Every finding on record at Vitas Healthcare Corporation of California

It is required that the hospice designates a registered nurse member of the IDG: ensure the implementation of the interdisciplinary plan of care. Hospice care and services provided to patients and families follow the individualized plan of care. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy "Frequency" (dated 08/15/2023) stated in part, "Frequency is part of the Plan of Care (POC). Frequency is based on assessment... Frequency is based on the IDG/patient care plan week- starts the day after the team meeting and ends on the next team meeting day ... frequency is individualized based on assessed patient and family needs ... Declined visits - document the declination and reason if known in the clinical record ..." In 11 of 19 (58%) clinical records reviewed, the agency did not ensure that the hospice care and services provided followed the plan of care (POC). Clinical Record 1: The patient elected the hospice benefit on 01/11/2024 with a diagnosis of malignant neoplasm of the brain. The patient resided at a facility for people with intellectual disabilities. The plan of care dated 07/09/2024 to 09/07/2024 ordered two (2) skilled nurse (SN) visits for the week of 07/19/2024. A review of the clinical record revealed three (3) SN visits dated 07/20/2024, 07/22/2024, and 07/23/2024 for the week of 07/19/2024. The POC ordered five (5) SN visits for the week of 07/26/2024. A review of the clinical record revealed four (4) SN visits dated 07/26/2024, 07/28/2024, 07/29/2024, and 07/30/2024 for the week of 07/26/2024. The Interdisciplinary Group ordered three (3) SN visits for the week of 08/16/2024. A review of the clinical record revealed one (1) visit dated 08/16/2024 for the week of 08/16/2024. The POC ordered one (1) SN visit for the week of 08/23/2024. No SN visit was documented for the week of 08/23/2024. Clinical Record 2: The patient elected the hospice benefit on 06/13/2024 with the diagnoses of cerebral atherosclerosis and severe vascular dementia with behavioral disturbance. The patient resided in an assisted living facility (ALF). The POC dated 06/13/2024 to 08/12/2024 did not order Chaplain visits for the week of 06/14/2024. The Chaplain documented one (1) visit dated 06/17/2024. The week of 06/21/2024, the POC ordered one (1) Chaplain visit. The Chaplain documented two (2) visits (06/21/2024 and 06/25/2024) for the week of 06/21/2024. The week of 07/12/2024, the POC ordered one (1) Chaplain visit. The Chaplain documented two (2) visits (07/12/2024 and 07/18/2024) for the week of 07/12/2024. The Interdisciplinary Group ordered two (2) Chaplain visits for the week of 07/19/2024. The Chaplain documented one (1) visit (07/25/2024) for the week of 07/19/2024. In addition, the POC ordered three (3) Skilled Nurse (SN) visits during the week of 08/02/2024. The SN documented two (2) visits (08/06/2024 and 08/07/2024) for the week of 08/02/2024. The week of 08/09/2024, the POC ordered one (1) Chaplain visit. No Chaplain visit was documented for the week of 08/09/2024. Clinical Record 3: The patient elected the hospice benefit on 03/13/2023 with a diagnosis of Alzheimer's dementia. The patient resided at home with family. The POC dated 07/05/2024 to 09/03/2024 ordered a Skilled Nurse (SN) two (2) times for the week of 07/12/2024. No SN visit was documented for the week of 07/12/2024. The week of 07/19/2024, the POC ordered one (1) SN visit. Two (2) SN visits were documented (07/21/2024 and 07/24/2024) for the week of 07/19/2024. Clinical Record 4: The patient elected the hospice benefit on 05/25/2024 with the diagnosis of chronic obstructive pulmonary disease. The patient resided at home with family. The POC dated 06/23/2024 to 08/22/2024 did not order SN services for the week of 06/28/2024. One SN visit was documented on 06/29/2024 for the week of 06/28/2024. The POC dated 06/23/2024 to 08/22/2024 did not order SN services for the week of 07/05/2024. Two (2) SN visits were documented (07/08/2024 and 07/10/2024) for the week of 07/05/2024. Four SN visits were ordered for the week of 07/19/2024. Five (5) SN visits were documented (07/21/2024, two (2) visits on 07/22/2024, 07/23/2024, and 07/25/2024) for the week of 07/19/2024. Clinical Record 5: The patient elected the hospice benefit on 07/01/2024 with the diagnosis of end-stage heart failure. The patient resided at home with family. The POC dated 07/01/2024 to 08/30/3035 ordered SN services twice (2) for the week of 07/05/2024. One (1) SN visit was documented (07/09/2024) for the week of 07/05/2024. Additionally, the POC ordered one (1) Social Work (SW) visit. No SW visit was completed for the week of 07/05/2024. Clinical Record 6: The patient elected the hospice benefit on 02/12/2024 with the diagnosis of atherosclerotic heart disease of the native coronary artery with coronary atherosclerosis due to a calcified lesion. The patient resided at home with family. The plans of care dated 04/12/2024 to 06/11/2024 and 06/11/2024 to 08/10/2024 ordered SN services twice the week of 06/07/2024. No SN visits were documented for the week of 06/07/2024. The POC ordered no SW services for the week of 08/02/2024. One (SW) visit was documented (08/02/2024) for the week of 08/02/2024. Clinical Record 9: The patient elected the hospice benefit on 04/30/2022 with the diagnosis of chronic systolic congestive heart failure. The patient resided in an ALF. The POC dated 06/18/2024 to 08/17/2024 ordered SN services three (3) visits for the week of 07/05/2024. One SN visit was documented (07/09/2024) for the week of 07/05/2024. The POC did not order Chaplain (CH) visits for the week of 07/05/2024. One was documented (07/10/2024) for the week of 07/05/2024. The POC ordered SN services three (3) visits for the weeks of 07/26/2024 and 08/09/2024 and six (6) times for the week of 08/16/2024. Two (2) SN visits were documented (07/28/2024 and 08/01/2024) for the week of 07/26/2024, and two (2) SN visits were documented ( 08/13/2024 and 08/15/2024) for the week of 08/09/2024. Two (2) SN visits were documented (08/20/2024 and 08/22/2024) for the week of 08/16/2024. The POC did not order CH visits for the weeks of 07/26/2024, 08/02/2024, and 08/14/2024. One (1) CH visit was documented (07/31/2024) for the week of 07/26/2024, two (2) CH visits were documented (08/02/2024 and 08/07/2024) for the week of 08/02/2024, and one (1) CH visit was documented for the week of 08/14/2024. Additionally, during the week of 08/16/2024, the POC ordered one (1) Chaplain visit, but none were documented. Clinical Record 10: The patient elected the hospice benefit on 01/01/2024 with the diagnosis of unspecified severe protein-calorie malnutrition. The patient lived alone at home. The plans of care dated 03/31/2024 to 06/29/2024 and 06/29/2024 to 08/28/2024 ordered SN visits two (2) times for the week of 06/14/2024 and three (3) times for the week of 07/19/2024. One (1) SN visit was documented (06/19/2024) for the week of 06/14/2024, and two (2) SN visits were documented (07/19/2024 and 07/22/2024) for the week of 07/19/2024. Clinical Record 11: The patient elected the hospice benefit on 10/15/2021 with the diagnosis of multiple sclerosis. The patient resided in a nursing facility (NF). The POC dated 06/01/2024 to 07/31/2024 ordered SW services one (1) visit for the week of 07/19/2024. No SW visit was documented for the week of 07/19/2024. The POC did not order CH services for the week of 06/14/2024. One (1) CH visit was documented (06/20/2024) for the week of 06/14/2024. Clinical Record 12: The patient elected the hospice benefit on 07/05/2022 with the diagnosis of Alzheimer's disease. The patient resided at an ALF. The plans of care dated 05/25/2024 to 07/24/2024 and 07/24/2024 to 09/22/2024 ordered SN visits two (2) times for the week of 07/05/2024, three (3) times for the weeks of 07/12/2024 and 07/19/2024, and two (2) times for the week of 07/26/2024. One (1) SN visit was documented (07/09/2024) for the week of 07/05/2024, two (2) SN visits were documented (07/12/2024 and 07/16/2024) for the week of 07/12/2024, two (2) SN visits were documented (07/21/2024 and 07/25/2024) for the week of 07/19/2024, and one (1) SN visit was documented (07/28/2024) for the week of 07/26/2024. Clinical Record 13: The patient elected the hospice benefit on 10/07/2023 with the diagnosis of unspecified heart disease. The patient resided in an ALF. The POC dated 06/03/2024 to 08/02/2024 ordered SN services two (2) visits the week of 06/28/2024, three (3) visits the week of 07/12/2024, and four (4) visits the week of 07/19/2024. One (1) SN visit was documented (06/28/2024) for the week of 06/28/2024, two (2) SN visits were documented (07/12/2024 and 07/16/2024) for the week of 07/12/2024, and three (3) SN visits were documented (07/19/2024 (two visits), and 07/24/2024) for the week of 07/19/2024. During a joint clinical record review and interview, the Patient Care Administrator (PCA) confirmed that these visits did not follow the plan of care.

