DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		 (X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER		 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED
051770 A. BUILDING __________
B. WING ______________ 		01/25/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
VITAS HEALTHCARE CORPORATION OF CALIFORNIA 355 LENNON LANE, SUITE 150, WALNUT CREEK, CA, 94598
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation
LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE

 TITLE

 (X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
(X4) ID
PREFIX
TAG		 SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY SHOULD BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
L0533      
31403 Based on interview and record review, the hospice agency did not reassess the response to care for one of three sampled patients, Patient 1. Patient 1 expressed discomfort and resistance when staff provided ADL (activities of daily living, such as toileting and bathing) care. The staff did not develop a plan to address Patient 1's agitation and consider alternative interventions. This failure resulted in staff not managing Patient 1's resistive behavior for Patient 1. Findings: Record review of the document "Symptom Management" (not dated) showed, "The hospice must conduct and document in writing a patient-specific comprehensive assessment that identifies the patient's need for hospice care and services, and the patient's need for physical, psychological, emotional, and spiritual care." Record review of the document "Case Sheet" showed Patient 1's Start of Care was 4/13/19 with diagnoses which included, Cerebral Atherosclerosis (buildup of plaque in the blood vessels of the brain). Review of the document, "RN-Initial Comprehensive Assessment" dated 4/13/19, showed Patient 1 could get easily upset or agitated with ADL care. The plan included maintaining a quiet, safe environment and for staff to communicate with Patient 1 in a calm manner. Review of the document, "Nursing-Updated Comprehensive Assessment" (NUCA) dated 4/15/19, showed Patient 1 was resistive to ADL care. Furthermore, a call was made to the doctor and Patient 1's medications to treat agitation were increased. Review of the NUCA dated 4/27/19 showed Patient 1 became agitated when turned to change his wet brief (diaper). Review of the document, "Physician Visit Note" dated 5/29/19 showed Patient 1 was "...Not tolerating ADL care. He is somewhat abusive with his language, refuses to be shaved, and often to have his brief changed..." There was no documentation in the clinical record which showed a plan was developed to address Patient 1's continuous agitation with ADL care. In an interview on 6/18/19 at 3:51 p.m., the Registered Nurse Team Manager (RNTM 1) confirmed Patient 1's plan of care had not been updated to reflect the increase in medications to control agitation or his continued resistance to ADL care. RNTM 1 stated previous interventions had been in place to address the resistance to ADL care but she was not sure what they were. In an interview on 6/18/19 at 4:15 p.m., Registered Nurse 1 (RN 1) confirmed she had not updated the plan of care. RN 1 stated the purpose for updating the plan would be to reassess whether steps taken have been effective in reducing his agitation and possibly try new approaches.
L0554      
31403 Based on interview and record review, the hospice agency did not maintain the responsibility to coordinate care for one of three sampled patients (Patient 1). There was no plan for staff to monitor and evaluate Patient 1's response to increases of his psychoactive (affects mood, thinking, behavior) medications. This failure contributed to Patient 1 experiencing side effects related to several prescribed psychoactive medications and had sustained a fall. Findings: Record review of the document "Case Sheet" showed Patient 1's Start of Care was 4/13/19 with diagnoses that included Cerebral Atherosclerosis (buildup of plaque in the blood vessels of the brain) and received home health services at theAssisted Living Facility (ALF). Record review of the "Interdisciplinary Care Plan" dated 4/13/19, showed the agency was to provide the "Services to adequately address symptoms/concerns..." Record review of the "Interdisciplinary Plan of Care Revision/Physician Orders" dated 4/15/19, showed the agency's nursing staff were to "Maintain safety. To notify (name of hospice agency) of changes/worsening behavior." Record review of the "RN-Initial Comprehensive Assessment" dated 4/13/19, showed Patient 1 was alert with periods of confusion. The plan of care indicated, "Patient will be comfortable, free from injury." Record review of the document "Admissions Orders/Hospice Certification. Initial Plan of Care" dated 4/13/19, showed Patient 1's medications included Quetiapine (Seroquel) Furmarate 25 mg (milligram) two tablets every night at bedtime. Quetiapine is an antipsychotic medication with side effects that include aggressive, angry, violent behavior and suicidal thought. [Reference: www.fda.gov]. The doctor also ordered another antipsychotic medication, Haldol which could cause drowsiness and lethargy. [Reference: www.nlm.nih.gov]. Record review of the document, "Nursing-Updated Comprehensive Assessment" (NUCA) dated 4/15/19, showed licensed nursing staff notified the doctor regarding Patient 1's behavior which included, "Periodical angry outburst, yelling." Further review of the interventions indicated the doctor ordered Patient 1 to receive Depakote (mood stabilizer) 500 mg. Depakote side effects included dizziness, weakness, and headache. [Reference: www.depakote.com] twice a day. In addition, Seroquel 12.5 mg every morning was newly prescribed. The "Response to Care" showed the "Facility staff agreed to the plan of care. Will continue to monitor behavior." Review of the NUCA dated 4/23/19 showed Patient 1 fell while walking from his kitchen area at the ALF) for independent senior living. Review of the medication orders dated 4/25/19 showed further increases in medication dosages as follows: Ativan one tablet twice a day for anxiety. Seroquel 25 mg take 3 tablets at bedtime. Depakote 500 mg. Take one tablet three times a day for agitation. Review of the NUCA dated 4/26/19 showed Patient 1 was lethargic, had slurred speech, and had an unwitnessed fall. Agency staff documented, "Instructed staff to check on patient frequently and notify (hospice name) of any changes." In an interview 6/18/19 at 3:51 p.m. with the agency's Registered Nurse Team Manager (RNTM 1), RNTM 1 stated there were medical technicians at the ALF who could check on Patient 1 every two hours. In an interview on 6/18/12 at 4:15 p.m., Registered Nurse 1 (RN 1) stated she told the ALF staff about the increases to Patient 1's medication dosages and asked them (ALF) to "Monitor" Patient 1 for side effects. In an interview on 6/19/19 at 1:25 p.m., the agency's Vice President of Pharmacy Services (VPPS) stated staff should be monitoring patients on antipsychotic medications, and looking for drug interactions, QT elevations (changes on an EKG or electrocardiogram machine that records the electrical activity of the heart), and changes in behavior or drowsiness. In an interview on 7/8/19 at 11:10 a.m., the Health Services Director (HSD) at the ALF stated the ALF is not a medical setting. Staff are available around-the-clock but not at the bedside and could not commit to providing one to two hour checks. Record review of the policy and procedure titled, "Interdisciplinary Team (IDT) Policies Assessment dated 11/15/16 indicated, "To identify changes that have taken place since the initial assessment and includes information on the patients progress toward desired outcomes, as well as a reassessment of the patient's response to care."