Every finding on record at Vitas Healthcare Corporation Atlantic

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current: prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; [and] other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: the effectiveness of drug therapy; drug side effects; actual or potential drug interactions; duplicate drug therapy; [and] drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review and interview. In 3 of 23 (13%) clinical records reviewed, the agency did not ensure that all medications were included in the drug profile. Clinical Record 10: The patient elected hospice care on 05/27/2024. On 05/27/2024, oxygen was ordered at 2 liters per nasal cannula, pro re nata/as needed (PRN) dyspnea. The drug profile dated 05/27/2024 did not include documentation of oxygen. Clinical Record 20: The patient elected hospice care on 01/23/2024. Oxygen was ordered at 2 liters per nasal cannula pro re nata/as needed (PRN) at the time of admission. The drug profile dated 01/23/2024 did not include documentation of oxygen. On 03/12/2024, the oxygen order was changed to 4 liters per nasal cannula, continuously. The drug profile did not include documentation of oxygen 4 liters per nasal cannula, continuously. Clinical Record 23: The patient elected hospice care on 02/02/2024. Oxygen was ordered at 2 liters per nasal cannula PRN on 02/02/2024. The drug profile did not include documentation of oxygen from 02/02/2024 through the patient's discharge on 04/16/2024 During a joint clinical record review, the Patient Care Administrator confirmed that the drug profiles for records # 20, #10 and #23 did not contain documentation of oxygen and oxygen should have been included.

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

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

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

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

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

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

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

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

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

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

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

Based on staff interview and document review it was determined the agency's Emergency Preparedness Plan failed to be reviewed and updated at least every 2 years. --- Findings:The agency's Emergency Preparedness Plan (EPP) was reviewed in the agency on 03/01/2023 with the Administrator and QAPI manager. The EPP titled "VS COVID 19 Pandemic March 11, 2020; National Emergency March 13, 2020 TBD (to be determined)" contained outdated policies and procedures. Some of the policies and procedures read as follows: Therapist visits have been suspended 03/30/2020; Many Social Work or Chaplain visits with patient or primary care giver can be done using telehealth; Volunteer patient visits have been suspended; We should not be doing funeral visits and Registered Nurse in person visit one time per week. In addition, the agency's employee contact list was also outdated with the previous Administrator's name and phone number listed. The QAPI manager updated a new employee contact list while on survey. The agency's EPP failed to contain a reviewed and updated plan. The lack of the above noted information was reviewed and acknowledged with the Administrator and QAPI manager prior to and during the exit conference conducted in the agency on 03/07/2023.

Based on staff interview and document review it was determined the agency's Emergency Preparedness Plan failed to review and update the all-hazard approach to include emerging infectious disease threats and risk assessment to include man-made disasters such as cyber-attacks. --- Findings:The agency's Emergency Preparedness Plan (EPP) was reviewed in the agency on 03/01/2023 with the Administrator and QAPI manager. The EPP failed to identify any specific emerging infectious disease threats or man-made disasters such as cyber-attack that offered strategies that would affect the hospice's ability to provide care. The lack of the above noted information was reviewed and acknowledged with the Administrator and QAPI manager prior to and during the exit conference conducted in the agency on 03/07/2023.

Based on staff interview and document review it was determined the agency's Emergency Preparedness Plan (EPP) failed to conduct exercises to test the EPP at least annually. --- Findings:The agency's Emergency Preparedness Plan (EPP) was reviewed in the agency on 03/01/2023 with the Administrator and QAPI manager. The EPP documented a state of emergency fuel shortage on 05/12/2021. The hospice failed to conduct an additional exercise opposite the year of the full scale exercise. The lack of the above noted information was reviewed and acknowledged with the Administrator and QAPI manager prior to and during the exit conference conducted in the agency on 03/07/2023.

