Vitalcaring Group

“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 record review and interview the agency failed to ensure: 1. The patient received therapy services per referral orders for 1 (Patient #1) of 17 (Patient #1, Patient #2, Patient #3, Patient #4, Patient #5, Patient #6, Patient #7, Patient #8, Patient #9, Patient #10, Patient #11, Patient #12, Patient #13, Patient #14, Patient #15, Patient #16, and Patient #17) sampled patients reviewed for receiving services per physician orders; and 2. The patient had capillary blood glucose monitoring per physician orders for 1 (Patient #1) of 8 (Patient #1, Patient #2, Patient #5, Patient #6, Patient #7, Patient #11, Patient #14, and Patient #15) sampled patients with orders for capillary blood glucose monitoring. Findings: Patient #1 Review of Patient #1’s referral dated 05/23/2023 revealed an order for occupational therapy (OT) and speech therapy (ST). Review of Patient #1’s record revealed no documented evidence of Patient #1 having received neither an occupational therapy nor a speech therapy evaluation. Further review revealed no documented evidence of a reason as to why Patient #1 did not receive the occupational therapy or speech therapy services. Review of Patient #1’s Home Health Certification and Plan of Care for Certification Period of 10/03/2023 through 12/01/2023 revealed, in part, nurse to monitor and report a pattern of three or more blood glucose levels greater than 240 milligrams/deciliter (mg/dl). Review of Patient #1’s record for Certification Period of 10/03/2023 through 12/01/2023 revealed no documented evidence and the agency presented no documented evidence of the skilled nurse having assessed Patient #1’s capillary blood glucose levels. In an interview on 11/29/2023 at 3:27 p.m., S1Administrator/Director of Nursing (DON) stated the agency had no documented evidence for the reason Patient #1 did not receive OT and ST services. S1Administrator/DON further stated the agency had no documented evidence to present of the skilled nurse had monitored Patient #1’s capillary blood glucose.”

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure the registered nurse (RN) performed hand hygiene after removing gloves and prior to applying sterile gloves for 1 (Patient #6) of 7 (Patient #1, Patient #2, Patient #3, Patient #4, Patient #5, Patient #6, and Patient #7) sampled patients observed during home visits. Findings: Review of Suprapubic Catheter Change Methods by J Wound Ostomy Continence Nursing 2017 published by Lippincott Williams & Wilkins revealed, in part, perform hand hygiene prior to donning sterile gloves. Further review revealed asepsis (sterile technique) is maintained to reduce the risk of infection. Review of Patient #6’s Home Health Certification and Plan of Care for certification period dated 11/01/2023 through 12/30/2023 revealed Patient #6 was to receive skilled nurse services for insertion of suprapubic catheter maintenance every month. Observation on 11/29/2023 at 8:55 a.m. revealed S2RN set up her barrier and supplies in preparation of changing Patient #6’s catheter. S2RN then removed her non-sterile gloves did not perform hand hygiene and then proceeded to apply sterile gloves and complete the suprapubic catheter change. In an interview on 11/29/2023 at 9:20 a.m., S2RN stated she should have performed hand hygiene after removing her non-sterile gloves and prior to applying her sterile gloves and completing the suprapubic catheter change. In an interview on 11/29/2023 at 10:01 a.m., S1Administrator/Director of Nursing (DON) stated S2RN should have performed hand hygiene between glove changes.”

“Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA’s quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This Standard is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure all infections were included in the agency’s infection control logs to ensure appropriate surveillance and investigation of infectious diseases for 3 (Patient #1, Patient #12, and Patient #15) of 4 (Patient #1, Patient #5, Patient #12, and Patient #15) sampled patients reviewed who received antibiotics for infections. Findings: Patient #1 Observation on 11/28/2023 at 8:31 a.m. revealed Patient #1 had a prescription for Bactrim (medication used to treat infections) Double Strength (DS) one tablet by mouth twice a day filled on 11/01/2023. In an interview on 11/28/2023 at 8:31 a.m., Patient #1 stated she received Bactrim after her surgery. Patient #12 Review of Patient #12’s Client Medication Record revealed Patient #12 received Ciprofloxacin (medication used to treat infections) 500 milligrams (mg) one tablet by mouth every 12 hours for diverticulitis with a start date of 10/08/2023. Patient #15 Review of Patient #15’s Client Medication Record revealed Patient #15 received Levofloxacin (medication used to treat infections) 500 mg one tablet daily for pneumonia with a start date of 05/11/2023. Review of the agency’s Infection Control Logs for November 2022 through November 2023 revealed no documented evidence and the agency presented no documented evidence Patient #1, Patient #12, and Patient #15’s infections listed above had infection control reports completed, nor did the agency have any documented evidence Patient #1, Patient #12, and Patient #15’s infections were including the agency’s surveillance of infections. In an interview on 11/29/2023 at 2:13 p.m., S1Administrator/Director of Nursing (DON) stated the agency did not have infection control reports for the above named patients. S1Administrator/DON further stated the agency was not tracking and trending infections the patients were admitted with, and therefore did not ensure an agency wide surveillance of infections.