Every finding on record at Liberty Healthcare Group, LLC

An unannounced on-site recertification survey was conducted on 09/15/2025-09/17/2025. No deficiencies for emergency preparedness were identified.

An unannounced on-site recertification survey was conducted on 09/15/2025-09/17/2025. Standard level deficiencies to the Medicare Conditions of Participation were identified.

Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on agency policy, clinical record review and staff interviews, the agency failed to notify the physician of a blood pressure that was not assessed for 1 of 4 discharged patients. (patient #4) Findings included: A policy, Coordination and Communication Activities (revised 03/2024), received on 09/15/2025 at 2:51 from the administrator stated, “Home Health staff will maintain on-going communication with all physicians involved in the plan of care… that addresses the following, at a minimum: … findings that are outside of established parameters…failure to follow the plan of care…” Patient #4 was admitted on 03/29/2024 with diagnoses of encounter for change or removal of surgical wound dressing, hypertension secondary to endocrine disorders (high blood pressure), and chronic combined systolic and diastolic heart failure (condition where heart doesn’t pump blood effectively). The plan of care for 03/29/2024-05/27/2024 included orders for skilled nurse visits 1 time a week for 1 week, 2 times a week for 2 weeks, 1 time a week for 2 weeks, 1 every other week for 5 weeks, 4 PRN (as needed), and “Notify Physician of vital sign parameters out of range: … Systolic BP [blood pressure]: Greater (>) Than 170 Less Than () Than 100 Less (<) Than 55.” Review of the clinical record revealed the following: During the SN [skilled nurse] visit on 08/06/2024 licensed practical nurse (LPN) #3 documented, “SN unable to obtain BP due to inabitiy [SIC] to hear correctly.” During the SN visit on 08/13/2025 (LPN) #3 documented, “SN unable to obtain BP due to inabitiy [SIC] to hear correctly.” During the SN visit on 08/21/2025 (LPN) #3 documented, “SN unable to obtain BP due to inabitiy [SIC] to hear correctly.” During the SN visit on 08/27/2025 (LPN) #3 documented, “SN unable to obtain BP due to inabitiy [SIC] to hear correctly.” During the SN visit on 09/13/2025 (LPN) #3 documented, “SN unable to obtain BP due to inabitiy [SIC] to hear correctly.” Further review revealed that there was no documentation that the physician was notified. During an interview conducted on 09/14/2025 at 2:15 PM LPN #3 stated, “The patient was a dialysis patient. I would try on the right leg… I did call the doctor. I do document communication with the RN [registered nurses] and doctors.” During an interview conducted on 09/16/2025 at 4:10 PM the clinical manager stated, “If it’s [failure to obtain blood pressure] 1 time only, they should notify the doctor. If it continues, they should get an order to discontinue the blood pressure.”

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on agency policy, observation, and staff interviews, the agency failed to perform hand hygiene after contact with inanimate objects in the patient’s environment while performing wound care. (patient #12) Findings included: A policy, Hand Hygiene, home care (reviewed 09/15/2025) received on 09/16/2025 at 1:25 PM from the agency administrator stated, “Using an alcohol-based hand rub is appropriate for decontaminating the hands before direct contact with the patient; … and after contact with inanimate objects in the patient’s environment…” Patient #12 was admitted on 09/04/2025 with a diagnosis of laceration with a foreign body (wound). The plan of care for 09/04/2025-11/02/2025 included orders for skilled nurse (SN) visits 2 times a week for 1 week, 3 times a week for 2 weeks, 2 times a week for 6 weeks, with 4 PRN (as needed) and “SN to perform wound care to RLE [right lower extremity] skin tear. Cleanse wound with Normal saline, pat dry, apply polymem [wound dressing] to wound bed and overlap wound edges by ½” cover and secure with kerlix and tape, apply ace wrap from toes to just below knee for compression using clean technique every other day for 2 weeks starting 9/16/25. SN may teach patient/caregiver to perform wound care.” During a home visit conducted on 09/16/2025 at 9:25 AM RN (registered nurse) #5 performed hand hygiene and donned clean gloves, cleansed the wound, applied polymen dressing, wrapped the extremity with gauze, removed the trash, removed the gloves, removed the patient’s shoes and socks and applied the ace wrap. RN #5 failed to perform hand hygiene after removing the patient’s shoes and socks. During an interview conducted on 09/16/2025 at 1:15 PM RN #5 stated, “It’s not like I touched the bottom of her shoes… Yes” [would normally perform hand hygiene after touching the shoes]. During an interview conducted on 09/16/2025 at 1:19 PM the administrator stated, “I would expect that they clean their hands after touching anything before touching the patient.”

