Lifespark Home Health

“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 home health agency (HHA) failed to notify the provider when staff was unable to complete a service indicated on the plan of care for 1 of 3 patients (P1). P1’s care plan indicated the HHA would be completing skin assessments. Due to P1’s physical status the staff was unable to fully visualize P1’s skin during visits. A concern arose that P1 had pressure ulcers on her back and the HHA was unaware of the potential ulcers. Findings include: P1’s Home Health Certification and Plan of Care for certification period 10/2/24 – 11/30/24 indicated P1’s pertinent diagnoses were contusion (a blunt force injury) of the abdomen wall, chronic congestive heart failure, morbid obesity, chronic respiratory failure, and chronic pain. P1 received skilled nursing (SN) visits weekly for symptom management, physical therapy (PT) and occupation therapy (OT). P1’s order included skilled nurse to observe and assess integumentary (skin, hair, nails, and glands) status. SN to provide skilled teaching related to altered skin integrity including pathophysiology, nutrition, medication regimen. Skilled nurse to report significant changes in status to physician for early intervention. P1’s skilled nursing admission visit note indicated P1 did not have any pressure ulcers (damage to the skin from constant pressure on the area), stasis ulcers (a sound caused by abnormal or damaged veins), or surgical wounds. P1’s integumentary status was assessed, and bruising was noted. The note did not indicate the location of the bruising. P1’s skilled nursing visit note dated 10/9/24 indicated P1’s integumentary status was assessed and P1 had bruising. The note did not indicate what areas of skin were assessed or the location of the bruising. P1’s skilled nursing visit note dated 10/18/24 indicated P1’s integumentary status was assessed with no problems identified. P1’s skilled nursing visit note dated 10/20/24 indicated P1’s integumentary status was assessed with no problems identified. P1’s skilled nursing visit note dated 10/22/24 indicated P1’s integumentary status was assessed with no problems identified. Upon interview on 10/29/24 at 12:01 p.m. a first responder, indicated his team had been to P1’s home multiple times to assist with transfers or falls. On 10/17/24 P1 called stating she had an emergency. Upon arrival the first responders found P1 in a hospital bed in her kitchen seated on multiple urine and feces soiled pads. He stated P1’s weight 400+ lbs. When the team transferred P1 he noticed “bed sores” on her lower back and buttocks region. He described the area as open skin sores with redness covered in feces. P1 was taken to the emergency department for a complaint of abdominal pain. Upon interview on 10/29/24 at 3:18 p.m. P1 stated she was not certain whether she had skin ulcers on her back or not as she cannot visualize them. She stated she was not certain what the HHA was doing for her skin. P1 was offered a home visit by the state evaluator however declined the visit. Upon interview on 10/30/24 at 10:48 a.m. physical therapist (PT)-a stated he saw P1 for an evaluation visit. He got P1 to sit on the side of bed with taxing effort on her part and maximum effort on his part. He stated she was seated on a soiled disposable pad. P1 had a patient care assistant (PCA) through a different agency with her and PT-A held P1 in a seated position and the PCA changed the soiled pad. PT-A stated he did not notice P1’s skin because he was not looking at her skin he was concerned with her mobility. He stated P1 was unable to reposition herself and unable to transfer safely with assistance of one staff member due to her weight and physical condition. Upon interview on 10/30/24 at 11:27 a.m. registered nurse (RN)-B stated she was told by P1 that she had gone to the emergency department on 10/17/24 and was released the same evening. P1 told RN-B that she was found covered in urine and feces because her irritable bowel syndrome (IBS) had acted up. RN-B stated she had not been able to assess P1’s skin because P1 is bedbound and immobile in bed except for use of her arms. P1 was unable to reposition herself even with the use her siderails. RN-B stated was unable to position P1 to fully assess all her skin. RN-B stated she was not certain if P1’s back and buttock had pressure ulcers. RN-B denied reporting her inability to assess P1’s skin to the provider. RN-B stated she had a plan to complete one of her skilled nursing visits along with PT so both could attempt to position P1 audit her skin, but P1 cancelled the PT visit. Upon interview on 10/30/24 at 1:36 p.m. RN-C stated when she assessed P1, P1 was unable to “even roll herself from side-to-side”, therefore she was unable to view the skin of her backside. She did not report to the provider that she was unable to compete the skin assessment. In addition, RN-C stated the HHA “probably” should have reported P1 as a vulnerable adult. Upon interview on 10/31/24 at 10:00 a.m. P1’s providers nurse, RN-D stated the clinic did not receive any phone calls, emails, or fax documents with concerns for P1’s skin. She stated the only information received was P1’s recertification which indicated the HHA was assessing her integumentary status and a few notifications of delayed or missed visits. Upon interview on 10/31/24 at 1:12 p.m. the Administrator stated she was aware P1 had called emergency services often, but not aware the staff could not assess her skin fully. Her expectation was if staff cannot complete an order to notify the provider. An agency policy titled Monitory Patient’s Response/Reporting to Physician with a revision date of 2022 indicated the patient’s physician (or other authorized licensed independent practitioner) will be contacted on the same day when any of the following occur: F. When there is a problem implementing the plan of care.”

