Every finding on record at Vitas Healthcare Corporation Midwest

It is required that each patient’s individualized written plan of care: reflects patient and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy "VS Care Planning" (dated 02/19/2016) read in part, "A plan is a dynamic document that changes as the patient condition changes. Goals, outcomes, and interventions often require frequent revision or discontinuation, or creation of new goals, outcomes, and interventions unique to that patient... POC Revision/Physician Order - Updates the POC based on assessment findings... Used to update interventions, goals, and outcomes for all care planning..." In 1 of 23 (4%) clinical records reviewed, the agency did not ensure that the patient's plan of care identified planned interventions based on problems identified in the updated comprehensive assessments. Clinical Record 8: The patient elected the hospice benefit on 04/11/2024. The nursing comprehensive assessment dated 05/03/2024, documented "Patient having signs and symptoms (s/s) of urinary tract infection (UTI) with frequent urge to urinate with little urine and burning with urination... new order for Macrodantin 100mg BID x5 days and cranberry supplement TID." On 05/03/2024, the physician ordered: "Nitrofurantoin Macrocrystal 100mg by mouth twice a day for a urinary tract infection." The plan of care and the Interdisciplinary Group (IDG) meeting dated 05/10/2024 did not include documentation of an identified problem or intervention for the urinary tract infection. During a joint clinical record review and interview on 06/13/2024, the Patient Care Administrator confirmed that the plan of care had not been updated and stated that the nurse was newer and required reeducation regarding updating the plan of care with changes to the patient's assessment.

Based on document review and interview, it was determined the Facility failed to develop and maintain a comprehensive Emergency Preparedness Plan inclusive of all requirements. Findings include: 1. The Hospice failed to develop and implement emergency preparedness policies and procedures, based on it's Emergency Plan, risk assessment, and communication plan; as part of its comprehensive Emergency Preparedness Program (EPP), that would be reviewed and/or updated at least annually. See tag E0013 2. The Hospice failed to develop and implement emergency preparedness policies and procedures, related to the inclusion of the provision of subsistence needs for staff and patients whether they evacuate or shelter in place, including, but not limited to food, water, medical and pharmaceutical supplies, alternate sources of energy to maintain temperatures to protect patient health and safety and for the safe and sanitary storage of provisions. See tag E0015 3. The Hospice failed to develop and implement emergency preparedness policies and procedures, related to follow up of staff and patient, services that are needed and to inform State and local officials of any on duty staff and patients that cannot be contacted. See tag E0016 4. The Hospice failed to develop and implement emergency preparedness policies and procedures, inclusive of arrangements to inform State and local emergency preparedness officials about homebound Hospice patients in need of evacuation from their residence at any time. See tag E0019 5. The Hospice failed to develop and implement emergency preparedness program (EPP) policies and procedures to address a system of medical documentation protecting patient information to be updated at least annually. See tag E0023 6. The Hospice failed to develop and implement EPP policies and procedures, inclusive of arrangements with other Facilities/Providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services for its patients. See tag E0025 7. The Hospice failed in develop and implement EPP polices and procedures, inclusive of arrangements for an alternate means of communication in the absence of their normal means of communication methodologies. See tag E0029 8. The Hospice failed to ensure a communication plan including a policy for sharing of patient information was developed and implemented. See tag E0033 9. The Hospice failed to ensure all new and existing staff, contracted staff and volunteers were provided training on the Emergency Preparedness Program. See tag E0037

Based on request for documents and staff interview, it was determined the Hospice failed to develop and implement emergency preparedness policies and procedures, based on it's Emergency Plan (EP), risk assessment, and communication plan; as part of its comprehensive Emergency Preparedness Plan (EPP), that would be reviewed and/or updated at least annually. This has the potential to affect all 151 current patients, staff and volunteers. Findings include: 1. A request for policies and procedures based on the facility Emergency Preparedness Plan (EPP) was made to the Performance Improvement Specialist (E#2) on 3/14/22 at 2:00 PM. E#2 provided the facility Emergency Preparedness Plan (undated), a 10 page document but was unable to provide any policies or procedures. There were no policies and procedures thus there was no review documented, at least annually. 2. An interview with the National Patient Care Administrator (E#6) was conducted on 3/16/22 at 11:15 AM. E#2 reported the corporate office understood the policies and procedures could be included within the plan. When asked to point out the policies and procedures included in the EP, E#6 was unable to locate them and was not able to provide individual policies and procedures.

