FEB. 18.2085 9:29AM SENIOR HOME CHRE D-5 wee 0119414850421 A77TAC HW mMenT A STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. SENIOR HOME CARE INC. d/blal SENIOR HOME CARE INC., Respondent. ] ee ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Heatth Care Administration (hereinafter “Agency’), by and through its undersigned counsel, and files this Administrative Complaint against Respondent, SENIOR HOME CARE INC. (hereinafter “Respondent’) pursuant to Sections 120.569 and 420.57, Florida Statutes (2004), and as grounds therefore, alleges the following: NATURE OF THE ACTION 1. This is an action to impose an administrative fine in the amount of three thousand dollars ($3000.00) against SENIOR HOME CARE ING. pursuant to Sections 400.474(2)(a) and 400.484(2)(b), Florida Statutes (2004) based on one (1) repeat class “II) deficiency cited at a survey on OF about January 13, 2005. JURISDICTION AND VENUE 2. This Court has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes (2004). eee LEENA FEB. 18.2085 9:22AM SENIOR HOME CARE p-8 NO. 421 P.3718 01119414850421 ) 3. The Agency has jurisdiction over Respondent pursuant to Chapter 400, Part IV, Florida Statutes (2004). 4, Venue shall be determined pursuant 10 Rule 28-106.207, Florida Administrative Code (2004). PARTIES 5. Pursuant to Chapter 400, Part IV, Florida Statutes, and Chapter 59A-8, Florida Administrative Code, the Agency is the regulatory agency responsible for the licensure of home health agencies and for the enforcement of all applicable state laws and rules governing home health agencies. 6. At all times material hereto, SENIOR HOME CARE INC, was a home health agency located at 405 Commercial Court, Bldg. A, Suite C, Venice, FL 34292. 7. At all times material hereto, Respondent was licensed by the Agency to operate a home health agency in Sarasota County having been issued license number 299991620 by the Agency. 8. At all times relevant hereto, SENIOR HOME CARE INC. is and was a licensed home health agency required to comply with Chapter 400, Part IV, Florida Statutes, and Chapter 59A-8, Florida Administrative Code. COUNT THE AGENCY FAILED TO ENSURE THAT CHANGES AND/OR NEED FOR CHANGES WERE COMMUNICATED TO THE PHYSICIAN, AND CARE DID NOT FOLLOW THE PLAN OF TREATMENT in violation of Rule 59A-8,0215(2), Florida Administrative Code (2004) and Section 400.487(2), Florida Statutes (2004) - CLASS Ill DEFICIENCY a FEE, 18.2985 9:2@AM SENIOR HOME CARE D-8 NO.4z1 P4718 01119414850421 9. The Agency re-alleges and incorporates by reference paragraphs one (1) through eight (8) above as if fully set forth herein. 40. | Onor about January 43, 2005, Agency surveyors conducted a review of patient records which revealed the following: Based on a review of 13 clinical records, the agency failed to notify the physician jn 2 cases of changes in the status of the patient (#4 & 6). Care did not follow the plan of treatment in 4 jnstances (#3, 7, 8, & 14). The findings include: 1. Patient #4 was admitted to the agency on 11/13/04 following & Cardiovascular Accident. Due to the severity of the CVA, the patient req sired the services of nursing, physical therapy, occupational therapy, speech therapy and a home health aide for personal care services. On 11/17/04, the nurse documented that the patient had fallen the prior day and that the spouse had to call 911 to help get him up. No apparent injuries were noted and the patient was not taken to On 12/23/04, the physical therapist saw the patient and noted that the patient had been taken to the emergency room 2 nights prior for vertigo and constipation. The patient reported having vertigo. during the therapist's visit and seemed "slightly depressed.” The clinical record lacked evidence that the physician was notified. 2. Patient #6 was admitted to the agency on 12/3/04 with the primary diagnosis of Drug Abuse. The history given in the clinical record showed that the spouse had been the primary caregiver, running in the 140's. On 12/4/04, the nurse documented 2 blood sugars, $43 and 477. The nurse continued to see he patient in the home and recorded the following blood sugars, 12/7104-264, 12/10/04-77, 12/13/04-426, and 12/15/04-351. It could not be seen that the nurse ever notified the physician of any of these elevated blood sugars. 3. Patient #3 was admitted to the agency on 10/6/04, for diagnoses that included decubitus ulcer buttocks, paraplegia, and protein-calorie malnutrition. Per the POT (Plan of Treatment) dated 12/5/04, nursing was to see this patient 3 times per week for 2 weeks. The POT had orders for skilled nursing to cleanse buttock wound with normal saline, pat dry, pack with foam, use skin prep around wound, and apply wound vac. Documentation in the nursing clinical note for 12/6/04 and 12/8/04 revealed the nurse used adaptic dressing to edge of wound. There was no physician's order in the POT for skilled nursing to apply this wound dressing. 4. Patient #7 was admitted to the agency on 11/13/04 with physician orders for Skilled nursing, Physical Therapy. Occupational Therapy, Speech Therapy, 4 Home Health Aide, and a Medical FER.18.2085 9:22AM — SENIOR HOME CARE D8 No.421 -P.S/18 01119414850421 Social Service Worker. Per the POT (Plan of Treatment), the physical therapist was to see the atient 3 times a week for 4 weeks, effective 11/16. The physical therapist saw the patient on 11/15/04 for an evaluation. There was.no order for that visit. Between 11/16/04 and 12/5/04, the therapist only saw the patient twice a week, During the 4th week of service, the physical therapist saw the patient 3 times. On 12/9/04, anew order was received from the physician that instructed the therapist to continue to treat the patient 3 times a week for another 4 weeks effective 12/13/04, During the weeks of 12/13/04 and 12/20/04, the physical therapist only saw the patient twice a week, pee ; ‘ The Occupational therapist was to see the patient for an evaluation. The OT. did not see this patient until 11/22/04 (9 days after the start of care). The OT then proceeded to see the patient 3 times a week for the next 4 weeks without the benefit of physician's orders. On 12/13/04, the OT received orders to continue services 3 times a week for 3 weeks and 1 time a week for 1 week (from 12/20/04 thru 1/11/05). 