Vitalcaring Group

“Based on medical record (MR) review, agency policies and procedures, and interviews with staff it was determined the agency failed to ensure the physician ordered visit frequency was followed for each discipline. This deficient practice affected four of 14 MR reviewed including Home Visit (HV) # 3, MR # 1, MR # 2, MR # 6, and had the potential to affect all patients admitted to this hospice. Findings include: Agency Policy: Plan of Care (Hospice) Policy Number: 4-060.1 Revised: 12/2024 ...Policy: A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the Hospice program. The Care provided to the patient must be in accordance with the plan of care... Procedure: ...4. The plan of care will identify the patient’s needs and services to meet those needs...It must state, in detail, the scope and frequency of services to meet the patient’s and family/caregiver’s needs... 14. Care provided to the patient will be in accordance with the plan of care. Agency Policy: Missed Visits Policy Number: 4-038.1 Revised: 12/2024 Purpose: To ensure that missed visits are documented and does not affect the quality of patient care. Policy: Missed visits will be communicated to the Clinical Care Manager and the patient’s physician. The missed visit will be rescheduled for the same week if possible. Missed visits will be documented in the clinical record. Procedure: ...2. If a visit is missed and not rescheduled the clinician will: a. Notify the physician ... of the missed visit and reason for the missed visit... c. If an aide visit is missed the aide will contact the case manager or Clinical Care Manager and the manager/supervisor will take appropriate measures... 4. MR # 6 was admitted to the agency on 2/10/25 with a terminal diagnosis of Atherosclerotic Heart Disease of Native Coronary Artery. Review of the physician’s order dated 3/10/25 revealed an order for SN two visits per week for four weeks and one visit per week for one week, effective week of 3/9/25 due to decline and increased educational needs. Review of the SN Visit Report Notes for the week of 3/9/25 revealed the SN performed one visit this week and not the two visits as ordered. There was no documentation of a physician order to omit the SN visit. Review of the IDG Summary Report dated 3/12/25 revealed no documentation the missed visit was discussed with the physician. An interview was conducted on 3/20/25 at 1:04 PM with EI # 1, who confirmed the agency failed to ensure the SN visit frequency was followed. 1. HV # 3 was admitted on 9/9/24 and recertified for hospice care from 12/8/24 to 3/7/25 with a terminal diagnosis of Atherosclerotic Heart Disease. Review of the Hospice Recertification and Plan of Care (POC) dated 12/8/24 revealed physician’s orders for Skilled Nurse (SN) two visits per week for 13 weeks. Review of the SN Visit Report Notes for the week of 12/22/24 through 12/28/24 revealed one of the two physician ordered SN visits were completed. There was no documentation of a physician order to omit the SN visit. Review of the IDG (Interdisciplinary Group) Summary Report dated 12/26/24 revealed no documentation the missed visit was discussed with the physician. An interview was conducted on 3/20/25 at 11:50 AM with Employee Identifier (EI) # 3, Vice President of Operations, who confirmed the agency failed to ensure the SN visit frequency was followed. 2. MR # 1 was admitted 11/8/24 and recertified for Hospice care from 2/6/25 to 5/6/25 with a terminal diagnosis of Acute Myeloblastic Leukemia. Review of the Hospice Recertification and POC dated 2/6/25 revealed physician’s orders for Hospice Aide (HA) one visit per week for one week, three visits per week for 12 weeks, then one visit per week for one week. Review of the HA Visit Notes from 2/16/25 through 2/22/25 revealed two of three of the HA visits were completed.There was no documentation of a physician’s order to omit the visit. Review of the IDG Summary Report dated 2/27/25 revealed no documentation the physician was notified of the missed visit. An interview was conducted on 3/20/25 at 12:10 PM with EI # 1, Branch Director, who confirmed the agency failed to ensure the visit frequency for the HA was followed. 3. MR # 2 was admitted on 11/1/24 and recertified for hospice care from 1/30/25 to 4/29/25 with a terminal diagnosis of Occlusion and Stenosis of Bilateral Carotid Arteries. Review of the Hospice Recertification and POC dated 1/30/25 revealed physician’s orders for SN one visit per week for one week, two visits per week for 12 weeks, then one visit per week for one week. Review of the SN Visit Notes from 2/9/25 through 3/1/25 revealed one of the two ordered SN visits were completed in each of the three weeks. There was no documentation of a physician’s order to decrease the SN visits during those three weeks and no documentation the physician was notified of the missed visits.In an email received on 3/20/25 at 4:02 PM, EI # 3 confirmed the agency failed to ensure the visit frequency for the SN was followed.”

