Vitacare Health Services, Inc.

“Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This Standard is not met as evidenced by: Based on the review of the Agency’s Error Summary report and Staff interview, it was determined in 18 of 114 reports submitted for the last 12 months, the Agency failed to submit all timely reports. Finding include: 1. The Agency’s Error Summary report for 05/01/24 through 04/25/25, was reviewed on 05/14/25 at 11:10 AM. The report included 15.79% of the OASIS reports were not submitted timely, resulting in a warning. 2. The above findings were confirmed, during the interview with the Administrator and Director of Nursing, on 05/14/25 at 10:30 AM.”

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on clinical record reviews, and Staff interviews, it was determined in 3 of 13 (Pts. #1, 8, and 12) clinical records reviewed, the Agency failed to ensure Staff provide service indicated in the PsOC. 2. Pt. #8 was admitted to the home health services on 02/14/25 with the diagnosis of Type 2 Diabetes Mellitus with Diabetic Neuropathy. The clinical record was reviewed on 05/13/25. The clinical record contained a POC dated 02/14/25, that required the SN to assess the patient 2 times a week for 9 weeks. The SN failed to visit the patient twice, during the week of 05/04/25 (week #4). 3. Pt. #12 was admitted to the home health services on 11/14/24 with the diagnosis of Type 2 Diabetes Mellitus without Complications. The clinical record was reviewed on 05/13/25. The clinical record contained a recertification POC dated 01/13/25, that required the SN to assess the patient’s heart rate 1 time a week for 9 weeks. The SN failed to assess the patient heart rate, during the week of 01/16/25 (week #1). 4. The above findings were confirmed, during the interview with the Administrator and Director of Nursing, on 05/14/25 between 10:00 AM and 1:00 PM. Findings include: 1. Pt. #1 was admitted to home health services on 03/11/25 with the diagnosis of, but not limited to, Chronic Systolic (Congestive) Heart Failure. The clinical record was reviewed on 05/12/25. The clinical record contained the POC for the certification period of 03/11/25 to 05/09/25. The POC required, “Notify Physician of vital sign parameters out of range… Systolic Blood Pressure: greater than (>) 160 mm Hg less than () than 90 mm Hg less than ( The weekly SN visit notes dated 3/25/25 (156/92), 4/1/25 (136/92), and 4/8/25 (148/92) contained a Diastolic Blood Pressure greater than 90. The record lacked documentation the SN notified the Physician.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on clinical record reviews, interview, and observation during a home visit, and Staff interviews, it was determined in 3 of 13 (Pts. #1, 2, and 3) clinical records reviewed, the Agency failed to ensure the PsOC included interventions and/or medications. Findings include: 1. Pt. #1 was admitted to home health services on 03/11/25 with the diagnosis of, but not limited to, Chronic Systolic (Congestive) Heart Failure. The clinical record was reviewed on 05/12/25. The clinical record contained the POC for the certification period of 03/11/25 to 05/09/25. The POC required, “SN Frequency: 1w9… SN to perform complete physical assessment each visit with emphasis on CHF…” The SOC assessment completed by the SN and dated 03/11/25 included a weight of 250 pounds. The record contained weekly visit notes from 03/18/25 to 04/29/25, and the recertification assessment dated 05/06/25, all completed by the SN and lacked the patient’s weight. During an interview with the Administrator and Director of Nursing on 05/14/25 at 10:30 AM, the Director of Nursing stated Pts. with CHF should be “weighed daily, a scale is sent to the Pt.” During the same interview, the Director of Nursing confirmed the POC effective 03/11/25 lacked instructions for assessing the patient’s weight. 2. Pt. #2 was admitted to home health services on 04/11/25 with the diagnosis of, but not limited to, Unspecified Quadriplegia. A home visit was conducted with Staff #2 on 05/03/25. During the home visit, an interview was conducted with the primary caregiver that stated, the Pt. has an “Intrathecal Baclofen Pump” that was inserted in 2004. The caregiver raised the patient’s shirt and observed the pump implanted in the abdominal area. The caregiver presented a document that contained Pt. #2 receives Baclofen 2,000.0 MCG/ML Monday through Sunday, total daily dosage 262.0 MCG/day. The clinical record was reviewed on 05/12/25. The clinical record included POC effective 04/11/25. The POC lacked the Intrathecal Baclofen Pump. 3. Pt. #3 was admitted to home health services on 12/20/24 with the diagnosis of, but not limited to, Amyotrophic Lateral Sclerosis. The clinical record was reviewed on 05/13/25. The clinical record included the weekly SN visit notes from 03/12/25 to 04/08/25, 04/24/25 to 04/29/25; and the recertification assessment dated 04/14/25 contained documentation the Pt. had a gastrostomy tube and received “twocal, 2 cans 2x/day”. A home visit was conducted on 05/13/25 with the Administrator. During the home visit, an interview was conducted with the caregiver. During the interview, the caregiver presented the nutritional supplement “TWOCAL HN 2.0”, 8 ounces per container. The caregiver stated the Pt. usually received four 8-ounce containers a day, but it was placed on hold recently. Received instructions from a dietician to start two 8-ounce containers a day, and flush gastrostomy tube with 2-ounces of water before and after each feeding. As of 05/13/25, the PsOC for the certification period of 02/18/25 to 04/18/25 and effective 04/19/25 lacked TWOCAL HN 2.0 amount and frequency to be given, gastrostomy tube care and maintenance. 4. During an interview with the Administrator and Director of Nursing on 05/14/25 at 10:30 AM, both confirmed the PsOC were incomplete.”

“Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This Element is not met as evidenced by: Based on clinical record reviews, Agency policy review, and Staff interviews, it was determined that 2 of 13 (Pts. #5 and 1) clinical records reviewed, the Agency failed to ensure clinical records were complete and accurate. 2. Pt. #5 was admitted to the home health services on 04/25/25 with the diagnoses of Encounter for Change or Removal of Surgical Wound Dressing and Type 2 Diabetes Mellitus without Complications. The clinical record was reviewed on 05/13/25. The clinical record contained an SN visit note dated 05/12/25 that lacked the heart rate and the blood glucose. 3. The Agency policy titled; “Medication Reconciliation” was reviewed on 5/14/25. The policy required, “… staff will accurately and completely reconcile medications across the continuum of care… Procedure… 3. Any discrepancies… are reconciled and documented. If necessary, calls must be placed to the primary physician to determine accuracy and completeness…” 4. The above findings were confirmed, during the interview with the Administrator and Director of Nursing, on 05/14/25 between 10:00 AM and 1:00 PM. Findings include: 1. Pt. #1 was admitted to home health services on 03/11/25 with the diagnosis of, but not limited to, Chronic Systolic (Congestive) Heart Failure. The clinical record was reviewed on 05/12/25. The clinical record included the SN visit note dated 04/22/25 that contained, “SN met with pt at his house. Pt is aox3… Endorses right knee pain, states taking Tylenol with relief.” The “Medication Profile” form completed by the SN for the certification period of 03/11/25 to 05/09/25 lacked “Tylenol”.”