Every finding on record at Vitacare Health Services, Inc

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 05/15/25. The Agency was in compliance with the Condition, 42 CFR 484.22, Establishment of the Emergency Program for this survey.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 05/15/25. Standard level deficiencies cited. Abbreviations: / = per x= times # = number AM = morning SN = Skilled Nurse POC = Plan of care SOC = Start of care RN = Registered Nurse PM = afternoon/evening Pt./ Pts. = Patient/Patients CHF= Congestive Heart Failure MmHg = Millimeter of Mercury a/ox3 = alert/oriented times three MCG/ML = micrograms per mililiter OASIS = Outcome and Assessment Information Set

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 the review of the Agency’s Error Summary report and Staff interview, it was determined in 18 of 114 reports submitted for the last 12 months, the Agency failed to submit all timely reports. Finding include: 1. The Agency’s Error Summary report for 05/01/24 through 04/25/25, was reviewed on 05/14/25 at 11:10 AM. The report included 15.79% of the OASIS reports were not submitted timely, resulting in a warning. 2. The above findings were confirmed, during the interview with the Administrator and Director of Nursing, on 05/14/25 at 10:30 AM.

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 clinical record reviews, and Staff interviews, it was determined in 3 of 13 (Pts. #1, 8, and 12) clinical records reviewed, the Agency failed to ensure Staff provide service indicated in the PsOC. 2. Pt. #8 was admitted to the home health services on 02/14/25 with the diagnosis of Type 2 Diabetes Mellitus with Diabetic Neuropathy. The clinical record was reviewed on 05/13/25. The clinical record contained a POC dated 02/14/25, that required the SN to assess the patient 2 times a week for 9 weeks. The SN failed to visit the patient twice, during the week of 05/04/25 (week #4). 3. Pt. #12 was admitted to the home health services on 11/14/24 with the diagnosis of Type 2 Diabetes Mellitus without Complications. The clinical record was reviewed on 05/13/25. The clinical record contained a recertification POC dated 01/13/25, that required the SN to assess the patient’s heart rate 1 time a week for 9 weeks. The SN failed to assess the patient heart rate, during the week of 01/16/25 (week #1). 4. The above findings were confirmed, during the interview with the Administrator and Director of Nursing, on 05/14/25 between 10:00 AM and 1:00 PM. Findings include: 1. Pt. #1 was admitted to home health services on 03/11/25 with the diagnosis of, but not limited to, Chronic Systolic (Congestive) Heart Failure. The clinical record was reviewed on 05/12/25. The clinical record contained the POC for the certification period of 03/11/25 to 05/09/25. The POC required, “Notify Physician of vital sign parameters out of range… Systolic Blood Pressure: greater than (>) 160 mm Hg less than () than 90 mm Hg less than ( The weekly SN visit notes dated 3/25/25 (156/92), 4/1/25 (136/92), and 4/8/25 (148/92) contained a Diastolic Blood Pressure greater than 90. The record lacked documentation the SN notified the Physician.