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure patients had an accurate medication reconciliation of all medications currently taking for 5 (Patient #1, Patient #2, Patient #3, Patient #4, and Patient #6 ) of 7 (Patient #1, Patient #2, Patient #3, Patient #4, Patient #5, Patient #6, and Patient #7) sampled patients observed during home visits. Findings: Patient #1 Review of Patient #1’s Client Medication Report revealed, in part, Eliquis (medication used to prevent blood clots) 2.5 milligrams (mg) one tablet by mouth twice a day, and Wellbutrin Extended Release (medication used to treat depression) 150 mg one tablet by mouth daily. Observation on 11/28/2023 at 8:31 a.m. revealed no Eliquis was present in the home, and Wellbutrin XL 300 mg one tablet by mouth daily with a fill date of 11/01/2023 was present in the home. In an interview on 11/28/2023 at 8:31 a.m., Patient #1 stated the Eliquis had been stopped since her surgery at the beginning of October 2023, and Patient #1 confirmed she was taking the Wellbutrin XL 300mg. Review of Patient #1’s Hospital Discharge Note dated 10/18/2023 revealed, in part, Wellbutrin XL 300mg one tablet by mouth every morning. Review of Patient #1’s Office Visit Note dated 10/25/2023 revealed current medications of, in part, Eliquis 2.5 mg tablet one by mouth twice a day, and Wellbutrin XL 300mg one tablet by mouth every morning. In an interview on 11/29/2023 at 3:27 p.m., S1Administrator/Director of Nursing (DON) stated the agency did not have an accurate reconciliation of Patient #1’s medication. S1Administrator/DON further stated the clinicians should be reviewing all medication by reviewing the orders, progress notes, and medication bottles every visit, and notifying the physician of any discrepancies. Patient #2 Review of Patient #2’s Client Medication Report revealed no documented evidence of the following medication having been included as current medication, in part, Lipomax 10/2/5% (compound cream to treat pain); Alprazolam (medication used to treat anxiety); and Ondansetron (medication used to treat nausea). Observation on 11/28/2023 at 9:55 a.m. during Patient #2’s home visit revealed the following medications were present in the home, in part, Lipomax 10/2/5% apply 2-3 grams to affected area five times a day; Alprazolam 0.5 mg tablet take half to one tablet by mouth twice a day as needed for anxiety with a filled date of 11/17/2023; and Ondansetron 8 mg one tablet every hours as needed for nausea with a filled date of 10/25/2023. Further observation revealed Medication List marked effective 11/18/2023 per Patient #2’s caregiver with the medication listed above as current medication. In an interview on 11/28/2023 at 9:55 a.m., Patient #2 stated she was taking the medication per the 11/18/2023 Medication List per her caregiver. Review of Patient #2’s referral documentation revealed the following medication was listed as current medication, in part, Lipomax 10/2/5% apply 2-3 grams to affected area five times a day; and Alprazolam 0.5 mg tablet take half to one tablet by mouth twice a day as needed for anxiety. In an interview on 11/29/2023 at 3:29 p.m., S1Administrator/DON further stated the agency did not have an accurate medication reconciliation for Patient #2. Patient #3 Review of Patient #3’s Client Medication Report revealed the following medication were listed as medication and dosage Cyproheptadine (medication used to increase appetite) 4mg one tablet by mouth twice a day; and Prednisone (steroid medication used to treat inflammation) 10mg take a half a tablet by mouth daily. Further review revealed no documented evidence of the following medication having been assessed, in part, Clonidine (medication used to treat blood pressure) 0.1mg one tablet by mouth twice a day; Prednisone 2.5 mg one tablet daily; and Prednisone 1 mg one tablet daily. Observation on 11/28/2023 at 10:45 a.m. revealed the following, in part, Clonidine 0.1 mg one tablet by mouth twice a day with a filled date of 09/12/2023 dispensed amount 180 tablets; Prednisone 2.5mg one tablet by mouth daily for 14 days with a filled date of 11/17/2023; Prednisone 1mg one tablet by mouth daily for 14 days with a filled date of 11/17/2023; and no evidence of Cyproheptadine present in the home; no evidence of Prednisone 10mg in the home. In an interview on 11/28/2023 at 10:47 a.m., Patient #3’s caregiver confirmed Clonidine was a current medication. Patient #3’s caregiver further stated the Cyproheptadine was never started due to insurance issues, and the physician was currently weaning her off of the prednisone and confirmed the 2.5mg and 1mg tablet prednisone was the current doses. In an interview on 11/29/2023 at 3:31 p.m., S1Administrator/DON stated the agency did not have an accurate medication reconciliation of Patient #3’s medication. Patient #4 Review of Patient #4’s Client Medication Report revealed no documented evidence of the following medication had been identified as current medication, in