Based on document review and staff interview, it was determined the Hospice failed to develop and implement Emergency Preparedness Program (EPP) policies and procedures, inclusive of the provision of subsistence needs for staff and patients whether they evacuate or shelter in place, including, but not limited to food, water, medical and pharmaceutical supplies, alternate sources of energy to maintain temperatures to protect patient health and safety and for the safe and sanitary storage of provisions. This has the potential to affect all 151 current patients, staff and volunteers. Findings include: 1. A request for policies and procedures related to the EPP was made to the Performance Improvement Supervisor (E #2) on 3/14/22 at 2:00 PM. There were no policies or procedures provided inclusive of the provision of subsistence needs for staff and patients whether they evacuate or shelter in place, including, but not limited to food, water, medical and pharmaceutical supplies, alternate sources of energy to maintain temperatures to protect patient health and safety and for the safe and sanitary storage of provisions 2. An interview was conducted with the National Patient Care Administrator (E #6) on 3/16/22 at 11:15 AM. E #6 reviewed the EP program (EPP) and was unable to provide policies related to the provision of subsistence needs for staff and patients whether they evacuate or shelter in place, including, but not limited to food, water, medical and pharmaceutical supplies, alternate sources of energy to maintain temperatures to protect patient health and safety and for the safe and sanitary storage of provisions

Based on request for documents and staff interview, it was determined the Hospice failed to develop and implement emergency preparedness policies and procedures, related to follow up of staff and patient, services that are needed and to inform State and local officials of any on duty staff and patients that cannot be contacted. This has the potential to affect all 151 current patients and staff. Findings include: 1. A request was made to Performance Improvement Specialist (E #2) on 2/14/22 at 2:00 PM for the policies and procedures related to follow up for on duty staff and patient, for services needed and who to contact, both State and locally to report findings. There were no policies and procedures provided addressing follow up and reporting during an emergency. 2. An interview was conducted with the National Patient Care Administrator (E #6) on 3/16/22 at 11:15 AM. E #6 reviewed the EP and was unable to find information related to follow up of staff and patients or reporting of needs, as well as staff or patients unable to be located, to State and local officials.

Based on document review and staff interview, it was determined the Hospice failed to develop and implement Emergency Preparedness Program (EPP) policies and procedures, inclusive of arrangements to inform State and local emergency preparedness officials about homebound Hospice patients in need of evacuation from their residence at any time. This has the potential to affect all 151 current patients. Findings include: 1. A request for policies and procedures related to the EPP was made to E #2 on 3/14/22 at 2:00 PM. There were no policies or procedures provided inclusive of arrangements .arrangements to inform State and local emergency preparedness officials about homebound Hospice patients in need of evacuation from their residence at any time 2. An interview was conducted with the National Patient Care Administrator (E #6) on 3/16/22 at 11:15 AM. E #6 reviewed the EP program (EPP) and was unable to provide policies related to arrangements to inform State and local emergency preparedness officials about homebound Hospice patients in need of evacuation from their residence at any time

Based on a request for documents and staff interview, it was determined the Hospice failed to develop and implement emergency preparedness (EP) policies and procedures to address a system of medical documentation protecting patient information to be updated at least annually. This has the potential to affect all 151 current patients, staff, and volunteers. Findings include: 1. A request was made to Performance Improvement Specialist (E #2) on 2/14/22 at 2:00 PM for the policies and procedures related to a system for documentation as part of their EP Program. There were no policies and procedures provided to indicate what documentation system would be implemented in the case of an emergency situation. 2. An interview was conducted with the National Patient Care Administrator (E #6) on 3/16/22 at 11:15 AM. E #6 reviewed the EP and was unable to find any mention of a documentation system, including preserving, confidentiality and availability of patient information.

Based on document review and staff interview, it was determined the Hospice failed to develop and implement Emergency Preparedness Program (EPP) policies and procedures, inclusive of arrangements with other facilities/providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services for its patients. This has the potential to affect all 151 current patients. Findings include: 1. A request for policies and procedures related to the EPP was made to E #2 on 3/14/22 at 2:00 PM. There were no policies or procedures provided inclusive of arrangements with other facilities/providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services for its patients. 2. An interview was conducted with the National Patient Care Administrator (E #6) on 3/16/22 at 11:15 AM. E#6 reviewed the EP program (EPP) and was unable to provide policies related to arrangements with other facilities/providers in the event this was needed.