5, Patient #8 most recent recertification date is 12/19/04. The patient was being seen for an open wound to the right leg. Physician orders included applying antibiotic cream to the . Observation during 2 home visit on 1/11/05 revealed the nurse applied antibiotic ointment instead of the cream. Ms 6. Patient #14 was admitted to the agency on 12/19/04 for nursing and personal care services. The patient was noted to be Oxygen dependent and the orders on the POT included orders for the patient and titrate the Oxygen liters according to the pulse ox results when it was tested, On the day of admission the pulse ox reading was 88%. The clinical record contained no visit not for 12/26/04 or any reason for the missed visit. The patient was seen the next day but no Pulse ox reading was documented for that date. 40. This was a repeat deficiency, 4S a survey conducted on or about March 47-20, 2003 also revealed: . Based on a review of 15 clinical records and staff interview, care did not follow the physician's orders in 6 of the cases reviewed (Patients #4, #6, #11, #16 and #17). Inone of the records _reviewed the agency did not ensure physician's orders were signed within 30 days as required (Patient #20). ‘The findings include: 1. Patient #16 was admitted to the agency On 3/8/03 for care by 4 psych nurse, physical therapy and a home health aide. Per areview of the clinical record, it was noted that no aide visit was made to assist the patient until the 7th day of care. The patient slipped and fell on the 6th day of care while trying to take a shower alone. ‘When the chart was reviewed on 3/17 it could not be determined if physical therapy had ever visited this patient. No other information was available when it was requested from the agency. Seen EE FEB.19.2005 9:22AM — SENTOR HOME CARE D-8 NO.421 P6718 01119414850421 , 2. There was no physician's order for the treatment provided to the right leg wound of Patient #4. The documentation in the record for Patient #4 revealed on 1/24/03 the patient developed a wound on the right lower extremity (right shin). There was a physician's order dated effective 1/23/03 and a second order dated 1/28/03, in the record indicating this area was to be cleansed with soap and water, and a dry sterile dressing was to be applied and Coban applied. The nurse provided wound care to this area py cleansing with soap and water, applying Sulfamylon and applying a dry sterile dressing on 1/28, 1/29, 1/30 and 2/4. There was no physician's order for this particular treatment. 3, Patient #6 had orders on the plan of treatment dated 3/2/2003 for the Medical Social Worker. (MSW) to visit. On the coordination of care record dated 3/2/2003, the note indicated the patient == was placed on the independent side of the ALF the patient was living in. "Poor placement MSW needed for finances and assist family with planning. Pt (patient) negative and angry. Daughter tearful and fighting ith siblings over situation.” Jn the oasis evaluation dated for 3/2/2003, the documentation reflected the patient was angry over the placement and had poor insight into her ability to live alone. The documentation further reflected the daughter was verbalizing concerms about finances. There was n0 visit by the MSW documented in the record at the time of chart review by the surveyor on 3/18/2003. After surveyor intervention, it was determined the MSW had not made the visit as ordered. Administrative staff were unaware the visit had not been made to this patient. After interview about this issue the MSW contacted the patient and family and made a visit to this home on 3/19/2003. 4. Patient #11's care was reviewed for the certification period of 1/25 through 3/25/03. The nurse was providing wound care to 2 pilonidal cyst on the patient's coccy% area. Numerous modifications to the plan of treatment were located in this record. However, there was no physician's orders in the record for care from 2/22/03 through 3/8/03. During this period, the nurse made visits and provided wound care a total of 4 times. There was no orders for this care located in the record. Interview with administrative staff indicated thete were BO orders for the care in the record. 5, Patient #17 receives cate from the Physical Therapist. During a home visit made on 3/20/03 at approximately 10:15 AM., it was noted the therapist jnstructed the patient and her spouse in the use of heat. There were no orders for this care from the physician. 66. Patient #20 bad a stat of care dated 11/9/02. The plan of treatment was not signed by the physician until 12/17/02. This is a total of 38 days after the start of care not within 30 days as 42. This is characterized as a class Ili deficiency for which an administrative fine in the amount of five hundred dollars ($500.00) for each patient impacted is appropriate w ———— FEB: 18.2885 3:2108M SENIOR HOME CARE D-8 NO.421 P.7718 1419414850421 pursuant to Section 400.419(1}(c); Florida Statutes (2004). The total fine comes to three thousand dollars ($3000.00). CLAIM FOR RELIEF WHEREFORE, the Agency respectfully requests the following relief: 4) Make factual and legal findings in favor of the Agency on Count |; 2) Impose a fine of three thousand dollars ($3000.00) for Count | against Respondent, 3) Enter whatever other relief as this court deems just and appropriate. NOTICE Respondent hereby is notified that it has a right to request an administrative hearing pursuant to Sections 420.569 and 420.57, Florida Statutes (2002). Specific options for administrative action are set out in the attached Election of Rights form and explained in the attached Explanation of Rights form. All requests for 4 hearing shall be sent to Richard Shoop, Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Building 3, Mail Stop #8; Tallahassee, Florida, 32308. SENIOR HOME CARE INC. IS FURTHER NOTIFIED THAT IF THE REQUEST FOR HEARING {Ss NOT RECEIVED BY THE AGENCY WITHIN TWENTY-ONE (21) DAYS OF RECEIPT OF THIS ADMINISTRATIVE COMPLAINT BY FAMILY HOME “HEALTH, A FINAL ORDER WILL BE RENDERED BY THE AGENCY FINDING THE DEFICIENCY AND/OR VIOLATION CHARGED AND IMPOSING THE PENALTY SOUGHT IN THE ADMINISTRATIVE COMPLAINT. J Respectfully submitted on this iP day of February, 2005 —————E——————— FEB, 18.2085 9:21AM SENIOR HOME CARE D-8 NO.421 P.8712 1119414850421 ain Fowier Rar No.; 3339067 Respondent's Counsel Assistant General Counsel Agency For Health Care Administration 2295 Victoria Avenue, Room 346C Fort Myers, FL 33901 (239) 338-3203 (239) 332372 fax CERTIFICATE OF SERVICE | HEREBY CERTIFY that one original Administrative Complaint has been sent via certified mail retum receipt requested (retum receipt # 7004 4460 0002 9084 1556) to Julie Odenweller, Administrator, SENIOR HOME CARE INC., 405 Commercial Court, Bldg, A, Suite C, Venice, FL 34292 on this [> day of February, 2005. 