filled syringes. State pt is declining. States [family] is aware. Pt states pain is all over. No SOB. CML [comfort medication list] reviewed, pt has PRN Tramadol and scheduled Tylenol but unable to swallow. Pt had PRN Ativan and Zofran today. Currently in bed with HOB elevated. Advised re-positioning with pillows for comfort. Will send nurse, nurse will call with eta and call back for any needs/changes. Agreed to plan, no further needs. Thanked." 3/21/2023 6:19 p.m., "TRANSFER TO DIS [dispatch]" 3/21/2023 6:24 p.m., "Read Receipt ... To: [EMP5 (Vitas RN)]" EMP5 arrived at 7:35 p.m. (almost 2 hours after Telecare call was first logged) completed the nursing visit at approximately 8:35 p.m. and obtained an order for comfort med Roxanol 5mg every 3 hours as needed. However, the agency was unable to obtain the Roxanol since local pharmacies did not carry this medication. 3/21/2023 11:23 p.m., "CONVERSATION ... [family] called to report pt. is in pain, doesn't have Morphine to give her ... ask for assistance. Agreed to hold for a nurse." No morphine is available and once again family calls Telecare again. The family is transferred to Telecare staff for assessment, evaluation, and planning. 3/21/2023 11:26 p.m., "TRANSFER TO TRI ... Triage nurse agreed to take call." 3/21/2023 11:37 p.m., "CONVERSATION ... Spoke with [family] who stated pt is still in a lot of pain. Caller states they cannot get the morphine till the morning, that no pharmacies were open for local fill. Caller states nurse tried to give Tramadol but even with applesauce pt was unable to swallow it. Reviewed cml [comfort medication list], pt currently has orders for Ativan. Caller states she forgot about that and pt is definitely anxious due to the pain. Advised pull was small and can be dissolved under the tongue if pt is not swallowing. Caller states she will reach out to nurse and have her give it. Advised will check back with her in 30 minutes to see if effective. Advised will also reach out to oncall nurse to see if she had any suggestions. Caller agreed to call back. CB number verified." 3/21/2023 11:49 p.m., "Spoke with [EMP5 (Vitas RN)] regarding above pt. OCN stated he/she called multiple pharmacies for Morphine and was unsuccessful. She states pt can no longer take pills. advised of above, she stated that [on-call physician] may order something rectally if Ativan not effective. Advised will f/u with [family] in 30 min, if Ativan not effective will call [on-call physician]." 3/22/2023 12:13 a.m., "PHYSICIAN CALLE[D] Called to advise of above. [On-call physician] reviewed pt chart while on phone with her. New orders received to increase Ativan to 0.5mg every 4 hours as needed for anxiety, and advised may give Tylenol ES 500mg tab 1 tab rectally every 4 hours as needed for pain. Read back verified." 3/22/2023 12:13 a.m., "FACILITY CALLED ... Called to advise of above. Advised of new orders from our on-call doctor to help control pt's pain for tonight. [ALF staff] advised he gave Ativan, and was going to check on her in 30 min. He states pt appeared to be in pain, calling out. Advised will fax new orders." 3/22/2023 12:26 a.m., "CARGIVER CALLE[D] ... Call back to advise of new orders and to check pt status." 3/22/2023 2:30 a.m., "CONVERSATION ... [ALF Med Tech] ... Caller is reporting that pt has expired. Family is bedside. Offer SW and Chap offered. Both declined. Caller not able to pronounce." 3/22/2023 2:38 a.m., "[Vitas] NURSE SENT." Per "REPORT OF DEATH" note, the registered nurse arrive onsite at facility at 3:15 a.m. and the patient was pronounced at 3:25 a.m. Patient expired 9 hours and 44 minutes after first call to Telecare staff without ever receiving necessary comfort medications. Interviews with local human resource manager (EMP4) on April 26, 2023, and EMP2 at 2 p.m. confirmed agency does not directly supervise these remote staff, that the administrator and governing body from the Vitas parent location in Cranberry Township do not maintain personnel files for telecare staff, and that the hospice does not provide orientation or performance evaluations for these staff.