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 clinical record reviews, interview, and observation during a home visit, and Staff interviews, it was determined in 3 of 13 (Pts. #1, 2, and 3) clinical records reviewed, the Agency failed to ensure the PsOC included interventions and/or medications. Findings include: 1. Pt. #1 was admitted to home health services on 03/11/25 with the diagnosis of, but not limited to, Chronic Systolic (Congestive) Heart Failure. The clinical record was reviewed on 05/12/25. The clinical record contained the POC for the certification period of 03/11/25 to 05/09/25. The POC required, “SN Frequency: 1w9… SN to perform complete physical assessment each visit with emphasis on CHF…” The SOC assessment completed by the SN and dated 03/11/25 included a weight of 250 pounds. The record contained weekly visit notes from 03/18/25 to 04/29/25, and the recertification assessment dated 05/06/25, all completed by the SN and lacked the patient’s weight. During an interview with the Administrator and Director of Nursing on 05/14/25 at 10:30 AM, the Director of Nursing stated Pts. with CHF should be “weighed daily, a scale is sent to the Pt.” During the same interview, the Director of Nursing confirmed the POC effective 03/11/25 lacked instructions for assessing the patient’s weight. 2. Pt. #2 was admitted to home health services on 04/11/25 with the diagnosis of, but not limited to, Unspecified Quadriplegia. A home visit was conducted with Staff #2 on 05/03/25. During the home visit, an interview was conducted with the primary caregiver that stated, the Pt. has an “Intrathecal Baclofen Pump” that was inserted in 2004. The caregiver raised the patient’s shirt and observed the pump implanted in the abdominal area. The caregiver presented a document that contained Pt. #2 receives Baclofen 2,000.0 MCG/ML Monday through Sunday, total daily dosage 262.0 MCG/day. The clinical record was reviewed on 05/12/25. The clinical record included POC effective 04/11/25. The POC lacked the Intrathecal Baclofen Pump. 3. Pt. #3 was admitted to home health services on 12/20/24 with the diagnosis of, but not limited to, Amyotrophic Lateral Sclerosis. The clinical record was reviewed on 05/13/25. The clinical record included the weekly SN visit notes from 03/12/25 to 04/08/25, 04/24/25 to 04/29/25; and the recertification assessment dated 04/14/25 contained documentation the Pt. had a gastrostomy tube and received “twocal, 2 cans 2x/day”. A home visit was conducted on 05/13/25 with the Administrator. During the home visit, an interview was conducted with the caregiver. During the interview, the caregiver presented the nutritional supplement “TWOCAL HN 2.0”, 8 ounces per container. The caregiver stated the Pt. usually received four 8-ounce containers a day, but it was placed on hold recently. Received instructions from a dietician to start two 8-ounce containers a day, and flush gastrostomy tube with 2-ounces of water before and after each feeding. As of 05/13/25, the PsOC for the certification period of 02/18/25 to 04/18/25 and effective 04/19/25 lacked TWOCAL HN 2.0 amount and frequency to be given, gastrostomy tube care and maintenance. 4. During an interview with the Administrator and Director of Nursing on 05/14/25 at 10:30 AM, both confirmed the PsOC were incomplete.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: Based on clinical record reviews, Agency policy review, and Staff interviews, it was determined that 2 of 13 (Pts. #5 and 1) clinical records reviewed, the Agency failed to ensure clinical records were complete and accurate. 2. Pt. #5 was admitted to the home health services on 04/25/25 with the diagnoses of Encounter for Change or Removal of Surgical Wound Dressing and Type 2 Diabetes Mellitus without Complications. The clinical record was reviewed on 05/13/25. The clinical record contained an SN visit note dated 05/12/25 that lacked the heart rate and the blood glucose. 3. The Agency policy titled; “Medication Reconciliation” was reviewed on 5/14/25. The policy required, “… staff will accurately and completely reconcile medications across the continuum of care… Procedure… 3. Any discrepancies… are reconciled and documented. If necessary, calls must be placed to the primary physician to determine accuracy and completeness…” 4. The above findings were confirmed, during the interview with the Administrator and Director of Nursing, on 05/14/25 between 10:00 AM and 1:00 PM. Findings include: 1. Pt. #1 was admitted to home health services on 03/11/25 with the diagnosis of, but not limited to, Chronic Systolic (Congestive) Heart Failure. The clinical record was reviewed on 05/12/25. The clinical record included the SN visit note dated 04/22/25 that contained, “SN met with pt at his house. Pt is aox3… Endorses right knee pain, states taking Tylenol with relief.” The “Medication Profile” form completed by the SN for the certification period of 03/11/25 to 05/09/25 lacked “Tylenol”.

Recertification survey completed. Standard level deficiencies cited. Abbreviations: # = number AM = morning SN = Skilled Nurse POC = Plan of care SOC = Start of care PM = afternoon/evening Pt./ Pts. = Patient/Patients

