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 weights were obtained in accordance with the plan of care for three (Patients #3, 6 and 8) of 17 patients. Patient #3 A review of the plan of care dated 08/24/24 to 10/06/24 showed a skilled nurse frequency of three visits per week for one week, seven visits per week for eight weeks and one visit per week for one week with orders to obtain the patient’s weight with each skilled nurse visit. A review of the clinical record showed the following: Skilled nurse assessments dated 08/08/24 and 08/10/24 documented no weights for the week of 08/08/24 to 08/10/24 (two of three visits with no weights obtained). Skilled nurse assessments dated 08/11/24, 08/12/24, 08/13/24, 08/14/24, 08/15/24 and 08/16/24 documented no weights for the week of 08/11/24 to 08/17/24 (six of seven visits with no weights obtained). Skilled nurse assessments dated 08/18/24, 08/19/24, 08/21/24, 08/22/24 and 08/24/24 documented no weights for the week of 08/18/24 to 08/24/24 (five of seven visits with no weights obtained). Skilled nurse assessments dated 08/25/24, 08/26/24, 08/27/24, 08/28/24, 08/29/24 and 08/30/24 documented no weights for the week of 08/25/24 to 08/31/24 (six of seven visits with no weights obtained). Skilled nurse assessments dated 09/03/24, 09/04/24 and 09/05/24 documented no weights for the week of 09/01/24 to 09/07/24 (three of seven visits with no weights obtained). Skilled nurse assessments dated 09/09/24 documented no weights for the week of 09/08/24 to 09/14/24 (one of seven visits with no weights obtained). Skilled nurse assessments dated 09/17/24, 09/18/24 and 09/19/24 documented no weights for the week of 09/15/24 to 09/21/24 (three of seven visits with no weights obtained). Skilled nurse assessments dated 09/23/24, 09/24/24, 09/25/24, 09/26/24 and 09/27/24 documented no weights for the week of 09/22/24 to 09/28/24 (five of seven visits with no weights obtained). Skilled nurse assessments dated 09/30/24, 10/01/24, 10/02/24 and 10/03/24 documented no weights for the week of 09/29/24 to 10/05/24 (four of seven visits with no weights obtained). Patient #6 A review of the plan of care dated 08/05/24 to 10/03/24 showed a skilled nurse frequency of one visit per week for nine weeks with orders to obtain the patient’s weight with each skilled nurse visit. A review of the clinical record showed the following: A skilled nurse assessment dated 08/07/24 documented no weights for the week of 08/05/24 to 08/10/24 (one of one visit with no weights obtained). A skilled nurse assessment dated 08/16/24 documented no weights for the week of 08/11/24 to 08/17/24 (one of one visit with no weights obtained). A skilled nurse assessment dated 08/30/24 documented no weights for the week of 08/25/24 to 08/31/24 (one of one visit with no weights obtained). A skilled nurse assessment dated 09/10/24 documented no weights for the week of 09/08/24 to 09/14/24 (one of one visit with no weights obtained). A skilled nurse assessment dated 09/18/24 documented no weights for the week of 09/15/24 to 09/21/24 (one of one visit with no weights obtained). Patient #8 A skilled nurse assessment dated 08/28/24 documented no weights for the week of 08/28/24 to 08/31/24 (one of one visit with no weights obtained). A skilled nurse assessment dated 09/03/24 documented no weights for the week of 09/01/24 to 09/07/24 (one of one visit with no weights obtained). A skilled nurse assessment dated 09/17/24 documented no weights for the week of 09/15/24 to 09/21/24 (one of one visit with no weights obtained). A skilled nurse assessment dated 09/24/24 documented no weights for the week of 09/22/24 to 09/28/24 (one of one visit with no weights obtained). A skilled nurse assessment dated 10/03/24 documented no weights for the week of 09/29/24 to 10/05/24 (one of one visit with no weights obtained). A skilled nurse assessment dated 10/08/24 documented no weights for the week of 10/06/24 to 10/12/24 (one of one visit with no weights obtained) A skilled nurse assessment dated 10/14/24 documented no weights for the week of 10/13/24 to 10/19/24 (one of one visit with no weights obtained) On 10/31/24 at 1:55 pm., Staff A stated the plan of care was not followed for the obtainment of weights for Patients #3, 6 and 8.”

