Every finding on record at Vitas Healthcare Corporation of Illinois

It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to: assess the quality of care and services provided by the hospice aide; [and] ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy "Supervision, Delegation and Coordination" (updated 07/15/2019) read in part, "The RN should provide direction and guidance to the HA … The RN must complete a HA Supervisory visit during the nursing visit to the patient at least every 14 days when hospice aide services are on the plan of care … Hospice Aide supervisory visits will be documented on the Visit Summary that accompanies the RN visit..." In 2 of 19 (11%) clinical records reviewed in which Hospice Aide (HA) services were provided, the agency did not ensure that the Registered Nurse supervised the HA at least every fourteen days. Clinical Record 2: The patient elected the hospice benefit on 06/12/2023. The plan of care (POC) ordered, and the patient's frequency grid included HA visits three times a week for the weeks of 02/29/2024, 03/07/2024, and 03/14/2024. For the week of 03/21/2024, the POC ordered HA visits twice weekly. The Registered Nurse documented a HA supervisory visit on 02/29/2024. The next HA supervisory visit was documented on 03/18/2024, with eighteen (18) days outstanding. Clinical Record 15: The patient elected the hospice benefit on 11/30/2023. The plan of care ordered, and the patient's frequency grid included one HA visit weekly for the weeks of 02/21/2024, 02/28/2024, 03/06/2024, and 03/13/2024. The Registered Nurse documented a HA supervisory visit on 02/21/2024. The next HA supervisory visit was documented on 03/13/2024, with twenty (20) days outstanding. During a joint clinical record review and an interview on 05/10/2024, the Senior Patient Care Administrator and the National Patient Care Administrator confirmed that there were gaps in the supervision of the hospice aides of more than fourteen days for clinical records #2 and #15.

It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services provided to patients/families are in a defined role and under the supervision of a designated hospice employee. Volunteer services are: noted in the plan of care; [and] documented in the patient record, including the time spent. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy "Care Planning" stated in part, "Care Plan Components...Scope is the discipline that will perform the interventions. Each intervention must have an assigned scope. Ensure the intervention is within the scope of practice of the assigned discipline... VOL = Volunteer... The frequency of each intervention is to be at each visit by the assigned discipline unless otherwise indicated in the intervention... Best Practice: Collaboration and Communication...Collaboration and Communication Examples by role ..Volunteer...changes in POC, frequency, interventions, etc. … " In 3 of 3 (100%) clinical records reviewed, the agency did not ensure that the volunteer visit frequency was noted in the patient's plan of care. Clinical Record 5: The patient elected the hospice benefit on 01/11/2024. The patient's plan of care ordered, and the patient's frequency grid for the weeks of 03/22/2024 and 04/19/2024 included no hospice volunteer visits. Volunteer visits were documented as completed on 03/26/2024 and 04/19/2024. The POC did not include orders for volunteer services. Clinical Record 9: The patient elected the hospice benefit on 07/02/2022. The patient's plan of care ordered, and the patient's frequency grid for the weeks of 02/21/2024, 03/13/2024, 03/27/2024, 04/17/2024, and 04/24/2024 included no hospice volunteer visits. Volunteer visits were documented as completed on 02/22/2024, 03/14/2024, 03/30/2024, 04/18/2024, and 04/29/2024. The POC did not include orders for volunteer services. Clinical Record 10: The patient elected the hospice benefit on 11/28/2023. The patient's plan of care ordered, and the patient's frequency grid for the weeks of 02/08/2024, 02/15/2024, and 04/03/2024 included no hospice volunteer visits. Volunteer visits were documented as completed on 02/08/2024, 02/15/2024, and 04/08/2024. The POC did not include orders for volunteer services. During a joint clinical record review and interview on 05/10/2024, the Senior Patient Care Administrator and the National Patient Care Administrator confirmed there were no volunteer frequency orders for the volunteer visits for clinical records #5, #9, and #10.

