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 ______________ 		05/27/2021
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)
L0557      
32525 Based on interview and record review, the agency failed to ensure care was coordinated among the clinicians for one of 3 sampled patients (Patient 1) when the Social Worker (SW) failed to report episodes of moderate to severe pain to the Case Manager or the hospice physician and failed to document pain during telephone visits. This failure increased the potential for Patient 1's pain to be poorly managed. Findings: According to Patient 1's 'Physician Visit Note' dated 1/25/21, he was admitted for hospice care on 1/23/21 with a primary diagnosis of congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should), a history of cancer of the jaw and had been recently admitted to the hospital for abdominal pain where they found several areas of metastases (cancer spread). A review of Patient 1's 'Plan of Care (POC)/Physician Orders' by the care team dated, 1/23/21 indicated the pain management goal on a scale of 0-10 (0 being no pain and 10 being the absolute worst pain imaginable) was 1 out of 10. The POC indicated the specific actions to manage the pain were to assess the pain level each visit, administer pain medications as ordered and evaluate the effectiveness of the medications. A review of the initial assessment, dated 1/23/21 indicated Patient 1 reported a pain level of 4 out of 10 and the POC goal was to manage pain to a level of 1 out of 10. The assessment indicated Patient 1 had reported, "moderate pain at present in his abdomen." Patient 1's SW telephone visit notes were reviewed as follows: 1/29/21 and timed at 9:20 a.m. to 9:30 a.m., reflected Patient 1 had stated his pain, "It's a 5 but, I'm OK ... I'm OK, I have meds this is my norm, I always have pain ... I'm O.K." 1/29/21 and timed at 9:30 a.m. to 10:35 a.m., reflected Patient 1 had stated, "My pain is a 8 but, I'M O.K, I'll take my meds but, I'm always in pain ... it's my norm." The documentation did not indicate Patient 1 had refused a phone call from a Registered Nurse (RN) or a hospice physician to discuss the pain issue. 1/29/21 and timed at 10:35 a.m. to 11:35 a.m., Patient 1's pain severity rating was not documented. 2/2/21 and timed at 2:15 p.m. to 2:45 p.m., Patient 1's pain severity rating was not documented. 2/2/21 and timed at 2:50 p.m. to 3:20 p.m., Patient 1's pain severity rating was not documented. 2/5/21 and timed at 1:35 p.m. to 2 p.m., Patient 1's pain was documented as 4 out of 10. There was no documented evidence the SW contacted the RN case manager or Patient 1's physician on 1/29/21 and 2/5/21 to report his verbalization of pain that was not being managed as per the POC goals. During an interview with the SW on 2/18/21, at 11:36 a.m., she stated she did not report Patient 1's pain to the case manager or the hospice physician. The SW stated she was not aware of Patient 1's POC pain management goal. The SW further stated she, "always asks my patients about pain ... about a 5 we report to nurse." The SW stated she was not surprised by the level of pain that Patient 1 had verbalized on 1/29/21. When the SW was asked if Patient 1's care enhanced his quality of life, she didn't answer. During an interview with the Patient Care Administrator (PCA) on 2/19/21, at 1:11 p.m., the PCA stated she would have expected the SW to notify Patient 1's RN case manager or the hospice physician about Patient 1's uncontrolled pain. A review of the agency's 'Documentation ... Procedure' dated 8/2/18 under pain indicated, "The patient should be asked about pain; and the entire pain assessment should be completed if the patient has pain ..." A review of the agency's undated 'Symptom Management' standards indicated, "The patient has a right to ... Receive effective pain management ... from the hospice for conditions related to the terminal illness. Patients should be asked about or observed for pain every visit ... Severity and idea [sic] ratings should be obtained at every visit ... Patient self-report is the most reliable indicator of the severity ... All disciplines contribute to the assessment ... RNs are responsible for in-depth assessments which include both data collection and analysis of assessment findings ...The social worker and chaplain are responsible for the indepth assessment of the patient ... particularly in regard to the effect of the physical symptoms [e.g. pain] on the patient's quality of life." According to the 'Textbook of Palliative Care Nursing' 2006, 2nd edition, pp. 132-133 indicated, "All (name of accreditation organization) certified clinical settings must evaluate their procedures to ensure that pain is appropriately assessed, treated, and documented. Inadequate pain relief hastens death by increasing physiological stress... Furthermore, pain may lead to spiritual death as the individual's quality of life is impaired."
