Lifespring in Home Care of Eastern Pa

“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 a review of agency policy, a review of clinical records, and an interview with the agency Administrator, the agency failed to administer patient treatment as ordered by the physician for one (1) out of four (4) patient home visit observations (Observation #1). Findings Include: Agency policy/procedure reviewed on June 27, 2024 at approximately 1:30 p.m. ‘3.03.2’ ‘Care Planning, Coordination of Services, and Quality of Care’ ‘Conformance with physician Orders’ “Drugs, services, and treatments will be administered only as ordered by the physician.” Patient home visits were conducted on June 26, 2024 between approximately 9:00 a.m. and 1:30 p.m. Observation #1: During a home visit for (CR#1) on 06/26/24 at approximately 9:00 a.m., the registered nurse (employee #9) performed wound care. The physician orders for wound care are as follows: “Skilled nurse to provide wound care to ....... Cleanse wounds with water and Dove soap, pat dry. Apply Acticoat 3 to wound beds. Apply unna boot and coban. Cover with tubifast blue ....” Employee #9 was asked to verbalize the steps of the wound care and what items were being utilized as she was providing care. Employee #9 applied “Hydrafera Blue” to the wound areas. Employee#9 did not apply Acticoat 3 to the wound areas, as ordered by the physician. Employee #9 ‘Direct Care Visit Summary’ dated 06/26/24, signed 06/27/24 at 12:28 p.m., include but was not limited to, wound care comments “Redressed with Hydrafere Blue, wrapped with rolled gauze. Tubigrip applied.” No documentation provided of employee #9 obtaining new/updated physician orders for wound care. An interview conducted with the agency Administrator on June 27, 2024 at approximately 1:45 p.m. confirmed the above findings”

“Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA’s internal policies. (4) When services are provided on the basis of a physician or allowed practitioner’s verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA’s policies, must document the orders in the patient’s clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA’s internal policies. This Element is not met as evidenced by: Based on a review of agency policy, a review of clinical records, and an interview with the agency Administrator, the agency failed to obtain the physicians countersignature within 10 days of obtaining verbal orders, per policy, and or per state regulation within 30 days, for four (4) out of ten (10) clinical records (CR) reviewed (CR#1, CR#3, CR#8, CR#10). Findings Include: Pennsylvania ‘Act of June 30, 2022, P.L. 391, No. 30’ “Health Care Facilities Act’ is amended to read : “ .... (4) “Within 30 days of issuance, an order of home health care services must be signed and dated by a physician, nurse practitioner, or physician assistant.” Agency policy/procedure reviewed on June 27, 2024 at approximately 1:30 p.m. ‘3.15’ ‘Medical Policies and Physician Orders’ ‘Procedure’ “ ..... Verbal orders must be sent for confirmation and countersigned by the physician within 10 days and received back no less than 30 days.” A review of CRs was conducted on June 27, 2024 at approximately 11:00 a.m. The patients start of care (SOC) is listed below. CR#1 SOC 08/13/22: Patients certification period of 08/13/22-10/11/22 was reviewed. Verbal physician’s order taken by a registered nurse on 08/13/2022. The physician’s countersignature was obtained on 10/20/22. (69 days). Patients certification period of 10/12/22-12/10/22 was reviewed. Verbal physician’s order taken by a registered nurse on 10/09/2022. The physician’s countersignature was obtained on 12/19/22. (69 days). CR#5 SOC 04/27/24: Patients certification period of 04/27/24-06/25/24 was reviewed. Verbal physician’s order taken by a registered nurse on 04/27/2024. The physician’s countersignature was obtained on 06/12/24. (47 days). CR#8 SOC 02/08/24: Patients certification period of 02/08/24-04/07/24 was reviewed. Verbal physician’s order taken by a registered nurse on 02/08/2024. The physician’s countersignature was obtained on 03/11/24. (32 days). CR#10 SOC 11/27/23: Patients certification period of 01/26/24-03/25/24 was reviewed. Verbal physician’s order taken by a registered nurse late on 01/30/2024. The physician’s countersignature was obtained on 04/05/24. (71 days). An interview conducted with the agency Administrator on June 27, 2024 at approximately 1:45 p.m. confirmed the above findings”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on review of agency policy, clinical records, and an interview with the agency Administrator, agency failed to send a discharge summary to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the home health agency (HHA) (if any) within five (5) business days of the date of the order for discharge from the responsible physician or sending a completed transfer summary within 2 business days of a planned transfer or becoming aware of an unplanned transfer for three (3) of three (3) discharged clinical records (CR) reviewed (CR#8, CR#9, CR#10). Findings include: Agency policy/procedure reviewed on June 27, 2024 at approximately 1:30 p.m. ‘3.12.1.F’ Patient Transfer/Discharge’ ‘Procedure’ ‘Discharge/Transfer Summaries:’ “A completed discharge summary is sent to the primary care practitioner .... within 5 business days of the patients discharge. A completed transfer summary is sent within 2 business days of becoming aware of a planned transfer, if the patients care will be immediately continued in a health care facility. A completed transfer summary is sent within 2 business day of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the agency becomes aware of the transfer.” A review of CRs was conducted on June 27, 2024 at approximately 11:00 a.m. The patients start of care (SOC) is listed below. CR#8 SOC 02/08/24: Patient transferred to a hospital on May 2, 2024. Documentation of a ‘Transfer Summary’ dated May 9, 2024 being sent late on May 15, 2024. (4 business days) CR#9 SOC 01/24/24: Patient discharged from agency on February 28, 2024. Documentation provided of sending a Discharge Summary to the physician on 03/14/24. (11 business days) CR#10 SOC 11/27/23: Patient transferred to a hospital on February 28, 2024. No documentation provided of a ‘Transfer Summary’ being completed and being sent to the receiving health care facility. An interview conducted with the agency Administrator on June 27, 2024 at approximately 1:45 p.m. confirmed the above findings”