4 LW ~~ JO OWLER WAR. 1.2005 3:53PM SENIOR HOME CARE NO. 1683 Ff. ‘=. ATTACH mewT B “Se, Aya HY Occurrence Report Ve Cur Facility? Y/N ALFName_ \ Patient (] Employee Division: Patient # or Title (if employee) - 14a sex28L Male (0 Female Age: & Incident Date: 7// | St OF Incident Time: IK am))__om Exact Location: 5s fcme_oae Reported:/_| HE1O ¢ Condition Before Incident Brief desert of incident’ (No 9 pinigns. facts only; inglude name ard af dress of any 1 Alert 7 é5l .. 02 Confused 03 Sedated 04 Disoriented 05 Unconscious 06 Agitated 07 Other. . What Occurred . rr Rexson incident Occured 701 From bed 01 With assistance ____ 10 Improper footwear © Witnessed ___02 From chair 02 W/O assistance —_11 Floor condition by SHC staff _..03 From commode “03 Helf rails up ~ 12 Fainted = ° 04 From equipment “04 Full rails up __.13 Lost balance KUrwinessed ~—_08 Ambulatin ~~05 PT lowered rails ___ 14 Weak — x08 Slipped flow ~_06 Climbed over rail ~~ 15 Violated activity orders _ Other 07 Rails down ~ 16 Incontinent 08 Removed restraints 17 Other semen Medication” | Type incident Reason Incident Occurred 08 Dosage ___ 18 Transcription ~_ 26 Container contents 09 Route” . 419 Labeling ~__27 Calculation ’ 10 Unordered 20 Patient !0 ~ 28 Milegible 11 Duplication 21 Documentation “29 Unconfi irmed order 12 Omission 22 Stop orders __30 IV mixture 13° Wrong med 23 Missing meds ~__31 Dispensing 14 Time given 24 Too early ~~ 32. Late delivery 25 Too late 33__ Other Medication Involved _..01 Analgesic ___06 Antidepressant ___11 Narcotic - ~__02 Antlamhythmic __07 Antihistamine ___.12 Sedative __.03 Antibiatie — 08 Diuretic _ 13 Steroid 04 Anticoagulant __..09 Insulin ___14 Vasodilator ___0§ Anticonyulsant “10 Laxative _.15 Vasopressor Brand Name 16 Other. Treatment and Type Incident Reason incident Occurred Diagnostic Tests -16 IV injection 34 Technique __41 Other 35 patient ID 36 Time/Sequence 17 Patient care 18 Improper diet RRA 49 Omitted 37 Decumentation 20 Duplicated 38 Fail to check orders , 21° Incorrect 39 Fail to follow orders ropriate specimens 22 Other Reason Incident Occurred Burns p 23 Hot pads & packets 42 Faulty equipment ___ 24 Electrical 43 Unprotected exposure ~_25 Shower/Bath __.44 Overexposure =~ . __ 26 Friction ___45 Improper handling 727 Radiation _ 46 Lack of supervision __.28 Chemical __4T Temperature extreme 29 Other Other p : Reason Incident Occurred 30 Missed visit due to 49 Missed visit not rescheduled-explain scheduling error ____50 Other-explain __51 Other-explain rn AMAR, 1. 2005 3:53PM SENIOR HOME CARE NO. 1683. 3 The Incident Result Body Part injury PMB, Boeken apparent i 18 Infectious Disease __01 Abdomen ___ 14 Intemal Organs Must 02 Aggravated previous .___ 14 Inhalation ___02 Ankle we 1S Knee - a, Complete condition ___ 15 Intemal injuries ___03 Arm __ 16 Leg This ___ 03 Allergic reaction ____ 16 Laceration ___04 Back 17 Nack Section __. 04 Asphyxia ___ 17 Puncture ~_05 Buttocks _ 18 Shoulder *— 05 Broken tooth ~~ 18 Shock ~_06 Chest —_ 19 Skin ~~ 06 Bruise ~_ 19 Sprain ~_07 Elbow ~~ 20 Toe ____ 07 Burn ____ 20 Strain ___08 Eye ___ 21 Wrist ~__ 08 Concussion ___ 21 Strangulation ___09 Face ___22 Other __ ___09 Confusion ____. 22 Stroke ___ 10 “_. 10 Deceased . ~_ 23 Needle-stick/ blood or 11 ___ 11 Dislocation ‘ body fluid exposure _. 12 12 Fracture 24 Other 13 med? (If Was employee present when incident a ‘Was MD. notified of incident? WasPuemployee/seen by MQ? Wag Puemployee hospitalized? Did employee retum to work? worked: Supervisor Investigation Ait > o> dun g fa XS! gor tony if yes, describe hia ata — @ sure _Uthy. Eins one Wed. boy § pete i bck +b : Tavurt ; ern 38 Receiving Physical Therapy at time of occurrence. evaluation requested Post Occurrencs Patient (mark as applicable) {J N/A Ry’ Received Physical Therapy recently. [] Physical Therap Action Taken/Follow-Up: co. _ <| Nothiel PT. Spoke z PT re; posible reed for [itt dur en home ~ PT wilf - discuss © Spovte - . . i Severity Code: Codes: oF, jo Injury (Circle Your Choice) Insignificant (First Ald, No additional treatment, No physician visit) 2 Minor (Requires treatment, example: sutures, ongoing wound care, physician visit) , Must Complete 3 Major (Fractures, permanent injury requiring ongaing care, lass of work, hospitalization) 4 Grave (death) ‘This Section Signature of Supervisor Comments: Include results of Diagnostic tests and reasqn hospitalized (if applicable) Mail/Deliver to Corporate — Performance Improvement Coordinator karan - 0) ATTACH MmetwT C ua Y SHC Log # Kid Physician’s Telephone Order Confirmation ior Home Care, Inc.® 2 767-9520 To: nti! LLL y he Phone#: GF: SYFIS lame of Physician) . Date: Z 2v From ph LAL ———e Signature of nurse or physical therapist Time: 1G? bor: (Also place signature just below written orders) Facility: Patient: ° 2a. Patient #: G/B /ook SV7IS . lam ent) We have received your telephone orders for the above mentioned patient. These orders are listed below, for your review. Please sign and return to our office in the enclosed envelope within 48 hours. rey) Thank you. ORDERS: LD. 2 Axe fd... y ibe Ld a Od Mikes 2 gia Supplies: Z. L a Z a Anu aan Amina eAny ome..n-t.