Based on a request for documents and staff interview, it was determined the Hospice failed to develop and implement emergency preparedness (EP) policies and procedures to address how the Hospice would communicate with an alternate means of communication in the absence of their normal means of communication methodologies. This has the potential to affect all 151 current patients, staff, and volunteers. Findings include: 1. A request was made to Performance Improvement Specialist (E #2) on 2/14/22 at 2:00 PM for the policies and procedures related to how the Hospice would communicate with an alternate means of communication in the absence of their normal means of communication methodologies. 2. An interview was conducted with the National Patient Care Administrator (E #6) on 3/16/22 at 11:15 AM. E #6 reviewed the EP and was unable to find any mention of a plan on how the Hospice would communicate with an alternate means of communication in the absence of their normal means of communication methodologies.

Based on request for documents and staff interview, it was determined the Hospice failed to establish an Emergency Preparedness Program (EPP) communication plan which included a method for sharing information and medical documentation for patients under the Hospice care, as necessary, with other health providers to maintain the continuity of care and a means for providing information about the general condition and location of patients. Findings include: 1. A request was made to Performance Improvement Specialist (E #2) on 2/14/22 at 2:00 PM for the policies and procedures related to a communication plan to address methods for sharing of information and medical documentation. There were no policies and procedures provided for review. 2. An interview was conducted with the National Patient Care Administrator (E #6) on 3/16/22 at 11:15 AM. E#6 reviewed the EP program (EPP) and was unable to provide policies related to sharing of patient information.

Based on document review and interview, it was determined the Hospice failed to ensure all new and existing staff, contracted staff and volunteers were provided training on the Emergency Preparedness Plan (EPP). This has the potential to affect all staff and the 151 current patients. Findings include: 1. The document titled "Emergency Preparedness Plan" (undated) was reviewed on 03/16/2022. The plan on page 10 indicates under "IV. Training. Emergency Preparedness Program Staff Training includes: Training during orientation Annual Update Training". 2. A request for documentation to indicate EP training was completed for all employees, including contracted staff and volunteers was made on 3/16/22 at 1:30 PM. No documentation for any training was provided. 3. An interview was conducted with the National Patient Care Administrator (E #6) on 03/16/2022 at 11:15 AM. E #6 stated, "I am being transparent. I was told some training was completed but not documented. No training has been done recently. We have had new employees and it was not completed."

Based on document review and staff interview, it was determined in 3 of 14 (Pt #3, Pt 6, Pt #7) patients, the Hospice failed to follow the plan of care (POC). This has the potential to affect all 151 patients receiving care from the Agency. Findings include: 1. Pt #3. SOC 11/18/202. Diagnosis: cerebral atherosclerosis. The clinical record was reviewed on 11/15/22 at 3:40 PM. The record contained the POC "Visit Frequency Grid," (undated), indicating the hospice aid (HA) was to conduct home visits 2 times a week starting 11/02/2022, and skilled nursing visits were to be conducted 3 times a week, starting 11/02/2022. The record lacked documentation the HA conducted a second visit for the week of 01/19/2022 or documentation the HA provided any service for the week of 01/19/2022, 01/26/2022, 02/02/2022,02/09/2022,02/16/2022, 02/23/2022, 03/02/2022, and 03/09/2022. The record lacked documentation that skilled nursing conducted a second visit for the week of 01/12/2022, and 02/23/2022. The record lacked documentation the IDG was notified of these missed visits. 2. Pt #6. SOC 04/23/2021. Diagnosis: heart failure. The clinical record was reviewed on 03/15/2022 at 12:10 PM. The record contained the POC "Visit Frequency Grid," (undated), indicating skilled nursing visits were to be conducted 2 times a week, starting 04/28/2021. The record lacked documentation that skilled nursing conducted a second visit for the week of 02/24/2021. The record lacked documentation the IDG was notified of this missed visit. 3. Pt #7. Start of Care (SOC) 01/14/2022. Diagnosis: vascular dementia. The clinical record was reviewed on 03/15/2022 at 2:50 PM. The record contained the plan of care (POC) "Visit Frequency Grid," (undated), indicating the hospice aid (HA) was to make home visits 1 time a week for two weeks, starting 01/18/2022. The record lacked documentation an aid visit was conducted for the weeks of 01/26/2022 to 02/01/2022 and 02/02/2022 to 02/08/2022. The record lacked documentation the Intra Disciplinary Group (IDG) was notified of these missed visits. 4. On 02/16/2022 at approximately 3:00 PM, the policy "VS Team Visit Schedules" revised 10/27/2017, was reviewed. Under "1. Visits not Completed per the POC" it reads "d) Communicate the declination with the IDG to determine if a change in POC is warranted. 5. On 03/16/2022 at approximately 12:30 PM, an interview with the Patient Care Administrator (E #3) was conducted. E #3 confirmed the POC's for the above patients were not followed.