Responsibilities of skilled professionals CFR(s): 484.75(b) Standard: Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following: This STANDARD is not met as evidenced by: Based on clinical record review and staff interviews, the agency failed to assess blood pressures for 1 of 4 discharged patients. (patient #4) Findings included: Patient #4 was admitted on 03/29/2024 with diagnoses of encounter for change or removal of surgical wound dressing, hypertension secondary to endocrine disorders (high blood pressure), and chronic combined systolic and diastolic heart failure (condition where heart doesn’t pump blood effectively). The plan of care for 03/29/2024-05/27/2024 include orders for skilled nurse visits 1 time a week for 1 week, 2 times a week for 2 weeks, 1 time a week for 2 weeks, 1 every other week for 5 weeks, 4 PRN (as needed), physical therapy (PT) 1 time a week for 1 week, 2 times a week for 3 weeks, 1 time a week for 1 week, occupational therapy (OT) 1 time a week for 1 week, and “Notify Physician of vital sign parameters out of range: … Systolic BP [blood pressure]: Greater (>) Than 170 Less Than () Than 100 Less (<) Than 55.” Review of the clinical record revealed the following: During the registered nurse (RN) visits 08/01/2024, 09/09/2024, and 09/25/2024 RN #9 documented blood pressure reading assessments. During the PT visit on 09/10/2024 PT #10 documented a blood pressure reading assessment. During the OT visit on 08/02/2024 OT #11 documented a blood pressure reading assessment. During the physical therapy assistant (PTA) visits on 08/08/2024, 08/09/2024, 08/13/2024, 08/20/2024, 08/26/2024, 08/26/2024, PTA #12 documented blood pressure readings assessments. During 5 of 5 SN [skilled nurse] visits on licensed practical nurse (LPN) #3 documented, “SN unable to obtain BP due to inabitiy [SIC] to hear correctly.” During an interview conducted on 09/14/2025 at 2:15 PM LPN #3 stated, “The patient was a dialysis patient… I would try on the right leg…” An interview conducted on 09/15/2025 at 4:10 PM with the clinical manager revealed that the expectation would be for staff to discuss problems with blood pressure assessments.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on agency policy, clinical record review, and staff interviews, the agency failed to document the correct dose of oxygen for 1 of 4 patients with an order for supplemental oxygen. (patient #5) Findings included: A policy, Legal Aspects of Clinical Documentation (revised 01/2025) received on 09/15/2025 at 2:51 PM from the administrator stated, “Chart completely, concisely and accurately…” Patient #5 was admitted on 07/20/2025 with a diagnosis of chronic obstructive pulmonary disorder (lung disease that blocks airflow). The plan of care for 07/20/2025-09/17/2025 included orders for skilled nurse visits 2 times a week for 2 weeks, 1 time a week for 7 weeks, 3 PRN (as needed) and “OXYGEN 3L [3 liters] continuous nasal” Review of the clinical record revealed the following: On 08/22/2025 licensed practical nurse (LPN) #3 documented “Oxygen use, continuous LPM [liters per minute] 2 via nasal cannula.” On 08/28/2025 LPN #3 documented, “Oxygen use, continuous LPM 2 via nasal cannula.” On 09/03/2025 LPN #3 documented, “Oxygen use, continuous LPM 2 via nasal cannula.” On 09/09/2025 LPN #3 documented, “Oxygen use, continuous LPM 2 via nasal cannula.” During an interview conducted on 09/17/2025 at 8:39 AM LPN #3 stated, “That’s probably like a mistake, an error on my part, instead of putting 3, I put 2…” During an interview conducted on 09/17/2025 at 8:42 AM the administrator stated, “She should have double checked her documentation.”

