Every finding on record at Vitas Healthcare of Texas, L.P.

It is required that the hospice inpatient facility has documented and dated written reports of Life Safety Code fire drills at varied times on all shifts. This standard was not met as evidenced by document review and interview. A review of the fire drill logs revealed the agency did not ensure compliance with the National Fire Protection Act (NFPA) section 18/19.7.1.6 which stated in part, "Fire drills conducted at unexpected times under varying conditions, at least quarterly, on each shift." Document 6: (Agency name) "Management Standard: Fire" (no date) stated in part, "Fire drills are held quarterly at unexpected times under varying conditions, held during each shift." The agency's fire drill logs for 2023: first quarter, documented fire drills were held on February at 1400 and March at 1330, and for the fourth quarter a documented fire drill was held on December at 1640. There were no documented fire drills for the second shift for these quarters. During a joint review of the fire drill logs on 05/30/2024, the In-patient Unit (IPU) Team Manager reported that those were the only drills documented on the logs kept in the unit. On 06/05/2024, prior to the exit, the Patient Care Administrator (PCA) confirmed that there were no additional documented fire drills. The PCA confirmed that the IPU had two shifts (8 am to 8 pm and 8 pm to 8 am). Review of the fire drill logs revealed the agency did not ensure compliance with the National Fire Protection Act (NFPA) section 18/19.7.1.6 which stated, "Fire drills conducted at unexpected times under varying conditions, at least quarterly, on each shift."

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current: prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; [and] other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: the effectiveness of drug therapy; drug side effects; actual or potential drug interactions; duplicate drug therapy; [and] drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review, document review, and interview. The agency document "Pharmacy Process" (no date) stated in relevant parts, "Each nursing updated comprehensive assessment visit begins with a review of the patient's plan of care which includes current medications...the chart medication list should be reviewed during each patient visit and during IDG (interdisciplinary group) to ensure it is up to date including active and discontinued medications." In 1 of 30 (3%) clinical records reviewed, the agency did not ensure that the comprehensive assessment included a review of the patient's current medications. Clinical Record 20: The patient elected the hospice benefit on 04/18/2024 with a diagnosis of cerebral atherosclerosis. On 04/18/2024, the physician ordered: "Cefuroxime Axetil (Ceftin) 500 milligrams give one (1) tablet by mouth twice a day for UTI (urinary tract infection) until 04/27/2024." A clinical record review on 05/30/2024 revealed that the current drug profile documented, "Ceftin 500 milligrams give one tablet by mouth twice a day for UTI." The drug profile was not updated to reflect that the Ceftin was to be discontinued as of 04/27/2024. On 06/05/2024, the Patient Care Administrator (PCA) confirmed that when the medication was entered into the system, the nurse did not add the stop date and missed this during the medication reconciliations. The PCA reported that confirmation was obtained from the hospice pharmacy that this antibiotic was only "profiled" by the hospice but was not dispensed as the patient already had the medication at the time of admission, thus the patient received and administered the correct number of pills.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 1 of 21 (5%) clinical records reviewed in which Hospice Aide (HA) services were accepted, the agency did not ensure that the Registered Nurse (RN) provided the Hospice Aide specific written patient care instructions. Clinical Record 16: The patient elected hospice care on 11/07/2022 with a diagnosis of Parkinson's disease and dementia. A clinical record review revealed a physician order for continuous oxygen at 3 liters via nasal cannula effective 04/17/2024. A comprehensive nursing assessment dated 05/29/2024 documented that the patient remained on continuous oxygen. The HA care plans, effective from 04/17/2024 to the present, did not instruct the HA on oxygen precautions and provide the HA with instructions regarding the patient's use of oxygen during personal care. During an interview on 06/04/2024, the Patient Care Administrator (PCA) confirmed that the HA care plan should have included the information on the oxygen.

References: NFPA 101-Life Safety Code 2012 edition. 18.3.4 Detection, Alarm, and Communications Systems. 18.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6. 9.6 Fire Detection, Alarm, and Communications Systems. 9.6.1 General. 9.6.1.3 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use. NFPA 72 National Fire Alarm and Signaling Code -2010 edition Chapter 14 Inspection, Testing, and Maintenance 14.1 Application. 14.2 General. 14.2.1 Performance. 14.2.1.1 Performance Verification. 14.2.1.2 Impairments. 14.2.1.2.2 System defects and malfunctions shall be corrected. . Based on observation, record review and interviews, the facility failed to ensure the Fire Alarm system was maintained according to NFPA 72, 14.2.1.2.2 as referenced by NPFA 101, 9.6.1.3.. The fire alarm remote annunciator was in "trouble" status. This violation can affect patients in the event of a fire, by delayed notification, exposing them to smoke inhalation and other fire related injuries. Findings included: Observation on 12/29/2021 at 10:54 a.m. revealed Vitas Healthcare of Texas, which is an inpatient unit hospice facility, was located on the 3rd floor of a 3-story building. Further observation revealed the 1st floor of the building is occupied by a dialysis clinic. Observation on 12/29/2021 at 10:55 a.m. revealed the fire alarm remote annunciator on the 1st floor of the building (where the dialysis clinic was located) was in trouble status and silenced. Record review of the inspection tags on the 1st floor remote annunciator revealed it was "Yellow-Tagged" (indicating a system problem) by the Fire Alarm company on 08/24/2021. The reason for the Yellow Tag was indicated as: "Device #87 1st Floor Lobby Vitas Failed sensitivity test". Observation on 12/29/2021 at 11:25 a.m. revealed the fire alarm remote annunciator on the 3rd floor (where the IPU-Hospice is located) was in trouble status and silenced. Record review of the remote annunciator revealed it was not tagged. Observation on 12/29/2021 at 11:27 a.m. revealed the Main Fire Alarm Panel located in the Mechanical Room of the building, was in normal status. Record review of the panel's service tags revealed the fire alarm panel was "Blue tagged" (indicating no issues with fire alarm system). The Blue tag was dated 08/24/2021. Record review of a fire alarm system inspection report dated 08/24/2021 indicated the fire alarm system on the 3rd floor had passed its inspection. In an interview at each of the observations, the General Manager stated he saw and agreed that the fire alarm remote annunciator on the 1st floor was in trouble status, silenced and yellow-tagged; that the fire alarm remote annunciator on the 3rd floor was in trouble status, silenced but not tagged; and that the main fire alarm control panel was in normal status and blue-tagged. The General Manager stated he did not know for how long the fire alarm remote annunciator on the 3rd floor was in trouble status. At this time, the General Manager proceeded to call the landlord to inquire about why the yellow-tag on the 1st floor remote annunciator had not been addressed. In a phone interview at approximately 11:30 a.m. on 12/29/2021 a representative from the landlord indicated that the fire alarm company had visited the premises in 3 occasions (September 2, 2021; October 5, 2021; and December 8, 2021) to address the yellow-tag on the 1st floor fire alarm remote annunciator, but that Vitas staff had turned them away. At the end of the phone interview, the landlord's representative stated that she had contacted the fire alarm maintenance company to go in the next day (12/30/2021) to address all issues related to the fire alarm system in the building. .