Based on clinical record review, staff interview and the agency's Interdisciplinary Group (IDG) policy, it was determined the agency's IDG failed to document the updated comprehensive assessment with the patient's progress toward goals and outcomes no less than every 15 days noted in the patients plans of care for one (1) of (23) clinical records in the survey sample (Clinical record #6). --- Findings: Twenty-three (23) paper charts (clinical records) were reviewed in the agency on February 28 through March 02, 2023. Clinical records #24 and #25 were selected and reviewed for bereavement services only. The clinical record of patient #6 was reviewed for the timeframe of 01/05/2023 to 03/04/2023. Per clinical record documentation (Interdisciplinary Group) IDG meetings were held on 01/31/2023 and 02/21/2023; 21 days in between these dates. Select Policy Review: On 02/27/2023 the MFI requested the agency's IDG policy. The Administrator provided the policy that was titled "INTERDISCIPLINARY TEAM POLICIES ASSESSMENT". The policy read in part as follows: An updated comprehensive assessment will be completed by the IDG members in consultation with the attending physician (if any) at least every 15 days unless state regulations require more frequent intervals. To identify changes that have taken place since the initial assessment and includes information on the patient's progress toward desired outcomes, as well as a reassessment of the patient's response to care. All significant findings identified during assessments and updated assessment will be documented in the patient's record. On 03/06/2023 at 1:30 PM, the QAPI manager stated, "no care plans for the missing IDG meetings". The agency failed to contain documentation of an IDG meeting at least every 15 days. The lack of documentation in reference to the patient's progress toward outcomes and goals was reviewed with the Administrator and QAPI manager prior to and during the exit conference conducted in the agency on 03/07/2023.

Based on a review of clinical records and staff interview it was determined the agency failed to ensure care and services were provided in accordance with the patient's plan of care for two (2) of (23) clinical records in the survey sample. (Clinical record #s 3 and 17). --- Findings: Twenty-three (23) paper charts (clinical records) were reviewed in the agency on February 28 through March 02, 2023. Clinical records #24 and #25 were selected and reviewed for bereavement services only. 1 The clinical record for patient #3 was reviewed for the time frame of 09/28/2022 through 12/27/2022. The plan of care for the above noted time frame contained orders for Skilled Nurse (SN) to visit the patient two (2) times a week. The clinical record failed to contain documentation of a second SN visit or missed visit for the time frame of 10/06/2022 to 10/12/2022. On 03/06/2023 at 1:30 PM the QAPI manager confirmed no documentation of the SN second visit for the above note time frames. 2 The clinical record for patient #17 was reviewed for the time period of 12/26/2022 through 03/26/2023. The plan of care for the above noted time frame contained orders for SN to visit the patient two (2) times a week. The clinical record failed to contain documentation of a second SN visit or missed visit for the time frame of 02/02/2023 to 02/08/2023. On 03/01/2023 at 11 AM the Administrator confirmed no documentation of the SN second visit for the above note time frames. The lack of documentation of care being provided in accordance with the patient's plan of care was acknowledged by the Administrator and QAPI Manager during the clinical record reviews and exit conference of 03/07/2023.

Based on staff interview and a review of volunteer personnel files it was determined the staff failed to obtain and document criminal background checks from the Virginia State Police for (10) of (10) volunteer personnel files (#'s 1-10). --- Findings: Ten (10) volunteer personnel files who have direct patient contact or access to patient records, were reviewed on 03/02/2023. Ten (10) of (10) volunteer files contained a report from a third-party vendor with no evidence the Virginia State Police Report was done (#1-10). On 03/02/2023 at 10 AM, the Volunteer Coordinator stated, "We use (name redacted-third party vendor) who does the national registry criminal checks. We don't have the Virginia State Police report". The Volunteer Coordinator acknowledged the above noted deficiency regarding the lack of obtaining a processed criminal background reports on all hospice employees who have direct patient contact or access to patient records. The Administrator and QAPI manager acknowledged the deficient practice during the exit conference conducted on 03/07/2023.