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 policy review, clinical record review, and staff interview, the agency failed to document peripherally inserted central catheter (PICC) exposed catheter length and arm circumference measurements as ordered for 1 of 1 patients (Patient #4) with a PICC. Findings include: A document titled Lippincott Procedures - Peripherally inserted central catheter (PICC) dressing change, and reviewed 08/19/22, was received from the agency director on 01/25/23 at 3:30 PM. This document revealed, “…Use a sterile tape or the incremental markings on the catheter to measure the external length of the catheter from hub to skin entry to make sure that the catheter hasn’t migrated” and “Measure upper-arm circumference when clinically indicated to assess for the presence of edema and deep vein thrombosis...” A policy 9514098, last revised 03/2021 and titled Scope of Services: Skilled Nursing, was received from the agency director on 01/25/23 at approximately 4:50 PM. This policy revealed, “1. Nursing services are provided by or under the supervision of a registered nurse (RN) and in accordance with a physician’s plan of care…6. The duties of the professional registered nurse (RN) include, but are not limited to…e. Implementing the plan of care and providing nursing services that are ordered by the physician as indicated in the plan of care…” Patient #4 was admitted to the agency on 12/22/22 with diagnoses including cellulitis (skin infection) of left finger and chronic osteomyelitis (bone infection), left hand. Plan of Care from 12/22/22 to 02/19/23 included orders for skilled nursing 1 time per week for 1 week, 2 times per week for 8 weeks and 4 PRN (as needed). This Plan of Care included orders for a PICC line sterile dressing change every 7 days or PRN with additional instructions to measure the arm circumference 3 centimeters above the insertion site and length of exposed PICC line from insertion site to hub with each dressing change. Employee #4, RN Case Manager, conducted skilled nursing visits with documented PICC line dressing changes on 12/26/21, 01/02/23, 01/09/23, and 01/23/23. Of these skilled nursing visits, arm circumference measurements were documented on 01/23/23 and there was no documentation regarding the length of exposed PICC line from insertion site to hub during any of the visits reviewed. In a telephone interview on 01/25/23 at 4:18 PM, Employee #4, stated, “…From the insertion site to the end of the PICC line…it’s in there all the way…there was nothing to measure” and “I wrote them [arm circumference measurements] down in my paperwork but I think a couple of times I missed to put it in there…Every time we’re supposed to measure to make sure there is no increase in size. It should have been in the chart.” In an interview on 01/25/23 at 4:24 PM, Employee #1, Clinical Manager, stated, “It’s [arm circumference and length of exposed catheter from insertion site to hub]to be measured at every dressing change, weekly.”

An onsite recertification survey was conducted 09/26/22 to 09/28/22. No deficiencies to the Emergency Preparedness Program were identified. ABH

An onsite recertification survey was conducted 09/26/22 to 09/28/22. Deficieinces to the Medicare Conditons of Participation were identified. ABH

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on policy and procedure, clinical record review, observation and patient interview the agency failed to review all current medications for 1 of 7 patients that received a virtual home visit (#7). Findings included: Review of policy “Medication Profile and Drug Regimen Review”, revised 03/2021 was received from the clinical manager on 09/27/22 at 8:10 a.m. The policy stated,” …on every subsequent visit to the patient throughout the episode of care…reviews the medication profile with the patient/caregiver to identify new, changed, or discontinued medications …” Patient #7 was admitted on 06/23/22 with diagnoses of ventricular tachycardia (lower chambers of the heart beat quickly), COVID-19, pneumonia, COPD (lung disease), acute on chronic systolic heart failure, and type 2 diabetes. The plan of care for 08/22/22 to 10/20/22 included the following orders: skilled nursing 2 times a week for 1 week, and 1 time a week for 8 weeks, and physical therapy 1 time a week for 4 weeks. A virtual home visit was conducted on 09/22/22 at 1:20p.m. with the nurse. A review of current medications was conducted with the patient during the home visit. The review revealed the following discrepancies: magnesium oxide (supplement) 400mg (milligrams) take 1 tablet daily by mouth wasn’t included on the medication profile. Per interview with patient, he has been taking this medication for over a year. Citalopram (used for depression) 20 mg by mouth daily. Per interview with the patient, he stopped taking this medication in July 2022.