It is required that each patient’s individualized written plan of care: reflects patient and family goals; 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 “Care Planning” (05/16/2023) stated in part, “Hospice uses a collaborative team approach to care planning in order to address each symptom from an interdisciplinary point of view. A plan of care is a dynamic document that changes as the patient’s condition changes. Goals, outcomes, and interventions often require frequent revision or discontinuation or the creation of new goals, outcomes, and interventions unique to that patient... Updates to the POC are based on assessment findings and used to update interventions, goals, and outcomes for all care planning, including physician orders and non-pharmacological (nursing, psychosocial, and spiritual interventions) ... symptoms are care planned under related symptom categories ... Psychosocial for example: anxiety, depression, impaired coping, etc...Care plan components - symptom/problem - issues identified by the patient and family and/or ...through assessment ... by the interdisciplinary team...” In 1 of 19 (5%) clinical records reviewed, the agency did not ensure that the patient’s plan of care (POC) identified planned interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 16: The patient elected the hospice benefit on 10/04/2023 and was discharged on 04/11/2024. The plans of care dated 10/04/2023 to 01/01/2024, 01/01/2024 to 04/01/2024, and 04/01/2024 to 05/31/2024 ordered SW services: once weekly for the weeks of 01/05/2024, 02/23/2024, and 03/22/2024. In the visit note dated 02/28/2024, the SW documented providing education on anticipatory grief, and “Visit was completed with daughter ... coping appropriately and provided education and grief needs...” On 03/27/2024, the SW documented working with the patient’s daughter on anticipatory grief. The “Plan of Care reviews/Interdisciplinary Group Meetings” for 02/01/2024, 02/15/2024, 02/29/2024, 03/14/2024, and 04/11/2024 documented that the SW visited the patient once a month. A clinical record review revealed no “Interdisciplinary Plan of Car Revision/Physician Order for the SW. No SW interventions were documented on the plan of care or plan of care updates. Interventions documented were within the Social Worker’s visit notes. During a joint clinical record review and interview, the Patient Care Administrator confirmed the findings.

It is required that a revised plan of care includes: information from the patient's updated comprehensive assessment; [and] record of the patient's progress toward the outcomes and goals specified in the plan of care. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy "Care Planning" (05/16/2023) stated in part, "Hospice uses a collaborative team approach to care planning in order to address each symptom from an interdisciplinary point of view. A plan of care is a dynamic document that changes as the patient condition changes. Goals, outcomes, and interventions often require frequent revision or discontinuation or the creation of new goals, outcomes, and interventions unique to that patient... Updates to the POC are based on assessment findings and used to update interventions, goals, and outcomes for all care planning, including physician orders and non-pharmacological (nursing, psychosocial, and spiritual interventions) ... symptoms are care planned under related symptom categories ... Psychosocial for example: anxiety, depression, impaired coping, etc...Care plan components - symptom/problem - issues identified by the patient and family and/or ...through assessment ... by the interdisciplinary team..." In 6 of 19 (32%) clinical records reviewed, the agency did not ensure that the patient's revised plan of care (POC) included information from the patient's updated comprehensive assessment and progress toward the outcomes and goals specified in the plan of care. Clinical Record 6: The patient elected the hospice benefit on 02/12/2024. The "Interdisciplinary Plan of Care Revision/Physician Orders" dated 02/15/2024 ordered the Social Worker (SW) to assist the patient/family with community resources and to educate regarding the patient's disease progression. The plans of care dated 04/12/2024 to 06/11/2024 and 06/11/2024 to 08/10/2024 ordered Chaplain (CH) services: one (1) visit the week of 06/14/2024, and Social Worker (SW) services: one (1) visit the weeks of 06/21/2024 and 06/28/2024. In the "Psychosocial/Spiritual Updated Comprehensive Assessment" dated 06/18/2024, the Chaplain documented, "Pt stated that he was experiencing some pain in his back... Interventions performed: active socialization, devotional, prayer..." In the "Psychosocial/Spiritual Updated Comprehensive Assessment" dated 06/272024, the SW documented, "Funeral in place ... pt grateful for Veteran's