- Le V2 Physician’s Signature Pinkie teen dintahe Daw Q/9NIQ7 ns aEaE SENIOR HOME CARE, INC. Developed: August, 2002 Revised: AmevT VACUUM ASSISTED CLOSURE (V.A.C-®) ATTAC 4 POLICY: Senior Home Care Inc.’s (SHC) patients who may benefit from the procedure (as determined by their physician) receive treatment through an extended period of exposure to sub-atmospheric pressure to promote wound healing. The skilled nurse or physical therapist performs the procedure by physician order. PURPOSE: To promote wound healing through the application of continuous and/or intermittent sub- atmospheric pressure (vacuum assisted closure-V.A.C. also called negative pressure_-wound therapy or NPWT) Boe a * yen A CONTRAINDICATIONS TO THE PROCEDURE: ee , me ts on : “~ ‘s, * Patients with paca e Malignancy in the wound Untreated osteomyelitis Fistulas to body organs or cavities Necrotic tissue with eschar present Exposed arteries or veins in the area of proposed treatment SPECIAL CONSIDERATIONS: e A written order for the NPWT pump and supplies-signed and dated by the treating physician-must be received by the supplier before items are delivered to the patient » The supplier must obtain a quantitative monthly assessment of the wound healing progress, from the clinician (nurse or therapist) to determine whether the patient continues to qualify for Medicare coverage of equipment and supplies e Wound measurements must be documented at least weekly in the clinical progress/visit notes e Bleeding precautions (education and lifestyle modification) must be instituted with patients who have active bleeding, difficult wound homeostasis, are on anticoagulant therapy or who will have V.A.C. therapy to irradiated areas e Sub-atmospheric pressure therapy must be active for a minimum of 22 hours a day. If therapy is inactive (“off”) for more than two hours per day, the special therapy dressing must be removed © Two types of V.A.C. are available. The supplier follows Medicare guidelines of mobility, wound-type and drainage amounts to determine whether the mains-powered (plugged into an electric socket) or the Mini V.A.C. (ambulant V.A.C.) is appropriate e Only clinicians (skilled nurse or physical therapist) trained in the use of V.A.C. may use the system e All blood and body fluid is considered to be potentially infectious. Standard precautions apply. Follow SHC policy on biohazardous waste e Items such as SkinPrep®, hydrocolloid skin barriers, Q-Tips®, measuring devices, scissors, gloves and biohazardous waste containers are not supplied by the V.A.C. supplier and will be drawn from SHC stock SENIOR HOME CARE, ENC. Developed: August, 2002 Revised: VACUUM ASSISTED CLOSURE (V.A.C.®) VERIFICATION OF ELIGIBILTY FOR THE TREATMENT: 1) An Initial Statement of Ordering Physician (SOP) will be provided by the supplier. It must be completed and signed by the physician prior to the start of therapy. The ISOP includes a wound profile, wound measurement and a physician prescription e Complete Sections I, II and Ill of the ISOP and fax to the supplier. Supplier will verify within 48 hours that eligibility criteria are met NOTE: Type of foam (one of two types, or both) supplied will depend on how ISOP section Il is completed e Fax Section IV (Physician’s Prescription Section) of ISOP to the physician for completion. Have physician’s office fax signed order to SHC and follow with mailed original signature e Fax signed Section IV to supplier. Mail originals to supplier. Copy to chart 2) The supplier will notify SHC by phone and release equipment and supplies for delivery upon receipt of ISOP signed by the physician and verification of eligibility by Medicare oN PROCEDURE: 1) Verify the physician’s order. 2) Confirm that the equipment and supplies are at the site of treatment 3) Assemble equipment, including V.A.C. unit (mains-powered or MiniV.A.C.) Tubing and canister set(s) Foam (one or both types) and dressing set(s) Hydrocolloid or other skin preparation items (not supplied) Scissors Gloves Biohazardous waste containers Electrical adaptor (3-to-2 pronged adaptor) Wound camera and Consent Form (unless already initialed on Patient Consent) NOTE: Although many V.A.C. components are sterile, the dressing application and management are “clean” procedures, i.e. not sterile. 4) Wash hands. Use standard precautions 5) Prepare the wound site e Aggressively clean wound per orders e Debride necrotic tissue, eschar if trained and authorized (only PT and only by physician order) Irrigate wound with Normal Saline if ordered Dry and prepare periwound tissue as appropriate to receive adhesive drape If necessary, “window” an area of 3-5 cm around the wound with a hydrocolloid dressing or similar (not supplied) to form a base for attachment of the V.A.C. drape 6) Apply V.A.C dressing (foam pieces and drape) e Select and open V.A.C. dressing kit with enough foam to fill entire wound cavity e Size and trim drape to cover foam dressing, plus 3-5cm border of intact skin. Keep extra drape to cover tubing and patch leaks as needed SENIOR HOME CARE, INC. Developed: August, 2002 Revised: VACUUM ASSISTED CLOSURE ( V.A.C.®) e Cut foam to fit size and shape of wound (s) including tunnel and undermined areas”, © Gently place foam into wound cavity, covering entire wound base and sides, tunneleth and undermined surfaces wn Py NOTE: When using more than one piece of foam, at least one edge of each foam. piece must touch at least one other foam piece to facilitate suctioning of fluid ant debris and to prevent opposing wound surfaces from being forced into contact wi one another See, e Cover both the foam and the surrounding 3-5 cm of healthy tissue with the drape to & ensure an occlusive seal ; NOTE: Do not stretch drape when applying. Do not compress foam into wound with drape. This will minimize shearing/tension on tissue surrounding the wound © Cut off the tip of the V.A.C. tubing at a 45-degree angle just proximal to the fenestrations Cut small hole in drape and sponge to accommodate tip of tubing Place the tubing, beveled side down into one piece of foam, such that minimal pressure will be applied to the wound