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
051779 A. BUILDING __________
B. WING ______________ 		04/04/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
VITAS HEALTHCARE CORPORATION OF CALIFORNIA 2710 GATEWAY OAKS DRIVE, SUITE 100 SOUTH, SACRAMENTO, CA, 95833
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)
L0519      
32525 Based on interview and record review, the agency failed to ensure there was a clear communication process included in their policy on staffing for patients on continuous care for one of 3 sampled patients (Patient 1) when the family was not notified a nurse was not scheduled to cover the night shift. This failure resulted in Patient 1's family being unable to make a determination to stay with her on the night she passed away. Findings: A review of the an 'Intake Information' received by the Department early this year, in part indicated, "... we had RN [agency's name] nurses around the clock for 3 days ... My wife and I were there most of the day and night until 9:30pm ... that is the only reason my wife and I left that night ...[the night Patient 1 died]" According to Patient 1's 'Case Sheet' she was admitted under hospice care on 8/10/21 with a terminal diagnoses of heart failure. A 'Physician Order' dated 8/11/21 indicated to discontinue the routine level of care and begin ICC (Intensive Comfort Care) level of care at 4:15 p.m. as Patient 1 was having shortness of breath. During an interview and concurrent record review with the Clinical Manager (PCA) and the General Manger (GM) on 1/31/22 at 11:41 a.m., when the GM was asked how patients or their families were notified when a nurse was not scheduled for a certain shift, she stated the nurse normally called family prior to a visit. The PCA indicated the nursing schedule for patients on ICC was not planned that far out and was determined a couple of hours prior to the next shift based on staff availability and based on whether the 8 hours guaranteed for ICC in 24 hours was met. The PCA further indicated if the patient had an urgent need, regardless of the ICC order, the patient or family are made aware to call the after hours phone number for assistance. An interview conducted with the agency's Physician on 2/1/22 at 2:10 p.m., she stated the intent of ICC was to manage a difficult symptom to a level the patient can tolerate. The Physician stated some of the patients might need ICC for a few hours and others a longer period. The Physician stated ICC guaranteed a patient received a total of 8 hours in 24 hours. The Physician stated it would have been appropriate for the agency to notify Patient 1's family that an 8 hour shift was already covered and a nursing visit was not guaranteed for the night shift. Review of the agency's undated policy titled, "... Management Standard" under Continuous Care Staffing Need indicated, "Each program should make every effort to staff and confirm staffing on all CC shifts prior to turning the program over to CC After Hours ... Best Practice ... program should staff patients out 2-3 days .." The policy did not indicate how patients, families and/or caregivers would be notified if a ICC shift was not being covered.