Based on clinical record reviews and staff interviews, it was determined that the hospice failed to effectively manage, and control pain and other symptoms related to the patient's terminal illness. Specifically, the agency staff failed to discover a total bedbound patient with pain, who did not have a caregiver 24 hours/7 days a week to administer pain medication for one (1) out of five (5) clinical records reviewed in the survey sample: (Clinical record: #1). --- The findings: Five clinical records were reviewed in the agency on 11/01/2022 via paper charts with the assistance of the Administrator and Performance Improvement Specialist. The clinical record for patient #1 was reviewed for the time period of 08/01/2022 to 09/07/2022. The initial certification of 08/01/2022 by the hospice's Medical Director documented the patient was a resident at an independent living facility and was dependent for bathing, mobility, transfers, toileting, dressing and minimal assist for eating. The Medical Director scored the patients PPS (Palliative Performance Scale) at 20%. According to the PPS, the 20% score is for patients who are totally bed bound, unable to do any activity due to extensive disease, total care, intake of minimal to sips and conscious level can be full or drowsy with or without confusion. SN (Skilled Nurse) notes documented the patients pain was provoked by multiple wounds on 08/01/2022, 08/04/2022, 08/22/2022, 08/25/2022, 8/29/2022, and 09/01/2022 that was relieved by liquid Morphine. On 11/01/2022 at 9:52 AM, this MFI (Medical Facilities Inspector) called patient #1s hospice nurse (staff member #3) and asked if the agencys aide was trained to administer Morphine to the patient. Staff member #3 stated, "No because there was always another caregiver (from a home health agency) or Power of Attorney present when I visited and I taught them." In addition, the hospice nurse confirmed that the patient did not reside in an assisted living facility but in a retirement community center. The patients hospice care plan contained orders for aide visits 3 to 4 times a week beginning 08/02/2022 and consisted of sponge bath, grooming of hair, brush teeth and change linens. In reviewing the aides notes, the aide provided care from 0.25 minutes to 1.37 hours each visit from 08/02/2022 to 09/06/2022. On 11/01/2022 at 11:16 AM, this Medical Facilities Inspector (MFI) called the Registered Nurse (name withheld) at a home health agency (name withheld) who was the case manager for their aide taking care of this patient. The Registered Nurse stated the aide (name withheld) was scheduled to see the patient Mondays, Tuesdays and Wednesdays for 12 hours per day....8 AM to 8 PM. In addition, the Registered Nurse documented on a formal complaint form that on 08/15/2022, a visit was made to this patients apartment and noted a box of Morphine 15 ml/100 mg oral solution was on the over-bed table, pushed against the wall. In the box of Morphine was 4 syringes with 0.25 ml each of liquid not labeled. The Registered Nurse observed the patient could not hold a cup and the aide held the drink and placed the straw to the patients lips. The hospice care plan and the interview with the Registered Nurse from a home health agency revealed the patient did not have 24/7 care and was dependent on others to feed him. The clinical record contained a note from the hospice agencys Licensed Medical Social Worker (staff member #9) of 08/19/2022 that read in part as follows: ";V (name of hospice agency abbreviated) updated team that patient may need higher level of care as he resides in retirement apartment. Visit was set for 08/22/2022 with sister and Power of Attorney". The clinical record contained a note from the hospice agencys Licensed Medical Social Worker (staff member #8) of 08/22/2022 documented a visit with the sister and Power of Attorney and provided them with a list of facilities due to sister is from California and there is no medical care at the retirement facility. The clinical record contained a note from the hospice agencys Licensed Medical Social Worker (staff member #8) of 09/01/2022 that read in part as follows: ";Sister moved in retirement apartment down the hall from the patient and provides some care. Educated sister about patient need for 24-hour care". On 11/01/2022 at 12 PM, this MFI called the independent living facility (name withheld) where the patient resided. The MFI asked the person who answered the phone if this was an assisted living facility, the person stated, no and we don't have any medical people employed here...we don't even open medication bottles, but we do have agencies who are not associated with us that come in and take care of residents here. On 11/01/2022 at 12:05 PM, this MFI requested the agency's policy/practice regarding the medication administration for patients who need care 24 hours/7 day per week from the Administrator. No policy or practice was provided by the agency. The hospice Administrator on 11/01/2022 at 2 PM stated, "We were under the impression that the patient had 24-hour care because there was always a caregiver present when our staff visited. I spoke with our hospice nurse (staff member #3) and she indicated that the agency found this out later and that patient needed placement to another facility for higher care." According to the hospice agencys clinical records and staff interviews, the total bedbound patient resided in an independent retirement community apartment with no medical care onsite except for agency visits and occasional Power of Attorney visits from 08/01/2022 to 09/01/2022. The patient did not receive effective pain management when no visits were made due to patient being unable to self-administer pain medications. The hospice Administrator, Performance Improvement Specialist, National Patient Care Administrator, and General Manager acknowledged the above noted findings during the exit conference on 11/01/2022.