Based on review of agency policy, clinical records (CR), and staff (EMP) interview, nursing services failed to ensure the patient's comprehensive assessment identified and met the needs of the patient for one (1) of three (3) discharged clinical records (CR1). Findings included: Note: Agency is located in Cranberry Township Pennsylvania Review of agency policy on April 26, 2023, at 10:40 a.m. showed, "INTERDISCIPLINARY TEAM POLICIES ASSESSMENT ... 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." Review of registered nurse job description on May 2, 2023, at 1:15 p.m. showed, "JOB RESPONSIBILITIES ... Completes initial and ongoing comprehensive assessments including physical ... in order to provide palliation of end of life symptoms." Review of CR1 on April 26, 2023, at 10:40 a.m. revealed patient was admitted to routine home care on 2/15/2023 with a diagnosis of heart failure (chronic diastolic congestive heart failure). The medications Tramadol and Tylenol were ordered to be taken by mouth for pain and discomfort. The episode was unremarkable, and the patient complained of mild pain that was arthritic in nature. On 3/21/2023, at 1 p.m., the registered nurse made a home visit on 3/21/2023 at 1 p.m., and noted, "pt [patient] c/o [complains of] nausea. Refusing meals. pt in bed resting - wanted to be left alone. [FS] facility staff gave Zofran [medication for nausea]." The registered nurse did not assess the patient's pain. On 3/21/2023 at 5:38 p.m., the patient's [family] called after hours on-call stating patient was in pain and not able to swallow medications. The local on-call nurse made a home visit at 7:35 p.m. During the visit the RN obtained an order for Roxanol but the facility could not obtain via its contracted pharmacy. Review of CR1's on-call "TELECARE CALL" logs on April 26, 2023, at 11:40 a.m. showed that on 3/21/2023 at 5:41 p.m., the family reported the patient was in pain, "called stating PCG feels [family] won't make it. Caller states pt is not swallowing meds but complains of stomach pain. Expressed sympathy. Caller agreed to hold for a nurse." On 3/21/2023 at 7:35 p.m., the registered nurse made an on-call home visit and documented, "FS [facility staff] report pt [patient] not responding much, not swallowing, [decreased] appetite, taking sips of fluid. ... Unable to palpate radial pulse, [decreased] urine output. ... New order- Roxanol [comfort medication] 5mg SL [taken under the tongue] [as needed] for pain / sob [shortness of breath]." On 3/21/2023 at 11:23 p.m., the patient's family called after hours on-call again, "[Family] called to report pt. is in pain, doesn't have Morphine to give her ... ask for assistance." Per "REPORT OF DEATH" note, the registered nurse arrived onsite at facility at 3:15 a.m. and the patient was pronounced at 3:25 a.m. Patient expired 9 hours and 44 minutes after first call to Telecare staff without ever receiving necessary comfort medications. Interview with EMP2 on April 26, 2023, at 11:26 a.m. confirmed above findings, and that patient's pain was not assessed during the 1 p.m. nursing visit on 3/21/2023, and only several hours before family called to report patient was in pain. The family was interviewed by phone on May 8, 2023, at 11 a.m. She was asked why the Roxanol could not be obtained, "Well first of all it wasnt available because most pharmacies close between 7 [p.m.] and 8 [p.m.] at night, and they [Vitas] dont have their own pharmacy to be able to get anything and dont have the ability ... no way for them to get any medications after hours. ... I felt the nurse who saw her that day [3/21/2023 at 1 p.m. (see above)] could have gotten the ball rolling."

Based on review of agency policy, email, clinical records (CR), and staff (EMP) interview, the governing body failed to assume full legal authority and responsibility for the day-to-day management of the hospice and the provision of all hospice services to ensure the palliation and management of symptoms related to the terminal illness, and provided services utilizing an IDG (interdisciplinary group) from other states/locations without direct control from the parent agency's governing body (L651), and failed to ensure nursing service, and drugs and biologicals were routinely available on a 24-hour basis 7 days a week (L653). This condition was not met as evidenced by the above non-compliance and resulted in an Immediate Jeopardy. Findings included: The parent agency located in Cranberry Township, Pennsylvania utilized an after-hours on-call "Telecare" system staffed by out-of-state interdisciplinary group (IDG) comprised of nurses and other personnel who assessed, evaluated, and triaged the parent's hospice patients. This IDG would then decide if this information should be sent to the parent agency's on-call nurse for further investigation. This IDG was not under the control of the parent agency's governing body. This out-of-state IDG and its supervisors, who were also not part of the parent agency, were located across the country with some providing remote supervision (living in Florida and supervising call-center staff located in New Jersey). The agency's "Telecare" system orchestrated by the agency's corporation was the root-cause contributor to a process of care failure that left a patient without necessary nursing services comfort medications during end-of life. Immediate Jeopardy was identified on May 8, 2023, 2023, at 12:56 p.m. due to the agency's failure to provide necessary nursing services, and drugs and biologicals related to the palliation of symptoms associated with the terminal illness. IJ template and findings provided to agency on at 1:13 p.m. A plan to remove the Immediate Jeopardy was submitted on 5/9/2023 at 3:51 p.m. and was rejected on 5/10/2023 at 8:20 a.m. A plan to remove the Immediate Jeopardy was submitted on 5/11/2023 at 4:31 p.m. and was rejected on 5/12/2023 at 8:34 a.m. A plan to remove the Immediate Jeopardy was submitted on 5/15/2023 at 6:30 p.m. and was rejected on 5/16/2023 at 9:16 a.m. A plan to remove the Immediate Jeopardy was submitted on 5/16/2023 at 4:58 p.m. and was accepted on 5/17/2023 at 10:00 a.m. The Immediate Jeopardy was abated onsite on 5/18/2023 at 12:10 p.m. based on full implementation of the agency's plan to include revised policies, practices, and staff education concerning changes made.