Based on document review and staff interview, it was determined the Hospice failed to ensure the quality assessment and performance improvement program (QAPI) continuously assessed data of potential problems to be identified in order to assess whether a problem existed. This has the potential to affect all patient receiving care at an Agency with a current census of 151 patients. Findings include: 1. On 03/15/2022 at approximately 2:00 PM, the "Complaint" log for the past calendar year was reviewed. It indicated there were three "service comments" related to staff not being able to acquire medications from the pharmacy. a) Service Comment (complaint #82438 dated 09/09/2021) reads "The pharmacy stated it will take 4 hours or more for emergency lorazepam". b) Service Comment (complaint #8199 dated 08/26/2021) reads "they only keep one bottle of morphine in stock and it goes to the first hospice that needs it. They are frequently out of morphine." c) Service Comment (complaint #8199 dated 08/23/2021) indicated an Agency staff member needed urgent pain medication for imminent patient. When the staff member informed the pharmacist of the pain crisis, the pharmacist stated "hospice patients are not priority and services are first come first served. The medication would have to wait until the pharmacist performed COVID swabs on a room full of customers and that would take him 1 1/2 hours." When the Agency staff member stressed the importance of this medication, the pharmacist "preceded to hang up on her." 3. On 03/16/2022, at approximately 10:30 AM, a letter from the Vice President, Pharmacy Services (E #5) to the Senior General Manager (E #4) was reviewed. It reads "Upon receipt of the service comment, the situation was escalated to our pharmacy partner, to reach out to the pharmacy to discuss the reported shortage of medication. The pharmacy partner reviewed the incident with the pharmacist in charge. The pharmacist in charge stated that due to low utilization the pharmacist has been unable to order more than one bottle of Roxanol at a time from his wholesaler due to allocation restrictions based on previous use. The pharmacist would continue to try and order additional supplies through his wholesaler to increase the amount on hand. Going forward, the pharmacist indicated that the hospice nurse could contact his staff to determine what stock they had on hand and whether another pharmacy would need to be utilized." 4. On 03/16/2022, at approximately 8:30 AM, an interview with the Patient Care Administrator (E #3) and the E #4 was conducted. E #3 indicated that "Service Comment" #81190 was escalated to E #5, which in turn discussed the medication shortage with their pharmacy partner. The pharmacy partner reviewed the incident and stated that "due to low utilization the pharmacy was unable to order more than one bottle of Roxanol (medication used to treat moderate-to-severe acute and chronic pain) at a time from the wholesaler due to allocation restrictions based on previous use". 5. On 03/16/2022, at approximately 11:00 AM, an interview with Patient Care Administrator (E #3) was conducted. When E #3 was asked if there were any performance improvement projects related to patient's not getting pain/anxiety medications in a timely manner or issues related to pharmacies not being able to supply the pain/anxiety medication, E #3 replied "No".

Based on document review and staff interview it was determined for 2 of 12 (Pt #10 #11) clinical records with aide visits, the Hospice failed to ensure the hospice aide assignment sheet was completed per policy. This failure has the potential to affect all hospice patients receiving aide services. Findings include: 1. The Hospice policy dated 1/18/22, titled, "Hospice Aide/Homemaker Volunteer Request" was reviewed on 3/17/22. The policy page 4, under "Personal Care (Hospice Aide Services-including extension of nursing services)...Day(s) of Week/Time of Day preferred" bullet 1 "If specific days of week and/or times of day are requested, place a check mark in the correct boxes. Otherwise, place a mark in the "Not Specified" box." 2. The clinical record of Pt # 10 was reviewed on 3/16/22. Pt #10 was admitted for services on 12/1/21. The "Hospice Aide/Homemaker Request" form with "Request Date: 12/2/21" was completed by the registered nurse (RN). There was no documentation to indicate frequency of "Day(s) of Week:" specified. Therefore, the form was incomplete. 3. The clinical record of Pt # 11 was reviewed on 3/16/22. Pt #11 was admitted for services on 1/17/22. The "Hospice Aide/Homemaker Request" form with "Request Date: 1/17/22" was completed by the RN. There was no documentation to indicate frequency of "Day(s) of Week:" specified. Therefore, the form was incomplete. 4. On 3/17/22 at 10:00 AM, an interview was conducted with the patient care administrator (E#3). E#3 reviewed the ""Hospice Aide/Homemaker Request" form for Pt #10 and Pt #11. E#3 confirmed the forms were incomplete and should have been completed by the RN.