Based on review of clinical records and staff interview, it was determined that the hospice agency failed to provide services in accordance with current clinical practice guidelines and accepted professional standards of practice in one (1) of five (5) clinical records in the survey sample (Clinical record #1). --- The findings: Five clinical records were reviewed in the agency on 11/01/2022 via paper charts with the assistance of the Administrator and Performance Improvement Specialist. The clinical record for patient #1 was reviewed for the time period of 08/01/2022 to 09/07/2022. The hospice care plan contained orders for Morphine (oral-concentrate) take 0.25 ml (5 mg) by mouth every 4 hours as need for pain. The patient was visited by a Registered Nurse Case Manager from a home health agency on 08/15/2022 who supervised their aide for personal care three times a week. It was documented on a formal complaint form by the Registered Nurse on 08/15/2022, a visit was made to this patients apartment and noted a box of Morphine 15 ml/100 mg oral solution was on the over-bed table, pushed against the wall. In the box of Morphine was 4 syringes with 0.25 ml each of liquid not labeled. On 11/01/2022 at 9:52 AM, this MFI (Medical Facilities Inspector) called the nurse (staff member #3) who left the morphine at the patient's bedside. The nurse stated, "I prefilled the syringes with Morphine and placed them in the patient's Morphine box." The nurse confirmed the prefilled syringes were not labeled. On 11/01/2022 at 2:00 PM, staff #1 provided the MFI the agency's assessment policy titled "Pharmacy Policies: Drug Labeling And Storage". The policy read in part as follows: "Proper labeling of drugs and biologicals is required based on currently accepted professional standards including accessory and cautionary instructions as well as expiration dates when applicable." According to the American Society of Anesthesiologists, a research and scientific association of physicians organized to raise the standards of medical practice... the medication name, patients name, dosing amount with instructions, medication expiration date and date of dispensing along with the preparers initials on each syringe to reduce medication errors (https://www.asahg.org). The above noted findings were reviewed with Administrator and the Performance Improvement Specialist during the clinical record review, and again with the Administrator, Performance Improvement Specialist, National Patient Care Administrator, and General Manager at the exit conference of 11/01/2022.

