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 interview, the Agency failed to encode and electronically transmit each completed OASIS assessment to the CMS system, within 30 days of completing the assessment of the patient for 36 of 1659 assessments processed for the time reviewed of 06/01/2024 to 12/31/2024. This failure resulted in quality data used to continuously improve the effectiveness of home healthcare failing to be reported to CMS in the required time frame. The findings included: The HHA Error Summary Report, retrieved from the iQIES website for the time of 06/01/2024 to 12/31/2024 was reviewed. Review of the HHA Error Summary Report for the time-period 06/01/2024 to 12/31/2024 identified Error #-3330. The description for Error #-3330 read in part, “Record Submitted Late: The submission date is more than 30 days after M0090 (Item M0090 specifies the date the actual assessment was completed) on this new record.” The documentation further identified the number of assessments with the error was 36 assessments and the percentage of assessments with this error was 2.17% of the total of 1659 assessments completed by the Agency. A joint interview was conducted with the Alternate Administrator and the Regional Director on 4/14/2025 at 4:00 p.m. The HHA Error Summary Report was reviewed with the Alternate Administrator. The Alternate Administrator stated the Agency was not aware of the late submissions of OASIS assessments, however she acknowledged the late submission. The Regional Director also stated that the issue was with the delayed Face to Face dates and completion from providers. During a record review of an Agency policy titled, “OASIS Data Transmission,” dated for revision 12/2024, read in part, “…. 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. “”

“Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This Element is not met as evidenced by: Based on record review and interview, the Agency failed to coordinate care delivery to ensure patient needs were met in that: Patient #3’s needs were not addressed when Patient #3’s family member notified the Agency of a change in status related to complications involving his indwelling urinary catheter (a hollow tube inserted into the bladder to facilitate urination). This failure had the potential to place Patient #3 at risk of hospitalization. Review of the clinical record of Patient #3 revealed a start of care date of 5/10/2022 for a primary diagnosis of Encounter for fitting and Adjustment of Urinary Device related to Benign Prostatic Hyperplasia (lower urinary tract symptoms and retention of urine) (care of a catheter inserted inside the male genitals because the client has difficulty passing urine). Further review of the clinical record of Patient #3 revealed an order, dated 4/29/2024, which revealed the following Physician Orders: “skilled nursing visits once weekly, then once every two weeks, with two additional visits as need for catheter care.” Review of the Client #3’s clinical record revealed that the family member of Patient #3 called into the agency on 6/6/2024 and informed the agency that “the foley cath” (urinary indwelling catheter) is not working properly as not urine coming through and would like a nurse to come check it. If a nurse is not available, requesting a call back so that he can take [Patient #3] to urgent care…” Review of the clinical record of Patient #3 for the time-period reviewed revealed that the record did not include documentation that a PRN (as needed) visit was completed between 6/6/2024 to 6/8/2024 Review of the clinical record of Patient #3 revealed nursing visit note from RN E,” dated 6/8/2024, revealed, “[family member] called reporting Foley catheter is out…noted no foley in place upon arrival. [Family member] had supplies on hand…Foley cath placed without difficulty.” During an interview with the Administrative Assistant, on 4/22/2025 at 3:00 p.m., The Administrative Assistant revealed that when she received the call from Patient #3’s family member on 6/6/2024, she informed the Branch Manager verbally at the time of the call. She further revealed that she doesn’t know what the Branch Manager did after the phone call, but it was standard procedure to inform the Branch Manager when a call was received for a visit request. During an interview with the previous Administrator/Alternate Nursing Supervisor on 4/16/2025 at 3:00 p.m., the previous Administrator/Alternate Nursing Supervisor was asked regarding the phone call incident on 6/6/2024, stated she doesn’t recall the incident regarding Patient #3’s foley catheter. During the exit conference on 4/22/2025 at approximately 5:00 PM, the President stated she didn’t know this incident occurred but understands the importance of visiting a patient as soon as possible with issues from a Foley catheter as it is considered an emergency in home care. Review of the Agency’s policy and procedure manual revealed a policy titled “Care/Service Coordination,” dated 12/2024, which read in part, “Timely and ongoing communication is the responsibility of each member of the [care team] and will be appropriate to the needs and abilities of the patient and relevant to the care and service provided. The clinician will be responsible for facilitating communications about changes in the patient’s status among assigned employees…J. Coordination of care delivery to meet the patients’ needs and involve the patient…in the coordination of care activities…11. All organization employees involved in patient care…will have access to the plan of care and other relevant patient information to ensure coordination and continuity. All employees will be knowledgeable regarding patient needs, goals of care and services.””