package... Interventions performed: provided emotional support and life reflection....Visit completed w/pt and spouse in their room. Pt hard of hearing (HOH), alert x2 w/ no pain at this time.... Provided emotional support to pt and spouse who are coping well ..." The "Plan of Care Reviews/Interdisciplinary Group Meetings" dated 05/09/2024, 05/23/2024, 06/06/2024, 06/20/2024, and 06/27/2024 documented that the SW visited the patient once (1) a month. The revised plans of care did not include documentation, including the SW's updated assessments and the patient's progress toward the SW's goals. Clinical Record 8: The patient elected the hospice benefit on 03/01/2023. The "Interdisciplinary Plan of Care Revision/ Physician Order" dated 03/03/2023 ordered the SW to encourage the patient's/family's expression of thoughts and feelings regarding the patient's terminal progression and to provide education and materials on end-of-life and grief for adults and children. The plans of care dated 04/24/2024 to 06/23/2024 and 06/23/2024 to 08/22/2024 ordered SW services: once a week for the weeks of 06/14/2024 and 06/28/2024. In the "Psychosocial/Spiritual Updated Comprehensive Assessment" dated 06/14/2024, the SW documented, "Pt in bed, a/o x0, nonresponsive during the visit. PCG has no new identified concerns ... PCG and family have yet to finalize mortuary - have resources but due to culture are not comfortable finalizing yet. SW will continue to monitor and support EOL choices." The "Plan of Care Reviews/Interdisciplinary Group Meetings" dated 05/09/2024, 05/23/2024, 06/06/2024, 06/13/2024, and 06/20/2024 documented that the social worker was visiting the patient monthly. The revised plans of care did not include documentation, including the SW's updated assessments and the patient's progress toward the SW's goals. Clinical Record 10: The patient elected the hospice benefit on 01/01/2024. The "Interdisciplinary Plan of Care Revision/ Physician Order" dated 01/03/2024 ordered the SW to assist the patient with their fear of loss of autonomy with life reflections, acceptance, and education. The POC dated 06/29/2024 to 08/28/2024 ordered SW services: one (1) visit the week of 07/05/2024. In the "Psychosocial/Spiritual Updated Comprehensive Assessment" dated 05/28/2024, the SW documented, "Interventions performed ... education and support provided ... Plan of Care - interventions effective, continue the plan…Visit w/pt and daughter .... Pt alert x3 w/no pain reported and doing well. Pt has good safety awareness and doesn't overdo it. Lots of support in place w/no needs." On 7/10/2024, the SW documented, "Funeral in place ... pt still able to safely remain in home…Interventions performed ... Education re: decline; emotional support…Plan of Care - interventions effective, continue plan…Visit done w/pt and dtr in living area. Pt alert x4. Denied any pain...continues to do well at home w/help. No issues reported..." The "Plan of Care Reviews/ Interdisciplinary Group Meetings" dated 05/09/2024, 05/23/2024, 06/06/2024, 06/20/2024, 06/27/2024, 07/11/2024, 07/18/2024, 08/01/2024, 08/15/2024, and 08/29/2024 documented that the SW was visiting the patient once a month. The revised plans of care did not include documentation, including the SW's updated assessments and the patient's progress toward the SW's goals. Clinical Record 15: The patient elected the hospice benefit on 12/19/2023 and died on hospice services on 04/28/2024. The "Interdisciplinary Plan of Care Revision/Physician Order" dated 12/21/2023 ordered the SW to assist the patient/family with coping skills utilizing life reflection and active listening to support maximum adjustment to the patient's terminal illness and to assist the patient with acceptance of the decline in health status. Additionally, the SW planned to assist and support the family with grief needs. The plans of care dated 12/19/2023 to 03/18/2024 and 03/18/2024 to 06/16/2024 ordered the SW once a week for the weeks of 02/16/2024, 03/15/2024 and 03/29/2024. In the "Psychosocial/Spiritual Updated Assessment" dated 02/16/2024, the SW documented, "Mortuary still pending ... Interventions performed: life reflection and social support..." On 04/03/2024, the SW visit note documented, "Mortuary still pending... active listening and support provided ... Pt lethargic and reports no appetite and just being tired all the time. Provided emotional support ... "The "Plan of Care Reviews/Interdisciplinary Group Meetings" dated 02/01/2024, 02/15/2024, and 02/29/2024 documented only that the social worker visited the patient once a month. The psychosocial problems/interventions section of "Plan of Care Reviews/Interdisciplinary Group Meetings" dated 03/14/2024, 03/28/2024, 04/11/2024, and 04/25/2024 was blank. The revised plans of care did not include documentation, including the SW's