“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 home health agency (HHA) failed to administer a treatment ordered by the physician for 1 of 3 patients (P3). P3’s provider placed an order with the HHA to measure and fit P3 for specialized leg wraps on 6/19/24. The agency did not order P3’s leg wraps until 9/18/24. Findings include: P3’s Providers order dated 6/19/24 indicated to please measure/fit patient for Farrow wrap 4000 or Sigvaris Compreflex wraps. Please ensure patient has wraps available to bring to his clinic appointment in one week for reapplication. P3’s Providers order dated 7/11/24 indicated to measure/fit patient for Farrow wrap 4000 or Sigvaris Compreflex and send to his next clinic appointment. Please ensure patient has wraps available to bring to clinic appointment for reapplication. P3’s Home Health Certification and Plan of Care for certification periods 7/31/24 - 9/28/24 indicated P3’s pertinent diagnoses were chronic venous insufficiency (improper functioning of the vein valves in the leg causing swelling and skin issues) and non-pressure ulcer of the right lower leg with fat layer exposed. P3 required skilled nursing (SN) weekly for wound complications. A telephone voicemail recorded message dated 9/17/24 at 10:36 a.m. between the provides licensed practical nurse (LPN)-A and the HHA registered nurse (RN)-A indicated LPN-A called the HHA and spoke to RN-A with concerns that P3 had orders for wraps faxed in July and August and concerned that he didn’t have them at his appointment on 9/13/24. RN-A clarified receiving the orders from July and August and stated she didn’t order the wraps because P3’s diagnosis wasn’t lymphedema therefore the HHA could not order the wraps. LPN-A verified the wraps were for chronic venous hypertension not lymphedema. RN-A stated she wasn’t sure if anyone from the HHA had ordered P3’s wraps and she would get back to LPN-A. LPN-A stated the provider would have ordered the wraps, but since P3 was on a skilled home care Medicare episode the HHA has to order all supplies per Medicare guidelines. A second telephone voicemail recording dated 9/17/24 with no time stamp indicated RN-A placed a call to LPN-A and stated the HHA measured P3 but did not order the Farrow wraps. She also stated she had spoken with the management team at the HHA, and the agency needed to discharge P3, but she would get the wraps sent to the HHA office and get the wraps to P3. A third telephone voicemail recording dated 9/19/24 with no time stamp indicated RN-A returned a call to LPN-A indicating the HHA discharged P3 and the HHA did have an extra visit and they would provide a visit to measure for P3’s wraps. P3’s occupational therapy visit note dated 9/18/24 indicated the therapist took P3’s measurements and educated P3 on the nature of the lymphedema and strategies for donning/doffing the wraps along with the wearing schedule. The HHA’s clinical manager ordered the wraps. The note did not indicate how or when P3 would receive the wraps. Upon interview on 10/29/24 at 11:54 a.m. P3’s provider stated he had been treating P3 for pressure ulcers and placed orders with the HHA two months in a row to order leg wraps for P3 and the order wasn’t completed. P3 was discharged from the agency on 9/13/24 as the agency indicated the wounds had healed and P3 came to the clinic 9/17/24 with no leg wraps and the ulcer had re-opened. The provided stated the unhealed ulcers were a chronic concern and P3 really needed the wraps. Upon interview on 10/30/24 at 8:31 a.m. P3 stated he did receive the wraps following his discharge from the HHA and was aware he should have had them sooner that than he received them. Upon interview on 10/30/24 at 11:45 a.m. RN-A stated she did review P3’s orders and saw the order from 6/19/24 and stated she didn’t think the HHA was responsible for ordering wraps. In addition, she stated Farrow wraps are for lymphedema and the agency was not treating him for lymphedema. RN-A spoke the HHA with management team, the wraps were ordered, and an occupational therapy visit was created to measure P3 on 9/18/24. RN-A was not certain if P3 had the wraps or not at the time of the state survey. Upon interview on 10/31/24 at 11:01 a.m. LPN-A stated P3’s wraps were originally ordered on 6/19/24 and the provider wanted P3 to have dressing changes twice a week, once by the HHA and once in the clinic. The HHA was to cleanse the wound, cover and place the wraps on P3 and then clinic would do the same. P3 saw the provider monthly and clinical staff weekly. LPN-A stated when P3 saw the provider on 8/26/24 he didn’t have the wraps, so the provider ordered them again. On P3’s provider appointment on 9/17/24 he still didn’t have the wraps, and P3 had been discharged from the HHA that was when LPN-A called the HHA for clarification. Upon interview on 10/31/24 at 1:12 p.m. the Administrator stated she was unaware of the order for wraps back in July and stated that when a client is on Medicare services the HHA is required to order the supplies. The Administrators expectations were staff follow all provider orders. A policy regarding provider orders was not obtained.”