Lifespring Home Care

“Immediate reporting of abuse by all staff CFR(s): 484.50(e)(2) Any HHA staff (whether employed directly or under arrangements) in the normal course of providing services to patients, who identifies, notices, or recognizes incidences or circumstances of mistreatment, neglect, verbal, mental, sexual, and/or physical abuse, including injuries of unknown source, or misappropriation of patient property, must report these findings immediately to the HHA and other appropriate authorities in accordance with state law. This Element is not met as evidenced by: Based on interview and record review the agency failed to report an allegation of abuse to the Texas Health and Human Services Commission (HHSC) and Department of Family Protective Services (DFPS) within 24 hours for 1 of 10 clients (Client #9) reviewed that received services from the agency. This failure to immediately report an allegation of abuse to HHSC and DFPS delayed the state investigation and placed (Patient # 9) at risk for continued abuse if the allegation was substantiated. During pre-survey preparation on 07/09/2025, a review was conducted of TULIP (Texas Unified Licensure Information Portal) a database utilized by the state to maintain licensing, demographic information, complaints and self-reported incidents on Home Health and for the State of Texas. Review of the agency information failed to reveal the agency had submitted self-reported incidents of alleged abuse, neglect or exploitation. Record review of Complaint log documentation: Revealed a document titled, “COMPLAINT FORM.” The date of the complaint/problem was dated May 1st, 2024, and signed by the Administrator on 05/07/2024. The complaint form included approximately 11 pages of documents attached to the complaint. The report read in part, “On Friday, 05/03/2024 at 5:00 PM I received a phone call… Family Member (FM) wants to file a complaint against one of our male nurses for inappropriate contact between this male nurse and (Client 9)… the nurse began rubbing her neck and shoulders, then moved his hand down into her cleavage and “rubbed up and around” each breast… FM Z stated several times during my phone call with him that he wanted no legal pressure, but wanted to ensure that no further female patients would endure abuse at this nurse’s hands…” Phone interview with the Administrator on 07/14/2025 at 11:47 a.m., the surveyor discussed the complaint that involved client 9 that the surveyor reviewed from the agency complaint log. The administrator explained that she was the agency employee that spoke with Family Member Z regarding the complaint and the Administrator was the person that conducted the agency investigation. The surveyor asked the Administrator if the documentation in the complaint form was accurate. The Administrator stated, “yes, of course it is.” The surveyor asked the Administrator what the agency policy was regarding when to report an allegation of ANE to the state. The Administrator stated, “Any serious allegation…” The surveyor asked the Administrator what the agency considered a serious allegation. The Administrator stated, “I don’t know. She couldn’t even remember anything. I’m not going to ruin a nurse’s career over something like that.” The surveyor asked if the allegation was serious enough for the Administrator to contact the police to file a report, then wouldn’t that be serious enough to report to the state. The Administrator stated, “I don’t know. I did what I felt I had to do. The son expected me to do something, but I didn’t know what to do so I thought that was the best thing to do…” The surveyor asked the Administrator if the agency reported the allegation of abuse to HHSC or DFPS. The Administrator stated, “We didn’t believe it ever happened. We never even thought about reporting it to the state because we didn’t take it seriously.” The surveyor asked the Administrator why the agency didn’t report the complaint of abuse to DFPS and HHSC. The Administrator stated, “because it never occurred to do it. I am very complaint with the rules. She couldn’t remember the date or the time or the nurse and frankly I didn’t know what else to do.” On 07/17/2025 at 12:21 PM., an interview was conducted with the agency’s Administrator and Alternate Administrator. The surveyor reviewed the agency policy titled, “Identifying and Reporting Abuse, Neglect, Misappropriation, or Exploitation of Patients” with the Administrator and Alternate Administrator. The surveyor asked the Administrator according to the agency policy how long the agency had to report allegation of abuse neglect or exploitation. The Administrator stated, “5 days.” Review of the agency’s policy & procedure manual included a policy titled, “IDENTIFYING AND REPORTING ABUSE, NEGLECT, MISAPPROPRIATION, OR EXPLOITATION OF PATIENTS” DOC ID: 3.08.1 with a revised date: 12/23/2021. The document read in part, ... “PURPOSE: To define reporting requirements for situations of child or adult abuse and/or neglect… PROCEDURE When Abuse, neglect, and/or exploitation are suspected… They will immediately make recommendation to the appropriate reporting agencies as mandated by law… This reporting will be completed within at least five working days of the incident.””