Every finding on record at Lifeline Homecare Services LLC

Extended Substantial Allegation Survey Substantial Allegation 70971 An entrance conference was conducted on 07/28/22 with administrative staff, and an exit conference was conducted on 07/29/22 with administrative staff. No deficiencies were cited related to allegation(s) contained in substantial allegation 70971 completed on 07/29/22; however, the facility was found not to be in compliance with all requirements for Home Health Agency participation and the following deficiencies are cited. Lifeline Homecare Services LLC 369084, is not in compliance with the requirements at 42 CFR Part 484, Subpart B, C for Home Health Agencies. Lifeline Homecare Services LLC is precluded from offering its own aide training and/or competency evaluation program for a period of two years from the exit date of this survey.

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 medical record review and staff interview, the agency failed to patients received home health services as written in the plan of care for one of three patients reviewed (Patient #1). Findings include: Review of Patient #1's medical record revealed an admission date of 08/06/21 with diagnoses including Diabetes, Autistic Disorder, Osteomyelitis and Chronic Kidney disease (stage 2 mild). The physician’s ordered plan of care for the certification period dated 02/02/22 to 04/02/22 revealed patient was to have one Skilled Nursing (SN) visit per week. Further review of the patient's record revealed the patient had SN visits on 02/03/22, 02/05/22, 02/07/22, 02/09/22, 02/10/22, 02/12/22, 02/15/22, 02/16/22, 02/17/22, 02/18/22, 02/19/22, 02/20/22, 02/21/22, 02/23/22, 02/24/22, 02/25/22, 02/26/22, 02/27/22, 02/28/22, 03/01/22, 03/04/22, 03/05/22, 03/06/22, 03/07/22, 03/09/22, 03/10/22, 03/11/22, 03/12/22, 03/13/22, 03/14/22, 03/16/22, 03/17/22, 03/18/22, 03/19/22, 03/20/22, 03/21/22, 03/24/22, 03/25/22, 03/26/22, 03/27/22, 03/28/22, 03/31/22, 04/01/22, 04/02/22 and 04/03/22. On 07/28/22 at 3:45 PM Staff L and Staff M confirmed in an interview that the patient's physician ordered plan of care revealed orders for one skilled nursing visit per week however they stated the patient should have been seen daily and that was an error.

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 medical record review and staff interview, the agency failed to ensure the individualized plan of care included all types of services and equipment necessary for a patient for one of three patients reviewed (Patient #1). Findings include: Review of Patient #1's medical record revealed an admission date of 08/06/21 with diagnoses including Diabetes, Autistic Disorder, Osteomyelitis and Chronic Kidney disease (stage 2 mild). Review of the Skilled Nursing (SN) notes from 02/03/22 to 04/03/22 revealed the patient required an ambulatory aide. The SN notes from 02/03/22 to 04/03/22 revealed the patient had a wound to the right foot with an appearance of "pink/red," that there was a callous over healed wound site, and that the patient's right foot wound dressing was intact. Review of the physician ordered plan of care for the certification period dated 02/02/22 to 04/02/22 revealed no evidence the patient required the use of an ambulatory aid. There were no orders for any type of wound dressing or care for wounds. On 07/28/22 at 2:24 PM Staff M stated in an interview that Patient #1's leg was in a cast and wound care was provided by a wound clinic and not the home health agency nurses. On 07/28/22 at 3:45 PM Staff L and Staff M verified in an interview that Patient #1's physician ordered plan of care did not include orders for an ambulation aid, orders for a wound dressing or wound clinic services.

Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This CONDITION is not met as evidenced by: Based on medical record review and staff interview, the agency failed to ensure skilled professionals provided services that are ordered by the physician or allowed practitioner as indicated in the plan of care (G710). The agency failed to ensure skilled professionals prepared clinical notes at each visit (G716). The cumulative effect of this systemic practice resulted in the agency's inability to ensure that the patients' skilled needs would be met.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on medical record review and staff interview, the agency failed to ensure skilled professionals provided services that are ordered by the physician or allowed practitioner as indicated in the plan of care for one of three patient records reviewed (Patient #1). Findings include: Review of Patient #1's medical record revealed an admission date of 08/06/21. The physician ordered plan of care for the certification period dated 02/02/22 to 04/02/22 revealed orders for the nurse to report to the physician a pulse greater than 110 and less than 55. Review of the Skilled Nurse (SN) note dated 02/28/22 revealed a pulse rate recorded as 113 and a SN dated 03/05/22 a pulse rate recorded as 114. There was no documentation the physician was notified. On 07/28/22 at 3:45 PM Staff L and Staff M verified in an interview that the increased pulse rates were not documented as reported to the physician.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on medical record review and staff interview, the agency failed to ensure skilled professionals prepared clinical notes at each visit for one of three patients reviewed (Patient #1). Findings include: Review of Patient #1's medical record revealed the patient was admitted to the agency on 08/06/21 with diagnoses including Diabetes, Autistic Disorder, Osteomyelitis and Chronic Kidney disease (stage 2 mild). Review of Skilled Nursing (SN) visit notes from 02/02/22 through 04/03/22 revealed the following: On 02/03/22 the patient was seen by the SN who documented vital signs as Temperature (T) 97.5 Fahrenheit (F), Pulse (P) 102, Respiratory rate (R) 18 and Blood Pressure (BP) 134/79. The note further revealed the SN documented used supplies of a lancet, gloves, alcohol swabs and glucose strips. The SN noted the patient’s neurological status was alert, oriented, forgetful, grip strong and Pupils Equal, Round, Reactive to Light and Accommodation (PERRLA). The SN documented the gastrointestinal system as soft, distended, bowel sounds present in all four quadrants and bowel sounds absent, the last bowel movement (BM) was not documented. The SN documented the integumentary system as warm, dry, pink mucous membrane, normal for race and callous over healed wound site, the SN noted the patient was not at risk for pressure ulcers. The SN documented cardiovascular status as apical/radial pulses regular, tenderness and capillary refill. The SN documented the respiratory system within normal limits (WNL), unlabored and clear. The SN documented the musculoskeletal system as unsteady, weakness, stiffness, and use of an ambulatory aid. The SN documented he performed fall prevention teaching. The SN documented psychosocial as cooperative. The SN documented nutrition as diabetic diet with normal appetite. The SN documented the patient's blood sugar as 140, done by the patient/caregiver without symptoms of hyperglycemia or hypoglycemia. The SN check marked boxes on the SN note indicating he had performed diabetic care, teaching, inhalation prescription, activity restrictions, diet/fluid intake, safety, universal precautions, assessment of the disease process and sharps disposal per protocol. The SN documented treatment/instructions/comments as, “Assessment completed vitals WNL right foot wound dressing intact teaching completed to take medications on time voice understanding left in care of family." The SN noted the patient's response to teaching was he/she verbalized an understanding, needed further instruction and no teaching guide was utilized. The SN documented the patient’s activity level as independent requiring the assistance of one to two to leave the home and poor endurance. The SN documented medications were reviewed and there were no medication issues noted. The SN documented there was no caregiver available and the patient's next appointment was scheduled for 05/24/17. The SN documented the patient’s pain level at zero out of 10. The SN documented no problems with the patient’s ears/eyes/nose/throat. The SN documented process of care measures identified and addressed at the visit as, diabetic foot care, at risk for falls and high-risk medications. The SN noted a wound to the right foot with an appearance of “pink/red.” On 02/05/22 the only documented change to the SN visit note was the patient’s vital signs which were recorded as T 97.6, P 118, R 18, BP 127/89. The remainder of the SN note was identical to the note dated 02/03/22. On 02/07/22 the only documented change to the SN visit note was the patient’s vital signs which were recorded as T 97.0, P 102, R 18, BP 129/71. The remainder of the SN note was identical to the note dated 02/03/22. On 02/09/22 the only documented change to the SN visit note was the patient’s vital signs which were recorded as T 98.6, P 99, R 18, BP 132/73. The remainder of the SN note was identical to the note dated 02/03/22. On 