A. Based on clinical record review and staff interview, it was determined the Hospice failed to follow the POC. This was found in 7 of 16 (Pts. #7, 8, 11, 6, 13, 9, and 10) clinical records reviewed. Findings include: 1. Pt. #7. SOC 9/14/21. Hospice Diagnosis: Chronic Combined Systolic (Congestive) and Diastolic Heart Failure. The clinical record was reviewed on 11/16/21 at 2:50 PM. The record contained the POC "Visit Frequency Grid," which included the 9/22/21 Physician's order: "HA 2x/wk." The record lacked documentation the HA provided a second visit for the weeks of 10/27/21 to 11/2/21, as well as 11/3/21 to 11/9/21. The record lacked documentation the IDG was notified of these missed visits. 2. Pt. #8. SOC 9/14/21. Hospice Diagnosis: Cerebral Atherosclerosis. The clinical record was reviewed on 11/16/21 at 3:40 PM. The record contained the POC "Visit Frequency Grid," which included the 9/15/21 Physician's order: "HA 2xwk." The record lacked documentation the HA provided a second visit for the weeks of 9/22/21 to 9/28/21, 9/29/21 to 10/5/21, 10/6/21 to 10/12/21, 10/20/21 to 10/26/21, and 10/27/21 to 11/2/21. The record lacked documentation the HA provided any service for the week of 10/13/21 to 10/19/21. 3. Pt. #11. SOC 9/11/21. Hospice Diagnosis: Huntington's Disease. The clinical record was reviewed on 11/17/21 at 12:10 PM. The record contained the POC "Visit Frequency Grid," which included the 9/11/21 Physician's order: "Nurse 2," indicating the Nurse was to visit the Pt. twice per week. The record lacked a second Nursing visit for the week of 10/28/21 to 11/3/21. The record lacked documentation the IDG was notofoed of this missed visit. 4. Pt. #6. SOC 9/14/20. Hospice Diagnosis: Cerebrovascular Accident Secondary to Occlusion and Stenosis of the Right Middle Cerebral Artery. The clinical record was reviewed on 11/17/21 at 9:25 AM. The record contained the "Visit Frequency Grid..." effective 7/14/21 requiring the Nurse to provide service "2" times a week. IDG updates to the POC were included in the form titled, "Plan of Care Review Updated Comprehensive Assessment" dated 8/31/21 which lacked any changes to the 2 times a week Nurse visit frequency. As of 11/17/21, the record lacked documentation the SN provided any service during the week of 9/15/21 to 9/21/21. 5. Pt. #13. SOC 9/26/21. Hospice Diagnosis: Cerebral Atherosclerosis. The clinical record was reviewed on 11/16/21 at 3:00 PM. The record contained the Initial POC dated 9/26/21 requiring: "...Weekly Staff Frequency: SW PPOC". The "Visit Frequency Grid..." form effective 9/27/21 required the SW to provide service "x1m". The form titled, "Plan of Care Review Updated Comprehensive Assessment" dated 9/28/21, 10/12/21 and 10/26/21 lacked any changes to the visit frequency of 1 time a month. As of 11/16/21, the record lacked documentation the SW provided any service during the month of October 2021. 6. Pt. #9 SOC: 9/7/21. Hospice Diagnosis: Malignant Neoplasm of Unspecified Ovary. The clinical record was reviewed on 11/16/21 at 3:50 PM. The record included the POC "Visit Frequency Grid," requiring "Nurse 2xwk" from 9/7/21 to 9/23/21 and then "Nurse 1xwk" from 9/24/21 to 11/3/21. The record lacked documentation of a second Nurse visit for the weeks of 9/10/21 to 9/16/21 and 9/17/21 to 9/23/21 and lacked documentation of a Nurse visit for the week of 9/24/21 to 9/30/21. 7. Pt. #10 SOC: 9/10/21. Hospice Diagnosis: Malignant Neoplasm of Connective and Soft Tissue. The clinical record was reviewed on 11/16/21 at 4:05 PM. The record included the POC "Visit Frequency Grid" requiring "Nurse 2xwk" and "HA 2xwk" beginning 9/10/21. The record lacked documentation of a second Nurse visit and a second HA for the week of 9/17/21 to 9/23/21. 8. During an interview with the Pt. Care Administrator on 11/17/21 at 2:35 PM and on 11/18/21 at 9:45 AM and 10:30 AM, the Pt. Care Administrator confirmed the findings.