“Based on review of employee files, agency policy, and interview with staff it was determined the agency failed to ensure vaccinations against bloodborne pathogens were offered to each employee. This affected one of six employee files reviewed including Employee Identifier (EI) # 7, Registered Nurse, and had the potential of affect all employees. Agency Policy: Bloodborne Pathogens and Hepatitis B Exposure Control Plan Policy Number: 6-029.1 Revised: 12/2024 Purpose: To provide guidelines to reduce the risk of occupational exposure to bloodborne pathogens, including Hepatitis B (HPV). ...Procedure: 1.1. The organization shall ensure that the exposure control plan is made accessible to employees. ...3. Information will be provided to new direct care employees upon hire regarding the risks of exposure... 4. Determination of the new direct care employee’s current HBV vaccination will be completed in the pre-employment health assessment. 5. The vaccine and vaccination will be offered free of charge within ten (10) days of employment... 7. An employee who has not been previously been vaccinated and who declines administration of the HBV vaccine is required to sign a declination statement... 1. A review of six employee personnel files including health information was conducted on 3/20/25. EI # 7 was hired as a full time RN on 4/15/24. There was no documentation EI # 7 was offered or received the Hepatitis B vaccine and no documentation the employee declined the vaccination. An interview was conducted on 3/20/25 at 1:00 PM with EI # 1, Branch Director, who confirmed the agency failed to ensure each employee was offered vaccinations against bloodborne pathogens.”

“Based on medical record (MR) review, agency policy and procedure, and interview with staff it was determined the agency failed to ensure the Aide Care Plan was updated to include all instructions for the Hospice Aide (HA).This affected one of 12 patients receiving HA services including MR # 9 and had the potential to affect all patients receiving HA services. Agency Policy: Aide Care/ServicesPolicy Number: 4-031.1Revised: 12/2024Purpose: To define the process for the development and use of an aide care plan.Policy: Each patient receiving aide services will have an individualized care plan developed by an appropriate professional and used to direct the care performed by the assigned aide.Procedure: ...1. The aide care plan will be individualized to the specific patient and may include: ...H. Specific procedure to be performed...3. The Case Manager, or other appropriately skilled professional, will review changes to the aide care plan with the assigned aide, as appropriate... MR # 9 was admitted 5/3/24 with a terminal diagnosis of Congestive Heart Failure. Review of the Hospice Certification and Plan of Care dated 5/3/24 revealed physician’s orders for Skilled Nurse (SN) two visits per week for nine weeks then one visit per week for one week and HA three visits per week for eight weeks then one visit per week for one week. Review of the physician’s order dated 5/20/24 revealed orders for Zinc Oxide, a skin barrier cream, to be applied to blanchable area of redness to buttocks during perineal care daily. Review of the Aide Care Plan Report dated 5/5/24 revealed instructions for the HA to provide perineal care to MR # 9 every visit. There was no documentation the Aide Care Plan Report was updated to include the application of the barrier cream during perineal care.Review of the HA Visit Note Reports dated 5/20/24 through 7/1/24 revealed no documentation Zinc Oxide was applied to the buttocks during perineal care. An interview was conducted on 3/20/25 at 12:00 PM with Employee Identifier # 1, Branch Director, who confirmed the agency failed to update the Aide Care Plan with the new physician’s order.”

“Based on review of personnel files, agency policy and procedure, and interview with staff, it was determined the agency failed to ensure the competency of each employee was assessed annually. This deficient practice affected one of six personnel files reviewed including Employee Identifier (EI) # 6, Hospice Aide (HA), and had the potential to affect each patient admitted to this agency. Findings include: Agency Policy: Competency ProgramPolicy Number: 7-029.1Revised: 12/2024Purpose: To ensure that the competence of clinical organization employees is assessed, maintained, and improved on a continuing basis. Policy: ...Employees will demonstrate knowledge and proficiency of skills appropriate to their assigned responsibilities, including an ability to perform specified duties determined by the organization...Procedure: ...3. The organization will clearly identify and define the skills, which are essential to observe for the determination of competence, for each job category. In the identification of core competence, the essential skills will be demonstrated upon hire and annually thereafter... 1. EI # 6, was hired as a full time HA on 2/1/21.A review of EI # 6’s personnel file revealed the last competency evaluation was conducted on 5/2/21. An interview was conducted on 3/20/25 at 1:00 PM with EI # 1, Branch Director, who confirmed the skills competency was not evaluated for each employee annually per agency policy.”