OIG Report Includes VITAS ‘Immediate Jeopardy’ Finding

VITAS Healthcare, the nation’s largest hospice provider and a subsidiary of Chemed Corp. (NYSE: CHE), received an “immediate jeopardy” finding from Missouri state surveyors for missing required home visits, insufficient wound care for a patient’s pressure ulcer, and failing to sufficiently manage patients’ pain, according to a state survey findings report obtained by Hospice News.

The incidents occurred at a VITAS location in St. Louis. The news was first reported by the Washington Post.

These incidents were among 12 serious patient safety events, involving a number of hospices across the country, discussed in a new report from the U.S. Department of Health & Human Services Office of the Inspector General. 


The report, Safeguards Must Be Strengthened to Protect Medicare Hospice Beneficiaries from Harm, is one of two that OIG released this week on safety concerns in the hospice industry.

VITAS offered no comment on the OIG report to Hospice News. However, the survey findings from the state of Missouri indicated that VITAS submitted a plan of correction to address the deficiencies. After a follow-up survey, the state determined that the immediate jeopardy condition was abated.

“Immediate Jeopardy represents a situation in which entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment or death,” according to CMS’ State Operations Manual. “These situations must be accurately identified by surveyors, thoroughly investigated, and resolved by the entity as quickly as possible. In addition, noncompliance cited at [immediate jeopardy] is the most serious deficiency type, and carries the most serious sanctions for providers, suppliers, or laboratories (entities).”


When surveyors find an immediate jeopardy situation, they are required to notify CMS. The cited organization must take immediate action to eliminate the safety risk. Following that, the hospice would be required to submit a plan of correction to their state agency, showing how they will prevent similar incidents from recurring.

OIG identified the 12 incidents discussed in the report through a review of condition-level survey findings from 2016. The inspector general also examined CMS Certification and Survey Provider Enhanced Reports (CASPER), which contains deficiency data from state agency surveys.

A condition-level deficiency occurs when non-compliance with a standard or regulation represents a severe health or safety breach.

In addition to the VITAS incidents, OIG called out several other serious safety events from a number of unidentified hospices, including a case in which an organization allowed maggots to develop at the site of a patient’s feeding tube. A number of other incidents involved hospices failing to report or investigate allegations of patient abuse.

The OIG did not independently verify the information contained in the survey reports and recognized that these severe incidents did not necessarily reflect the industry as a whole.

“The 12 cases of harm featured in this report do not represent the majority of hospice beneficiaries or the majority of hospice providers,” the report stated. “Due to the purposive sampling of deficiencies, we cannot determine the prevalence of harm suffered by all hospice beneficiaries.”

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