A. Based on a review of clinical records and staff interview, it was determined the Hospice failed to ensure the POC included the required services, visit frequency and provide services as required by the POC. This was found in 6 of 16 (Pts. #2, 6, 12, 7, 8 and 11) clinical records reviewed. Findings include: 1. Pt. #2. SOC 8/13/21. Hospice Diagnosis: Alzheimer's Disease. The clinical record was reviewed on 11/16/21 at 11:30 AM. The record contained the SW visit note dated 10/27/21. The initial POC dated 8/13/21 included "...SW PPOC...", referring to the POC Visit Frequency Grid and update(s) to the POC by the IDG. The form titled "Visit Frequency Grid Addendum General Plan of Care...Planned Visits By Discipline" completed by the IDG and effective 8/13/21 does not require the Pt. to receive any SW services. Update to the POC by the IDG contained in the form titled, "Plan of Care Review Updated Comprehensive Assessment" dated 10/26/21 lacked a frequency for SW services. As of 11/16/21, the POC/IDG did not require or approve the SW service provided on 10/27/21. 2. Pt. #6. SOC 9/14/20. Hospice Diagnosis: Cerebrovascular Accident Secondary to Occlusion and Stenosis of the Right Middle Cerebral Artery. The clinical record was reviewed on 11/17/21 at 9:25 AM. The record contained the SW visit notes dated 11/9/21 and 11/15/21. The initial POC dated 9/14/20 included "...SW PPOC..." The "Visit Frequency Grid..." effective 9/15/20 required the SW to provide service "1 x/mo". The forms titled, "Plan of Care Review Updated Comprehensive Assessment" dated 10/26/21 and 11/9/21 lacked any updates to the SW visit frequency. As of 11/17/21, the POC/IDG did not require or approve the SW service provided on 11/15/21. 3. Pt. #12. SOC 4/29/21. Hospice Diagnosis: Cerebral Aterosclerosis. The clinical record was reviewed on 11/17/21 at 1:00 PM. The record contained the SN visit notes dated 10/7/21, 10/8/21, 10/10/21 and 10/12/21 during the week of 10/7/21 to 10/13/21. The initial POC dated 4/29/21 included "...Weekly Staff Frequency: Nurse X 1..." The "Plan of Care Review Updated Comprehensive Assessment" forms dated 9/30/21 and 10/6/21 lacked any updates to the Nurse's visit frequency. As of 11/17/21, the POC/IDG did not require or approve the nursing services provided on 10/10/21 and 10/12/21. The record contained the SW visit notes dated 10/5/21, 10/6/21, 10/15/21 and 10/22/21 for October 2021. The initial POC dated 4/29/21 included "...Weekly Staff Frequency...SW PPOC". The "Visit Frequency Grid..." effective 7/21/21 required SW service "1x/mo". The "Plan of Care Review Updated Comprehensive Assessment" forms dated 9/30/21, 10/6/21 and 10/20/21 lacked any updates to the Social Worker's visit frequency. As of 11/17/21, the POC/IDG did not require or approve the SW services provided on 10/15/21 and 10/22/21. The record also contained the Music Therapy visit notes dated 10/28/21 and 11/4/21. The initial POC dated 4/29/21 did not include Music Therapy. The "Visit Frequency Grid..." effective 9/30/21 required: 1 Music Therapy visit from 9/30/21 to 10/14/21 and 1 Music Therapy visit from 10/14/21 to 10/21/21. The Plan of Care Review Updated Comprehensive Assessment" forms dated 9/30/21, 10/6/21 and 10/20/21 lacked any updates to the Music Therapist's visit frequency. As of 11/17/21, the POC/IDG did not require or approve the Music Therapy services provided on 10/28/21 and 11/4/21. 4. Pt. #7. SOC 9/14/21. Hospice Diagnosis: Chronic Combined Systolic (Congestive) and Diastolic Heart Failure. The clinical record was reviewed on 11/16/21 at 2:50 PM. The record contained the POC "Visit Frequency Grid," which included the 9/22/21 Physician's order: "HA 2x/wk." The record lacked documentation the HA provided a second visit for the weeks of 10/27/21 to 11/2/21, as well as 11/3/21 to 11/9/21. The record lacked documentation the IDG was notified of these missed visits. 5. Pt. #8. SOC 9/14/21. Hospice Diagnosis: Cerebral Atherosclerosis. The clinical record was reviewed on 11/16/21 at 3:40 PM. The record contained the POC "Visit Frequency Grid," which included the 9/15/21 Physician's order: "HA 2xwk." The record lacked documentation the HA provided a second visit for the weeks of 9/22/21 to 9/28/21, 9/29/21 to 10/5/21, 10/6/21 to 10/12/21, 10/20/21 to 10/26/21, and 10/27/21 to 11/2/21. The record lacked documentation the HA provided any service for the week of 10/13/21 to 10/19/21. The record lacked documentation the IDG was notified of these missed visits. 6. Pt. #11. SOC 9/11/21. Hospice Diagnosis: Huntington's Disease. The clinical record was reviewed on 11/17/21 at 12:10 PM. The record contained the POC "Visit Frequency Grid," which included the 9/11/21 Physician's order: "Nurse 2," indicating the Nurse was to visit the pt. twice per week. The record lacked a second Nursing visit for the week of 10/28/21 to 11/3/21. The record lacked documentation the IDG was notified of this missed visit. 7. During an interview with the Pt. Care Administrator on 11/17/21 at 1:35 PM, the Pt. Care Administrator stated missed visits should be discussed and documented at the next IDG meeting following the missed visit. 8. During an interview with the Pt. Care Administrator on 11/17/21 at 2:35 PM and 11/18/21 at 9:45 AM, the Pt. Care Administrator confirmed the above findings.