Based on review of agency policy, email, clinical records (CR), and staff (EMP) interview, the governing body failed to assume full legal authority and responsibility for the day-to-day management of the hospice and the provision of all hospice services to ensure the palliation and management of symptoms related to the terminal illness, and provided services utilizing an IDG (interdisciplinary group) from other states/locations without direct control from the parent's governing body for one (1) of three (3) discharged records (CR1). Findings included: Note: Agency is located in Cranberry Township Pennsylvania Review of agency policy on April 28, 2023, at 1:40 p.m. showed: "GOVERNING BODY ... The governing body assumes full legal responsibility for the management of the hospice, the provision of all hospice services ... PROCEDURE(S) ... 2. Appoint the members of the interdisciplinary group ("IDG") ... to participate in the establishment of policies governing the day-to-day provision of hospice care and services, to include a. A doctor of medicine or osteopathy b. A registered nurse c. A social worker d. A chaplain or other counselor. 3. Adopt and revise, as needed, policies that govern the operation and administration of the organization. These policies are available to patients/families or their agents upon request." "PROFESSIONAL MANAGEMENT OF THE HOSPICE PATIENT ... PROCEDURE(S) 1. The organizational structure in each office will follow the reporting order defined in the job descriptions and organizational chart for VITAS." Review of CR1 on April 26, 2023, at 10:40 a.m. revealed patient was admitted to routine home care on 2/15/2023 with a diagnosis of heart failure (chronic diastolic congestive heart failure). The medications Tramadol and Tylenol were ordered to be taken by mouth for pain and discomfort. The episode was unremarkable, and the patient had minimal complaints of pain. The patient resided in an assisted living facility. On 3/21/2023 at 5:38 p.m., the patient's family called after hours on-call stating the patient was in pain and not able to swallow medications. A local Vitas on-call nurse made a home visit at 7:35 p.m. and documented, "FS [facility staff] report pt [patient] not responding much, not swallowing, [decreased] appetite, taking sips of fluid. ... Unable to palpate radial pulse, [decreased] urine output. ... New order- Roxanol [comfort medication] 5mg SL [taken under the tongue] [as needed] for pain / sob [shortness of breath]." During the visit the RN obtained an order for Roxanol but the facility could not obtain the medication via its contracted pharmacy related to the time of day the orders were received. Interview with EMP2 on April 26, 2023, at 11:26 a.m. confirmed the patient's facility uses a "[local pharmacy]," and sometimes medications can also be obtained from local pharmacy via courier. EMP2 noted the patient's comfort pain medication Roxanol could not be obtained because the local pharmacies were closed, "could not find it at this time of night. We try to anticipate anything coming down the pike and should have been Roxanol already ordered. In this case it looks like it could have been ordered on 21st [3/21/2023]." The following "Telecare Call" logs show how the agency utilized remote call center staff located out of state. For instance, these staff members can be located in New Jersey, Illinois, or Florida. Interviews with local human resource manager (EMP4), and EMP2 confirmed agency does not directly supervise these remote staff. The administrator and governing body from the Vitas parent location in Cranberry Township do not maintain personnel files for telecare staff, nor does it provide orientation or performance evaluations for these staff. The below transcript shows how this deficient practice cause a delay in care with the patient expiring without medications necessary for symptom management. Review of on-call "TELECARE CALL" logs on April 26, 2023, at 11:40 a.m. showed non-agency staff or staff who were not directly controlled or supervised by independently certified parent agency, assessed, and triaged the patient and obtained physician orders. The remainder of the patient's clinical record is summarized from the below Telecare entries. 3/21/2023 5:41 p.m., "called stating PCG feels [patient] won't make it. Caller states pt is not swallowing meds but complains of stomach pain. Expressed sympathy. Caller agreed to hold for a nurse." Call taken by TC1 (patient care coordinator) 3/21/2023 5:44 p.m., "Transferred to TRI [triage]." Call taken by TC1 3/21/2023 6:19 p.m., "Returned call to facility, spoke with [facility] med tech. States pt not responding much, not swallowing or eating/drinking which started yesterday. PT having pain - no comfort meds place. States if morphine is ordered they will need pre-filled syringes. State pt is declining. States [family] is aware. Pt states pain is all over. No SOB. CML [comfort medication list] reviewed, pt has PRN Tramadol and scheduled Tylenol but unable to swallow. Pt had PRN Ativan and Zofran today. Currently in bed with HOB elevated. Advised re-positioning with pillows for comfort. Will send nurse, nurse will call with eta and call back for any needs/changes. Agreed to plan, no further needs. Thanked." Call taken by TC2 (registered nurse) 3/21/2023 6:19 p.m., "TRANSFER TO DIS [dispatch]" Call taken by TC2 3/21/2023 6:24 p.m., "Read Receipt ... To: [EMP5 (Vitas RN)]" EMP5 arrived at 7:35 p.m. (almost 2 hours after Telecare call was first logged) completed the nursing visit at approximately 8:35 p.m. and obtained an order for comfort med Roxanol 5mg every 3 hours as needed. However, the agency was unable to obtain the Roxanol since local pharmacies did not carry this medication. The assisted living facility where patient was located only wanted to use its pharmacy. This is the only time an agency RN is with the patient. The remaining actions, assessments, and orders are performed remotely by Telecare (call center) staff who could be located in New Jersey or Chicago Illinois. 