Vitalcaring Group

“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 record review and interviews, the agency failed to ensure each OASIS (Outcome and Assessment Information Set) was successfully transmitted to the Centers for Medicare and Medicaid Services (CMS) system within 30 days of completion. This deficient practice had the potential to affect all 134 patients according to the agency’s active census. Findings: Review of the agency’s revised policy dated 12/2024 and titled, “OASIS Data Transmission” revealed, in part: Procedure: 1. The organization will encode and electronically transmit completed OASIS data to the national internet Quality Improvement Evaluation System (IQIES) for each applicable patient within thirty (30) days of completing the assessment of the patient. Review of the agency’s OASIS Agency Final Validation Report with a submission date of 10/30/2025 revealed 1 of 10 records were processed with a message the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency’s OASIS Agency Final Validation Report with a submission date of 11/05/2025 revealed 1 of 10 records were processed with a message the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency’s OASIS Agency Final Validation Report with a submission date of 12/01/2025 revealed 1 of 2 records were processed with a message the record was submitted late due to a submission date of more than 30 days after date on the record. An interview was conducted with S2ADM on 12/02/2025 at 10:37 a.m. The above assessments were reviewed. S2ADM confirmed the above assessments should have been submitted within 30 days of completion and were not. An interview was conducted with S1DOO on 12/04/2025 at 1:40 p.m. S1DOO confirmed the above records were submitted late. S1DOO stated OASIS Assessments should have been submitted within 30 days of completion.”

“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 observations, record reviews, and interviews, the agency failed to maintain an accurate medication profile for 1 (#4) of 5 sampled patients reviewed who received home visits. This deficient practice had the potential to affect all 134 patients, according to the agency’s current active census reported on 12/01/2025. Findings: Review of the agency’s policy with revision date 01/2025 titled, “Medication Profile” revealed, in part: Procedure 3. A drug regimen review will be performed at the time of admission, when updates to the comprehensive assessments are performed, when care is resumed after a patient has been placed on hold, and with the addition of a new medication. Review of Patient #4’s clinical record revealed Patient #4 was placed on hospital hold on 11/03/2025, and home health services were resumed on 11/18/2025 with a primary diagnosis of Urinary Tract Infection, Site Not Specified. Review of Patient #4’s Resumption of Care (ROC) orders dated 11/18/2025, for Certification Period 10/29/2025 through 12/27/2025, revealed a Skilled Nursing frequency of 2 visits times every week for 1 week and 1 time visit every week for 5 weeks effective 11/16/2025, and Physical Therapy frequency of 1 time a week for 1 week effective 11/23/2025. An observation was made on 12/03/2025 at 9:30 a.m. when a home visit was conducted with Patient #4, Patient #4’s daughter, and S3RN. S3RN reviewed and compared Patient #4’s current medication profile list with his current home medications, which revealed a bottle of Docusate Sodium 100mg tablet one tablet at bedtime with fill date 11/17/2025 was present in the home. Patient #4 and his daughter verified Patient #4 was taking this medication daily. Review of Patient #4’s medication profile dated 12/01/2025 revealed no documented evidence of Docusate Sodium 100mg, one tablet at bedtime on or after 11/17/2025. Review of Patient #4’s ROC orders dated 11/18/2025 revealed no documented evidence Docusate Sodium 100mg, one tablet at bedtime was ordered on or after 11/17/2025. An interview was conducted with S3RN on 12/03/2025 at 10:00 a.m. S3RN confirmed the above medication was not on Patient #4’s current ROC orders dated 11/18/2025, or the medication profile provided by the agency dated 12/01/2025 and should have been. An interview was conducted with S2ADM on 12/04/2025 at 1:35 p.m. S2ADM was notified of the medication discrepancy found during the home visit above. S2ADM confirmed Patient #4’s agency medication profile list should have accurately reflected the medications currently prescribed and did not. An interview was conducted with S1DOO on 12/04/2025 at 1:40 p.m. S1DOO was notified of the medication discrepancy found during the home visit above. S1DOO confirmed Patient #4’s agency medication profile list should have accurately reflected the medications currently prescribed and did not.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on record reviews and interviews, the agency failed to ensure all services and treatments were administered only as ordered by a physician or allowed practitioner for 1(#13) of 13 sampled patients reviewed. This deficient practice had the potential to affect all 134 patients, according to the agency’s current active census reported on 12/01/2025. Findings: Review of the agency’s revised policy dated 12/2024 and titled, “Verification of Physician’s Orders,” revealed in part: Purpose To ensure the patient’s physician or allowed practitioner orders are obtained in accordance with applicable law and regulation. Policy Orders will be obtained from a licensed physician or allowed practitioner for care and services to be provided to Home Health patients. Review of Patient #13’s clinical record revealed a Start of Care (SOC) date of 08/31/2023 and a current Plan of Care (POC) for Certification Period 06/21/2025 through 08/19/2025 with diagnoses which included, in part: Encounter for Attention to Cystostomy, Encounter for Fitting and Adjustment of Urinary Device, and Other Retention of Urine. Review of Patient #13’s Visit Note Report dated 07/08/2025, completed by S5RN, revealed the following in part: Narrative S5RN flushed suprapubic catheter with 30 cc (Cubic centimeter) normal saline (NS). Patient tolerated well with minor bladder spasms after flushing. Further record review of the above POC and clinical record for Patient #13 revealed there was no current written physician order dated 06/21/2025 or after for the above suprapubic catheter irrigation and/or flush provided by S5RN on 07/08/2025 available for review. An interview was conducted with S2ADM on 12/04/2025 at 1:52 p.m. The above nursing documentation for Patient #13’s suprapubic catheter flush provided by S5RN on 07/08/2025 was reviewed. S2ADM confirmed all services and treatments should be administered only as ordered by a physician or allowed practitioner and was not. S2ADM confirmed there was no written order available for review for Patient #13’s suprapubic catheter flush performed on 07/08/2025. An interview was conducted with S1DOO on 12/04/2025 at 1:55 p.m. The above nursing documentation for Patient #13’s suprapubic catheter flush provided on 07/08/2025 was reviewed. S1DOO confirmed all services and treatments should be administered only as ordered by a physician or allowed practitioner and was not. S1DOO confirmed there was no written order available for review for Patient #13’s suprapubic catheter flush performed on 07/08/2025.”

“Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA’s internal policies. (4) When services are provided on the basis of a physician or allowed practitioner’s verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA’s policies, must document the orders in the patient’s clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA’s internal policies. This Element is not met as evidenced by: Based on interviews and record reviews, the agency failed to ensure a verbal order for Discharge was signed and dated by the patient’s physician in a timely manner, not to exceed 60 days for 1 (#13) of 4 closed records reviewed. Cross-referenced with State Regulations 9123. Patient Care Standards: C. Plan of Care (POC). The plan of care for each patient must be individualized to address the patient’s problems, goals, and required services. 1. The Plan of Care, telephone and/or verbal orders shall be signed by the authorized healthcare provider within a timely manner, not to exceed 60 days. Findings: Review of the agency’s revised policy dated 12/2024 and titled, “Physician Participation in Plan of Care (Home Health)” revealed the following, in part: Procedure 7. The total plan of care is renewed more frequently when: A. A patient elects a transfer to another Home Health agency. 8. Orders will be reviewed and revised by the patient’s physician or allowed practitioner based on: A. Changes in the care or service being provided. State-Specific Guidelines 2. Louisiana- the POC, telephone and/or verbal orders shall be signed by the authorized healthcare provider within a timely manner, not to exceed 60 days. Review of Patient #13’s clinical record revealed a Plan of Care (POC) for the Certification Period 06/21/2025 through 08/19/2025 with a primary diagnosis of Encounter for Attention to Cystostomy. Further review of Patient #13’s POC Discipline/Treatments orders revealed there was no discharge order/discharge plan for discharging Patient #13 per his request. Review of a Verbal Order dated 07/17/2025 for Patient #13 revealed the following: DC Patient, Patient to be admitted to another agency per patient request due to no Home Health Aide (HHA) services available. Further review revealed there was no signature by Patient #13’s physician within the 60 day timeframe. Patient #13 was discharged from the agency on 07/20/2025. An interview was conducted with S2ADM on 12/04/2025 at 1:48 p.m. S2ADM confirmed Patient #13’s Discharge order dated 07/17/2025 required a signature by his physician. S2ADM further confirmed Patient #13’s physician had not signed the verbal order for Discharge within the required timeframe and should have. An interview was conducted with S1DOO on 12/04/2025 at 1:50 p.m. S1DOO confirmed Patient #13’s Discharge order dated 07/17/2025 required a signature by his physician. S1DOO further confirmed Patient #13’s physician had not signed the verbal order for Discharge within the required timeframe and should have.”

“Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient’s condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This Element is not met as evidenced by: Based on record reviews and interviews, the agency failed to have the Plan of Care (POC) reviewed and revised by the physician every 60 days, beginning with the SOC (Start of Care) date for 2 (#9 and #12) of 13 sampled patients reviewed. Findings: Review of the agency’s revised policy dated 12/2024 and titled, “Physician Participation in Plan of Care (Home Health)” revealed in part: Procedure 6. The attending physician’s (or allowed practitioner) recertification will be obtained in intervals of at least every sixty (60) days when the patient’s plan of care is reviewed, the patient recertified, and more often, if warranted. Patient #9 Review of Patient #9’s clinical record revealed a Start of Care (SOC) date of 09/05/2025. Review of the Plan of Care (POC) for certification period 09/05/2025 through 11/03/2025 revealed the physician did not review and sign the POC within the 60 day timeframe. Patient #12 Review of Patient #12’s clinical record revealed a SOC date of 08/22/2024. Review of the POC for certification period 12/22/2024 through 02/17/2025 revealed the physician did not review and sign the POC within the 60 day timeframe. An interview was conducted with S2ADM on 12/04/2025 at 1:40 p.m. The above POCs for Patients #9 and #12 were reviewed. S2ADM confirmed Patients #9 and #12’s POC orders were not reviewed and signed by the physician within 60 days and should have been. An interview was conducted with S1DOO on 12/04/2025 at 1:45 p.m. The above POC for Patients #9 and #12 were reviewed. S1DOO confirmed Patients #9 and #12’s POC orders were not reviewed and signed by the physician within 60 days and should have been”.”

“Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on observations, record reviews, and interviews, the Home Health agency failed to provide the patient and his/her caregiver written information regarding the patient’s medication schedule/instructions for 2 (#1 and #5) of 5 patients reviewed with home visits. Findings: Review of the agency’s revised policy dated 01/2025 and titled, “Medication Profile” revealed in part: Procedure 6. Each patient will receive appropriate written material as appropriate for specific medications he/she is receiving. The material will contain information on actions of the medication, potential side effects, contraindications the patient should be aware of, and any special instructions when taking the specific medication. Patient #1 Review of Patient #1’s clinical record revealed a Start of Care (SOC) date of 09/12/2025. Patient #1’s current Plan of Care (POC) dated 11/11/2025 through 01/09/2025 revealed a primary diagnosis of Unspecified Open Wound, Right Ankle, Subsequent Encounter. An observation was conducted on 12/01/2025 at 10:45 a.m. of Patient #1’s home folder with Patient #1 and S5RN present. Patient #1 stated her husband assisted with all of her medications. There was no medication profile available in Patient #1’s home folder. An interview was conducted with S5RN on 12/01/2025 at 11:15 a.m. S5RN confirmed Patient #1s home folder did not contain a current medication profile and should have. Patient #5 Review of Patient #5’s clinical record revealed a Start of Care (SOC) date of 11/19/2025. Patient #5’s current Plan of Care (POC) dated 11/19/2025 through 01/17/2025 revealed a primary diagnosis of Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris. An observation was conducted on 12/03/2025 at 10:30 a.m. of Patient #5’s home folder with Patient #5 and S4PT present. Patient #5 stated he administered his own medications. There was no medication profile available in Patient #5’s home folder. An interview was conducted with S4PT on 12/03/2025 at 11:10 a.m. S4PT confirmed Patient #5’s home folder did not contain a current medication profile and should have. An interview was conducted with S2ADM on 12/04/2025 at 1:40 p.m. S2ADM confirmed Patient #1 and #5’s home folders should have had accurate medication profiles available for the patient/caregiver. An interview was conducted with S1DOO on 12/04/2025 at 1:42 p.m. S1DOO confirmed Patient #1 and #5’s home folders should have had accurate medication profiles available for the patient/caregiver.”