Every finding on record at Vitas Healthcare Corporation of California

The hospice registered nurse must complete an initial assessment within 48 hours after the election of hospice care unless the physician, patient, or representative requests that the initial assessment be completed in less than 48 hours. This standard was not met as evidenced by clinical record review and interview. In 1 of 23 (4%) clinical records reviewed, the hospice did not ensure that the hospice Registered Nurse (RN) completed an initial assessment within 48 hours of the patient's election of hospice care. Clinical Record 19: The patient elected the hospice care on 09/28/2023 with a terminal diagnosis of heart failure. On 09/29/2023 the RN attempted to admit the patient. The patient's son declined and stated he preferred a visit on Monday 10/02/2023. The RN completed the initial assessment on 10/02/2023, four (4) days after the patient elected hospice care. There was no evidence that the physician was notified of the delay in care or updated physician orders for admission. There was no evidence of an updated election of hospice care. During an interview and a joint record review on 05/17/2024, the Patient Care Administrator/RN confirmed the finding, stating they thought if the patient/family chose the visit date it would be within the standard. In 1 of 23 (4%) clinical records reviewed the hospice did not ensure that the RN initial comprehensive assessment was completed within 48 hours of the election of hospice care.

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 3 of 23 (13%) clinical records reviewed, the hospice did not ensure that the interdisciplinary group completed an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care. Clinical Record 5: The patient elected the hospice care on 06/28/2023 with a terminal diagnosis of pulmonary fibrosis. The Registered Nurse (RN) documented the need for a Medical Social Worker (MSW) evaluation in the initial comprehensive assessment. The MSW documented their initial assessment on 07/05/2023, six (6) days after the patient's election of hospice care. There was no documentation as to why the initial MSW assessment was not completed within five (5) calendar days after the election of hospice care. Clinical Record 10: The patient elected the hospice benefit on 02/09/2024 with a terminal diagnosis of unspecified severe protein-calorie malnutrition. The RN documented the need for a MSW evaluation in the initial comprehensive assessment. The MSW documented their initial assessment on 02/21/2024, twelve (12) days after the patient's election of hospice care. There was no documentation as to why the initial MSW assessment was not completed within five (5) calendar days after the election of hospice care. Clinical Record 12: The patient elected the hospice benefit on 02/14/2024 with a terminal diagnosis of cerebral atherosclerosis. The RN documented the need for a MSW and spiritual care (SC) evaluation in the initial comprehensive assessment. The SC and MSW documented their initial assessments on 02/22/2024, eight (8) days after the patient's election of hospice care. There was no documentation as to why the initial MSW and SC assessments were not completed within five (5) calendar days after the election of hospice care. During an interview and a joint record review on 05/13/2024 and 05/16/2024, the Patient Care Administrator/RN confirmed the findings. In 3 of 23 (13%) clinical records reviewed revealed the hospice did not ensure that the interdisciplinary group completed the comprehensive assessment within 5 calendar days after the election of hospice care.

It is required that a hospice aide provides services: ordered by the Interdisciplinary Group; included in the plan of care; permitted to be performed under state law and regulation; [and] consistent with the hospice aide training. This standard was not met as evidenced by clinical record review and interview. In 1 of 18 (6%) clinical records reviewed of patients receiving Hospice Aide (HA) services, the agency did not ensure that the HA provided services included in the plan of care. Clinical Record 9: The patient elected hospice care on 02/15/2023 with a terminal diagnosis of cerebral atherosclerosis. The HA care plan dated 03/23/2023 assigned the HA the relevant tasks: activity allowed, bedbound. The HA visit notes dated 04/30/2024, 05/01/2024, 05/02/2024, 05/08/2024, and 05/09/2024, documented "wheelchair used-performed." The HA care plan did not assign the task of "wheelchair used-performed." During an interview and a joint record review on 05/16/2024, the Patient Care Administrator/Registered Nurse (RN) confirmed the finding, stating that the facility staff are the ones who get the patient up into the wheelchair and the HA should not have documented "wheelchair used" task was performed as the HA was not the one completing it. In 1 of 18 (6%) clinical records reviewed with aide services provided, the agency did not ensure the hospice aide (HA) provided services as ordered by the IDG and included in the plan of care.