updated assessments and the patient's progress toward the SW's goals. Clinical Record 16: The patient elected the hospice benefit on 10/04/2023 and was discharged on 04/11/2024. The plan of care dated 04/01/2024 to 05/31/2024 ordered SW services: once weekly for the weeks of 01/05/2024, 02/23/2024, and 03/22/2024. In the visit note dated 02/28/2024, the SW documented providing education on anticipatory grief, and "Visit was completed with daughter ... coping appropriately and provided education and grief needs..." On 03/27/2024, the SW documented working with the patient's daughter on anticipatory grief. The "Plan of Care reviews/Interdisciplinary Group Meetings" for 02/01/2024, 02/15/2024, 02/29/2024, 03/14/2024, and 04/11/2024 documented that the SW visited the patient once a month. The revised plans of care did not include documentation, including the SW's updated assessments and the patient's progress toward the SW's goals. Clinical Record 18: The patient elected the hospice benefit on 03/14/2024 and revoked the hospice benefit on 04/01/2024. An "Interdisciplinary Plan of Care Revision/Physician's order" dated 03/15/2024 ordered the SW to support the patient/family in making end-of-life choices, encourage life review, explore feelings of loss and grief, and provide support as the finality of loss is absorbed. The plan of care dated 03/14/2024 to 06/11/2024 ordered SW services once a week for the weeks of 03/15/2024 and 03/22/2024. In the "Psychosocial/Spiritual Updated Comprehensive Assessment" dated 03/26/2024, the SW documented, "Patient's caregiver (PCG) has some concerns about pt leg/swelling. Pt also expressed concern. physician orders for life-sustaining treatment (POLST) was updated ...SW provided education on disease progression ..." The "Plan of Care Reviews/ Interdisciplinary Group Meetings" dated 03/21/2024 and 04/04/2024 documented that the SW visited the patient once a month. The revised plans of care did not include documentation, including the SW's updated assessments and the patient's progress toward the SW's goals. During a joint clinical record review and interview, the Patient Care Administrator confirmed the findings.

It is required that all entries in the patient record are legible, complete, and appropriately authenticated and dated by the person performing the care/service in accordance with hospice policy and with currently acceptable standards of practice. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy, "Correcting an Error in the Clinical Record," (05/06/2020) read in part, "The patient's medical record is considered a legal document... You may not draw several lines, scribble through, or attempt to obliterate an error. You may not attempt to fix an error by writing over something already written ... Place a single line through the incorrect documentation. Place your initials and the date you made the change directly above the incorrect documentation you lined out ..." In 5 of 19 (26%) clinical records reviewed, the agency did not ensure all entries in the patient's record were legible, and documentation was corrected per agency policy. Clinical Record 4: The patient elected the hospice benefit on 05/25/2024. On pages one (1), two (2), five (5), and six (6) of the "Nursing Updated Comprehensive Assessment" dated 07/22/2024, the visit dates were marked over and not corrected per the policy. On pages one (1) to six (6) of the "Nursing Updated Comprehensive Assessment" dated 08/27/2024, the visit dates were marked over and not corrected per the policy. Clinical Record 5: The patient elected the hospice benefit on 07/01/2024. The Psychosocial/Spriritual note was updated on 08/12/2024. The visit dates documented at the top of page three (3) were written over and not corrected per agency policy. Clinical Record 11: The patient elected the hospice benefit on 10/15/2021. On page one of the "Nursing Updated Comprehensive Assessment" dated 07/15/2024, the pain score "4" was written over and not corrected per agency policy. Clinical Record 12: The patient elected the hospice benefit on 07/05/2022. On page one of the "Nursing Updated Comprehensive Assessment" dated 06/14/2024, the visit date was written over and not corrected per agency policy. Clinical Record 13: The patient elected the hospice benefit on 10/07/2023. On page two (2) of the "Nursing Updated Comprehensive Assessment" dated 06/21/2024, the class number for the New York Heart Association Class (NYHA) was written over and not corrected per agency policy. On page six (6) of the "Nursing Updated Comprehensive Assessment" dated 08/23/2024, the date was written over and not corrected per policy. During a joint clinical record review and interview on 09/05/2024, the Patient Care Administrator (PCA) confirmed that corrections in the clinical record were not made per agency policy. ...

