Every finding on record at Vitas Healthcare Corporation of California

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. This standard was not met, as evidenced by clinical record review and interview. In 4 of 6 (67%) clinical records reviewed of patients who received Hospice Aide (HHA) services, the agency did not ensure that the Hospice Aide reported changes in the patient's care needs to the Registered Nurse (RN) as changes related to the plan of care (POC). Clinical Record 1: The patient elected hospice care on 11/11/2024. The plan of care ordered HHA services two (2) times per week. The HHA care plan dated 11/12/2024 assigned the HHA the task of shampooing hair every visit. The HHA visit note dated 11/21/2024 documented "Not performed/declined" or shampooing hair. A clinical record review revealed no evidence that the HHA reported the change in the HHA care plan and the patient's care needs to the RN. Clinical Record 3: The patient elected hospice care on 09/30/2024. The plan of care ordered HHA services three (3) times per week. The HHA care plan dated 11/01/2024 assigned the HHA the relevant task: apply lip balm every visit. The HHA visit note dated 11/12/2024 documented "Not performed/ declined" for applying lip balm. A clinical record review revealed no evidence that the HHA reported the change in the HHA care plan and the patient's care needs to the RN. Clinical Record 8: The patient elected hospice care on 11/06/2024. The plan of care ordered HHA services one (1) time per week. The HHA care plan dated 11/07/2024 assigned the HHA the relevant task: shave every visit. The HHA visit note dated 11/07/2024 documented "Not performed/declined" for shaving. A clinical record review revealed no evidence that the HHA reported the change in the HHA care plan and the patient's care needs to the RN. Clinical Record 12: The patient elected hospice care on 11/07/2024. The plan of care ordered HHA services three (3) times per week. The HHA care plan dated 11/08/2024 assigned the HHA the relevant task: shampoo hair every visit. The HHA visit note dated 11/12/2024 documented "Not performed/ declined" for shampooing the hair. A clinical record review revealed no evidence that the HHA reported the change in the HHA care plan and the patient's care needs to the RN. The Administrator and Patient Care Administrator stated in an interview on 12/05/2024 that the HHA did not report changes in the patient's needs to the RN as the changes related to the POC.

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary described in HCDT 40.I; and the patient’s record, if requested. This standard was not met, as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record reviews of a patient who revoked the hospice benefit to seek aggressive treatment, the agency did not ensure that a copy of the discharge summary was forwarded to the receiving hospital. Clinical Record 9: The patient elected the hospice benefit on 11/30/2024 and requested to revoke it on 12/01/2024 to seek aggressive treatment in a hospital. The clinical record did not include evidence that the agency forwarded the discharge summary to the receiving hospital. The Administrator and Patient Care Administrator stated in an interview on 12/05/2024 that the agency did not send the hospice discharge summary to the receiving hospital.