edges. Place tubing away from bony prominences. Tubing must not penetrate all the way through the foam © Cover tube at entry site and proximally with extra drape. Lift tubing gently near entry site and pinch 1-2 cm drape together undemeath the tube to form a seal and hold tube away from wound area. Extra foam may be used on top of the drape under the tube to prevent tube pressure on the wound and surrounding area(s) e Secure tube with an extra piece of drape or tape several centimeters proximal to the wound area, to prevent stress on the pri dressing over the wound ¢ On drape and in clinical note, record both date and number of foam pieces inserted into wound e Change dressing every 48 hours or every 12 hours in case of infection e Handle used V.A.C. dressings, canisters and tubing per biohazardous protocol 7) Connect the V.A.C. Device e Remove canister from sterile packaging and insert into V.A.C. unit until it clicks into place e Connect dressing tubing to the canister tubing Open both clamps Place the V.A.C unit on a level surface or hang from a footboard. Therapy will be discontinued and an alarm will sound if the unit is tilted beyond a 45-degree angle for more than three (3) seconds or if the canister is not secure 8) Initiate therapy e Depress green-lit power button. Adjust V.A.C. unit settings per physician’s order. The default vacuum setting is 125mmHg e Note the button marked THERAPY ON/OFF e Depress THERAPY ON button. In one minute or less, dressing should collapse, unless a leak is present. Most leaks occur around the tubing. Leaks can be fixed by gently pressing around the tubing or the dressing edges as appropriate. Excess drape may also be used to patch leaks ——————————— SENIOR HOME CaRE, INC. Developed: August, 2002 Revised: VACUUM ASSISTED CLOSURE (V.A.C.®) 9) Dressing Removal e Note number of foam pieces in the wound (number is written on the drape) e Raise tube connector above level of pump unit ¢ Tighten clamp on the dressing tube and separate tubing at the connector e Allow V.A.C. unit to pull exudate in the canister tube into the canister, then tighten clamp on canister tube : Depress THERAPY OFF button to deactivate pump Stretch drape horizontally and slowly pull up from skin. Do not peel off. Gently remove all foam pieces from the wound PAIN, DRESSING ADHERENCE AND OCCLUSION: 1) For the patient whose wound is painful, consider: e A lower target pressure, i.e. less suction or lower mm Hg 2) To counteract dressing adherence, consider: e Placing a single layer of either a non-adherent, porous material or an impregnated wide-meshed petrolatum dressing (not supplied) on the surface of the wound e Instilling 1% lidocaine solution or normal saline-with a physician’s order-into the proximal tubing or injecting same into the foam with the pump at about 50 mmHg. Clamp the tube and wait about 15-20 minutes before removing the dressing e Using the white Soft-Foam, which has smaller cells than the black foam. Soft- Foam bonds less easily with granulated tissue. NOTE: The denser, white Soft-Foam requires higher negative pressures to be effective 3) To remove an occlusion, consider: e Repositioning the proximal lumen of the tube e Instilling normal saline (not supplied) down the proximal tubing MULTIPLE WOUNDS AND BRIDGING BETWEEN SITES IN CLOSE PROXIMITY: 1) Through the application of a “Y” connector to the canister tubing, one V.A.C. unit can be used to treat multiple wounds simultaneously 2) When “bridging” an area of intact skin between two or more separate wounds e Use a barrier on the intact skin between the two areas to be treated e Form a bridge between the areas by abutting edges of foam so that there is one continuous foam bridge between them Place tubing as usually done, preferably in a large piece of foam Drape the entire area as if it was one wound All foam should collapse when treatment is begun INFECTED WOUNDS: 1) Wounds infected with greater than 10° colony-forming-units (CFU’s), must have the V.A.C dressing changed every 12 hours, then ———————— SENIOR HOME CARE, INC. Developed: August, 2002 . Revised: VACUUM ASSISTED CLOSURE (V.A.C.® nization is decreased below that threshold 2) Resume dressing changes every 48 hours when colo or clinical signs of infection have abated WOUNDS IN PROXIMITY TO FECAL INCONTINENCE: 1) Fecal incontinence is not a contraindication to V.A.C. therapy. Consider the following e Use a rectal collection system (with a physician’s order) e Frame the wound with a V.A.C drape or other skin barrier (not supplied) that will prevent the dressing from coming off due to contact with stool TUNNELING/UNDERMINING: TON eee 1) Use V.A.C. Soft-Foam (white foam) for filling tunnels 2) Cut foam slightly smaller than dimensions of tunnel/undermined area, leaving a “tail” to facilitate removal e Place foam against distal end of tunnel to promote granulation-for 2-3 dressing changes e Subsequently, leave approximately 1 cm dead space at distal end of tunnel e Evaluate wound for shortening or limiting foam packing every 2-3 dressing changes to accommodate increased granulation DISCONNECTING FROM THE UNIT: 1) Patients should not disconnect from the unit for more than two hours of any 24 hours e Ifthe two hours have been exceeded, the V.A.C. dressing must be replaced 2) To disconnect e Raise the connector above the level of the V.A.C. unit e Turn the unit OFF e Clamp both tubing clamps e Separate the tubing at the quick-release connector e Cover both free ends of the tubing with gauze and secure 1) To reconnect e Remove gauze from both free ends of the tubing e Connect the tubing e Unclamp both clamps e Depress green “ON” button e Select “NO” at “NEW PATIENT?” prompt. Previous settings will be resumed e Depress THERAPY ON e N TO DISCONTINUE THERAPY: WHEN TO DISCONTINUE Sea 1) When the established, physician-authorized goal of V.A.C. therapy has been met. Note that the goal may not have been full closure of the wound —— ——————— Developed: August, 2002 Revised: VACUUM ASSISTED CLOSURE ( V.A.C®) 2) When the wound dimensions show minimal or no progress for 1-2 weeks 3) Always obtain a