Based on observation, interview, and record review, the agency failed to ensure the medications listed in patient's current medication profile were available for use, the label of the blister pack containing the controlled medication was accurate as ordered by the physician, the over-the-counter (OTC) medications the patient's currently taking were included in agency's medication profile, and medications were not expired for four of six patients reviewed (Patients 2, 10, 11, and 12) when: 1. For Patient 2, the medication Dulcolax suppository 10 milligram (mg - unit of measurement) prn (as needed) for constipation was not available for use as ordered by the physician; 2. For Patient 10, the blister pack containing the medication Ativan (Lorazepam- a sedative used for anxiety) 0.5 mg tablet was labeled "take 1 tablet (0.5 mg) by mouth every 4 hours as needed for agitation" dated 10/12/22. The agency's current medication profile indicated Ativan 0.5 mg tablet, "take 2 tablets (=1mg) by mouth every 2 hours as needed for agitation; 3. For Patient 11, four OTC medications; Probiotic 100M one tablet daily, Cranberry 250 mg one tablet daily, One Daily (Multivitamin) one tablet daily, and Healthy Eyes, Eye Vitamin and mineral supplement were not listed in the patient's current medication profile. Two medications were expired. The Probiotic 100 M had an expiration date of April 2021, and the medication Imodium A-D (Loperamide HCL - used for diarrhea) 1 mg/7.5 Milliliter (ML - a unit of measurement) liquid had and expiration date of April 1, 2023; and 4. For Patient 12, one medication; Tylenol (Acetaminophen) 650 mg suppository was not available for use as ordered by the physician. These failures had the potential for patients and their primary care givers (PCG) not to be able to administer the medications as ordered, not to be able to identify the effectiveness of medications, increased the potential for medication errors and patients not receiving the correct dosage of the medication prescribed. --- Findings: 1. During a review of Patient 2's record on August 28, 2023, the record indicated Patient 2 was admitted to the agency on November 10, 2022, with diagnoses which included cerebral atherosclerosis (plaque buildup in the arteries of the brain) and vascular dementia (memory loss and problems with reasoning and judgement). During a home visit on August 29, 2023, at 9 a.m., at the Assisted Living Facility (ALF) conducted with Registered Nurse (RN) 1, Patient 2's medication profile was reviewed. Patient 2's medication profile indicated, "...Active Medications...Dulcolax...insert 1 suppository (=10mg) rectally every day as needed for constipation..." During a concurrent medication cart inspection and interview on August 29, 2023, at 9:40 a.m., RN 1 stated the Dulcolax suppository was not available. RN 1 stated the Dulcolax suppository should be available, as ordered by the physician. During an interview on August 30, 2023, at 2:05 p.m., with the National Patient Care Administrator (NPCA) she stated the nurse should do the medication reconciliation (the process of comparing a patient's medication orders with the medications the patient has been taking) on every visit. During an interview on August 30, 2023, at 3:10 p.m., with the Director of Patient Care Services (DPCS), she stated the Dulcolax suppository for Patient 2 should be available if it was ordered by the physician. 2. During a review of Patient 10's record, on August 28, 2023, the record indicated Patient 10 was admitted to the agency on October 14, 2019, with diagnoses which included heart failure (a condition in which the heart cannot pump or fill adequately). Patient 10 resides in an Assisted Living Facility (ALF). The physician's Face-To-Face encounter dated August 17, 2023, indicated Patient 10 was currently on the imminent (actively dying and transitioning) list as there was a change in condition, and the Mid-Arm Circumference (MAC - measures the nutritional status) had deceased from 17.8 cm to 16.2 centimeter (cm- a unit of measurement). Patient 2 was arousable, refusing his meals and medications, occasionally will take sips of ice water, had decreased urine output and declining rapidly. During a home visit on August 29, 2023, conducted with Registered Nurse (RN) 2, Patient 10 was observed lying in a hospital bed, with eyes closed. Patient 10 was arousable upon verbal call, responded "yes" and "no" to RN 2's questions. During a concurrent observation and medication reconciliation of Patient 10's medications, on August 28, 2023, at 10:22 a.m., with the ALF licensed staff, the blister pack containing the medication ATIVAN (LORAZEPAM) 0.5 MG tablet was observed. The label of the blister pack indicated "LORAZEPAM 0.5 MG TABLET. Take 1 tablet (=0.5 mg) by mouth every 4 hours as needed for agitation" with an original date of October 12, 2022. RN 2 was present during the medication reconciliation. The ALF licensed staff was observed checking Patient 10's active medications. The active medication list indicated "LORAZEPAM 1 As needed, Route: oral (by mouth), Direction: Take 1 tablet by mouth every 2 hours as needed for agitation." The agency's current medication profile indicated, "ATIVAN (LORAZEPAM) 0.5 MG