Based on record review, the Hospice Agency (HA) failed to ensure a registered nurse (RN) completed the initial assessment within 48 hours after the election of hospice care for one of 16 sampled patients (Patient 3). This failure resulted in delay of care and services to the patient. Findings: A review of Patient 3's profile, indicated the patient was admitted on 8/1/2022, with diagnosis including malignant neoplasm of upper lobe, unspecified (lung cancer). A review of Patient 3's Hospice Initial Certification of Terminal Illness dated 8/1/2022 indicated Patient 3's was terminally ill and has a prognosis of 6 months or less if the illness runs its expected course and was certified for hospice services. A review of Patient 3's Registered Nurse Initial Comprehensive Assessment dated 8/6/2022 indicated Patient 3's comprehensive assessment completed and signed by the RN on 8/6/2022, five days after the admission date.

7. A review of Patient 12's clinical record indicated a start of care date (SOC) of 4/15/21, with a primary diagnosis of heart failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood). A review of Patient 12's psychosocial initial comprehensive assessment and spiritual initial comprehensive assessment indicated no assessments were done by a Master of Social Work/social worker (MSW) and by a chaplain within 5 days of SOC. The psychosocial initial comprehensive assessment was completed by the MSW on 5/28/21, or 43 days after the SOC. The spiritual initial comprehensive assessment was completed by the chaplain on 5/4/21, 19 days after the SOC. 8. A review of Patient 13's clinical record indicated an SOC date of 3/28/21, with a primary diagnosis of cerebral atherosclerosis (the thickening and hardening of the artery walls in the brain, causing the arteries to narrow; when an artery becomes completely blocked or severely narrowed, blood flow to the brain can be compromised and a stroke can occur). A review of Patient 13's psychosocial initial comprehensive assessment indicated no assessment by a Master of Social Work/social worker (MSW) was completed within 5 days of SOC. The psychosocial initial comprehensive assessment was completed by the MSW on 4/6/21, 9 days after the SOC. 9. A review of Patient 14's clinical record indicated an SOC date of 4/9/19, with a primary diagnosis of Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). A review of Patient 14's spiritual initial comprehensive assessment indicated no assessment by a chaplain was completed within 5 days of SOC. The spiritual initial comprehensive assessment was completed by the chaplain on 4/17/19, 8 days after the SOC. During an interview with Patient Care Administrator (PCA) on 8/25/22 at 11:20 a.m., PCA stated she was aware both spiritual and psychosocial initial comprehensive assessments must be completed within 5 days of SOC, but sometimes the patient was not available, or the MSW or chaplain was not available within that time frame. PCA further stated it was important to have the initial comprehensive assessments within 5 days so that each discipline can give their input for the patient's plan of care. A review of the Hospice Agency (HA) policy titled, "Psychosocial/Spiritual Initial Comprehensive Assessment," dated 2018, indicated that both psychosocial and spiritual initial assessment should be completed within 5 days of admission unless otherwise specified in documentation. Based on interview and record review, the Hospice Agency (HA) failed to ensure all members of the interdisciplinary group (IDG- hospice physician, nurses, social worker, breavement, therapy services, chaplin, caregiver, dietitian) were involved in the completion of the comprehensive assessment within 5 days of the hospice election date for 9 of 16 sampled patients (Patients 2, 3, 5, 6, 7, 10, 12, 13, and 14). This failure has the potential to result in the delay in identifying the patients hospice care needs and services. Findings: 1. A review of Patient 2's profile, indicated the patient admitted on 4/20/2022, with diagnosis including Cerebral atherosclerosis. A review of Patient 2's "Admission orders/hospice certification" dated 4/20/2022 indicated "Frequency Social Worker (SW) per Plan of Care (POC)." A review of Patient 2's "Psychosocial/Spiritual Initial Comprehensive Assessment" dated 4/26/22, indicated SW initially assessed Patient 2 on 4/26/2022. A review of Patient 2's "RN-Initial Comprehensive Assessment" dated 4/20/2022, indicated "Bereavement SW and Chaplain evaluation requested". 