3/21/2023 11:23 p.m., "CONVERSATION ... [family] called to report pt. is in pain, doesn't have Morphine to give her ... ask for assistance. Agreed to hold for a nurse." Call taken by TC3 No morphine is available and once again family calls Telecare again. The patient is transferred to Telecare staff for assessment, evaluation, and planning. 3/21/2023 11:26 p.m., "TRANSFER TO TRI ... Triage nurse agreed to take call." Call taken by TC3 3/21/2023 11:37 p.m., "CONVERSATION ... Spoke with [family] who stated pt is still in a lot of pain. Caller states they cannot get the morphine till the morning, that no pharmacies were open for local fill. Caller states nurse tried to give Tramadol but even with applesauce pt was unable to swallow it. Reviewed cml [comfort medication list], pt currently has orders for Ativan. Caller states she forgot about that and pt is definitely anxious due to the pain. Advised pull was small and can be dissolved under the tongue if pt is not swallowing. Caller states she will reach out to nurse and have her give it. Advised will check back with her in 30 minutes to see if effective. Advised will also reach out to oncall nurse to see if she had any suggestions. Caller agreed to call back. CB number verified." Call taken by TC4 (licensed practical nurse) 3/21/2023 11:49 p.m., "Spoke with [EMP5 (Vitas RN)] regarding above pt. OCN stated he/she called multiple pharmacies for Morphine and was unsuccessful. She states pt can no longer take pills. advised of above, she stated that [on-call physician] may order something rectally if Ativan not effective. Advised will f/u with [family] in 30 min, if Ativan not effective will call [on-call physician]." Call taken by TC4 3/22/2023 12:13 a.m., "PHYSICIAN CALLE[D] Called to advise of above. [On-call physician] reviewed pt chart while on phone with her. New orders received to increase Ativan to 0.5mg every 4 hours as needed for anxiety, and advised may give Tylenol ES 500mg tab 1 tab rectally every 4 hours as needed for pain. Read back verified." Call taken by TC4 3/22/2023 12:13 a.m., "FACILITY CALLED ... Called to advise of above. Advised of new orders from our on-call doctor to help control pt's pain for tonight. [ALF staff] advised he gave Ativan, and was going to check on her in 30 min. He states pt appeared to be in pain, calling out. Advised will fax new orders." Call taken byTC4 3/22/2023 12:26 a.m., "CARGIVER CALLE[D] ... Call back to advise of new orders and to check pt status." Call taken by TC4 3/22/2023 2:30 a.m., "CONVERSATION ... [ALF Med Tech] ... Caller is reporting that pt has expired. Family is bedside. Offer SW and Chap offered. Both declined. Caller not able to pronounce." Call taken by TC5 (licensed practical nurse) 3/22/2023 2:38 a.m., "[Vitas] NURSE SENT." Per "REPORT OF DEATH" note, the registered nurse arrive onsite at facility at 3:15 a.m. and the patient was pronounced at 3:25 a.m. Review of parent agency's (Cranberry Township) organizational chart on April 26, 2023, at 12:57 a.m. showed agency administrator (EMP1/general manager) at the top. Telecare staff (TC) did not appear on the organizational chart. A review of personnel files of telecare staff listed above showed their orientation and/or performance evaluations were performed by staff who did not appear on the Parent agency's organizational chart. Review of a separate organizational chart for call center staff showed TC7 (vice president care connection center) at the top of the chart. TC7 has control of call center staff who supervise TC3, TC4, TC5, and their supervisors TC8, TC9, TC10, TC11. An email from EMP2 reviewed on May 1, 2023, at 11 a.m. showed that TC7 reports to the "Cincinnati office," and lives in Indiana. Review of email from EMP2, and "Telecare" personnel files on May 1, 2023, at 10 a.m. showed call center supervision does not occur at or from the Cranberry Township location but occurs at an intranational level as follows: TC1 (PCC) is located in Atlanta and was hired 3/27/2020. TC1's supervisor is TC8 who lives in Florida and remotely oversees the New Jersey (NJ) call center. TC1's orientation was completed by telecare trainers TC12 and TC14 both of whom are located in Florida. TC1's performance evaluation was completed by TC8 during April of 2023. TC2 (RN) is located in New Jersey and was hired 7/19/2021. TC2's supervisor is telecare team lead TC11 who lives in Connecticut (CT) and remotely oversees the NJ call center. TC2's orientation was completed by telecare trainer TC14 who is located in Florida. TC2's performance evaluation was completed by TC10 during April of 2023. TC10 lives in Connecticut and remotely oversees the NJ call center. TC3 (administrative) is located in Texas and was hired 2/13/2023. TC3's supervisor is TC18 located in Illinois. TC3's orientation was completed by telecare trainer TC16 located in Illinois. TC4 (LPN) is located in Illinois and was hired 3/28/2022. TC4's supervisor is TC11. TC4's orientation was completed by national patient care administrator TC24 located in Ohio. TC4's performance evaluation was