Based on a review of agency documents and interviews it was determined the agency failed to ensure the protection of the patient and the patient's caregiver(s) right to voice grievances and have those grievances investigated and a resolution reached with notification of the resolution made to the complainant in three (3) of five (5) clinical records in the survey sample (clinical record #1, 4 and 5). The findings were: A review of the complaint log in the agency on 1/11/2022 revealed no complaints were documented regarding patient #1 in the survey sample. The log did contain two (2) complaints similar in nature to the complaint being investigated with allegations of poor care being provided (clinical records #4 and 5). The log failed to contain evidence those complaints were investigated and that those complaints were resolved. An interview was conducted with the administrator, staff #1 to review the findings related to complaints identified in the complaint log on 1/12/2022 at 11:55 am. The administrator acknowledged that all complaints should have had a follow-up and no follow-up was conducted or documented for clinical records #4 and #5. A review of the clinical record for patient #1 on 1/11/2022 at 3:30 PM revealed a complaint had been been reported to the social worker (staff #5) when a bereavement call was made on 11/09/2021. Staff #5 documented "dtr (daughter) says they are unpleased with service, says there was a lack of nursing visits". Staff #5 further documented, "referred dtr to Vitas mainline and informed TM (team manager)". TM reports patient had 3 RN (registered nurse) visits in 5 days on 11/3, 11/6 and 11/8/2021. An interview with staff #5 on 1/12/2022 at 10:20 am revealed the staff member did not write up the complaint and was unaware of the agency's formal documentation process for complaints but did report it to the team manager. "To my knowledge that was the only concern and I just let the daughter know who to call." An interview with the administrator (staff #1) on 1/12/2022 at 10:30 am revealed complaints are reported to the team manager who then reports it to performance improvement and that starts the process for follow up. An interview with the team manager, staff #3 on 1/12/2022 at 11:30 am revealed, "I spoke with the husband because he was the power of attorney". He didn't understand why (other family member) complained. Team manager stated "I did not do a service follow-up". The patient got three (3) nursing visits in five (5) days. A review of the complaint policy, titled "Service Comment Process" states in part: Service Comment Guidelines, A: All complaints and grievances received from a patient, patients family/guardian or the patient's health care provider regarding treatment, care, or respect for the active, discharged, pending and/or not admitted patient's will be recorded via the Service Comment Electronic System (SCES) and investigated in an expeditious method. The complaint/grievance investigation begins immediately by the VITAS employee who witnesses/receives the service issue. Service comments will be reviewed by a Senior Manager in every program to assure appropriate and satisfactory follow-up.

Based on a review of clinical records and the agency's bereavement policy, it was determined the hospice failed to complete an initial bereavement assessment within five (5) calendar days of the election of the hospice benefit and start of care date in two (2) of six (5) clinical records reviewed in the survey sample (Clinical records #3 and 4). The findings: Five (5) clinical records were reviewed in the agency on January 11-13, 2022 as paper charts. 1. The clinical record for patient #3 had a documented election of benefit and start of care date of 11/13/2021. The record was reviewed for the certification period of 11/13/2021 to 2/11/2022. The clinical record contained an incomplete bereavement assessment. The Medical Social Worker completed part of the initial bereavement assessment and wrote a handwritten note on 11/15/2022 that read as follows: Chaplain to assess. The record failed to contain documentation of a complete bereavement assessment that included the required spiritual assessment for the certification period mentioned above. On 1/13/2022 at 9:30 AM the MFI (Medical Facilities Inspector) requested the agency's bereavement policy. The Administrator provided the MFI with the bereavement policy titled, "VS-Bereavement Visit" and a portion read as follows: An initial bereavement assessment of the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. On 1/13/2022 at 9:35 AM the MFI (Medical Facilities Inspector) conducted an interview with the Administrator regarding the missed chaplain assessment/visit; the Administrator called the chaplain on the phone. After the phone call the Administrator stated, the chaplain has the visit notes in his bag and will scan these in now. As of 1/13/2022 at 10:15 AM when the MFIs conducted the exit conference, the chaplain's visit notes had not been provided. 2. The clinical record for patient #4 had a documented election of Hospice benefit/start of care date of 7/14/2021. The record was reviewed for the certification period of 7/14/2021 to 10/12/2021. The clinical record contained an incomplete bereavement assessment. The Medical Social Worker completed part of the initial bereavement assessment and wrote a handwritten note on 11/15/2022 that read as follows: Chaplain to assess. The record failed to contain documentation of a complete bereavement assessment that included the required spiritual assessment for the certification period mentioned above. The lack of complete bereavement assessments was reviewed with the Administrator during clinical record review and during the exit conference of 1/13/2022 at 10:15 AM.

