Every finding on record at Virtue Health Care Services, Inc

An unannounced Complaint Survey, #2021012946 , was conducted on 09/24/2021 at Virtue Health Care Services, Inc., Home Health Agency provider. The provider is not in compliance with 42 CFR Part 484, Subpart A-C, Conditions of Participation for Home Health Agencies.

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 review and interview, the HHA (Home Health Agency)'s Skilled Nurse failed to obtain a physician's order prior to providing treatment for 1 of 3 sampled patients (Patient #1). The findings included: Review of Patient #1’s record documented a "Start of Care" date of 12/12/19. Continued review reveals a "Home Health Certification and Plan of Care" for the Certification period 8/9/21 to 10/7/21 that documented Skilled Nurse for 12 hours a day for 7 days a week for 60 days. Review of Patient #1’s "Shift Note Record Form," dated 9/7/21 documented a "rash" and the "Shift Note Record Form," dated 9/8/21 documented "impaired skin integrity rash." Further review reveals documentation that included the "Nurse applied some cream on the rash and no adverse reaction." Continued review documented, "… no sign of discomfort" and a "report was given to the family member." Review of the Patient #1’s record and the HHA’s documentation lacked evidence of documentation of a physician's order for the treatment of the patient's "rash." During an interview on 9/24/21 at 2:00PM, the Director of Nursing reviewed Patient #1’s record and acknowledged the findings.

Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the HHA (Home Health Agency) failed to ensure the coordination of care for 1 of 3 sampled patients as evidenced by HHA’s Skilled Nurse's failure to communicate with the patient's physician to provide the physician's ordered frequency of Skilled Nursing visits (Patient #1). The findings included: Review of Patient #1’s record documented a "Start of Care" date of 12/12/19. Continued review reveals a Home Health Certification and Plan of Care for the certification period 8/9/21 to 10/7/21 that documents Skilled Nurse for 12 hours a day for 7 days a week for 60 days. Review of Patient #1’s record lacked evidence of documentation of Skilled Nurse Visits for 8/19/21; 8/21/21/; 8/22/21; 8/23/21 and 8/24/21. Further review of the patient's record lacked evidence of documentation of a modification to the physician’s order. Continued review of the Home Health Agency’s documentation lacked evidence of documentation of notification to the physician of the "missed" Skilled Nurse's visits. During an interview on 9/24/21 at 2:00PM, the Director of Nursing reviewed Patient #1’s record and acknowledged the findings.

Integrate all orders CFR(s): 484.60(d)(2) Integrate orders from all physicians or allowed practitioners involved in the plan of care to assure the coordination of all services and interventions provided to the patient. This ELEMENT is not met as evidenced by: Based on record review and interview, the HHA (Home Health Agency) failed to ensure the Home Health Certification and Plan of Care was complete and accurate for 2 of 3 sampled patients as evidenced Patient #1’s Plan of Care that lacked the frequency for prn (as needed) medications and clarification for the administration of Oxygen and Pulse Oximetry and Patient #2's Home Health Certification and Plan of Care that lacked the sliding scale for Insulin (Patient #1 and #2). The findings included: 1. Review of Patient #1’s record documented a "Start of Care" date of 12/12/19. Continued review reveals a Home Health Certification and Plan of Care for the certification period 8/9/21 to 10/7/21 that documented Ibuprofen 110mg. (milligrams)/ 5ml. (milliliters) suspension, give 10ml. prn fever greater than 98.7. Further review lacked evidence of documentation of the frequency of the prn medication. Continued review of the Home Health Certification and Plan of Care documented, "Durable Medical Equipment- Oxygen via nasal cannula and Pulse Oximeter" that lacked evidence of documentation of the liters per minute of the Oxygen, frequency of the Oxygen administration and clarification for the administration of the Pulse Oximeter. During an interview on 9/24/21 at 2:00PM, the Director of Nursing reviewed Patient #1’s record and acknowledged the findings. 2. Review of Patient #2’s record documented a "Start of Care" date of 05/25/21. Continued review reveals a Home Health Certification and Plan of Care for the certification period 07/24/21 to 09/21/21 that documented SN (Skilled Nurse) 2 visits every 1 day (daily). Continued review documented Humulin R 100 units/ml (milliliter) solution for injection; subcutaneous every am (morning) according to " sliding scale (for Insulin)." Further review of the Home Health Certification and Plan of Care lacked evidence of documentation of a physician's ordered "sliding scale." During an interview on 9/24/21 at 2:10PM, the Director of Nursing reviewed Patient #2's record and acknowledged the findings.