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 policy review, clinical record review, and staff interview the agency failed to include all medications on the plan of care for 1 of 1 patients on oxygen (#11). Findings included: Review of policy “Care Planning: Initial Care Plan and Updates to the Plan of Care”, revised 03/2021 was received from the agency preceptor on 09/28/22 at 1:16 p.m. The policy stated,” … the plan of care also includes documentation of the following… all current prescription and over the counter medications…”. Patient #11 was admitted on 08/29/22 with diagnoses of hypertensive heart and chronic kidney disease with heart failure, acute on chronic congestive heart failure, acute and chronic respiratory failure, type 2 diabetes, and chronic kidney disease. Review of the start of care oasis visit on 08/29/22 revealed the patient was on 2 liter of continuous oxygen therapy, but it was not included on the plan of care. Interview with Employee #4 on 09/28/22 at 3:09 p.m., revealed “I didn’t know it was supposed to be on the med list”.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on policy and procedure review, clinical record review, and staff interview the agency staff provided wound care treatment without an order for 1 of 7 virtual home visits (#7). Findings included: Review of policy “Physician/NPP (nurse practioner) Interim Orders”, revised 04/2021 was received from the clinical manager on 09/27/22 at 8:10 a.m. The policy stated,” …drugs, services and treatments are administered only as ordered by a physician…”. Patient #7 was admitted on 06/23/22 with diagnoses of ventricular tachycardia (lower chambers of the heart beat quickly), COVID-19, pneumonia, COPD (lung disease), acute on chronic systolic heart failure, and type 2 diabetes. The plan of care for 08/22/22 to 10/20/22 included the following orders: skilled nursing 2 times a week for 1 week, and 1 time a week for 8 weeks, and physical therapy 1 time a week for 4 weeks. A virtual home visit was conducted on 09/27/22 at 1:20p.m. with the nurse. Employee #7 was observed applying Neosporin (antibiotic) cream to a band-aid and placing it on a skin tear of the patients left hand. Interview with Employee #7 on 09/28/22 at 2:57 p.m., stated, “no, I don’t have an order to do that”.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on policy and procedure review, direct observation and staff interview the agency staff failed to use proper hand hygiene for 1 of 7 virtual home visits (#1) and failed to use proper bag technique for 2 of 7 virtual home visits (#2 and #3). Findings included: Review of a policy “Exposure Control Plan: Engineering and Work Practice Controls”, revised 09/2021 was received from the clinical manager on 09/27/22 at 8:10 a.m. The policy stated,” ...before and after having direct contact with patients…”. Review of policy “Exposure Control Plan: Storage and Transport of Medical Equipment and Supplies”, revised 09/2021 was received from the clinical manager on 09/27/22 at 10:07 a.m. The policy stated,” …the clinician bag should not be placed in a location where it may become contaminated such as directly on the floor ...”. 1.Patient #1 was admitted on 06/18/22 with diagnoses of other sequelae of cerebral infarction (stroke), muscle weakness, type 2 diabetes, heart failure, and chronic kidney disease. The plan of care for 08/17/22 to 10/15/22 had orders for physical therapy 1 time a week for 9 weeks, and occupational therapy 1 time a week for 1 week, and 2 times a week for 2 weeks. A virtual home visit was conducted on 09/26/22 at 4:12 p.m. with the physical therapist. Employee #5 was observed not cleansing his hands after disinfecting the blood pressure equipment prior to touching the patient. Interview with Employee #5 on 09/28/22 at 2:47 p.m. revealed, “I cleaned my hands upon arrival and before putting them into the bag”. 2. Patient #2 was admitted on 07/21/21 with diagnoses of type 2 diabetes, unspecified dementia, long term use of oral hypoglycemic, and long-term use of anticoagulants. The plan of care for 09/19/22 to 11/17/22 had orders for physical therapy 1 time a week for 9 weeks. A virtual home visit was conducted on 09/27/22 at 2:03 p.m. with the physical therapist assistant. Employee #10 was observed placing the clinician bag on the floor during the visit. Interview with Employee #10 was conducted on 09/27/22 at 2:03 p.m. revealed, “yes my bag was on the floor, but it has wheels”. 3. Patient #3 was admitted on 08/25/22 with diagnoses of encounter for surgical after following surgery on the circulatory system, alcohol abuse in remission, presence prosthetic of heart valve, encounter for change of removal of surgical wound dressing, and long erm use of anticoagulants. The plan of care for 08/25/22 to 10/23/22 had orders for skilled nursing 1 time a week for 1 week, 2 times a week for 3 weeks, and 1 time a week for 5 weeks with 3 as needed visits for labs or complications. A virtual home visit was conducted with the registered nurse on 09/27/22 at 12:39 p.m. Employee #4 was observed placing the clinician bag on the floor during the visit. Interview with Employee #4 was conducted on 09/28/22 at 3:07 p.m. revealed, “yes, it was on the floor, I normally clean the bottom of it when I go back out to my car”.

Supervision of home health aides CFR(s): 484.80(h) Standard: Supervision of home health aides. This STANDARD is not met as evidenced by: Based on policy review, clinical record review, and staff interview the agency failed to provide home health aide supervision for 1 of 1 home health aide records reviewed (#5). Findings included: Review of policy “Home Health Aide Supervisory Visits”, revised 12/2016 was received from the agency home care administrator preceptor on 09/28/22 at 3:17 p.m. The policy stated,” …supervisory visit to all patients receiving home health aide services no less frequently than every 14 days, with or without the aide present…” Patient #5 was admitted on 01/07/22 and included diagnoses of pressure ulcer of left buttock, stage 2 (open skin), flaccid neuropathic bladder (underactive bladder), and encounter for fitting and adjustment of urinary device. The plan of care for 09/04/22 to 11/02/22 had orders for skilled nursing 1 time a week every other week, and home health aide orders were for 1 time a week for 9 weeks. Review of the skilled nurse visits for 08/09/22, 08/30/22, 09/12/22, and 09/17/22 revealed a home health aide supervision visit was not done the week of 08/22/22. Interview with Employee #6 on 09/28/22 at 2:49 p.m. revealed, “I was on vacation that week and I’m not sure if another registered nurse did a sup visit”.