Based on a review of clinical records, it was determined that the agency failed to ensure that the interdisciplinary group (IDG) included individuals from all of the required professional roles. Specifically, the agency failed to have a Chaplain present at the IDG meetings for one (1) of five (5) patients whose record was reviewed in the survey sample (Clinical record #3). The findings: Five (5) clinical records were reviewed in the agency on January 11-13, 2022 as paper charts. 1. The clinical record for patient #3 had a documented election of Hospice benefit/start of care date of 11/13/2021. The record was reviewed for the certification period of 11/13/2021 to 2/11/2022. The clinical record contained documentation that the IDG met on 11/17/2021, 12/1/2021, and 12/15/2021 and that patient #3 was discussed at those meetings. The clinical record failed to contain documentation that a Chaplain attended the IDG meetings held on the above dates. On 1/13/2022 at 9:35 AM the MFI (Medical Facilities Inspector) conducted an interview with the Administrator regarding the Chaplain's lack of documentation. The Administrator called the chaplain on the phone. After the phone call the Administrator stated, the chaplain has the information in his bag and will scan these in now. As of 1/13/2022 at 10:15 AM the MFI's conducted an exit conference and the chaplain's notes were not provided.

Based on a review of clinical records and staff interview, it was determined the agency failed to ensure their staff documented providing care according to the patient's plan of care for two (2) of five (5) clinical records in the survey sample (Clinical records: #1 and 3). The findings: Five (5) clinical records were reviewed in the agency on January 11-13, 2022 as paper charts. 1. The clinical record for patient #3 had a documented election of benefit/start of care date of 11/13/2021. The record was reviewed for the certification period of 11/13/2021 to 2/11/2022. The plan of care contained a physician's order for the chaplain to assess the patient 11/13/2021, then visit one time a month beginning 11/18/2021. The clinical record contained documentation of zero (0) chaplain visits for this certification period. On 1/13/2022 at 9:35 AM the MFI (Medical Facilities Inspector) conducted an interview with the Administrator regarding the missed chaplain assessment/visit and the Administrator called the chaplain on the phone. After the phone call the Administrator stated, the chaplain has the visit notes in his bag and will scan these in now. On 1/13/2022 at 10:15 AM the MFI's conducted an exit conference and the chaplain's visit notes were not provided prior to the exit conference. The clinical record failed to contain documented evidence of notification to the patient's physician of the missed chaplain visits. The above finding was acknowledged by the Administrator during the exit conference conducted in the agency on 1/13/2022 at 10:15 AM. 2. The clinical record for patient #1 revealed a care plan for the home health aide dated 11/02/2021 with no visit frequency on the plan of care. The written physician orders for the home health aide were listed as "assess" and the frequency grid that is part of the care plan had no listing for the home health aide. An interview with staff #7 conducted on 1/12/2022 at 4:50 PM revealed the nurse did not remember why an aide did not go to the home. An interview with staff #3 conducted on 1/13/2022 at approximately 9 AM revealed the "family didn't want an aide". The care plan was done by the nurse in the hospital (prior to admission). The patient would have been assessed when they were admitted to hospice and the aide would have started at that time if needed. There was no evidence in the record of the family refusing the aide services.

Based on a review of the clinical records and staff interview it was determined the agency staff failed to ensure that oxygen was listed as a medication on the plan of care for four (4) of five (5) patients assessed to be on oxygen therapy in the survey sample (Clinical records# 1, 3, 4 and 5). The findings: Five (5) clinical records were reviewed in the agency on January 11-13, 2022 as paper charts. 1. The clinical record for patient #3 had a documented election of benefit/start of care date of 11/13/2021. The care plan contained interventions for oxygen therapy however; oxygen was not listed in the medication profile section of the care plan. On 1/13/2022 at 9:38 AM the MFI asked staff member #3 to provide an updated medication profile to ensure the ordered treatments/medications were included in the medication profile. Staff member #3 provided the medication profile and acknowledged the failure to include oxygen to meet the needs of the above noted patient. 2. The clinical record for patient #4 had a documented election of benefit/start of care date of 7/14/2021. The care plan contained interventions for oxygen therapy however; oxygen was not listed in the medication profile section of the care plan. 3. The clinical record for patient #5 had a documented election of benefit/start of care date of 8/19/2021. The care plan contained interventions for oxygen therapy however; oxygen was not listed in the medication profile section of the care plan. 4. Clinical record #1 was reviewed for the certification period of 11/02/2021 through 1/31/2022. The clinical record contained comprehensive nursing assessments with documented use of oxygen. The plan of care and medication profile failed to list oxygen. The lack of oxygen on the medication profile in the above named records was reviewed with the Administrator during the clinical records review and again during the exit conference on 1/13/2022 at 10:15 AM.

