Every finding on record at Lifespring Home Care of Sayre, LLC

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 07/09/24 to 07/10/24. No deficiencies were cited as a result of the Emergency Preparedness Program survey.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency on 07/09/24 to 07/10/24. An entrance conference was conducted with Staff A. Staff A and B were identified as the contact persons for administrative and clinical issues. Findings were discussed during an informal exit conference with Staff A and B. Deficiencies were cited as a result of the re-certification 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 record review and interview, the agency failed to ensure an assessment of wounds was provided as ordered for two (Patient #1 and 2) of nine patients. Patient #1 A review of the plan of care dated 03/28/24 to 05/26/24 showed a primary diagnosis of aftercare following surgery for neoplasm and documented interventions for skilled nurse to assess 2 surgical incisions to left breast and left axilla region at each visit. The plan of care documented a skilled nurse frequency of one visit per day for one day, one visit per week for seven weeks and one visit per week for one week. A review of the clinical record showed the following: A skilled nurse assessment dated 03/28/24 documented no assessment of measurements of the two incisions areas identified in the plan of care. A skilled nurse assessment dated 04/05/24 documented no assessment of measurements of the two incisions areas identified in the plan of care. A skilled nurse assessment dated 04/09/24 documented no assessment of measurements of the two incisions areas identified in the plan of care. A skilled nurse assessment dated 04/17/24 documented no assessment of measurements of the two incisions areas identified in the plan of care. A skilled nurse assessment dated 04/22/24 documented no assessment of measurements of the two incisions areas identified in the plan of care. A skilled nurse assessment dated 05/02/24 documented no assessment of measurements of the two incisions areas identified in the plan of care. A skilled nurse assessment dated 05/08/24 documented no assessment of measurements of the two incisions areas identified in the plan of care. A skilled nurse assessment dated 05/14/24 documented no assessment of measurements of the two incisions areas identified in the plan of care. A skilled nurse assessment dated 05/23/24 documented no assessment of measurements of the two incisions areas identified in the plan of care. Patient #2 A review of the plan of care dated 04/20/24 to 06/18/24 showed a primary diagnosis of pressure ulcer of left buttock, stage II and documented interventions for the skilled nurse to assess wound #1 and 2 size, depth and drainage. The plan of care documented a skilled nurse frequency of one visit per week for one week and two visits per week for eight weeks. A review of the clinical record showed the following: Skilled nurse assessments dated 04/30/24 and 05/02/24 for the week of 04/29/24 to 05/05/24 (two of two assessments) documented no assessment of the size or depth of wound #1 or 2. Skilled nurse assessments dated 05/29/24 and 05/31/24 for the week of 05/27/24 to 06/02/24 (two of two assessments) documented no assessment of the size or depth of wound #1 or 2. On 07/10/24 at 11:45 am, Staff A stated the assessment of wounds were not followed as ordered in the plan of care for Patients #1 and 2.

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 record review and interview, the agency failed to ensure an individualized plan of care for nine (Patient #1, 2, 3, 4, 5, 6, 7, 8 and 9) of 9 patients. Patient #1 A review of the plan of care dated 03/28/24 to 05/26/24 showed a primary diagnosis of aftercare following surgery for neoplasm and documented no patient- specific interventions and education identified by the agency or patient related to the primary diagnosis. Patient #2 A review of the plan of care dated 04/20/24 to 06/18/24 showed a primary diagnosis of pressure ulcer of left buttock, stage II and documented no patient- specific interventions and education identified by the agency or patient related to the primary diagnosis. Patient #3 A review of the plan of care dated 04/08/24 to 06/06/24 showed a primary diagnosis of incontinence without sensory awareness and documented no patient- specific interventions and education identified by the agency or patient related to the primary diagnosis. Patient #4 A review of the plan of care dated 02/27/24 to 04/26/24 showed a primary diagnosis of pressure ulcer of sacral region, stage I and documented no patient- specific interventions and education identified by the agency or patient related to the primary diagnosis. Patient #5 A review of the plan of care dated 03/09/24 to 05/07/24 showed a primary diagnosis of chronic pain syndrome and documented no patient- specific interventions and education identified by the agency or patient related to the primary diagnosis. Patient #6 A review of the plan of care dated 01/04/24 to 03/03/24 showed a primary diagnosis of COVID-19 and documented no patient- specific interventions and education identified by the agency or patient related to the primary diagnosis. Patient #7 A review of the plan of care dated 05/10/24 to 07/08/24 showed a primary diagnosis of secondary malignant neoplasm of bone and documented no patient- specific interventions and education identified by the agency or patient related to the primary diagnosis. Patient #8 A review of the plan of care dated 04/10/24 to 06/08/24 showed a primary diagnosis of heart failure and documented no patient- specific interventions and education identified by the agency or patient related to the primary diagnosis. Patient #9 A review of the plan of care dated 04/05/24 to 06/03/24 showed a primary diagnosis of encounter for fitting and adjustment of urinary device and documented no patient- specific interventions and education identified by the agency or patient related to the primary diagnosis. On 07/10/24 at 11:25 am, Staff A stated the plan of care for Patients #1, 2, 3, 4, 5, 6, 7, 8 and 9 were not individualized to include patient- specific interventions related to the primary diagnosis.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency from 08/16/21. No deficiencies were cited as a result of the Emergency Preparedness Program survey.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency on 08/16/21. An entrance conference was conducted with Staff A and B. The survey process was explained. Questions were answered. Staff A was identified as the contact person for administrative issues and Staff B was identified as the contact person for clinical issues. Findings were discussed during an informal exit conference with Staff A and B and by telephone with Staff C. A standard level deficiency was cited as a result of the survey. Glossary: PIP Performance Improvement Project PIPs Performance Improvement Projects

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure PIPs were complete, clear and reflective of the agency for all 63 current patients and all employees. Findings: A review of administrative records showed a PIP initiated December 18, 2018 and continued through to 2021 which identified "Supplies" as the project. A review of the PIP documentation showed no: 1) no individualized PIP (this was for all agencies under this name including home health and hospice); 2) the current costs were not documented; 3) the goal for costs was not documented; and 4) the PIP was changed to focus on obtaining supplies related to COVID-19 (did not document current amount of supplies and what amount the agency would like to obtain) On 08/16/21 at 2:41 pm, Staff A stated the PIPs were missing some of the needed data.