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
491581 A. BUILDING __________
B. WING ______________ 		01/14/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
VITAS INNOVATIVE HOSPICE CARE 3251 OLD LEE HWY - SUITE 200, FAIRFAX, VA, 22030
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)
L0505      
27661 Based on a review of agency documents and interviews it was determined the agency failed to ensure the protection of the patient and the patient's caregiver(s) right to voice grievances and have those grievances investigated and a resolution reached with notification of the resolution made to the complainant in three (3) of five (5) clinical records in the survey sample (clinical record #1, 4 and 5). The findings were: A review of the complaint log in the agency on 1/11/2022 revealed no complaints were documented regarding patient #1 in the survey sample. The log did contain two (2) complaints similar in nature to the complaint being investigated with allegations of poor care being provided (clinical records #4 and 5). The log failed to contain evidence those complaints were investigated and that those complaints were resolved. An interview was conducted with the administrator, staff #1 to review the findings related to complaints identified in the complaint log on 1/12/2022 at 11:55 am. The administrator acknowledged that all complaints should have had a follow-up and no follow-up was conducted or documented for clinical records #4 and #5. A review of the clinical record for patient #1 on 1/11/2022 at 3:30 PM revealed a complaint had been been reported to the social worker (staff #5) when a bereavement call was made on 11/09/2021. Staff #5 documented "dtr (daughter) says they are unpleased with service, says there was a lack of nursing visits". Staff #5 further documented, "referred dtr to Vitas mainline and informed TM (team manager)". TM reports patient had 3 RN (registered nurse) visits in 5 days on 11/3, 11/6 and 11/8/2021. An interview with staff #5 on 1/12/2022 at 10:20 am revealed the staff member did not write up the complaint and was unaware of the agency's formal documentation process for complaints but did report it to the team manager. "To my knowledge that was the only concern and I just let the daughter know who to call." An interview with the administrator (staff #1) on 1/12/2022 at 10:30 am revealed complaints are reported to the team manager who then reports it to performance improvement and that starts the process for follow up. An interview with the team manager, staff #3 on 1/12/2022 at 11:30 am revealed, "I spoke with the husband because he was the power of attorney". He didn't understand why (other family member) complained. Team manager stated "I did not do a service follow-up". The patient got three (3) nursing visits in five (5) days. A review of the complaint policy, titled "Service Comment Process" states in part: Service Comment Guidelines, A: All complaints and grievances received from a patient, patients family/guardian or the patient's health care provider regarding treatment, care, or respect for the active, discharged, pending and/or not admitted patient's will be recorded via the Service Comment Electronic System (SCES) and investigated in an expeditious method. The complaint/grievance investigation begins immediately by the VITAS employee who witnesses/receives the service issue. Service comments will be reviewed by a Senior Manager in every program to assure appropriate and satisfactory follow-up.
L0531      
36944 Based on a review of clinical records and the agency's bereavement policy, it was determined the hospice failed to complete an initial bereavement assessment within five (5) calendar days of the election of the hospice benefit and start of care date in two (2) of six (5) clinical records reviewed in the survey sample (Clinical records #3 and 4). The findings: Five (5) clinical records were reviewed in the agency on January 11-13, 2022 as paper charts. 1. The clinical record for patient #3 had a documented election of benefit and start of care date of 11/13/2021. The record was reviewed for the certification period of 11/13/2021 to 2/11/2022. The clinical record contained an incomplete bereavement assessment. The Medical Social Worker completed part of the initial bereavement assessment and wrote a handwritten note on 11/15/2022 that read as follows: Chaplain to assess. The record failed to contain documentation of a complete bereavement assessment that included the required spiritual assessment for the certification period mentioned above. On 1/13/2022 at 9:30 AM the MFI (Medical Facilities Inspector) requested the agency's bereavement policy. The Administrator provided the MFI with the bereavement policy titled, "VS-Bereavement Visit" and a portion read as follows: An initial bereavement assessment of the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. On 1/13/2022 at 9:35 AM the MFI (Medical Facilities Inspector) conducted an interview with the Administrator regarding the missed chaplain assessment/visit; the Administrator called the chaplain on the phone. After the phone call the Administrator stated, the chaplain has the visit notes in his bag and will scan these in now. As of 1/13/2022 at 10:15 AM when the MFIs conducted the exit conference, the chaplain's visit notes had not been provided. 2. The clinical record for patient #4 had a documented election of Hospice benefit/start of care date of 7/14/2021. The record was reviewed for the certification period of 7/14/2021 to 10/12/2021. The clinical record contained an incomplete bereavement assessment. The Medical Social Worker completed part of the initial bereavement assessment and wrote a handwritten note on 11/15/2022 that read as follows: Chaplain to assess. The record failed to contain documentation of a complete bereavement assessment that included the required spiritual assessment for the certification period mentioned above. The lack of complete bereavement assessments was reviewed with the Administrator during clinical record review and during the exit conference of 1/13/2022 at 10:15 AM.