physician’s order prior to discontinuing therapy SENIOR HOME CARE, INC. ‘ANISTER CHANGE: CANISTER Ch 1) V.A.C. canister must be changed when full (unit will alarm) or at least weekly. Mains-powered V.A.C. unit’s canister holds 300 ml Follow universal precautions Tighten both clamps Disconnect canister tubing from dressing tubing Pull and hold release knob on V.A.C. unit and remove canister Dispose of canister per biohazardous waste protocol Replace with new (sterile) canister MONITORING COMPLIAN' ‘CE/PROGRESS AND DOCUMENTATION: 1) Number of hours of operation of the unit may be recorded and reset to zero e Depress “OPTIONS” e Use Right or Left arrows to determine hours of use e Reset 2) Monthly Wound Progress Form (MWPP), obtained from the supplier e Monthly cycle is based on the date V.A.C. therapy was initiated Complete Sections I and II Sign and date at the bottom of the MWPF Fax to the supplier Form may be completed up to seven (7) days prior to the due date MWPF authorizes the supplier to release further supplies. Supplier may also be called for overnight delivery of supplies 2) A Discharge Form-part of the package received from the supplier at the beginning of. therapy-must be completed and faxed to the supplier-see “When to discontinue Therapy” above 3) Supplier will coordinate with SHC regarding a “Letter of Medical Necessity” to Medicare every 120 days after initiation of therapy TRANSITIONING BETWEEN CARE SETTINGS: V.A.C. units may not be taken from one care setting to another, example-home care to hospital or vice-versa. If patient is leaving home care and therapy is to continue: e Contact supplier Document wound assessment on special forms as for beginning therapy Have physician write order as for initial therapy Replace V.A.C. dressing with physician-approved alternative prior to transfer Supplier will pick-up pump from patient’s home when notified Developed: August, 2002 Revised: VACUUM ASSISTED CLOSURE (V.A.C.®) STALLED PROGRESS IN HEALING AND POSSIBLE INTERVENTIONS: NOTE: Changes in any of the following items requires a physician’s order: aan The wounds to be treated; therapy settings; dressing change frequencies; length of treatment . 1) Minimal or no change in wound dimensions in 1-2 weeks aes e Ifashallow wound, cut foam smaller, to promote inward epithelial migration, e Provide a therapeutic pause in V-A.C Therapy for 1-2 days e Change Therapy settings from Intermittent to Continuous or vice-versa e Evaluate patient’s nutritional status e Evaluate pressure relief and patient positioning e Evaluate wound surface for inhibited granulation due to epithelialization Ui e SENIOR HOME CARE, INC. inexpected wound deterioration within last 48 hours Check therapy meter for actual number of hours of therapy received compared to the recommended 22-24 hours/day. Explore and remedy Check for small leaks with a stethoscope Assess for underlying infection Change dressing more frequently Clean wound more aggressively 3) Discolored areas/gray spots in wound bed may indicate potential necrosis e Rule out mechanical trauma e Decrease pressure by 25mm Hg e Switch to continuous negative pressure, if currently on intermittent setting © Use smaller piece(s) foam in all three dimensions to avoid possible capillary compression ALARM: — ee 1) Alarm will sound when e Canister is full e Leaks are present e Battery is low (MiniV.A.C. only) ¢ Unit is tilted more than 45 degrees for more than 3 seconds e System “on” but Therapy not “on” Alarm will sound every 15 minutes after being turned off until the problem is corrected or power is turned off BATTERY: 1) Battery in the mains-powered V.A.C. will last for 1 ¥% to 2 hours when disconnected from the electrical power supply e Plug into an electrical socket to restore mains-powered status Developed: August, 2002 SENIOR HOME CARE, INC. Revised: VACUUM ASSISTED CLOSURE ( V.A.C:®) TRAINING: %, 1) Level Clinician Training consists of the following, conducted by a certified preceptor i) « Demonstration te -e Discussion e Hands-on participation : e Written test mn e Two supervised dressing completions in the field (i.e. on a patient) e Completion ofa Sign-in Sheet for Level I training When the above have been completed, the supplier’s representative or the Level I clinician (preceptor) will complete a Dressing Application Log. A copy of this log and a copy of the Sign- in Sheet as well as a Letter on SHC letterhead attesting to date-of-completion will be forwarded to the supplier, who will have their corporate office issue a certificate 2) Level II Clinician Training will be conducted by the supplier and will qualify preceptors to train Level I clinicians. The supplier will complete all necessary paperwork. A certificate will be issued attesting to Level II status 3) Copies of training documents and the certificate will be kept in the employee’s personnel file COMPONENTS OF COMPREHENSIVE PHYSICIAN ORDERS: 1) For both V.A.C. and Mini V.A.C. e Product name Which wounds to be treated Wound measurements Therapy settings Dressing change frequency of treatment Applicable ICD-9 codes or descriptions Pre-medication Wound cleansing Alternate dressing in case of discontinuation of therapy RESOURCES: Supplier contact is KCI USA 1 888 275 4524 (24-hour customer service) Fax. 813 248 1925 Copies of required forms (ISOP, monthly wound progress form, discharge assessment form and supplemental wound form) are available for download from the G: drive, the website as well as from the supplier an Website: www.KCI.com Ww Cra 7 Patient Signature: A” Visit Time: Begin Diagnosis: Homebound Status: Prior level of function: OLOTLLA ELH LCi a pe Key: Strength: 1/5-5/ ROM: Degrees Vj Pertinent Hx: Wh 7 A Z2 FP_ ME SH Lae unctional Assessment Independent (0%) TH Strength [ Rom _| Shoulder Flexion . Standby Assist (1-10%) ‘Abduction } Min Assist (11-29%) Mod Assist (30-69%) Max Assist (70-100%) 17 | U Extension Tf [Assumes siting an A Supination Wivinnaa Sitting balance tds tals [| Wrist Flexion nin Transters w/e bed [_. extension Uf |4/e | J | N46 | Poem Ty Elbow Fiexion j_ Transfers toilet Me Transfers