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: A. Based on clinical records review and staff interviews, it was determined that the Agency staff failed to conform with Physician orders. This was found in 3 of 7 (Pts. #1, 7 and 5) clinical records reviewed. 3. Pt. #5 SOC 12/28/2021 Primary Diagnosis: Venous Insufficiency The clinical record was reviewed on 02/16/2022 at 2:30 PM. The clinical record included a physician’s note dated 01/04/2022. The note included an order, “…Nursing please hold off on changing the dressing this week—I will do it on January 11…” The clinical record also included a physician’s note dated 01/11/2022. The note included an order, “Nursing please hold off on changing the dressing this week—I will do it on January 18…” The clinical record included SN notes dated 01/07/2022 and 01/14/2022 that documented wound care was provided by the SN. During an interview with the Administrator, Director of Nursing and Intake Coordinator at 11:30 AM, the Director of Nursing acknowledged the wound care should not have been provided by the SN per physician's order. Physician notes dated 01/07/22 and 01/11/2022 also included an order of, “…2 Juven packets a day for wound healing…” A physician’s note dated 01/18/2022 included an order of, “Nursing please call family to explain about Juven…” The clinical record lacked any documentation that the patient/family was provided with or educated on Juven per physician’s order. 4. During an interview with the Administrator, Director of Nursing, and the Intake Coordinator from 10:30 AM through 12:00 PM the above findings of were confirmed. Findings include: 1. Pt. #1. SOC 02/15/2021. Primary Diagnosis: Type 2 Diabetes with Diabetic Peripheral Angiopathy Without Gangrene The clinical record was reviewed on 02/15/2022 at 12:45 PM. The POC for certification period of 12/12/21 to 02/9/22 required SN services 1 time a week for 9 weeks. The record included a missed visit documentation dated 01/17/2022 and 01/24/2022 by SN with Comments: “Nurse is sick....” The record lacked documentation of other SN visits attempted for week of 01/16/2022 and 01/23/2022 . No modification of Physician orders were found in the clinical record. 2. Pt. #7. SOC 10/16/21. Primary Diagnosis: Metabolic Encephalopathy The clinical record was reviewed on 02/16/2022 at 12:30 PM. The record contained an Admission order and POC effective 10/16/2021 for Occupational Therapy to evaluate and treat. The record lacked any documentation regarding an Occupational Therapy evaluation as ordered.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: A. Based on clinical record and Agency policy review and staff interview, it was determined the Agency failed to ensure clinical documentation entered into the clinical record was appropriately authenticated and complete. This was found in 6 of 7 (Pts. #1, 4, 7, 2, 5, 6 ) clinical records reviewed. 4. Pt. #2 SOC 12/06/2021 Primary Diagnosis: Parkinson’s Disease The clinical record was reviewed on 02/15/2022 at 2:15PM. The clinical record included blank consent forms titled, “Home Health Change of Care Notice” and “Notice of Medicare Non-Coverage” undated and signed by the patient. 5. Pt. # 5 SOC 12/28/2021 Primary Diagnosis: Venous Insufficiency The clinical record was reviewed on 02/16/2022 at 2:30 PM. The clinical record included a blank consent form titled, “Home Health Change of Care Notice” signed by the patient and dated 12/28/2021 (SOC date). 6. Pt. # 6 SOC 10/08/2021 Primary Diagnosis: Cellulitis of right lower limb The Clinical record was reviewed on 02/17/2022 at 9:30 AM. The clinical record included blank consent forms titled, “Notice of Medicare Non-Coverage,” and "Advance Beneficiary Notice of Non-Coverage," signed by the patient and dated 10/08/2021 (SOC date). 7. A policy titled, “Clinical Records” was reviewed on 02/17/2022 at 1:50 PM. The policy included, “…all entries must be legible, clear, complete and appropriately authenticated, dated and timed…” 8. During an interview with the Administrator, Director of Nursing, and Intake Coordinator from 10:30 AM through 12:00 PM the above findings were confirmed. The Administrator stated the forms were signed ahead of time in case they were to need them. The administrator agreed the forms should not have been signed until needed. Findings include: 1. Pt. #1. SOC 02/15/2021 Primary Diagnosis: Type 2 Diabetes with Diabetic Peripheral Angiopathy Without Gangrene The clinical record was reviewed on 02/15/2022 at 12:45 PM. The clinical record included a blank consenf forms titled: “Advance Beneficiary Notice of Non-coverage (ABN)” and “Home Health Change of Care Notice (HHCCN) signed by the patient and dated 2/15/21 (SOC date). 2. Pt. #4 SOC 12/10/2021 Primary Diagnosis: Hemiplegia Following Cerebral Infarct Affecting Left Nondominant Side The clinical record was reviewed on 02/16/2022 at 10:30 AM. The clinical record record included a blank consent form titled: “Notice of Medicare Non-Coverage”, undated and signed by the patient. 3. Pt. #7. SOC 10/16/2021 Primary Diagnosis: Metabolic Encephalopathy The clinical record was reviewed on 02/16/2022 at 12:30 PM. The clinical record included a blank consent forms titled: “Notice of Medicare Non-Coverage”, “Advance Beneficiary Notice of Non-coverage (ABN)” and “Home Health Change of Care Notice (HHCCN)", all signed by the patient and dated 10/16/21 (SOC date).