A. Based on observation and interview during a home visit, clinical record review and staff interview, it was determined the RN failed to notify the IDG of changes in a patient's skin condition. This was found in 1 of 2 (Pt. #3) Pts. who had a wound. Findings include: 1. Pt. #3 SOC: 12/20/20. Hospice Diagnosis: Cerebral Atherosclerosis. A home visit was conducted on 11/16/21 at 11:00 AM with the HA. During the home visit, the HA provided a sponge bath for Pt. #3. A pea-sized circular shaped open area, with a red wound base, whose edges was covered by a white substance, was on the right side of the buttocks, and another open area, which was covered by a white substance was on the left side of the buttocks. The HA stated that during the HA's previous visit, Pt. #3's skin was intact. The HA was interviewed during the home visit and stated that if there are any changes to the patient's condition, the nurse will be notified; and it is also discussed during the IDG Team Meeting. During the home visit, the Assisted Living Facility Aide was interviewed and confirmed that Pt. #3 had "some skin breakdown and we put a barrier cream on it at night." Pt. #3's clinical record was reviewed on 11/18/21 at 9:15 AM. The record contained "Home Health Aide/Homemaker note" dated 11/16/21 and included " ...Has slight skin breakdown on bottom. Bruising to hands." A copy of the IDG meeting notes was requested from the Agency, but the Pt. Care Administrator stated that it was not yet submitted and was not able to provide documentation for the IDG meeting on 11/17/21. A telephone interview was conducted with the RN on 11/18/21 at 11:04 AM. During the same interview, the RN stated that an IDG team meeting was conducted on 11/17/21. The RN stated that the following were discussed for Pt. #3: diet change, Hospice Aide care request, eye vitamins order, change in ambulation status and Hospice Aide providing sponge bath instead of a full shower. The RN failed to discuss with the IDG team, changes in Pt.#3's skin status as described in the Hospice Aide visit note. 2. An interview with the Pt. Care Administrator was conducted on 11/18/21 at 10:00 AM. The Pt. Care Administrator stated that any changes in Pt. are communicated in the IDG meeting. During the same interview, the Pt. Care Administrator confirmed the above findings.

A. Based on a review of clinical records, observation and interviews during a home visit, written contractual agreement, Hospice policy and staff interview, it was determined the Hospice failed to ensure medication management was coordinated between the Hospice and the Nursing Facility. This was found in 1 of 2 (Pt. #2) home visits conducted in a Nursing Facility. Findings include: 1. Pt. #2. SOC 8/13/21. Hospice Diagnosis: Alzheimer's Disease. The clinical record was reviewed on 11/16/21 at 11:30 AM. The record included the "Medication List" approved by the IDG which required the Pt. to receive: "Ativan (Lorazepam) 0.5 MG Tablet. Indication: Anxiety... Start Date: 08/13/21... take 1 tablet (=0.5 mg) by mouth every 6 hours as needed for anxiety". A home visit was conducted with E #1 in a Nursing Facility on 11/16/21 at 1:30 PM. During the home visit, the patient's Hospice folder was observed, reviewed, and lacked the Hospice's "Medication List". An interview was conducted with the Nursing Facility's Director of Memory Care and Clinical Manager/Psychotropic Nurse that reviewed the patient's Nursing Facility clinical record, and stated the Facility does not have a copy of the medications approved by the Hospice, the Pt. only receive medications ordered by the Nursing Facility's Physician. The Clinical Manager/Psychotropic Nurse stated the "Lorazepam was discontinued on 9/15/21" and presented a list of the medications the Pt. receive in the Facility, this list lacked Ativan (Lorazepam). During the same interview with the Nursing Facility's Clinical Manager/Psychotropic Nurse a question was asked, "Do this Pt. get anxious?" The Nursing Facility's Clinical Manager responded, "Yes..." During an interview with E #1 the same question was asked, and E #1 responded, "Yes..." As of 11/16/21, the Pt. does not have Lorazepam to give as needed for anxiety as required by the POC. 2. The written contractual agreement titled, "...Agreement for Nursing Facility Services" effective 6/22/21 was reviewed on 11/17/21 at 3:30 PM and contained: "...2.1 Facility Plan of Care. For each Residential Hospice Patient, Facility will develop a Facility Plan of Care which is consistent with his/her Hospice Plan of Care. Facility will make such modifications to each Residential Hospice Patient's Facility Plan of Care required for consistency with his/her Hospice Plan of Care..." 3. The Hospice policy titled, "...Pharmacy Process and Obtaining Orders" was reviewed on 11/17/21 at 3:45 PM. The policy required: "...9. CML Review a) The CML should be reviewed during each patient visit..." 4. During an interview with the Pt. Care Administrator on 11/17/21 at 2:35 PM, the Pt. Care Administrator confirmed the above findings, and stated a copy of the Hospice's Medication List should be reviewed by the Hospice Nurse every visit, and that the Nursing Facility should have a copy of the Hospice's Medication List to give the Pt. medications approved by the IDG.