02/10/22 the only documented change to the SN visit note was the patient’s vital signs which were recorded as T 98.6, P 103, R 18, BP 142/79. The remainder of the SN note was identical to the note dated 02/03/22. On 02/11/22 the only documented change to the SN visit note was the patient’s vital signs which were recorded as T 98.1, P 109, R 18, BP 142/86. The remainder of the SN note was identical to the note dated 02/03/22. On 02/12/22 the only documented change to the SN visit note was the patient’s vital signs which were recorded as T 98.6, P 109, R 18, BP 132/75. The remainder of the SN note was identical to the note dated 02/03/22. On 02/13/22 the only documented change to the SN visit note was the patient’s vital signs which were recorded as T 98.6, P 97, R 18, BP 134/84. The remainder of the SN note was identical to the note dated 02/03/22. On 02/15/22 the only documented change to the SN visit note was the patient’s vital signs which were recorded as T 97.6, P 108, R 18, BP 124/76. The remainder of the SN note was identical to the note dated 02/03/22. On 02/16/22 the only documented change to the SN visit note was the patient’s vital signs which were recorded as T 98.8, P 93, R 18, BP 127/86. The remainder of the SN note was identical to the note dated 02/03/22. On 02/17/22 the only documented change to the SN visit note was the patient’s vital signs which were recorded as T 98.0, P 97, R 18, BP 128/89. The remainder of the SN note was identical to the note dated 02/03/22. On 02/18/22 the only documented change to the SN visit note was the patient’s vital signs which were recorded as T 98.0, P 102, R 18, BP 118/85. The remainder of the SN note was identical to the note dated 02/03/22. On 02/19/22 the only documented change to the SN visit note was the patient’s vital signs which were recorded as T 96.7, P 102, R 18, BP 122/79. The remainder of the SN note was identical to the note dated 02/03/22. On 02/20/22 the only documented change to the SN visit note was the patient’s vital signs which were recorded as T 97.8, P 104, R 18, BP 129/75. The remainder of the SN note was identical to the note dated 02/03/22. On 02/21/22 the only documented change to the SN visit note was the patient’s vital signs which were recorded as T 98.0, P 104, R 18, BP 128/72. The remainder of the SN note was identical to the note dated 02/03/22. On 02/23/22 the only documented change to the SN visit note was the patient’s vital signs which were recorded as T 98.6, P 98, R 18, BP 143/86. The remainder of the SN note was identical to the note dated 02/03/22. On 02/24/22 the only documented change to the SN visit note was the patient’s vital signs which were recorded as T 98.1, P 110, R 18, BP 139/74. The remainder of the SN note was identical to the note dated 02/03/22. On 02/25/22 the only documented change to the SN visit note was the patient’s vital signs which were recorded as T 98.0, P 90, R 18, BP 142/84. The remainder of the SN note was identical to the note dated 02/03/22. On 02/26/22 the only documented change to the SN visit note was the patient’s vital signs which were recorded as T 97.3, P 102, R 18, BP 138/70. The remainder of the SN note was identical to the note dated 02/03/22. On 02/27/22 the only documented change to the SN visit note was the patient’s vital signs which were recorded as T 98.6, P 97, R 18, BP 128/72. The remainder of the SN note was identical to the note dated 02/03/22. On 02/28/22 the only documented change to the SN visit note was the patient’s vital signs which were recorded as T 97.3, P 113, R 18, BP 132/89. The remainder of the SN note was identical to the note dated 02/03/22. On 03/01/22 the only documented change to the SN visit note was the patient’s vital signs which were recorded as T 98.2, P 97, R 18, BP 132/89. The remainder of the SN note was identical to the note dated 02/03/22. On 03/02/22 the only documented change to the SN visit note was the patient’s vital signs which were recorded as T 98.2, P 102, R 18, BP 108/69. The remainder of the SN note was identical to the note dated 02/03/22. On 03/04/22 the only documented change to the SN visit note was the patient’s vital signs which were recorded as T 98.0, P 97, R 18, BP 132/79. The remainder of the SN note was identical to the note dated 02/03/22. On 03/05/22 the only documented change to the SN visit note was the patient’s vital signs which were recorded as T 98.7, P 114, R 18, BP 136/70. The remainder of the SN note was identical to the note dated 02/03/22. On 03/06/22 the only documented change to the SN visit note was the patient’s vital signs which were recorded as T 98.6, P 90, R 18, BP 138/76. The remainder of the SN note was identical to the note dated 02/03/22. On 03/07/22 the only documented change to the SN visit note was the patient’s vital signs which were recorded as T 98.2, P 98, R 18, BP 122/86. The remainder of the SN note was identical to the note dated 02/03/22. On 03/09/22 the only documented change to the SN visit note was the patient’s vital signs which were recorded as T 97.0, P 94, R 18, BP 129/72. The remainder of the SN note was identical to the note dated 02/03/22. On 03/10/22 the only documented change to the SN visit note was the patient’s vital signs which were recorded as T 97.2, P 99, R 16, BP 143/78. The remainder of the SN note was identical to the note dated 02/03/22. On 03/11/22 the only documented change to the SN visit note was the patient’s vital signs