L0541      
36944 Based on a review of clinical records, it was determined that the agency failed to ensure that the interdisciplinary group (IDG) included individuals from all of the required professional roles. Specifically, the agency failed to have a Chaplain present at the IDG meetings for one (1) of five (5) patients whose record was reviewed in the survey sample (Clinical record #3). The findings: Five (5) clinical records were reviewed in the agency on January 11-13, 2022 as paper charts. 1. The clinical record for patient #3 had a documented election of Hospice benefit/start of care date of 11/13/2021. The record was reviewed for the certification period of 11/13/2021 to 2/11/2022. The clinical record contained documentation that the IDG met on 11/17/2021, 12/1/2021, and 12/15/2021 and that patient #3 was discussed at those meetings. The clinical record failed to contain documentation that a Chaplain attended the IDG meetings held on the above dates. On 1/13/2022 at 9:35 AM the MFI (Medical Facilities Inspector) conducted an interview with the Administrator regarding the Chaplain's lack of documentation. The Administrator called the chaplain on the phone. After the phone call the Administrator stated, the chaplain has the information in his bag and will scan these in now. As of 1/13/2022 at 10:15 AM the MFI's conducted an exit conference and the chaplain's notes were not provided.
L0543      
36944 Based on a review of clinical records and staff interview, it was determined the agency failed to ensure their staff documented providing care according to the patient's plan of care for two (2) of five (5) clinical records in the survey sample (Clinical records: #1 and 3). The findings: Five (5) clinical records were reviewed in the agency on January 11-13, 2022 as paper charts. 1. The clinical record for patient #3 had a documented election of benefit/start of care date of 11/13/2021. The record was reviewed for the certification period of 11/13/2021 to 2/11/2022. The plan of care contained a physician's order for the chaplain to assess the patient 11/13/2021, then visit one time a month beginning 11/18/2021. The clinical record contained documentation of zero (0) chaplain visits for this certification period. On 1/13/2022 at 9:35 AM the MFI (Medical Facilities Inspector) conducted an interview with the Administrator regarding the missed chaplain assessment/visit and the Administrator called the chaplain on the phone. After the phone call the Administrator stated, the chaplain has the visit notes in his bag and will scan these in now. On 1/13/2022 at 10:15 AM the MFI's conducted an exit conference and the chaplain's visit notes were not provided prior to the exit conference. The clinical record failed to contain documented evidence of notification to the patient's physician of the missed chaplain visits. The above finding was acknowledged by the Administrator during the exit conference conducted in the agency on 1/13/2022 at 10:15 AM. 27661 2. The clinical record for patient #1 revealed a care plan for the home health aide dated 11/02/2021 with no visit frequency on the plan of care. The written physician orders for the home health aide were listed as "assess" and the frequency grid that is part of the care plan had no listing for the home health aide. An interview with staff #7 conducted on 1/12/2022 at 4:50 PM revealed the nurse did not remember why an aide did not go to the home. An interview with staff #3 conducted on 1/13/2022 at approximately 9 AM revealed the "family didn't want an aide". The care plan was done by the nurse in the hospital (prior to admission). The patient would have been assessed when they were admitted to hospice and the aide would have started at that time if needed. There was no evidence in the record of the family refusing the aide services.