part, Tizanidine (medication used to treat muscle spasms), and Topamax (medication used to treat migraines). Observation on 11/28/2023 at 1:10 p.m. revealed the following medication was present in Patient #4’s home, in part, Tizanidine 4mg one tablet by mouth twice a day with a filled date of 11/01/2023; and Topamax 25mg one tablet by mouth daily with a filled date of 11/01/2023. In an interview on 11/29/2023 at 3:36 p.m., S1Administrator/DON stated the agency did not have an accurate medication reconciliation of Patient #4’s medication. Patient #6 Review of Patient #6’s Client Medication Report revealed the following medication was listed as current medication, in part, Latanoprost 0.005% eye drops (eye drops used after cataract surgery); Prednisolone Acetatate (steroid eye drop used to treat inflammation) 1% eye drops; and Pyridium (medication used to decrease urinary discomfort) 100mg. Further review revealed the following medications were not listed as current medication, in part, Carafate (medication used to treat stomach issues), Oxybutynin (medication used to treat bladder disorder), Fluticasone Proprionate (nasal spray used to treat allergies); Torsemide (diuretic- medication used to remove excess fluid). Observation on 11/29/2023 at 8:30 a.m. revealed the following medications were not present in the home, in part, Latanoprost 0.005% eye drops (eye drops used after cataract surgery); Prednisolone Acetatate (steroid eye drop used to treat inflammation) 1% eye drops; and Pyridium (medication used to decrease urinary discomfort) 100mg. Further observation revealed the following medications were present in the home, in part, Carafate 1 gram by mouth three times a day with a filled date of 10/03/2023, Oxybutynin 5mg one tablet by mouth twice a day with a filled date of 11/12/2023, Fluticasone Proprionate 50 mcg per puff take two puffs each nostril every morning; Torsemide 10mg one tablet by mouth daily as needed with a filled date of 10/10/2023. In an interview on 11/29/2023 at 8:35 a.m., Patient #6 stated the Latanoprost and Prdnisolone eye drops were stopped a few weeks ago after his cataract surgery, and the Pyridium was stopped after his urinary tract infection cleared. Patient #6 further stated he was taking Carafate, Oxybutynin, Fluticasone Proprionate; and Torsemide as mentioned above. In an interview on 11/29/2023 at 3:34 p.m., S1Administrator/DON stated the agency did not have an accurate medication reconciliation of Patient #6’s medication.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the skilled nurse notified the patient’s physician with a change in wound status for 1 (Patient #1) of 17 (Patient #1, Patient #2, Patient #3, Patient #4, Patient #5, Patient #6, Patient #7, Patient #8, Patient #9, Patient #10, Patient #11, Patient #12, Patient #13, Patient #14, Patient #15, Patient #16, and Patient #17) patients reviewed for timely physician notification for change in status. Findings: Review of Patient #1’s Wound Record Report dated 10/30/2023 revealed Patient #1’s right flank surgical wound was documented as having small purulent (puss containing) drainage and a faint odor. Review of Patient #1’s record revealed no documented evidence and the agency presented no documented evidence of Patient #1’s physician having been notified of the change in Patient #1’s right flank wound status. In an interview on 11/29/2023 at 3:27 p.m., S1Administrator/Director of Nursing (DON) stated the agency had no documented evidence to present of Patient #1’s physician was notified of new purulent drainage and odor to the right flank surgical wound. S1Administrator/DON further stated the physician should have been notified immediately.”

“In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This Element is not met as evidenced by: Based on record review and interview the agency failed to ensure the skilled nurse obtained a mid-upper arm circumference or ankle circumference when a congestive heart failure patient was unable to stand for daily weights for 1 (Patient #15) of 5 (Patient #1, Patient #3, Patient #5, Patient #7, and Patient #15) sampled patients with weight parameters. Findings: Review of Medscape’s How Should Muscle Mass Be Measured in Heart Failure article dated 08/23/2023 revealed, in part, the use of mid-upper arm circumference (MUAC) to determine poor prognosis in patients with heart failure and suggest that it may be useful in developing treatment strategies in patients with heart failure. Further review revealed it seems that the often overlooked and simple measure of arm circumference might carry significant prognostic value. Patient #15 Review of Patient #15’s Home Health Certification and Plan of Care for certification dates 06/20/2023 through 08/18/2023 revealed order for, in part, skilled nurse to obtain ankle measurements every visit since patient cannot stand on scale. Review of Patient #15’s Skilled Nurse Visit Notes dated 06/22/2023 and 06/29/2023 revealed no documented evidence and the provider presented no documented evidence of the skilled nurse having obtained a weight or ankle circumference for Patient #15. In an interview on 11/29/2023 at 3:39 p.m., S1Administrator/Director of Nursing (DON) stated the agency had no documented evidence of Patient #15’s skilled nurse having obtained Patient #15’s ankle circumference on 06/22/2023 and 06/29/2023.”