TABLET" take 2 tablets (=1 mg) by mouth every 2 hours as needed for agitation. The ALF licensed staff was observed placing a facility's medication sticker at the blister pack indicating "DIRECTIONS CHANGED REFER TO CHART". During an interview with RN 2, she stated she did not conduct a medication reconciliation with the ALF's licensed staff during her visits. During a review of Patient 10's record on August 30, 2023, the physician's order dated October 12, 2022, indicated "Lorazepam 0.5 mg tablet, 1 tablet po (by mouth) Q (every) 4 hours PRN (as needed) for agitation". The physician's order dated 04/20/2023, indicated "Ativan 0.5 mg, give 2 tablets (=1 mg) q 2 hours prn agitation". During a review of Patient 10's medication administration record from ALF, obtained by the agency, indicated Patient 10 had not received the prn Ativan since July 1, 2023 through August 28, 2023. 3. During a review of Patient 11's record on August 28, 2023, the record indicated Patient 11 was admitted to the agency on March 4, 2020, with diagnoses which included Chronic Obstructive Pulmonary disease (COPD - lung disease). Patient 11, resides in a home with her family member (FM). The FM has Durable Power of Attorney (DPOA). The updated comprehensive assessment dated August 24, 2023, indicated Patient 11 was alert and oriented x 3, with oxygen at 5 liters/minute through nasal cannula (a plastic prong to the nose used to deliver oxygen) continuously and uses walker to ambulate short distances. During a home visit on August 29, 2023, at 11 a.m., with Certified Nursing Assistant (CNA) 1, Patient 11 was observed sitting on a recliner, alert, oriented and able to verbalized her needs. Patient 11 signed the home visit consent, in the presence of a FM. During a concurrent interview and medication reconciliation review on August 29, 2023, at 11:25 a.m., with Patient 11 and the FM, the following were observed: - Probiotic 100 M one tablet by mouth daily had an expiration date of April 2021. Patient 11 stated she has been taking the supplement for a long time and was not aware the medication had expired; - Cranberry 250 mg one tablet by mouth daily. Patient 11 stated she started taking the supplement last year; - One Daily , Multivitamin one tablet daily. Patient 11 stated she had been taking the multivitamin for a long time; - Healthy Eyes, Eye vitamin and mineral one tablet daily. Patient 11 stated she also had been taking the eye vitamin for a while; and - Imodium A-D (Loperamide HCL) 1 mg / 7.5 ml liquid, take 1 to 2 tablespoon (=15-30 ml) (2 to 4 mg) by mouth 1 time daily as needed for diarrhea had an expiration date of April 1, 2023. Patient 11 stated she did not know the Imodium liquid she was taking had expired. The FM stated she found a new bottle of Imodium liquid that had not expired. 4. During a review of Patient 12's record on August 28, 2023, the record indicated Patient 12 was admitted to the agency on July 7, 2023, with diagnoses which included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). Patient 12 resides in a skilled nursing facility (SNF). The physician's initial certification of illness dated July 9, 2023, indicated Patient 12 was admitted to the SNF for sepsis (blood infection) and heart failure. Patient 12 was bedbound, dependent requiring maximum assistance of activities of daily living, poor appetite, with an increasing confusion and agitation. Patient 12 had been showing considerable signs of decline. During a home visit on August 29, 2023, at 2 p.m., with Registered Nurse (RN) 4, Resident 12 was observed awake lying-in bed, able to answer yes and no. Patient 12 was able to follow simple instructions from RN 4. During a medication reconciliation on August 29, 2023, at 3 p.m., with the SNF licensed staff, one medication listed in Patient 12's current medication profile "Tylenol (Acetaminophen) 650 mg suppository prn every 6 hours as needed for fever" was not available for use as ordered by the physician dated July 8, 2023. During a concurrent interview and review of Patient 12's active medication profile, with RN 4, she stated she was not aware the Tylenol Suppository prn for fever was not available for use. She stated she had not visited Patient 12 for a while. During an interview conducted on August 31, 2023, at 10 a.m., with the Patient Care Administrator (PCA), she stated licensed staff should ask and look at patient's medications on every visit. She stated licensed staff should count controlled medications to prevent patients from receiving wrong dosages. She stated patients should not be using expired medications, all OTC medications should be included in patient's current medication profile, and all medications should be available for use as ordered by the physicians. A review of agency's policy and procedure titled, "VITAS Standard...Nursing Visit Pharmacological Overview...Chart Medication List (CML) Review," dated June 6, 2022, indicated , "...All visits begin with a review of patient's Plan of Care (POC) which includes current medications...Review Facility MAR...Reviewing medications in the home and performing a count...The CML should be reviewed during each visit and during IDG to ensure it is up to date including active and discontinued medications..."