completed during April of 2023 by TC11. TC5 (LPN) is located in Illinois and was also hired 3/28/2022. TC5's supervisor is telecare team lead TC9 whom lives in Illinois. TC5's orientation was completed by telecare trainers TC13 and TC14 both of whom are located in Florida. TC5's performance evaluation was completed during April 2023 by TC9. Review of agency policy on May 1, 2023, at 11 a.m. showed" "TITLE: JOB DESCRIPTION: CCC TELECARE LPN POLICY 9:98 POSITION SUMMARY The VITAS Telecare LPN is a member of the interdisciplinary team who is responsible for identifying the physical, psychological, social, and spiritual needs of those patients and families needing assistance during alternate hours. All clinical tasks for this supporting position will be performed under the collaboration and direction of the Telecare RN as needed. ... Provides clinical assessment and intervention utilizing the nursing process, VITAS Palliative Care Guide, and Triage Protocols. Coordinates all service delivery after hours including patient and family education, dispatching of interdisciplinary visits, and coordination of services with external vendors and resources as needed. Provides support and collaboration with Telecare staff to ensure favorable patient outcomes. Provides bereavement support to families. Documents interactions with patients, families, contacts, and vendors in the patient record to include the assessment, plan of care, caller agreement to the plan, any actions and interventions and the resolution of each patient/family interaction." "TITLE: JOB DESCRIPTION:CCC TELECARE RN POLICY 9:101 NUMBER: 1 of 3 POSITION SUMMARY The VITAS Telecare RN is a member of the interdisciplinary team who is the pivotal person responsible for identifying the physical, psychological, social, and spiritual needs of those patients and families needing assistance after normal business hours. He or she initiates appropriate interventions to the patients and families by utilizing the nursing process, the VITAS Palliative Care Guide, and Telecare Protocols during alternate hours. ESSENTIAL DUTIES & RESPONSIBILITIES All duties and responsibilities are to be performed in accordance with VITASs policies, procedures, guidelines, contractual commitments and governmental regulations. Provides clinical assessment and intervention utilizing the nursing process, VITAS Palliative Care Guide, and Triage Protocols. Serves as the patient and family advocate by communicating with the attending physicians, long term care facility staff, case managers, and others external to VITAS as necessary. Provides collaboration with LPN/LVNs. Coordinates all service delivery after hours including patient and family education, dispatching of interdisciplinary visits, and coordination of services with external vendors and resources as needed. Provides support and collaboration with Telecare staff to ensure favorable patient outcomes. Provides bereavement support to families. Documents interactions with patients, families, contacts, and vendors in the patient record to include the assessment, plan of care, caller agreement to the plan, any actions and interventions and the resolution of each patient/family interaction. Reviews all entries in the record made by Telecare LPN/LVNs and Patient Care Coordinators and ensures compliance with documentation Standards. Participates in the orientation of new team members as assigned by the supervising manager. Attends regularly scheduled in-services, staff meetings, and educational conferences. Develops and achieves professional growth goals and objectives, and reviews with supervising manager on a monthly basis. Seeks certification in the specialty of hospice nursing when qualified to do so. Instructs and documents appropriate use of medications, home medical equipment and supplies." "Position Description Position Title: CCC Patient Care Coordinator ... Reports To: Telecare Team Leader (Clinical / Non-Clinical) Dept: Care Connection Center POSITION SUMMARY The VITAS Healthcare Patient Care Coordinator is a member of the interdisciplinary team who effectively processes calls, answers general questions, provides information, and transfers calls to triage nurses when appropriate during alternate hours." "INTERDISCIPLINARY TEAM POLICIES ADMINISTRATIVE ON-CALL ... 5:39 ... POLICY To provide a high quality of hospice care directed by a physician and supervised by a registered nurse 24 hours a day, 7 days a week. OBJECTIVE(S) To provide safe continuity of hospice care for the patient and family 24 hours a day, 7 days a week adhering to the state and federal rules and regulations for hospice programs. PROCEDURE(S) ... 2. Problems of a serious nature related to ... hospice services will be referred to the team manager/patient care administrator on-call who may contact the general manager [EMP1]." "Resolution for Meeting of the Governing Body Health Regulatory Approvals November 16, 2022 APPROVAL OF INTERDISCIPLINARY GROUP ... NOW, THEREFORE, BE IT RESOLVED, that the governing body of the following programs confirms and approves the appointment of the persons set forth in the list presented to this meeting, to the interdisciplinary group for the respective hospice programs ... Pittsburgh Pennsylvania [Cranberry Township parent location] ... [EMP20] Medical director [EMP2] Nurse [EMP18] Social Worker [EMP19] Chaplain." Per email from EMP2 reviewed on May 1, 2023, at 2 p.m., the agency's governing body also includes EMP1 (administrator) and that this group comprises the agency's sole IDT with five (5) members.