2. A review of Patient 3's profile, indicated Patient 3 was admitted on 8/1/2022, with diagnosis including Malignant neoplasm of upper lobe, unspecified (lung cancer). A review of Patient 3's "RN-Initial Comprehensive Assessment" dated 8/6/2022, indicated "Bereavement - SW and Chaplain evaluation requested". A review of Patient 3's "Admission orders/hospice Certification" dated 8/1/2022 indicated "Frequency SW per POC." A review of Patient 3's "Psychosocial/Spiritual Initial Comprehensive Assessment" dated 8/8/2022, indicated SW and Chaplain initially assessed the patient on 8/8/2022. 3. A review of Patient 5's profile, indicated Patient 5 was admitted on 5/27/2022, with diagnosis including heart failure, unspecified (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood). A review of Patient 5's "RN-Initial Comprehensive Assessment" dated 5/28/28, indicated "Bereavement SW and Chaplain evaluation requested". A review of Patient 5's "Admission orders/hospice Certification" dated 5/26/2022 indicated "Frequency SW and Chaplain per POC." A review of Patient 5's "Psychosocial/Spiritual Initial Comprehensive Assessment" dated 6/6/2022, indicated Chaplain initially assessed Patient 5 on 6/6/2022. 4. A review of Patient 6's profile, indicated an admission for hospice on 6/26/22 with diagnosis of heart failure. A review of Patient's 6's record titled, "Admission orders/hospice recertification", dated 6/26/22, indicated "Frequency SW (social worker) per POC (Plan of Care). A review of Patient's 6's record titled, "Interdisciplinary Care Plan", dated 6/26/22, indicated, "SW confirm mortuary arrangements with patient's daughter ...". A review of Patient's 6's record titled, "RN-Initial Comprehensive Assessment", dated 6/27/22, indicated, "Bereavement SW evaluation requested". Further review of the record did not indicate the MSW saw the patient within 5 days of the SOC. 5. A review of Patient 7's profile, indicated an admission on 3/30/22, with diagnosis including cerebral infarction (brain attack). A review of Patient's 7's record titled, "Admission orders/hospice recertification", dated 3/30/22, indicated "Frequency SW (social worker) per POC (Plan of Care), Chaplain per POC. A review of Patient's 7's record titled, "RN Initial Comprehensive Assessment", dated 3/30/22, indicated, "Psychosocial SW evaluation requested ...Spiritual Chaplain evaluation requested ...". Further review of the record did not indicate the MSW and Chaplain saw the patient within 5 days of SOC. During an interview on 8/26/22, at 10:30 a.m., Registered Nurse 2 (RN 2), stated Patient 7 did not have a chaplain assessment and MSW assessment in the record. RN 2 stated the chaplain and MSW assessment should have been in the chart if they were done. 6. A review of Patient 10's profile, indicated an admission on 7/20/22, with diagnosis including chronic obstructive pulmonary disease (a condition making breathing difficult). A review of Patient 10's record titled "Admission Orders/Hospice Certification initial plan of care", dated 7/20/22, indicated "Frequency:...SW (social worker) per POC". Further review of the record indicated the MSW performed the assessment on 7/28/22. During an interview on 8/25/22, at 9:13 a.m., with the Nurse Practitioner (NP), she stated the medical social worker (MSW) was supposed to see the patients within 5 days of the start of care (SOC). The NP stated it was important for the MSW to see the patients to make sure the patients and family are aware the MSW is there to support their grief. There were no documented evidence the IDG met to identify, develop, and address all areas Patients 2, 3, 5, 6, 7, 10, 12, 13, and 14 needs for better care planning decisions related to the terminal illnesses and related conditions. A review of the HA's undated policy and procedure titled, "Psychosocial/Spiritual Initial Comprehensive Assessment" dated 2018 indicated that both psychosocial and spiritual initial assessment should be completed "within 5 days of admission unless otherwise specified in documentation".