which were recorded as T 97.6, P 108, R 18, BP 119/76. The remainder of the SN note was identical to the note dated 02/03/22. On 03/12/22 the only documented change to the SN visit note was the patient’s vital signs which were recorded as T 98.4, P 67, R 18, BP 124/82. The remainder of the SN note was identical to the note dated 02/03/22. On 03/13/22 the only documented change to the SN visit note was the patient’s vital signs which were recorded as T 98.0, P 96, R 18, BP 112/73. The remainder of the SN note was identical to the note dated 02/03/22. On 03/14/22 the only documented change to the SN visit note was the patient’s vital signs which were recorded as T 98.3, P 103, R 18, BP 141/79. The remainder of the SN note was identical to the note dated 02/03/22. On 03/16/22 the only documented change to the SN visit note was the patient’s vital signs which were recorded as T 98.4, P 86, R 18, BP 127/83. The remainder of the SN note was identical to the note dated 02/03/22. On 03/17/22 the only documented change to the SN visit note was the patient’s vital signs which were recorded as T 98.2, P 76, R 18, BP 133/76. The remainder of the SN note was identical to the note dated 02/03/22. On 03/18/22 the only documented change to the SN visit note was the patient’s vital signs which were recorded as T 97.6., P 98, R 18, BP 143/78. The remainder of the SN note was identical to the note dated 02/03/22. On 03/19/22 the only documented change to the SN visit note was the patient's vital signs which were recorded as T 98.6, P 92, R 18, BP 114/79. The remainder of the SN note was identical to the note dated 02/03/22. On 03/20/22 the only documented change to the SN visit note was the patient’s vital signs which were recorded as T 98.6, P 97, R 18, BP 136/76. The remainder of the SN note was identical to the note dated 02/03/22. On 03/21/22 the only documented change to the SN visit note was the patient’s vital signs which were recorded as T 98.1, P 90, R 18, BP 133/84. The remainder of the SN note was identical to the note dated 02/03/22. On 03/24/22 the only documented change to the SN visit note was the patient’s vital signs which were recorded as T 98.3, P 110, R 18, BP 125/76. The remainder of the SN note was identical to the note dated 02/03/22. On 03/25/22 the only documented change to the SN visit note was the patient’s vital signs which were recorded as T 97.7, P 109, R 18, BP 127/68. The remainder of the SN note was identical to the note dated 02/03/22. On 03/26/22 the only documented change to the SN visit note was the patient’s vital signs which were recorded as T 97.0, P 86, R 18, BP 124/76. The remainder of the SN note was identical to the note dated 02/03/22. On 03/27/22 the only documented change to the SN visit note was the patient’s vital signs which were recorded as T 98.2, P 98, R 16, BP 142/78. The remainder of the SN note was identical to the note dated 02/03/22. On 03/28/22 the only documented change to the SN visit note was the patient’s vital signs which were recorded as T 98.0, P 99, R 18, BP 136/79. The remainder of the SN note was identical to the note dated 02/03/22. On 03/29/22 the only documented change to the SN visit note was the patient’s vital signs which were recorded as T 98.3, P 102, R 18, BP 134/86. The remainder of the SN note was identical to the note dated 02/03/22. 03/31/22 the only documented change to the SN visit note was the patient’s vital signs which were recorded as T 97.2, P 103, R 18, BP 146/73. The remainder of the SN note was identical to the note dated 02/03/22. On 04/01/22 the only documented change to the SN visit note was the patient's vital signs which were recorded as T 98.6, P 78, R 18, BP 141/773 (this was how the BP was written in the visit note). The remainder of the SN note was identical to the note dated 02/03/22. On 04/02/22 the only documented change to the SN visit note was the patient’s vital signs which were recorded as T 98.4, P 94, R 18, BP 140/78. The remainder of the SN note was identical to the note dated 02/03/22. On 04/03/22 the SN note was identical to the note dated 02/03/22 with the exception of the vital signs which were recorded as T 97.8, P 96, R 18, BP 128/79 and the Treatments/Instructions/Comments which stated "patient alert and oriented x3 no sign of distress noted assessment completed per MD orders vitals WNL right foot wound dressing intact, denies pain or discomfort at this time, teaching completed to take medications on time patient voice understanding left in care of the family." There was documentation of missed nursing visits on 02/04/22, 02/06/22, 02/08/22, 02/14/22, 02/22/22, 03/03/22, 03/08/22, 03/15/22, 03/22/22, 03/23/22, and 03/30/22. On 07/28/22 at 3:45 PM Staff L and Staff M stated in an interview that it was very unlikely Patient #1’s blood sugar was 140 every day for a two-month period. Staff L and Staff M confirmed the only changes to the SN notes were the vital signs. Staff L and Staff M verified a wound could not have a dressing intact, be visualized and be healed simultaneously as documented in every SN note. Staff L and Staff M also verified the SN notes documented Patient #1 was left in care of family, but that it was also documented there was no available caregiver, and that the next scheduled appointment was 05/24/17 which was almost five years prior. Staff L and Staff M also stated that the blood pressure recorded as 141/773 had to be an error as it was incompatible with life.