tub/shower q V Standing balance Stairs/Uneven surface GAIT ASSESSMENT vanes © Crutches Cane (Standard, Hemi, Quad) Cl nwe O pwe___ % ef wa Assist __. Person Thumb Flexion Extension Hip Flexion Extension Abduction Int Rot Ext Rot Max (] Mod [7] Min Knee Flexion © Standby [1] Verbal Cues [) Indep. Extension Devices OSplints (Sling CJ Brace CG Prosthesis [] immobilizer CU Amputation OC Other: Ankle Dorsi Plantar Inversion Goals: (Short Term) oo ks.. on LF ATT AChMENT E » Physical Therapy Evaluation _ «i 2 iphysician’s Certification Date: ] |-IS=¢ 1Y Visit Type: Jeiinitial Eval (J Re-Eval Date: ol LIMITATIONS Cl Pain (Scale 1-10) Site N) Edema (1+-4+) Site r O Paratysis OD Paresis C1 Detormities © Contractures [J Amputation [] Tremors 0 Ataxia CO Dominant Side OR OL 0 Other | Describe: ul ORDERS: Treatment Codes: (Check ail that apply) “ Home Exercise Pgm Evaiuation therapeutic Exercise (1) Muscle Re-Education CO Electrotherapy OO Prosthetic Training Transfer Training Gi Pulmonary Physical Therapy Watts/CM2 ____ Minutes ait Training Oo CL) ultrasounc __ Site (0 Moist Hea! [J Ccld/ice [) Massage Site: 0 Other Specify Frequency/Duration: _s ; (72) 7 My signature certifies this pian of care to be medically necessary R. = Physician Name (Print) Pinta Ane aan Date Patient # /4 xTS Ba 19/8187 ad wn an a ran Services, wah wtielemamnen Chek i 7 Scenes _ ONT Aa ceeTRGATON ND LAN OF Tr HOME H TH CERTIFICATION AND PLAN OF T! MENT Fabent’s 4) Ctawn No. plan ire Dae > ‘J. Cenihcaton Penod 4. Meows! Record fy ry 11/13/2004 * | Fem 9471372004 «Te 1/91/2005 O8VE161-19273 107547 oe 7. Prowder Name, Address 2nd Telephone Number O8VE-Senior Home Care, inc. (239)277-1003 OMB No. 0038-0357 ATTACHMENT F- cemroin 4048 Evans Ave Suite 204 7 , FORT MYERS, FL 33901 OO, Lok TBs KBr 3/34/1922 10, Medications: Dose/Frequency/Route (ew (epenged % : -cpecm | Prncpte Dagnone ete Amoxicillin-500 MG 1 tab TID x 3 days Oral(n.,.. Pg 438 CVA(O) 9/7/2004 Stresstabs/Zinc-23.9 MG 1 tab BID Oral(N) , : Proed o Atenolo!-50 MG 1/2 tab BID Oral 73 Oem ‘Omer Pertinent Desgnoees Dave Lipitor-20 MG 1 tab QD Oral * y$7.89 REHABILITATION PROC NEC(E) 11/13/2004 Norvasc-5 MG 1 tab QD Oral Potassium Chloride-10 MEQ 2 tabs QD Oral Tylenol-325 MG 1-2 tabs Q 4 hrs PRN Oral 15. Satety Measures: Aspiration Precaution,Bleeding Precaution,Universal Precaution,Fali Precaution,Seizure Precaution,24 Hour Supervision 16. Nutone! Flag, Regular Diet,cut into small pieces, (Contd. Addendum) 17, Alergien: Morphine 18. A Funchonal Lamentions 118. 8. Activites Permitied 1 ( Ammuston $ (Parnes 9 [D tevany Bing L) Comotete Secrest 6 [_) Panta Weight Bearing A [) Wrreeicnaie 2 [IK] Bewevtincder fncominence) 8 [K] Extuence A [[] Ortones wan TO Sonree BRP 7 [[] trsepencent Attome 8 [7] Wanker 3 CD corwwaure 7 [ER] Areuation B [EK] Omer tSpectys [XZ] We As Toterated 8 (] crches c CT No Restrictions 4 DO Henang . 8 DO Speech See Addendum: OQ ‘Tranater Bed/Chair 9 OQ Cane D (— Other (Spectty) 15 [XD] Excercees Prescribed See Addendum 19. Monae! Simave: 1 Onented 3 Forgetiul s Disonented 7 (em 2 oO Comaiosa « 4 is) Depresses 6 eda] Lathanpic B (ote 20. Prognosis: 1 [} Poor 2 [) Guarded 3 Fair + [J Good 5 [] Excellent” ch ene a —— a cc O_O 21, Orders bor Diacapline and Trastments (Spectty Amount/FrequencyDuraton } HHA 3X1 WX4W; 2X1WX2W:eff 11/15/04: Take temperature, pulse & respirations each visit & assist with bathing, oral hygiene, dressing & activities of daily living.; Assist patient with transfers & ambulation. MSW 1X1MX1M:EVAL: OT 1X4WX1W:EVAL: * PT 3X1WX4W:eff 11/16/04; Physical Therapist to evaluate.; Perform (Cont'd. Addendum) IZ Goale/Renhanieaton PoentavOucrerpe Pans oats: Caregiver will be able to perform patient's ADL's as instructed within 6 weeks. (HHA); The patient and/or caregiver will accurately demonstrate home naintenance exercise program within 2 weeks. (PT); The patient will be safe in transfers & ambulation within 4 weeks, (PT); Patient will increase SBA sit - stand within 2 weeks. (PT); Patient will Improve amb. 2x50 with RW with supervision within 4 weeks. (PT), Patient/caregiver will verbalize understanding of nedication regimen, S/S of disease process and importance of reporting complications to the physician or nurse within 4 weeks. (SN); (Cont'd. Addendum) care, physics! therapy and/or speech therapy or continues to need occupahonal therapy, The palenl a under my care. and | have suthorized the services on this pian of care and will periodically revwew the pian. JEJESUS, ALEXANDER 251 PROCTOR ROAD sARASOTA, FL 34231 341)921-8645 28. Anyone who misrepresents, laisifies, o conceals essential information requred for payment of Federal funds may be subject to fine, imprisonment, or civil penalty under applicable Federal laws. PHYSICIAN Page iof 2 rm HCFA-88S (C+) (02-84) (Prnl Aagned) ORM, “e Form Approves OMB No. 0938-0357 cre uats eres ye mann tay menrnmte Pe ea re F-cancing Admancstrabon esi “ar . ADDENDUM TO: [X]PLAr = TREATMENT (DJ Mer AL UPDATE ieee an 1. Patents +t Cian No. 2. SOC Dale 3. Certhcation Penod 4. Medical Record t 5, Prowider No, 107547 41/11/2005 08VE161-19273 7. Provider Name OBVE-Senior Home Care, inc. (239)277-1003 4113/2004 | Fem: 41/13/2004 7? 