Based on observation, interview and record review, the hospice staff failed to review all medications the patients were taking and update the medication profile with the currently used medications for one of 16 sampled patients (Patient 12). This deficient practice had the potential to put the patient at risk for medication errors and adverse drug reactions. Findings: A review of Patient 12's clinical record indicated a start of care date (SOC) of 4/15/21, with a primary diagnosis of heart failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood). During a joint home visit with Registered Nurse 1 (RN 1) on 8/24/22, at 2 p.m., it was observed Patient 12 had Trazodone ( treat depression) 50 Mg tablet at her residence that was not found in her active medication list, which was current as of 8/24/21. The label on Trazodone 50 Mg indicated it was expired on 4/21/22. It was also observed the label on Levsin (treat stomach and intestinal condition) 0.125 Mg tablet sublingual indicated the medication was expired on 4/15/22. During an interview with RN 1 on 8/24/22, at 2:30 p.m., RN 1 stated she took over the care of Patient 12 from another RN. RN 1 was not the one who admitted Patient 12 to the hospice facility. RN 1 said she had no idea Trazodone 50 MG was prescribed for patient until today's visit. RN 1 further stated patient's family or caregiver never informed her about the Trazodone. RN 1 said she did not think Patient 12 ever took Levsin either. She stated that it was a collaborative effort between the hospice staff and patient's family/caregiver to keep patient's medication list updated and to ensure patient's medications were not expired. During an interview with Caregiver 1 (CG 1), CG 1 stated she didn't remember the last time Patient 12 took Trazodone. CG 1 said she also didn't remember the last time Patient 12 took Levsin. During an interview with Patient Care Administrator (PCA) on 8/25/22, PCA stated the visiting nurse should review patient's medication on each visit. Patient's family or caregiver may inform the nurse if patient stopped taking a certain medication. A review of facility undated policy, titled "VS Pharmacy Process and Obtaining Orders" indicated, "A physician order will be obtained for all: i. Drugs and Biologicals: e.g.: Medications, flu shots ... 8. Chart Medication List (CML) is part of the plan of care that lists the pharmacological interventions for each patient. The CLM should be reviewed during each patient visit and during Interdisciplinary Group (IDG) to ensure it is up to date including active and discontinued medications. ix. Expired medications - Best practice: Check the expiration date for patient medications during each visit.

Based on interview and record review, the hospice agency (HA) failed to conduct an initial bereavement assessment for 1 of 16 sampled patients (Patient 12). This deficient practice had the potential to impact family members' abilities to cope with the patient's terminal illness prior to and after death. Findings: A review of Patient 12's clinical record indicated a start of care date (SOC) of 4/15/21, with a primary diagnosis of heart failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood). A review of Patient 12's Interdisciplinary Group (IDG - a team responsible for the holistic care of the hospice beneficiary)/Plan of Care (POC) Review dated 8/10/22 indicated patient was receiving skilled nurse (SN) visits to manage neurosensory, musculoskeletal, physical pain, spiritual, psychosocial, and end of life choices. A review of Patient 12's medical records indicated that there was no initial bereavement assessment conducted. During an interview with the Director of Admission (DOA) on 8/26/22, at 1:55 p.m., DOA stated that initial bereavement assessment should be conducted upon admission. The DOA stated that initial bereavement assessment was to be done by the admitting Registered Nurse (RN) together with the Initial Comprehensive Assessment (ICA). The DOA said bereavement assessment was important because hospice services are rendered to terminally ill patients. Bereavement assessment provides more information on how the hospice agency can support patient and the family and/or caregiver in anticipating death; it specifies what the chaplain needs to do, bereavement needs of the family/caregiver, and support following patient's death. The DOA acknowledged the hospice staff did not conduct an initial bereavement on Patient 12. A review of the agency undated policy, titled "VS Bereavement Visit," indicated the nurse doing the assessment in the first 24 hours after admission opens the Initial Bereavement Plan of Care (BPOC). She/he almost always opens the first three interventions which all bereaved receive after death (unless declined).