Based on review of clinical records (CR), and staff (EMP) interview, the governing body failed to ensure drugs and biologicals were routinely available on a 24-hour basis 7 days a week for one (1) of three (3) discharged records (CR1). Findings included: Note: Agency is located in Cranberry Township Pennsylvania Review of CR1 on April 26, 2023, at 10:40 a.m. revealed patient was admitted to routine home care on 2/15/2023 with a diagnosis of heart failure (chronic diastolic congestive heart failure). The medications Tramadol and Tylenol were ordered to be taken by mouth for pain and discomfort. The episode was unremarkable, and the patient had minimal complaints of pain. On 3/21/2023 at 5:38 p.m., the patient's family called after hours on-call stating the patient was in pain and not able to swallow medications. A review of the on-call "Telecare" transcripts on April 26, 2023, at 11 a.m. revealed: 3/21/2023 5:41 p.m., "called stating PCG feels [patient] won't make it. Caller states pt is not swallowing meds but complains of stomach pain. Expressed sympathy. Caller agreed to hold for a nurse." Call taken by TC1 (patient care coordinator) 3/21/2023 5:44 p.m., "Transferred to TRI [triage]." Call taken by TC1 3/21/2023 6:19 p.m., "Returned call to facility, spoke with [facility] med tech. States pt not responding much, not swallowing or eating/drinking which started yesterday. PT having pain - no comfort meds place. States if morphine is ordered they will need pre-filled syringes. State pt is declining. States [family] is aware. Pt states pain is all over. No SOB. CML [comfort medication list] reviewed, pt has PRN Tramadol and scheduled Tylenol but unable to swallow. Pt had PRN Ativan and Zofran today. Currently in bed with HOB elevated. Advised re-positioning with pillows for comfort. Will send nurse, nurse will call with eta and call back for any needs/changes. Agreed to plan, no further needs. Thanked." Call taken by TC2 (registered nurse) 3/21/2023 6:19 p.m., "TRANSFER TO DIS [dispatch]" Call taken by TC2 3/21/2023 6:24 p.m., "Read Receipt ... To: [EMP5 (Vitas RN)]" EMP5 arrived at 7:35 p.m. (almost 2 hours after Telecare call was first logged) completed the nursing visit at approximately 8:35 p.m. and obtained an order for comfort med Roxanol 5mg every 3 hours as needed. However, the agency was unable to obtain the Roxanol since local pharmacies did not carry this medication. The assisted living facility where patient was located only wanted to use its pharmacy. This is the only time an agency RN is with the patient. The remaining actions, assessments, and orders are performed remotely by Telecare (call center) staff who could be located in New Jersey or Chicago Illinois. 3/21/2023 11:23 p.m., "CONVERSATION ... [family] called to report pt. is in pain, doesn't have Morphine to give her ... ask for assistance. Agreed to hold for a nurse." Call taken by TC3 No morphine is available and once again family calls Telecare again. The patient is transferred to Telecare staff for assessment, evaluation, and planning. 3/21/2023 11:26 p.m., "TRANSFER TO TRI ... Triage nurse agreed to take call." Call taken by TC3 3/21/2023 11:37 p.m., "CONVERSATION ... Spoke with [family] who stated pt is still in a lot of pain. Caller states they cannot get the morphine till the morning, that no pharmacies were open for local fill. Caller states nurse tried to give Tramadol but even with applesauce pt was unable to swallow it. Reviewed cml [comfort medication list], pt currently has orders for Ativan. Caller states she forgot about that and pt is definitely anxious due to the pain. Advised pull was small and can be dissolved under the tongue if pt is not swallowing. Caller states she will reach out to nurse and have her give it. Advised will check back with her in 30 minutes to see if effective. Advised will also reach out to oncall nurse to see if she had any suggestions. Caller agreed to call back. CB number verified." Call taken by TC4 (licensed practical nurse) 3/21/2023 11:49 p.m., "Spoke with [EMP5 (Vitas RN)] regarding above pt. OCN stated he/she called multiple pharmacies for Morphine and was unsuccessful. She states pt can no longer take pills. advised of above, she stated that [on-call physician] may order something rectally if Ativan not effective. Advised will f/u with [family] in 30 min, if Ativan not effective will call [on-call physician]." Call taken by TC4 3/22/2023 12:13 a.m., "PHYSICIAN CALLE[D] Called to advise of above. [On-call physician] reviewed pt chart while on phone with her. New orders received to increase Ativan to 0.5mg every 4 hours as needed for anxiety, and advised may give Tylenol ES 500mg tab 1 tab rectally every 4 hours as needed for pain. Read back verified." Call taken by TC4 3/22/2023 12:13 a.m., "FACILITY CALLED ... Called to advise of above. Advised of new orders from our on-call doctor to help control pt's pain for tonight. [ALF staff] advised he gave Ativan, and was going to check on her in 30 min. He states pt appeared to be in pain, calling out. Advised will fax new orders." Call taken byTC4 3/22/2023 12:26 a.m., "CARGIVER CALLE[D] ... Call back to advise of new orders and to check pt status." Call taken by TC4 3/22/2023 2:30 a.m., "CONVERSATION ... [ALF Med Tech] ... Caller is reporting that pt has expired. Family is bedside. Offer SW and Chap offered. Both declined. Caller not able to pronounce." Call taken by TC5 (licensed practical nurse) 3/22/2023 2:38 a.m., "[Vitas] NURSE SENT." Per "REPORT OF DEATH" note, the registered nurse arrive onsite