Every finding on record at Vitas Healthcare Corporation of California

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 and interview. In 2 of 14 (14%) clinical records reviewed, the agency did not ensure the plan of care (POC) reflected patient and family goals and interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 1: The patient elected hospice care on 09/14/2024. In the POC Review (Updated Comprehensive Assessment) dated 01/23/2025, the nurse, the social worker, and the spiritual counselor documented, "Facility staff and agency staff have observed episodes of agitation with symptom relief after prn Lorazepam 0.5 mg PO was given, as order." The interdisciplinary group (IDG) POC dated 01/23/2025 did not document goal(s) and intervention(s) for agitation. Clinical Record 13: The patient elected hospice care on 09/25/2024. The initial nursing assessment dated 09/26/2024 documented, "Patient mumbles unintelligibly and is agitated but seems to calm when Registered Nurse (RN) pats his shoulder." The interdisciplinary group (IDG) POC dated 09/26/2024 did not document goal(s) and intervention(s) for agitation. In an interview on 01/31/2025, the Patient Care Administrator and Alternate Patient Care Administrator confirmed that the POC did not reflect the patient and family goals and interventions based on problems identified in the comprehensive assessments.