Based on interview and record review, the agency failed to ensure the Hospice Aide (HA) 1 reported immediately to the Team Manager (TM) the incident of Registered Nurse (RN) 1 calling the patient a "blabbermouth" during their hospice visit on 02/20/2023, at the Skilled Nursing Facility (SNF) for one of one patient's reviewed (Patient) 1. This failure resulted in Patient 1 feeling upset and verbalized having panic attack symptoms. In addition, this failure resulted in a delay of the agency's investigation of RN 1's conduct which had an emotional impact to Patient 1. --- Findings: On 03/23/23, an unannounced visit was conducted with the agency to investigate one complaint. On 03/23/23, a review of Resident 1's record indicated, Patient 1 was admitted to the agency with the Start of Care (SOC) date of 10/15/21, with diagnoses which included multiple sclerosis (MS- a disease that affects the central nervous system, including the brain, spinal cord, and optic nerves). The updated comprehensive assessment dated 01/26/23, indicated Patient 1 was alert and oriented x 3. Patient 1 had increased dyspnea (difficulty breathing) during conversation, bedbound with contractures (a condition of shortening and hardening of muscles, tendons or other tissue, leading to deformity and rigidity of joints) and slight movement of her left pointer finger and thumb. The physician's Face-To-Face encounter dated 03/16/23, indicated the following: - Patient 1 was alert, oriented, and able to verbalized her needs; - Patient 1 was essentially paralyzed from the neck down, only able to use her left index and thumb in a pincher motion; - Dependent, requiring maximum assistance of her activities of daily living; - Bedbound with Performance Scale Score (PPS - a validated and reliable tool that can be used to assess patient's ability to function and determine how to move forward the end of life) of 30%. - Dyspneic with prolonged conversation and activities of care including showers; - Swelling in her peripheral al extremities managed by Lasix (medication used for fluid retention); - Chronic pain in her extremities managed by Baclofen, Tramadol, and Mobic (medications used for pain); and - Muscle atrophy (decrease in size and wasting of muscle tissue). Patient 1's Plan of Care (POC) for the certification period from 02/07/23 to 04/08/23, indicated Skilled Nurse (SN) visit once a week and Hospice Aide visit two times a week. On 03/23/23, at 11:02 a.m., an interview was conducted with Registered Nurse (RN) 1. RN 1 stated on 02/20/23, she visited Patient 1 at the SNF and HA 1 was present. RN 1 stated she was informed not to return and was put on administrative leave after. She further stated she was not aware Patient 1 was upset about her visit on 02/20/23. On 03/23/23, at 11:41 a.m., an interview was conducted with the Team Manager (TM). The TM stated the following: - On 02/24/23, Patient 1's family member (FM) called and requested RN 1 to be removed from Patient 1's care. The TM stated the FM did not elaborate and just told her "It was not a good fit". - On 02/27/23, HA 1 reported Patient 1 was upset about RN 1's visit on 02/20/23; and - RN 1 called Patient 1 a "blabbermouth". On 03/23/23, at 12:49 p.m., HA 1 was interviewed. HA 1 stated on 02/20/23, she visited Patient 1 approximately at 9 a.m., and RN 1 was in the room. HA 1 acknowledged she was present in the room when RN 1 called Patient 1 a "blabbermouth". On 03/27/23, at 1:26 p.m., HA 1 was interviewed. HA1 stated the following: - On 02/20/23, she conducted her HA visit approximately at 9 a.m, and RN 1 had been with Patient 1, since 8 a.m.; - RN 1 had walked in the room when Patient mentioned to her RN 1's age; - RN 1 responded by calling Patient 1 a "blabbermouth"; - She did not report the incident to the TM immediately. She was not aware when RN 1 called Patient 1 a "blabbermouth" that it was reportable; and - On 02/27/23, during her visit, Patient 1 verbalized being upset and had panic attack symptoms after RN 1's visit. On 03/27/23, at 2:27 p.m., an interview was conducted with the TM. The TM stated she confirmed with HA 1 that RN 1 called Patient 1 a "blabbermouth". She further stated HA 1 should have reported the incident immediately to her. On 03/27/23, at 2:49 p.m., an interview was conducted with Patient Care Administrator (PCA). The PCA stated HA 1 acknowledged RN 1 called Patient 1 a "blabbermouth". The PCA stated HA 1 should have reported the incident to the TM immediately. A review of VITAS Standard undated policy and procedure titled, "...Supervision Delegation and Coordination," indicated, "...A hospice aide provides services that are permitted to be performed under State law...Consistent with the hospice aide training...Reporting changes in the patient's condition..." A review of VITAS Healthcare Employee Handbook titled, "Employee Conduct," indicated Employees are expected and required to meet the normal standards of proper behavior for healthcare employees and to otherwise conduct themselves in an appropriate manner...unprofessional conduct, including that violates the technical or ethical standards of profession. During a review of the agency's policy and procedure titled,"...VITAS procedure for abuse, neglect, financial exploitation when suspected event takes place in home or residential facility," dated 03/02/21, indicated, "...Immediately make verbal contact with the team manager or manager on-call...If the team member is unsure whether the situation mandates a report, contacting the protective agency...is acceptable...VITAS staff member who is a mandated reporter with reasonable suspicion, is obligated to report..."