at facility at 3:15 a.m. and the patient was pronounced at 3:25 a.m. Patient expired 9 hours and 44 minutes after first call to Telecare staff without ever receiving necessary comfort medications. Interview with EMP2 on April 26, 2023, at 11:26 a.m. confirmed above findings, and the facility's pharmacy was unable to obtain the Roxanol. EMP2 noted the patient's comfort pain medication Roxanol could not be obtained because the local pharmacies were closed, "could not find it at this time of night. We try to anticipate anything coming down the pike and should have been Roxanol already ordered. In this case it looks like it could have been ordered on 21st [3/21/2023]." Interviews with EMP2, and EMP3 on April 26, 2023, at approximately 2 p.m. confirmed above findings-- patient never received Roxanol dose prior to expiring. An interview was conducted with the medical director (EMP20) on April 26, 2023, at 1:04 p.m. and he/she noted, "The problem is that not all local pharmacies carry Roxanol." An interview with EMP2 and review of agency's pharmacy contract on May 8, 2023, at 10:10 a.m. showed agency uses Enclara pharmacy services. EMP2 noted Enclara is a pharmacy manager and has the capability to provide new medication orders the next day and refills can be provided 2 days from the refill date. Enclara has no capability to provide medications on an emergent basis and agency obtains these medications from local pharmacies that can be retrieved either by courier or by family. During phone interview with EMP5 on May 8, 2023, at 10:20 a.m. he/she confirmed findings outlined in above "Telecare" transcripts and that he/she had contact with the patient at 7:35 p.m. on 3/21/2023 and contact with Telecare staff at 11:37 p.m. via phone with no other input/interaction with the emergent episode that night-- leaving the remainder of the actions with "Telecare" nurses. EMP5 clarified that he/she attempted to obtain the patient's Roxanol through local pharmacies, but the pharmacies were not open or did not carry the medication, "No 24 hour pharmacies in [the area] anymore. I feel kinda bad but there was nothing I could do I can't produce meds." I explained to the [family] that we couldn't get it [Roxanol] to her until the morning because it was almost 9 [p.m.]. ... I think they [facility's pharmacy] might have already been closed and there is no 24 hour pharmacy to get the meds and because of the late time." The family was interviewed by phone on May 8, 2023, at 11 a.m. She was asked why the Roxanol could not be obtained, "Well first of all it wasnt available because most pharmacies close between 7 [p.m.] and 8 [p.m.] at night, and they [Vitas] dont have their own pharmacy to be able to get anything and dont have the ability ... no way for them to get any medications after hours. Should have had some way to get medications. ... [EMP5] said he/she called 20 different pharmacies. [EMP5] could not get the medication. And that is what it came down to. I Sat with [patient] for 2 hours as she called out in pain. I called Vitas [Telecare] again. I talked to another nurse [Telecare]. On-call [Telecare] called the on-call doctor and got an order for Ativan under her tongue and [Tylenol] rectally. She would scream in pain if anyone touched her. ... I felt the nurse who saw her that day [3/21/2023 at 1 p.m. (see above)] could have gotten the ball rolling." A review of a list of local pharmacies on May 8, 2023, at 11:10 a.m. showed one local pharmacy listed as "24/7." EMP2 called the pharmacy at 11:30 a.m. and confirmed it was no longer open "24/7" and closes at 8 p.m.

Based on review of clinical records (CR), and staff (EMP) interview, the agency failed to obtain drugs and biologicals from community or institutional pharmacists or stock drugs and biologicals itself for one (1) of three (3) discharged records (CR1). Findings included: Note: Agency is located in Cranberry Township Pennsylvania Review of CR1 on April 26, 2023, at 10:40 a.m. revealed patient was admitted to routine home care on 2/15/2023 with a diagnosis of heart failure (chronic diastolic congestive heart failure). The medications Tramadol and Tylenol were ordered to be taken by mouth for pain and discomfort. The episode was unremarkable, and the patient had minimal complaints of pain. The patient resided in an assisted living facility. On 3/21/2023 at 5:38 p.m., the patient's family called after hours on-call stating the patient was in pain and not able to swallow medications. A local Vitas on-call nurse made a home visit at 7:35 p.m. and documented, "FS [facility staff] report pt [patient] not responding much, not swallowing, [decreased] appetite, taking sips of fluid. ... Unable to palpate radial pulse, [decreased] urine output. ... New order- Roxanol [comfort medication] 5mg SL [taken under the tongue] [as needed] for pain / sob [shortness of breath]." During the visit the RN obtained an order for Roxanol but the facility could not obtain the medication via its contracted pharmacy related to the time of day the orders were received. Interview with EMP2 on April 26, 2023, at 11:26 a.m. confirmed the patient's facility uses a "[local pharmacy]," and sometimes medications can also be obtained from local pharmacy via courier. EMP2 noted the patient's comfort pain medication Roxanol could not be obtained because the local pharmacies were closed, "could not find it at this time of night. We try to anticipate anything coming down the pike and should have been Roxanol already ordered. In this case it looks like it could have been ordered on 21st [3/21/2023]." Review of on-call "TELECARE CALL" logs on April 26, 2023, at 11:40 a.m. showed the hospice failed to provide the patient with necessary drugs and biologics. 