Based on record review and interview the interdisciplinary group (IDG) failed to update the comprehensive assessment in collaboration with the patient's attending physician for two of 16 patients (Patients 12 and 14). The deficient practice has the potential for the most recent accurate information will not be identified to make an accurate assessments and care planning decisions. Findings: a. A review of Patient 12's clinical record indicated a start of care date (SOC) of 4/15/21, with a primary diagnosis of heart failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood). A review of Patient 12's Plan of Care (POC) review indicated the last 5 Interdisciplinary Group (IDG) meetings took place on 6/1/22, 6/15/22, 6/29/22, 7/13/22, and 8/10/22. There was no IDG meeting documented within 15 days of 7/13/22. A review of the facility's document titled "IDG Agenda Report/Meeting Details" for Patient 12 dated 6/1/22, 6/29/22, and 7/13/22, showed no evidence that Patient 12 was discussed in the meetings. The same document also showed no evidence that all core members of the IDG were present in all 5 meetings for Patient 12. b. A review of Patient 14's clinical record indicated an SOC date of 4/9/19, with a primary diagnosis of Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). A review of the HA's document titled "IDG Agenda Report/Meeting Details" for Patient 14 dated 6/1/22, 6/29/22, and 7/13/22, showed no evidence that Patient 12 was discussed in the meetings. During an interview with Director of Admission (DOA) on 8/26/22 at 12:15 p.m., DOA stated the IDG meeting attendees not displayed in the "IDG Agenda Report/Meeting Details" was due to "a computer glitch." She also attributed Patient 12 and Patient 14's names not listed in the discussed patient list to "computer glitch." DOA was not able to provide evidence that Patient 12 and Patient 14 were discussed and that all core members of the IDG were present in every IDG meeting for Patient 12 and Patient 14. DOA stated that IDG meeting must be held no less than every 15 days for each patient, so that each discipline could contribute in updating patient's plan of care. A review of the HA's undated policy, titled "VS IDG POC Review Meeting," indicated all core members of the IDG must be present for all patient discussions. Attendance of team members is authenticated on the Team Meeting Agenda and Sign In sheet, including participation via phone.

