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
101545 A. BUILDING __________
B. WING ______________ 		06/17/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
VITAS HEALTHCARE CORPORATION OF FLORIDA 4450 W EAU GALLIE BLVD STE 250, MELBOURNE, FL, 32934
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)
L0591      
36646 Based on record reviews and interviews, the hospice failed to ensure the nursing needs of 1 out of 3 sample patients (SP), SP #3, were met by hospice staff. Findings include: A telephone interview with the relative of SP #3 on 6/16/2020 at 2:11 PM stated: On Friday, June 12th, the owner of the Assisted Living Facility (ALF) called around 8 AM. The owner stated that they needed to transfer SP #3 to the hospital because the Hospice Nurse (Staff B) who was supposed to take care of SP #3 left. The relative of SP #3 stated that the ALF owner also called to advise that the hospice was having a hard time sending a nurse to the ALF. Phone interview with Staff - A on 6/16/2020 at 2:41 PM stated she's known SP#3 for about three (3) months now and SP#3 is receiving continuous care. She is the primary nurse for SP #3. She stated "she remembered the administrator told her that the nurse from the staffing agency who is suppose to take care of the patient (SP#3) on Friday abandoned the patient when the nurse found out there were a few patients with COVID in the ALF." " I did not see the nurse at the ALF. She was told the nurse only stayed for a few minutes. I was there in the ALF around 10 AM to 10:30 AM." Phone interview with the Administrator/ owner of the ALF on 6/17/2020 at 8:05 AM regarding SP #3. She stated a nurse (Staff B) came on Friday (June 12th) around 9:00 AM. The nurse was wearing the complete PPE (Personal Protective Equipment)-gown, face mask, and gloves. " But when the nurse found out that there were other patients in the ALF that were COVID positive, she left. She did not tell me she was leaving. The patient (SP #3) was receiving continuous care from the hospice. There was no nurse. The nurse, Staff A (the primary nurse for SP #3) from the hospice came later. Record review of the hospice document titled Addendum Interdisciplinary Note dated 6/12/2020 showed 10:00 AM report given to hospice nurse via phone. During a phone interview with the ALF Administrator/ owner at 12:30 PM on 6/17/2020, she stated that the nurse Staff B (from the nurse registry staffing company) stayed only for a few minutes and told her "I am getting out of here". The administrator added she did not observe care rendered by Staff B. Record review of hospice record title: Addendum Interdisciplinary Note date of visit 6/12/2020 from Staff - B showed 8:00 AM arrived at patient's ALF. Complete assessment done and V/S (vital signs: Temperature, Respiratory rate, heart rate, blood pressure) taken. On 6/17/2020 at 2:30 PM, PCA - A stated there is no complete assessment of SP #3 documented; no vital signs documented. On 6/17/2020 at 3:10 PM, PCA - A confirmed and stated there is no complete assessment of SP #3 documented; and no vital signs documented as confirmed with her by the Nurse registry staffing company.
L0652      
36646 Based on record review and interview, the hospice failed to ensure staff (Staff - B), met the nursing needs of 1 out of 3 sample patients (SP), SP #3. Findings include: A telephone interview with the relative of SP #3 on 6/16/2020 at 2:11 PM stated: On Friday, June 12th, the owner of the Assisted Living Facility (ALF) called around 8 AM. The owner stated that they needed to transfer SP #3 to the hospital because the Hospice Nurse (Staff B) who was supposed to take care of SP #3 left. The relative of SP #3 stated that the ALF owner also called to advise that the hospice was having a hard time sending a nurse to the ALF. Phone interview with Staff - A on 6/16/2020 at 2:41 PM stated she's known SP#3 for about three (3) months now and SP#3 is receiving continuous care. She is the primary nurse for SP #3. She stated "she remembered the administrator told her that the nurse from the staffing agency who is suppose to take care of the patient (SP#3) on Friday abandoned the patient when the nurse found out there were a few patients with COVID in the ALF." " I did not see the nurse at the ALF. She was told the nurse only stayed for a few minutes. I was there in the ALF around 10 AM to 10:30 AM." Phone interview with the Administrator/ owner of the ALF on 6/17/2020 at 8:05 AM regarding SP #3. She stated a nurse (Staff B) came on Friday (June 12th) around 9:00 AM. The nurse was wearing the complete PPE (Personal Protective Equipment)-gown, face mask, and gloves. " But when the nurse found out that there were other patients in the ALF that were COVID positive, she left. She did not tell me she was leaving. The patient (SP #3) was receiving continuous care from the hospice. There was no nurse. The nurse, Staff A (the primary nurse for SP #3) from the hospice came later. Record review of the hospice document titled Addendum Interdisciplinary Note dated 6/12/2020 showed 10:00 AM report given to hospice nurse via phone. During a phone interview with the ALF Administrator/ owner at 12:30 PM on 6/17/2020, she stated that the nurse Staff B (from the nurse registry staffing company) stayed only for a few minutes and told her "I am getting out of here". The administrator added she did not observe care rendered by Staff B. Record review provided by the hospice Patient Care Administrator (PCA-B) at 1:10 PM showed title: Daily End of shift report showed ISSUE reason SP #3 : received a call from (the administrator of the Nurse Registry staffing company) Staff - B stated the ALF have 4 positive patients, and she don't feel good staying cause it is a small ALF. Record review of hospice record title: Addendum Interdisciplinary Note date of visit 6/12/2020 from Staff - B showed 8:00 AM arrived at patient's ALF. Complete assessment done and V/S (vital signs: Temperature, Respiratory rate, heart rate, blood pressure) taken. On 6/17/2020 at 2:30 PM, PCA - A stated there is no complete assessment of SP #3 documented; no vital signs documented. On 6/17/2020 at 3:10 PM, PCA - A confirmed and stated there is no complete assessment of SP #3 documented; and no vital signs documented as confirmed with her by the Nurse registry staffing company.
L0671      
36646 Based on record reviews and interviews, the hospice failed to ensure the clinical record contains correct clinical information that is available for 1 out of 3 sample patients (SP) SP #3. Findings include: During a phone interview with the Assisted Living Facility (ALF) Administrator/ owner at 12:30 PM on 6/17/2020, she stated that the nurse Staff B (from the nurse registry staffing company) stayed only for a few minutes and told her "I am getting out of here". The administrator added she did not observe care rendered by Staff B. Record review of hospice record title: Addendum Interdisciplinary Note date of visit 6/12/2020 from Staff - B showed 8:00 AM arrived at patient's ALF. Complete assessment done and V/S (vital signs: Temperature, Respiratory rate, heart rate, blood pressure) taken. On 6/17/2020 at 2:30 PM, hospice Patient Care Administrator (PCA - A) stated there is no complete assessment of SP #3 documented; no vital signs documented. On 6/17/2020 at 3:10 PM, PCA - A confirmed and stated there is no complete assessment of SP #3 documented; and no vital signs documented as confirmed with her by the Nurse registry staffing company.