3/21/2023 5:41 p.m., "called stating PCG feels [patient] won't make it. Caller states pt is not swallowing meds but complains of stomach pain. Expressed sympathy. Caller agreed to hold for a nurse." Call taken by TC1 (patient care coordinator) 3/21/2023 5:44 p.m., "Transferred to TRI [triage]." Call taken by TC1 3/21/2023 6:19 p.m., "Returned call to facility, spoke with [facility] med tech. States pt not responding much, not swallowing or eating/drinking which started yesterday. PT having pain - no comfort meds place. States if morphine is ordered they will need pre-filled syringes. State pt is declining. States [family] is aware. Pt states pain is all over. No SOB. CML [comfort medication list] reviewed, pt has PRN Tramadol and scheduled Tylenol but unable to swallow. Pt had PRN Ativan and Zofran today. Currently in bed with HOB elevated. Advised re-positioning with pillows for comfort. Will send nurse, nurse will call with eta and call back for any needs/changes. Agreed to plan, no further needs. Thanked." Call taken by TC2 (registered nurse) 3/21/2023 6:19 p.m., "TRANSFER TO DIS [dispatch]" Call taken by TC2 3/21/2023 6:24 p.m., "Read Receipt ... To: [EMP5 (Vitas RN)]" EMP5 arrived at 7:35 p.m. (almost 2 hours after Telecare call was first logged) completed the nursing visit at approximately 8:35 p.m. and obtained an order for comfort med Roxanol 5mg every 3 hours as needed. However, the agency was unable to obtain the Roxanol since local pharmacies did not carry this medication. The assisted living facility where patient was located only wanted to use its pharmacy. This is the only time an agency RN is with the patient. The remaining actions, assessments, and orders are performed remotely by Telecare (call center) staff who could be located in New Jersey or Chicago Illinois. 3/21/2023 11:23 p.m., "CONVERSATION ... [family] called to report pt. is in pain, doesn't have Morphine to give her ... ask for assistance. Agreed to hold for a nurse." Call taken by TC3 No morphine is available and once again family calls Telecare again. The patient is transferred to Telecare staff for assessment, evaluation, and planning. 3/21/2023 11:26 p.m., "TRANSFER TO TRI ... Triage nurse agreed to take call." Call taken by TC3 3/21/2023 11:37 p.m., "CONVERSATION ... Spoke with [family] who stated pt is still in a lot of pain. Caller states they cannot get the morphine till the morning, that no pharmacies were open for local fill. Caller states nurse tried to give Tramadol but even with applesauce pt was unable to swallow it. Reviewed cml [comfort medication list], pt currently has orders for Ativan. Caller states she forgot about that and pt is definitely anxious due to the pain. Advised pull was small and can be dissolved under the tongue if pt is not swallowing. Caller states she will reach out to nurse and have her give it. Advised will check back with her in 30 minutes to see if effective. Advised will also reach out to oncall nurse to see if she had any suggestions. Caller agreed to call back. CB number verified." Call taken by TC4 (licensed practical nurse) 3/21/2023 11:49 p.m., "Spoke with [EMP5 (Vitas RN)] regarding above pt. OCN stated he/she called multiple pharmacies for Morphine and was unsuccessful. She states pt can no longer take pills. advised of above, she stated that [on-call physician] may order something rectally if Ativan not effective. Advised will f/u with [family] in 30 min, if Ativan not effective will call [on-call physician]." Call taken by TC4 3/22/2023 12:13 a.m., "PHYSICIAN CALLE[D] Called to advise of above. [On-call physician] reviewed pt chart while on phone with her. New orders received to increase Ativan to 0.5mg every 4 hours as needed for anxiety, and advised may give Tylenol ES 500mg tab 1 tab rectally every 4 hours as needed for pain. Read back verified." Call taken by TC4 3/22/2023 12:13 a.m., "FACILITY CALLED ... Called to advise of above. Advised of new orders from our on-call doctor to help control pt's pain for tonight. [ALF staff] advised he gave Ativan, and was going to check on her in 30 min. He states pt appeared to be in pain, calling out. Advised will fax new orders." Call taken byTC4 3/22/2023 12:26 a.m., "CARGIVER CALLE[D] ... Call back to advise of new orders and to check pt status." Call taken by TC4 3/22/2023 2:30 a.m., "CONVERSATION ... [ALF Med Tech] ... Caller is reporting that pt has expired. Family is bedside. Offer SW and Chap offered. Both declined. Caller not able to pronounce." Call taken by TC5 (licensed practical nurse) 3/22/2023 2:38 a.m., "[Vitas] NURSE SENT." Per "REPORT OF DEATH" note, the registered nurse arrive onsite at facility at 3:15 a.m. and the patient was pronounced at 3:25 a.m. Patient expired 9 hours and 44 minutes after first call to Telecare staff without ever receiving necessary comfort medications. Interviews with EMP2, and EMP3 on April 26, 2023, at approximately 2 p.m. confirmed above findings-- patient never received Roxanol dose prior to expiring. An interview was conducted with the medical director (EMP20) on April 26, 2023, at 1:04 p.m. and he/she noted, "The problem is that not all local pharmacies carry Roxanol." The medical director noted that comfort kits (medications provided at start of care and used at end-of-life care for palliation of symptoms) are not provided because, "too many medications were being wasted."