L0594      
32525 Based on interview and record review, the agency failed to ensure the plan of care (POC) was followed for one of 3 sampled patients (Patient 1) when the Social Worker (SW) failed to complete the in person initial assessment and subsequent in person visits. This failure had the potential to result in poor psychosocial outcomes. Findings: According to Patient 1's 'Physician Visit Note' dated, 1/25/21, he was admitted for hospice care on 1/23/21 with a primary diagnosis of congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should), a history of cancer of the jaw and had been recently admitted to the hospital for abdominal pain where they found several areas of metastases (cancer spread). A review of Patient 1's 'Visit Frequency Grid' which was established by the team as part of the POC dated 1/23/21, indicated the SW was scheduled for an in person visit to assess him. Additionally, the SW was to visit the patient in person 2 times a month starting from 1/28/21. A review of the SW notes indicated she made phone calls to Patient 1 on 1/29/21, 2/2/21, 2/5/21 and on 2/10/21 (a day after Patient 1 committed suicide). There was no documented reason in Patient 1's clinical record why the SW did not make an in person visit to complete an assessment or make subsequent visits. Further review of the SW phone visit note dated 2/2/21 indicated in part, "Scheduled an Initial ... assessment visit with Pt [patient] for Thursday 2/4/21, Pt agreed." A review of another SW phone visit dated, 2/5/21 indicated, "Social Worker phoned Pt to reschedule the psychosocial visit ..." The note did not indicate the rescheduled date. There was no documentation in Patient 1's clinical record why the SW visit scheduled for 2/4/21 was not made. A review of the agency's 'Psychosocial ... Assessment' form dated, 6/20/18 indicated the SW was to evaluate a patient on suicidal ideation, dangers to others, indication or expression of distress, emotions and behaviors, adjustment to terminal illness, coping skills, psychiatric illness, social support system among others during an initial assessment visit. The agency failed to ensure Patient 1 was assessed in person by the SW when there was an opportunity to do so. An interview conducted with Licensed Nurse (LN) 1 on 2/16/21, at 2:06 p.m., LN 1 stated he was the regular nurse for Patient 1 and he was not aware the patient had declined any SW visits. When LN 1 was asked if the SW had made home visits for Patient 1, he stated, "You would have to ask them." During an interview with the Medical SW on 2/18/21, at 11:36 a.m., she stated Patient 1 had declined SW visits initially. The SW stated she heard Patient 1 declined her visits from a nurse during a care conference but she forgot to document. The SW stated she did not know why she failed to visit Patient 1 on 2/4/21. The SW stated she should have asked another SW to visit Patient 1 when she was given another assignment on 2/5/21. The SW stated she should have documented the next rescheduled visit on her 2/5/21 documentation. During an interview with the Patient Care Administrator (PCA) on 2/19/21, at 1:11 p.m., the PCA stated she was not aware Patient 1 had a scheduled assessment by the SW on 2/4/21. The PCA further stated the SW should have asked the agency to assign another SW to complete Patient 1's initial assessment on 2/5/21 or earlier. The PCA stated she was not sure why the SW did not schedule a visit after 2/5/21 and prior to Patient 1's death. The PCA stated the initial SW assessment should be completed in person within 5 days of admission. A review of the agency's 'Psychosocial ... Initial Assessment' dated 8/2/18 indicated, "The ... assessment must identify ... psychosocial, emotional ... needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process." The psychosocial assessment was to be completed "Within 5 days of admission unless otherwise specified in documentation."
