Every finding on record at Vital Care Health Systems

The following reflects the findings of the California Department of Public Health during an abbreviated standard survey for the investigation of a complaint. Complaint Number: CA0098929 Category: Quality of Care/Treatment See G572, G436 Representing the Department: Health Facilities Evaluator Nurse(s): HFEN 40615. The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility.

Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure blood glucose was checked, all morning medicines were administered, and wound care was provided, daily according to the physician’s order for one of three sampled patients (1). As a result, Patient 1 was admitted to the hospital with a high blood sugar. Findings: Per the Agency’s Patient’s Profile, Patient 1 was admitted on 10/4/22 with diagnoses which included Diabetes Mellitus (high levels of sugar in the blood). On 7/13/23 at 11:40 A.M., a joint record review and interview with the Intake Coordinator (IC) was conducted. The Service Authorization for direct skilled services for home health nurse was approved for dates of service from 4/24/23 through 7/23/23. The physician’s order indicated SN to check fasting blood sugar, administer all morning medicines, and foley catheter care every day. Wound care to left leg surgical site, left ischium, bilateral buttocks every three days and as needed. Right foot wound dressing every other day. Patient 1 clinical records showed that there were no skilled nurse (SN) visits made on the week of 5/26/23 through 5/30/23. The IC stated that there was no documentation found that visits were made. On 7/13/23 at 12:45 PM an interview with the Chief Executive Officer (CEO) was conducted. The CEO stated, missed patient visit should have been communicated to the PACE (program of all-inclusive care for the elderly) coordinator to ensure services were provided according to the physician’s order. On 7/13/23 at 1:01 P.M., an interview with the PACE coordinator was conducted. The PACE coordinator stated that she did not receive any communications from the SN on the week of 5/26/23 through 5/30/23. She further stated that she followed up with the SN about the timeliness of her documentation. On 7/13/23 at 1:10 P.M., an interview with the DPCS (Director of Patient Care Services) was conducted. The DPCS stated, there were missing visits and documentation for week of 5/26/23 through 5/30/23. The DPCS stated missing vising should have been communicated and documented by the SN to ensure care and services were provided per the physician’s order. A review of the agency’s policy and procedure, titled Care Planning Process, revision date Nov 2017, “… provide clinical direction to clinicians providing direct patient care…”

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 interview and record review, the agency failed to ensure the ordered frequency of visits were followed for one of three sampled patients (1). As a result, the patient did not receive the services needed as ordered by the physician and was admitted to the hospital. Findings: Per the Agency’s Patient’s Profile, Patient 1 was admitted on 10/4/22 with diagnoses which included Diabetes Mellitus (high levels of sugar in the blood). On 7/13/23 at 11:40 A.M., a joint record review and interview with the Intake Coordinator (IC) was conducted. The Service Authorization for direct skilled services for home health nurse was approved for dates of service from 4/24/23 through 7/23/23. The frequency of visits for a nurse was daily and as needed for the duration of three months which started on 4/24/23. Patient 1 clinical records showed that there were no skilled nurse (SN) visits made on the week of 5/26/23 through 5/30/23. The IC stated that there was no documentation found that visits were made. On 7/13/23 at 12:45 PM an interview with the Chief Executive Officer (CEO) was conducted. The CEO stated, missed patient visit should have been communicated to the PACE (program of all-inclusive care for the elderly) coordinator to ensure services were provided according to the physician’s order. On 7/13/23 at 1:01 P.M., an interview with the PACE coordinator was conducted. The PACE coordinator stated that she did not receive any communications from the SN on the week of 5/26/23 through 5/30/23. She further stated that she followed up with the SN about the timeliness of her documentation. On 7/13/23 at 1:10 P.M., an interview with the DPCS (Director of Patient Care Services) was conducted. The DPCS stated, there were missing visits and documentation for week of 5/26/23 through 5/30/23. The DPCS stated missing vising should have been communicated and documented by the SN. A review of the agency’s policy and procedure, titled Missed Visits, revision date of April 2017 “… ensure that missed visits are documented and does not affect the quality of patient care…missed visits will be communicated to the clinical supervisor and the patient’s physician …”

The following reflects the findings of the California Department of Public Health during an abbreviated standard survey. Complaint Number: CA00717702 Category: Resident/Patient/Client Rights The investigation was limited to the specific complaint and does not represent the findings of a full inspection of the agency. Representing the California Department of Public Health: Health Facilities Evaluator Nurse 36471. A deficiency was identified from this survey. Glossary of Terms: Hypertension - abnormal blood pressure Skilled Service - treatment provided by a licensed health professionals like nurses, occupational therapists and physical therapist.

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 interview and record review, the agency failed to ensure a skilled service was ordered by the physician prior to providing physical therapy service, and contact the physician for acceptance of care, for 1 of 2 sampled patients (1). As a result, the agency provided unauthorized and unapproved physical therapy service. Findings: Patient 1 was admitted to the agency on 10/8/2020 with diagnoses which included hypertension, per the agency's Patient Profile. A review of Patient 1's medical record was conducted. According to the Physician/Healthcare Provider Communication Form, dated 10/6/2020, indicated "...can you please approve order for [agency] for your patient [1] ?" There was no documented evidence that the physician ordered a type of skilled service for Patient 1. On 2/4/21 at 2:45 P.M., an interview was conducted with the Administrator (ADM). The ADM stated the agency received a referral from the assisted living community with a physician's order for the agency to see Patient 1. The ADM was unable to provide documented evidence of the type of skilled service Patient 1 needed. The ADM stated the owner of the assisted living reported that Patient 1 had fallen and needed physical therapy service. On 2/4/21 at 4:13 P.M., an interview was conducted with the Physical Therapist (PT) 1. PT 1 stated he received a call from the agency to see Patient 1 because of weakness and history of fall. PT 1 further stated Patient 1 received only PT service from the agency. PT 1 stated after his initial assessment with Patient 1, he called the physician's office and spoke to a female person which he thought was the physician's assistant, and verified the orders. PT 1 stated he can not recall who he talked to. PT 1 stated he did not speak to Patient 1's primary care physician while Patient 1 was on service. On 2/4/21 at 4:30 P.M., an interview was conducted with the ADM. The ADM stated the agency had an order to see Patient 1 but did not have specific orders for licensed nurse or PT service from the physician. According to the agency's policy and procedure, revised 11/17, titled Admission Criteria and Process, "...1...The patient's physician (or other authorized licensed independent practitioner) must order and approve the provision of any service. A skilled service must be ordered....13. The admitting clinician will contact the physician for clarification, acceptance, or rejection of care..."