L0549      
36944 Based on a review of the clinical records and staff interview it was determined the agency staff failed to ensure that oxygen was listed as a medication on the plan of care for four (4) of five (5) patients assessed to be on oxygen therapy in the survey sample (Clinical records# 1, 3, 4 and 5). The findings: Five (5) clinical records were reviewed in the agency on January 11-13, 2022 as paper charts. 1. The clinical record for patient #3 had a documented election of benefit/start of care date of 11/13/2021. The care plan contained interventions for oxygen therapy however; oxygen was not listed in the medication profile section of the care plan. On 1/13/2022 at 9:38 AM the MFI asked staff member #3 to provide an updated medication profile to ensure the ordered treatments/medications were included in the medication profile. Staff member #3 provided the medication profile and acknowledged the failure to include oxygen to meet the needs of the above noted patient. 2. The clinical record for patient #4 had a documented election of benefit/start of care date of 7/14/2021. The care plan contained interventions for oxygen therapy however; oxygen was not listed in the medication profile section of the care plan. 3. The clinical record for patient #5 had a documented election of benefit/start of care date of 8/19/2021. The care plan contained interventions for oxygen therapy however; oxygen was not listed in the medication profile section of the care plan. 4. Clinical record #1 was reviewed for the certification period of 11/02/2021 through 1/31/2022. The clinical record contained comprehensive nursing assessments with documented use of oxygen. The plan of care and medication profile failed to list oxygen. The lack of oxygen on the medication profile in the above named records was reviewed with the Administrator during the clinical records review and again during the exit conference on 1/13/2022 at 10:15 AM. 27661
L0671      
36944 Based on a review of clinical records, staff interviews and the agency's pain policy, it was determined agency staff failed to document a complete pain assessment and a legible nursing note for one (1) of five (5) patients whose clinical records were reviewed in the survey sample (Clinical record# 4). In addition, the agency failed to ensure the clinical record contained a correct diagnosis for one (1) of five (5) patients in the survey sample (Clinical record #1). The findings: Five (5) clinical records were reviewed in the agency on January 11-13, 2022 as paper charts. 1. The clinical record for patient #4 had a documented election of benefit/start of care date of 7/14/2021. The clinical record contained a Skilled Nurse (SN) on-call note on 7/16/2021 that was partially legible. The portion of the note that was legible described the patient's caregiver called to report patient #4 was in pain. The patient's caregiver declined a visit after the SN recommended to wait 30 minutes after administering a medication. It is unclear from the note where the patient's pain was and what medications were recommended or any other specifics. On 1/12/2022 at 2:30 PM the MFI (Medical Facilities Inspector) requested that staff member #8 attempt to read the on-call SN report dated 7/16/2021. Staff member #8 was unable to read the note. On 1/12/2022 at 4:20 PM the MFI requested that staff member #3 have the SN who wrote this note (7/16/2021) to read it. Staff member #3 stated, that nurse no longer is employed with us. Staff member #3 attempted to read the above mentioned on-call note dated 7/16/2021 but was unable to determine where the patient was having pain, what was given as a medication and why a visit was declined. In addition, the clinical record contained a Skilled Nurse (SN) visit note dated 7/18/2021. The note failed to have a pain assessment except for a hand written note that read as follows: Fentanyl patch applied last night and pt (patient) continues to take prn (as needed) Dilaudid. The blank pain assessment section of the note contained an intervention section that was also left blank. This intervention section is used to score the care plan goal of 0-10 regarding which interventions were used and the response to that care. On 1/12/2022 at 2:30 PM the MFI reviewed the SN visit note dated 7/18/2021 with staff member #8. Staff #8 confirmed the pain assessment portion of the note was not complete. On 1/13/2022 at 3:00 PM the MFI reviewed the agency's pain policy and procedure titled, "Pain Assessment". A portion of the policy read as follows: A pain assessment should be completed and documented every visit when a patient is on any pain medication, when they have a diagnosis that puts them at risk for pain, or when the patient expresses pain verbally or exhibits non-verbal pain behavior. The lack of complete pain assessments and a legible clinical note in the record was reviewed with the Administrator during the exit conference on 1/13/2022 at 10:15 AM. 27661 2. Clinical record #1 was reviewed for the certification period of 11/02/2021 through 1/31/2022. The patient had a primary diagnosis of lung cancer with brain metastases as documented in the hospital discharge summary and the hospital records on file. Throughout the clinical record, to include an electronic form titled Vitas Medication list/signed physician orders and nursing notes/comprehensive assessment the patient's diagnosis is listed as malignant neoplasm of the pharynx. The hospital records contained a list of multiple other comorbidities however, neoplasm of the pharynx was not one of those listed. The findings were shared with the administrator (staff #1) during an interview on 1/12/2022 at 11:55 am.