L0671      
32525 Based on interview and record review, the agency failed to ensure the clinical record was complete, accurate and documented in a timely manner for one of 3 sampled patients (Patient 1) when: 1. Patient 1's pain was not documented during phone visits; and, 2. An initial assessment finding was documented 2 days after Patient 1 committed suicide. This failure had the potential to result in the physician and the clinical staff not having accurate information in the clinical record. Findings: According to Patient 1's 'Physician Visit Note' dated 1/25/21, he was admitted for hospice care on 1/23/21 with a primary diagnosis of congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should), a history of cancer of the jaw and had been recently admitted to the hospital for abdominal pain where they found several areas of metastases (cancer spread). A review of Patient 1's 'Plan of Care (POC)/Physician Orders' by the care team dated, 1/23/21 indicated the pain management goal on a scale of 0-10 (0 being no pain and 10 being the absolute worst pain imaginable) was 1 out of 10. The POC indicated the specific actions to manage the pain were to assess the pain level each visit, administer pain medications as ordered and evaluate the effectiveness of the medications. A review of the initial assessment, dated 1/23/21, indicated Patient 1 reported a pain of 4 out of 10 and the POC goal was to manage pain to a level of 1 out of 10. The assessment indicated Patient 1 had reported, "moderate pain at present in his abdomen." 1. Patient 1's Social Worker (SW) notes were reviewed as follows: 1/29/21 and timed at 10:35 a.m. to 11:35 a.m., reflected Patient 1's pain severity rating was not documented. 2/2/21 and timed at 2:15 p.m. to 2:45 p.m., reflected Patient 1's pain severity rating was not documented. 2/2/21 and timed at 2:50 p.m. to 3:20 p.m., reflected Patient 1's pain severity rating was not documented. During an interview with the SW on 2/18/21, at 11:36 a.m., she stated she did not report Patient 1's pain to the case manager or the hospice physician. The SW stated she was not aware of Patient 1's POC pain management goal. The SW further stated she, "always ask my patients about pain ... about a 5 we report to nurse." The SW stated she was not surprised by the level of pain that Patient 1 had verbalized on 1/29/21. When the SW was asked if Patient 1's care enhanced his quality of life, she didn't answer. 2. A review of Patient 1's note documented by Licensed Nurse (LN 1) on 2/11/21 indicated, "During our conversation Patient was asked about any plans of harming self or has any weapon in the house. ... Patient stated "no. No S/Sx [signs or symptoms] of suicidal ideation observed during my visit." A review of Patient 1's initial assessment by LN 1 dated, 1/23/21 indicated no comments under the psychosocial portion of the assessment that contained evaluation of suicidal ideation, dangers to others, indication or expression of distress, emotions, adjustment to terminal illness, psychiatric illness and social support system. Under the environmental safety, firearms/ammunition was not marked and the section was marked as, "No environmental or safety concerns identified." During an interview with LN 1 on 2/16/21, at 2:06 p.m., he stated Patient 1 had no signs of committing suicide and he was not aware he had a gun and ammunition. LN 1 stated he did not interview Patient 1's family members who lived next to his apartment. LN 1 stated he should have documented the assessment under the comment section. A further review of Patient's 1's record reflected a note dated 2/11/21 documented by LN 1 as a late entry for 1/29/21. The note indicated LN 1 had assessed Patient 1 for risks for self harm and the patient had stated he did not have any weapon. This documentation was completed two days after Patient 1 shot himself to death on 2/9/21. During an interview with the Patient Care Administrator (PCA) on 2/19/21, at 1:11 p.m., the PCA stated LN 1 should have documented the assessment findings the same day on 1/29/21. The PCA stated the SW should have been documented Patient 1's pain level during her interactions with him. A review of the agency's 'Documentation' policy dated, 8/2/18 indicated, "Documentation is expected to take place at the time of the visit or event ... Information to be included in the clinical record will be documented completely and available in the program office no later than 7 calendar days after care and service provided."