Based on a review of clinical records, staff interviews and the agency's pain policy, it was determined agency staff failed to document a complete pain assessment and a legible nursing note for one (1) of five (5) patients whose clinical records were reviewed in the survey sample (Clinical record# 4). In addition, the agency failed to ensure the clinical record contained a correct diagnosis for one (1) of five (5) patients in the survey sample (Clinical record #1). The findings: Five (5) clinical records were reviewed in the agency on January 11-13, 2022 as paper charts. 1. The clinical record for patient #4 had a documented election of benefit/start of care date of 7/14/2021. The clinical record contained a Skilled Nurse (SN) on-call note on 7/16/2021 that was partially legible. The portion of the note that was legible described the patient's caregiver called to report patient #4 was in pain. The patient's caregiver declined a visit after the SN recommended to wait 30 minutes after administering a medication. It is unclear from the note where the patient's pain was and what medications were recommended or any other specifics. On 1/12/2022 at 2:30 PM the MFI (Medical Facilities Inspector) requested that staff member #8 attempt to read the on-call SN report dated 7/16/2021. Staff member #8 was unable to read the note. On 1/12/2022 at 4:20 PM the MFI requested that staff member #3 have the SN who wrote this note (7/16/2021) to read it. Staff member #3 stated, that nurse no longer is employed with us. Staff member #3 attempted to read the above mentioned on-call note dated 7/16/2021 but was unable to determine where the patient was having pain, what was given as a medication and why a visit was declined. In addition, the clinical record contained a Skilled Nurse (SN) visit note dated 7/18/2021. The note failed to have a pain assessment except for a hand written note that read as follows: Fentanyl patch applied last night and pt (patient) continues to take prn (as needed) Dilaudid. The blank pain assessment section of the note contained an intervention section that was also left blank. This intervention section is used to score the care plan goal of 0-10 regarding which interventions were used and the response to that care. On 1/12/2022 at 2:30 PM the MFI reviewed the SN visit note dated 7/18/2021 with staff member #8. Staff #8 confirmed the pain assessment portion of the note was not complete. On 1/13/2022 at 3:00 PM the MFI reviewed the agency's pain policy and procedure titled, "Pain Assessment". A portion of the policy read as follows: A pain assessment should be completed and documented every visit when a patient is on any pain medication, when they have a diagnosis that puts them at risk for pain, or when the patient expresses pain verbally or exhibits non-verbal pain behavior. The lack of complete pain assessments and a legible clinical note in the record was reviewed with the Administrator during the exit conference on 1/13/2022 at 10:15 AM. 2. Clinical record #1 was reviewed for the certification period of 11/02/2021 through 1/31/2022. The patient had a primary diagnosis of lung cancer with brain metastases as documented in the hospital discharge summary and the hospital records on file. Throughout the clinical record, to include an electronic form titled Vitas Medication list/signed physician orders and nursing notes/comprehensive assessment the patient's diagnosis is listed as malignant neoplasm of the pharynx. The hospital records contained a list of multiple other comorbidities however, neoplasm of the pharynx was not one of those listed. The findings were shared with the administrator (staff #1) during an interview on 1/12/2022 at 11:55 am.