3. A review of Patient 6's profile, indicated an admission to Hospice Agency on 6/26/22 to diagnoses including heart failure. A review of Patient's 6's record titled, "Admission orders/hospice recertification", dated 6/26/22, indicated "Frequency SW (social worker) per POC (Plan of Care). A review of Patient's 6's record titled, "Interdisciplinary Care Plan", dated 6/26/22, indicated, "SW confirm mortuary arrangements with patient's daughter ...". A review of Patient's 6's record titled, "RN-Initial Comprehensive Assessment", dated 6/27/22, indicated, "Bereavement SW evaluation requested". Further review of the record did not indicate the MSW saw the patient within 5 days of the SOC. During an interview on 8/25/22, at 9:13 a.m., the Nurse Practitioner NP stated the first note of the Medical Social Worker (MSW) was on 7/12/22. The NP stated the MSW was supposed to see Patient 6 within the first 5 days of the start of care which was 6/26/22. The NP stated she did not know why the social worker didn't visit the patient. The NP stated "yes, it is part of the plan of care for the social worker to see the patient. The plan of care was created on 6/26/22." Based on observation, interview and record review, the hospice agency (HA) failed to follow the individualized plan of cares for 3 of 16 sampled patients (Patients 12, 15, and 6). This deficient practice resulted in the patient not receiving care according to the plan of care. Findings: 1. A review of Patient 12's clinical record indicated a start of care date (SOC) of 4/15/21, with a primary diagnosis of heart failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood). During a joint home visit with Registered Nurse 1 (RN 1) on 8/24/22, at 2 p.m., it was noted that Patient 12 had Trazodone (anti depressant) 50 mg tablet at her residence that was not included in her initial plan of care/admission orders, dated 4/15/21. Trazodone 50 Mg was also not included in any of the interdisciplinary plan of care revision/physician orders with the most recent one dated 7/12/22. During an interview with RN 1 on 8/24/22, RN 1 stated she took over care of Patient 12 from another RN. RN 1 was not the one who admitted Patient 12 to the hospice facility. RN 1 said she had no idea Trazodone 50 mg was prescribed for patient until today's visit. RN 1 further stated patient's family or caregiver never informed her about the Trazodone. During an interview with Caregiver 1 (CG 1), CG 1 stated she didn't remember the last time Patient 12 took Trazodone. CG 1 also didn't remember giving Levsin (treat stomach and intestinal condition) SL to patient. A review of the HA's document titled "Visit Frequency Grid" for Patient 12 that covered the benefit period of 6/9/22 to 8/7/22, indicated Patient 12 was to receive 11 skilled nurse (SN) visits. A review of the HA's document titled "Data Grid" for Patient 12 during the benefit period of 6/9/22 to 8/7/22, indicated Patient 12 only received 6 SN visits. There were no communication notes explaining the reason for the 5 missed visits. A review of the agency's undated policy, titled "VS Care Planning," indicated, e. POC Revision/Physician Order: - Updates the POC based on assessment findings, -Used to update interventions, goals and outcomes for all care plans including: Physician orders (pharmacological and treatment interventions). 2. A review of Patient 15's clinical record indicated an SOC date of 12/29/20, with a primary diagnosis of Alzheimer's disease (the most common cause of dementia, a general term for memory loss and other cognitive abilities serious enough to interfere with daily life). A review of the HA's document titled "Visit Frequency Grid" for Patient 15 that covered the benefit period of 6/22/22 to 8/21/22, indicated Patient 15 was to receive 9 skilled nurse (SN) visits, 18 Home Health Aide (HHA) visits, 2 social worker (SW) visits, and 2 chaplain visits. A review of the HA's document titled "Data Grid" for Patient 15 during the benefit period of 6/22/22 to 8/21/22, indicated Patient 15 only received 4 SN visits and 16 HHA visits. There were no communication notes explaining the reason for the 4 missed SN visits and 2 missed HHA visits. During an interview with Director of Admission (DOA) on 8/26/22 at 1 p.m., DOA stated if there were any notes regarding the missed visits, they would have showed on the data grid. She further stated since the data grid did not show any notes, then the SN or HHA who missed the visits did not put any notes. DOA acknowledged the reason for any missed visit should have been documented per agency's policy. DOA did not know why the SN and HHA for Patient 12 and 15 did not document the missed visits. A review of the HA's undated policy, titled "VS Team Visit Schedules," indicated for visits not completed per the POC, if a patient or family choose to decline or reschedule a visit, document declination and any suggestions or alternatives; document the declination and reason if known in the clinical record. For attempted visit, staff need to include confirmation of visit in documentation. If a visit was inadvertently missed, documentation should support measures taken to meet patient need.