16. | thin liquids, monitor swallowing 18.2. | requires assistance w/ all ADL's 18.b. | standby assist 21. | therapeutic exercises.; Instruct in transfer training.: Gait training with assistive device.; Establish and instruct in home exercise program. SN 1X1WX1W; 3X1WX1W; 2X1 WX2W: Skilled Nurse to assess vital signs and neuro status. Instruct in medications, diet, disease process, S/S of complications & home safety.; Perform wound care as follows: SN to assess skin integrity Q visit.; SN to draw Chem7, CBC 11/17 & send results to Dr. Juna.; MAY TAKE ORDERS FROM DRS. JUNA & ELLIOT. ST 2X1WX1WZEVAL; 1X 1WX2W: Speech Pathologist to evaluate.; Dysphagia treatment lowing least restrictive diet and safe swallowing facilitative techniques within 3 weeks. (ST) 22. | Dysphagia deficits will be reduced by foll Rehabilitation Potential: Fair Discharge Plans: Discharge when goals met to family with ph: ysician follow up visits. G8. Signalure of Physician 41. Opbonai Name/Signalure of Nurse/Therapist INTERMEDIARY Page 20 2 Form HOFA48? (C4) (487) ————_—————————— NO. 143 P.346 JAN. 12.2885 6:51PM SENIOR HOME ‘CARE D-8 ATTACh MEN T~ ia i -- Pr we At #7 Missed Treatment/Visit a A patient io: [lo] - A2B pate: ID) glou Patient Name: Pitt in the appropriate seco Thes fonn is used to document missed trealments/visits Instructions sechons(s) below and include necessary uatrative in Additional Comments Skilled Nursing Occupational Therapy Home Health Aide Speech Therapy Medical Social Wark pa Physical Therapy Date Admitted: Hospital: Date Discharged: Referring Physician: Reason Admitted: is ADDITIONAL COMMENTS if. 4 Completed by; Anbu Ly, AD) Li Y (Sonaifre) Physician notified of alteration in POC (_]. CLINIC.014 Page 1 of 1 Rev 3/14/97 ———— : 6:51PM SENIOR HOME CARE D-8 NO. 143 P.2v6 mee: ATTACH Men S- 1 7 ~ Missed Treatment/Visn a ae Patient ID: bi- 4272 date: 23 ula rill in the appropriate This farm i used to dvcument missed tecalnenta/vicils. Instructions. secttons(s) below and include necessary Narh itive in Additional Camments sechou Skilled Nursing Occupational Therapy Infusion <7, / Home Health Aide {_.] Speech Therapy Dietitian | Medical Social Work at Physical Therapy (] Other || oo Visits scheduled on: | . Patient Treatment Refusal Reason for refusal: ; i interim Hospitalization Date Admitted: Hospital: a Date Discharged: Referring Physician: Reason Admitted: s ADDITIONAL COMMENTS. |: Physician notified of alteration in POC [7] CLINIC.014 Page 1 of 1 Rev 3/11/97 - SIT ACA mez Te Lr FE Missed Treatment/Visit Patient 1D: /@/ 67 Date: [2[26fo¥ Senior Home Care, Ine.® Patient Name: Instructions: This form is used to document missed treatments/visits. Fill in the appropriate sections(s) below and include necessary narrative in Additional Comments section. a . - DISCIPLINE ; Skilled Nursing [_] Occupational Therapy {_] Infusion on Home Health Aide {_] Speech Therapy C] Dietitian - ‘ pr Medical Social! Work [_] Physical Therapy (] Other ‘ oe Scheduled Appointment Missed _- Visits scheduled on: 2.264 at | . Patient Tréatment Refusal..." BS gt eg Reason for refusal: ~.. Interim Hospitalization et le es [| Jeg Date Admitted: Hospital: Referring Physician: Date Discharged: Reason Admitted: “= ADDITIONAL COMMENTS AM/PM was missed due to: Completed by: (Title) (Signature) Physician notified of alteration inPoc (J me Nae Pane 1 af 1 Rev 2/11/87 Arran menT fe J Br /b hop Missed Treatment/Visit S49)" Patient Vv. eel: Pi Nect z 450 Date: >71I—O3 ent missed treatmontsivisits. Fill in the appropriate tive in Additional Comments section. “Ww Home Care, Inc.© Instructions: This form is used to docum sections(s) below and include necessary narra Medical Social Work (_] Physical Therapy Skilled Nursing Home Health Aide [_] Speech Therapy {_] Dietitian C] [_] Other Td Reason for refusal: [| ._ Interim Hospitalization Date Admitted: Hospital: Date Discharged: Referring Physician: Reason Admitted: TS - ADDITIONAL COMMENTS Completed by: (Signature) Physician notified of alteration in poc [] Jace) ATTACH MCAT # kK iG - ! Physical Therapy Evaluation 5 App 15 ’ BHysician’s Certification Pp Patient Signature: #3: 5q Date: o3/\ | 03 Visit Time: Begin \\-. Ge “End A324 ita Billa ¢,UNisit Type: Vi Initial ey Re-Eval y Senior Home Care, Inc.® Date: 93 3 Diagnosis: Homebound Status: ~ cA eur Wad . gawwe : nw Sd. Car SA $~A— Prior level of function: _S Pertinent Hx: Key: Strength: 1/5-5/5 | Strength | ROM _| Functional Assessment LIMITATIONS ROM: Degrees re [A | t | B | Independent (0%) O Pain (Scale 1-10) Site Shoulder Flexion lof [dy Wat Sn ee 20%) %) 0 Edema (1+-4+) Site - U i ~ ‘2 | Arducton Lg| 7} + Mod Assist (30-69%) D0 Paralysis 0D Paresis C0 Deformities int Ro! rill Y fil Max Assist (70-100%) © Contractures [) Amputation CO Tremors embed CA Nee Ol Dominant sce C18 Ot a Lh | omer Ads) Sitting balance Describe: X& ba SIM {| Transters wic bed Wy - Transfers toilet wis ee Transfers tud/shower wer Propels w/c Standing balance — NN Stairs/Unevan surface Finger Flexion Extension ORDERS: Treatment Codes: (Check all that apply) if Evaiuation Home Exercise Pgm GAIT ASSESSMENT TerLr Therapeutic Exercise [1] Muscle Re-Education Extension alker O Crutches Tyanster Training © Electrotherapy Abduction Cane (Standard, Hemi, Quad Az Gait Training D Prosthetic Training r___introt | | O nwe (j PwB % FW (J Pulmonary Physical Therapy [Ext at Assist _| Person [} Max (] Min | [) Ultrasound Watts/CM2 _..____ Minutes [nes Fiexon tf (0 Stanaby [] Verbal Cues Indep. Site ee Extension Ankie Dorsi CO Most Heat [) Cold/ice {1 Massage Devices (Splints {Sling (C Prosthesis i Site; _ _— O) Other — salty Specify Frequency/Duration: Qu, 5 Eversion Trunk Flexion Comments: ( ane Waare=: News } I boy wen QXoy a Se Q {Jaw ws) ¥ Wu iam NG ON Se CARD | Wowie ) Hv) Fi My signature certifies this plan of care to be medically necessary . Dr de Physicii lame (Print) 4 "Date an eo Goals, (gnon Term) ( CAW\D2, | Long Term _\ “AY : ¢ . CAS, cE) ak wien = Baw abl Vers Ss Ro cae ar Os et ee Rehab Potentiat: —_ Cr Dn Qa TN ae a er Oischarge Plan: Wirar Aw le, YY. wi 2D Vo oy , 34 | wh iS tO [Equipment Needs/Recommendations Ma 2) \ — Ne: _ ; Vy ne ian o 3/ \\} 23 Date Therapist's Sig nature ve A re D ———$—$—- Patien# GAT. Physician Signature # 1, c ATTACH men re Lt Oe fue 47) — sHetog# 208 Physician’s-Telephone Order Confirmation To: «. Cackonel- Phone#: G4 -LOe | (Name of Physician) . Date: A -li- G7 From: Qe . Een Wen Signature of nurse or physical therapist Time: ——— (Also place signature just below written orders) Facility ——. Patient#: O% VY6s Patient faueni We have received your telephone orders for the above mentioned patient. These orders are listed belo for your review. Please sign and return to our office in the enclosed envelope within 48 hours. \ VB are & ean No ttromi ce Ax be x: Thank you. ORDERS: wim OS OY DS & To ne Vo ees Von B-12- O33 ph Eve CQ) zon nu Decor. gS Seed hMiS> Vero REL Mw ES es a)ia)es en Date °g. 0. ——~" Physician’s Signature

Docket for Case No: 05-001307