“Assure implementation of plan of care CFR(s): 484.105(c)(5) Assuring the development, implementation, and updates of the individualized plan of care. This Element is not met as evidenced by: Based on record review and interview, the clinical manager failed to ensure the plan of care was implemented for 1 of 18 patients (Patient #11) whose records were reviewed, in that; after a Patient #11 was discharged home from the hospital, and there were no nursing visits done for 33 days. This failure had the potential to place Patient #11 at risk of rehospitalization or serious illness. Review of the clinical record of Patient #11 revealed a start of care date of 6/21/2023 for a primary diagnosis of Chronic Obstructive Pulmonary Disease (disease of the lungs). Further review of the clinical record of Patient #11 revealed a plan of care, dated 4/16/2024 which revealed the following Physician Orders: “SN: 1w9 Once a week for 9 weeks… to identify and evaluate co-morbid conditions including Chronic Obstructive Pulmonary Disease and other conditions that present themselves during the course of this episode to identify changes and intervention to minimize complications…” Review of the clinical record of Patient #11 for the time-period of 4/16/2024 to 6/14/2024 revealed that Patient #11 was hospitalized on 5/2/24 with the diagnosis of Pneumonia (infection of the lungs). Patient was discharged from the hospital 5/9/24 and a skilled nursing visit was made on 5/10/2024 for a resumption of care. Further review of the record of Patient #11 revealed that between 5/11/2024 to 6/14/2024, no nursing visits were made as ordered on the plan of care. Review of case conference documentation on 6/12/2024 by the previous Administrator/ Alternate Nursing Supervisor revealed, “Spoke with patient today regarding her ROC visit a few weeks ago and no visits after the ROC visit completed. Patient stated that she has been fine and didn’t feel like she really needed a nurse, which was why she did not call to inquire about nursing visits. However, she stated that the last few days she hasn’t been feeling as well and would like for the nurse to come assess her and continue HHS (Home Health Services) if warranted. Explained that patient’s EOE (end of event) was this Friday, 6/14/2024, so nurse would need to come tomorrow or Friday. Patient requested recert (recertification) visit on Friday, 6/14/2024, as she has an appt tomorrow. Discussed with scheduler and will put recert (recertification) visit on 6/14/2024.” Review of a client coordination note report dated 6/14/24 by Supervising Nurse revealed, “No return call from message left yesterday. Called patient to try to schedule visit for today. The family member of Patient #11 answered the call, reported patient passed away at home yesterday Thursday 6/13/2024 about 1PM.” During an interview with the previous Administrator/ Alternate Nursing Supervisor on 4/16/2025 at 3:00 p.m., the previous Administrator/Alternate Nursing Supervisor was asked about the phone call on 6/12/2024. She stated she doesn’t recall the incident regarding missed visits for Patient #11. During the exit conference on 4/22/2025 at approximately 5:00 PM, the President stated the incident occurred from a computer error precipitated by RN E, but understands the importance of ongoing visits of a patient that was hospitalized with issues of post hospitalization pneumonia. She also stated that measures have been put in place to prevent this incident from recurring. Review of the Agency’s policy and procedure manual revealed a policy titled “Ongoing Assessments,” dated 12/2024, which read in part, “The scope and intensity of ongoing assessments will be determined by the patient’s diagnoses, condition, desire for care, response to previous care, and the care setting…1. During each home visit, the appropriate clinician will re-evaluate the patient according to the problems identified during the initial visit and thereafter the comprehensive assessment…C. Factors that alleviate or exacerbate physical symptoms…” Review of the Agency’s policy and procedure manual revealed a policy titled “Home Health Plan of Care Process,” dated 12/2024, which read in part, “…2. All clinicians will consider the conclusion of initial and ongoing assessment in their care planning, including but not limited to: A. Individualized patient needs and …problems related to care, functional status and family/caregiver support system B: Changes in patient’s condition…J. Specific services and treatment to be provided…S. 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...14. Services to be provided will be based on the prioritized needs of the patient… Each patient will be monitored for … response to care…””