“Make complaints to the HHA CFR(s): 484.50(c)(3) Make complaints to the HHA regarding treatment or care that is (or fails to be) furnished, and the lack of respect for property and/or person by anyone who is furnishing services on behalf of the HHA; This Element is not met as evidenced by: Based on record review and interview, the agency failed to conduct and/or document the resolution of a complaint for five (Complainant #1, 2, 3, 4 and 5) of five complaints. Complainant #1 A review of agency complaint records showed an incomplete resolution of the complaint dated 12/02/23. Complainant #2 A review of agency complaint records showed an incomplete resolution of the complaint dated 02/22/24. . Complainant #3 A review of agency complaint records showed an incomplete resolution of the complaint dated 03/19/24. Complainant #4 A review of agency complaint records showed an incomplete resolution of the complaint dated 03/25/24. Complainant #5 A review of agency complaint records showed an incomplete resolution of the complaint dated 04/23/24. On 10/31/24 at 1:50 pm, Staff A stated documentation failed to show a resolution to the complaints for Complainant #1, 2, 3, 4 and 5.”

“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 record review and interview, the agency failed to ensure an individualized plan of care for sixteen (Patient #1, 2, 3, 4, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16 and 17) of 17 patients. Patient #1 A review of the plan of care dated 08/20/24 to 10/18/24 showed a primary diagnosis of encounter for fitting and adjustment of urinary device with no patient specific individualized interventions developed for the management of the primary diagnosis. Patient #2 A review of the plan of care dated 08/12/24 to 10/10/24 showed a primary diagnosis of hypertensive heart with heart failure with no patient specific individualized interventions developed for the management of the primary diagnosis. Patient #3 A review of the plan of care dated 08/08/24 to 10/06/24 showed a primary diagnosis of diabetes mellitus type II with no patient specific individualized interventions developed for the management of the primary diagnosis. Patient #4 A review of the plan of care dated 08/25/24 to 10/23/24 showed a primary diagnosis of hypothyroidism with no patient specific individualized interventions developed for the management of the primary diagnosis. Patient #6 A review of the plan of care dated 08/05/24 to 10/03/24 showed a primary diagnosis of hypertensive heart chronic kidney disease with heart failure with no patient specific individualized interventions developed for the management of the primary diagnosis. Patient #7 A review of the plan of care dated 08/05/24 to 10/03/24 showed a primary diagnosis of diabetes mellitus type II with foot ulcer with no patient specific individualized interventions developed for the management of the primary diagnosis. Patient #8 A review of the plan of care dated 08/28/24 to 10/26/24 showed a primary diagnosis of systemic lupus with no patient specific individualized interventions developed for the management of the primary diagnosis. Patient #9 A review of the plan of care dated 08/08/24 to 10/06/24 showed a primary diagnosis of unspecified atrial fibrillation with no patient specific individualized interventions developed for the management of the primary diagnosis. Patient #10 A review of the plan of care dated 07/26/24 to 09/23/24 showed a primary diagnosis of pressure ulcer stage II right heel with no patient specific individualized interventions developed for the management of the primary diagnosis. Patient #11 A review of the plan of care dated 08/02/24 to 09/30/24 showed a primary diagnosis of hypertensive chronic kidney disease with no patient specific individualized interventions developed for the management of the primary diagnosis. Patient #12 A review of the plan of care dated 08/02/24 to 09/30/24 showed a primary diagnosis of chronic obstructive pulmonary disease with no patient specific individualized interventions developed for the management of the primary diagnosis. Patient #13 A review of the plan of care dated 10/10/24 to 12/08/24 showed a primary diagnosis of age-related osteoporosis with no patient specific individualized interventions developed for the management of the primary diagnosis. Patient #14 A review of the plan of care dated 09/20/24 to 11/18/24 showed a primary diagnosis of encounter for orthopedic aftercare with no patient specific individualized interventions developed for the management of the primary diagnosis. Patient #15 A review of the plan of care dated 08/27/24 to 10/25/24 showed a primary diagnosis of diabetes mellitus type II with diabetic chronic kidney disease with no patient specific individualized interventions developed for the management of the primary diagnosis. Patient #16 A review of the plan of care dated 10/09/24 to 12/07/24 showed a primary diagnosis of encounter for other orthopedic aftercare with no patient specific individualized interventions developed for the management of the primary diagnosis. Patient #17 A review of the plan of care dated 08/29/24 to 10/27/24 showed a primary diagnosis of chronic pain syndrome with no patient specific individualized interventions developed for the management of the primary diagnosis. On 10/31/24 at 1:50 pm, Staff A stated the plan of care for Patients #1, 2, 3, 4, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16 and 17 were not individualized for the patient specific management of the primary diagnosis.”