Based on interview and record review, the Hospice Agency (HA) failed to ensure bereavement counseling service was available for 1 of 16 sampled patients and family members (Patient 5). This failure resulted in the patient and their family not receiving emotional support and resources for the dying process. Findings: A review of Patient 5's profile, indicated the patient was admitted on 5/27/2022, with diagnosis including heart failure, unspecified (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood). It also indicated an end date of 6/17/2022. A review of Patient 5's "Interdisciplinary Care Plan- Initial Bereavement" dated 5/26/2022, indicated section "Post Death Bereavement" was left blank and care plan was not signed by hospice staff. A review of Patient 5's Discharge Summary dated 6/23/22 indicated Patient 5 died on 6/17/2022. An interview on 8/25/2022 at 1:45 p.m., with Case Manager (CM), CM stated that during the bereavement process, "the nurse will go do a visit and confirm time of death, offer condolences, call mortuary and schedule a pickup time. We describe to the family that we offer bereavement for the next 12 months after passing of the patient, we call the team, the chaplain will follow up with family and see what services we can provide. I'm not sure if there's a standard of how quickly the chaplain is supposed to respond. I think it probably happens in 24 or 48 hours; I don't know for certain". An interview on 8/25/20222 at 3:15 p.m. with Medical Records Clerk (MRC), stated that the Director of Admissions (DOA) was unable to locate any bereavement notes for Patient 5. A review of facility's policy titled, "VS-Bereavement Visit" undated indicated, "Each day the chaplain should review the deaths from the previous day or weekend and ensure a condolence contact is made within 72 hours of the death (not counting the contact at the time of death). Any bereavement contacts by the nurse, social worker, and chaplain following the death are documented on the paper Post Death Bereavement Assessment ... Within 15 days from the death, the chaplain completes the Team Bereavement Assessment with input from the team." A review of facility's policy titled, "VS Care Planning" undated indicted, "Bereavement: 1. Initiated by the RN at the time of the Initial Comprehensive Assessment. 2. Describes the outcomes and interventions related to bereavement for the caregiver(s) such as anticipatory grief and support. 3. Includes a required intervention for nursing, Social Worker and chaplain to contact the primary caregiver following each visit".

Based on observation and interview the facility failed to ensure stored patient supplies were not expired for 4 of 16 sampled patients (Patients 6, 7, 8, 9, and 10). This failure had the potential to place patients at risk for infection and a delay in their care by having expired supplies out of its therapeutic (effective, curative) level. Findings: A review of Patient 6's profile, indicated an admission to the hospice agency (HA) on 6/26/22, with diagnoses including heart failure. A review of Patient 7's profile, indicated an admission to the HA on 3/30/22, with diagnoses including cerebral infarction (brain attack). A review of Patient 8's profile, indicated an admission to HA on 7/31/22, with diagnoses including end stage renal disease (kidney failure). A review of Patient 9's profile, indicated an admission to the HA on 9/15/20, with diagnoses including cerebral infarction (brain attack). A review of Patient 10's profile, indicated an admission to the HA on 7/20/22, with diagnoses including chronic obstructive pulmonary disease (a condition making breathing difficult). An observation on 8/24/22, at 8:30 a.m., the supply room was noted there were several supplies that were expired. A concurrent observation in the medical supply room and interview on 8/24/2022, at 8:30 a.m., with Director of Admissions (DOA), stated while looking at the sealed wound packing bottle, "it expired in February 2022. It may not be as effective and could place patient at risk for infection because it goes inside the body". DOA also stated that they check supplies monthly and will provide their monthly supply log. An interview on 8/24/2022, at 8:40 a.m., with the Medical Records Clerk (MRC), MRC stated that they do not keep/have a log of their supplies. MRC stated, "Last time I checked supplies was a couple of months ago. Honestly, I don't know what I am checking for, I check the expiration dates. We don't have a log for the supplies here". A review of facility's policy titled, "Medical Supplies" undated, indicated "The ... Registered Nurse ensures that appropriate and adequate supplies are provided to the patient ... each item should be inspected for package integrity and expiration date before use ...Expired items should be discarded per program process".