Every finding on record at Liberty Healthcare Group LLC

An onsite recertification survey was conducted 11/14/22-11/15/22. No deficiencies to the Emergency Preparedness Program were identified.

An onsite, unannounced recertification survey was conducted 11/14/22-11/15/22. Standard level deficiencies to the Medicare Conditions of Participation were identified.

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 oxygen on the medication list for 1 of 2 patients receiving oxygen therapy (Patient #8). Findings include: Policy 8986864, titled Medication List and Medication Review and last revised 12/2020, was received from the Regional Clinical Manager on 11/15/22 at 2:22 PM. This policy revealed, “At the time of a comprehensive assessment (SOC [start of care], Recertification), the registered nurse will assess and document a thorough medication history. This history will include documentation of all prescription and non-prescription medications the patient is using, administered by any route (e.g., oral, topical, inhalant, pump, and injection) and either self-administered or administered by a caregiver or another medical professional including…Oxygen therapy…” Patient #8 was admitted to the agency on 09/29/22 with diagnoses including chronic respiratory failure, chronic obstructive pulmonary disease (chronic lung disease leading to obstructed airways), and obstructive sleep apnea (sleep disorder where all or part of the upper airway is obstructed). Plan of Care from 09/29/22 to 11/27/22 revealed orders for skilled nursing 1 time per week for 4 weeks and physical therapy 1 time per week for 5 weeks. DME (durable medical equipment) and supplies included oxygen and O2 (oxygen) precautions were included with the safety instructions on the Plan of Care. The skilled nursing admission visit included documentation of oxygen use at 2 liters per minute via nasal cannula. Oxygen was not listed with the medications on the Plan of Care and was not on Patient #8’s Medication Profile at the time of survey. In an interview on 11/15/22 at 12:46 PM, Employee #1, Regional Clinical Manager, was asked for the agency’s policy regarding including oxygen on the medication list and stated, “It [oxygen] should be on there…she [Patient #8] was still on it [oxygen] at the time of discharge and it is not listed.”

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, and staff interview, the agency failed to notify the physician of a patient’s change in status for 1 of 9 (Patient #9) clinical records reviewed. Findings include: Policy 9010481, titled Coordination and Communication Activities and last revised 06/2018, was received from the agency’s Regional Clinical Manager on 11/15/22 at 2:25 PM. This policy revealed, “…Whenever there is more than one employee or discipline or more than one organization providing services to a patient, agency staff will ensure that ongoing coordination and communication activities take place consistently…In order to assure the development and coordination of a coordinated plan of care, communication with all physicians involved in the patient’s plan of care…is necessary…Subjects discussed in patient case conferences or other coordination and communication may include, but are not limited to, the following…Review of findings from patient assessments and interventions to determine appropriate internal and external resources necessary to meet patient needs…Communicating information regarding the patient’s needs, goals of care/service, and/or interventions to be implemented by each individual…” and “Home Health staff will maintain on-going communication with all physicians involved in the plan of care which includes verbal and/or written reports that address the following, at a minimum…Significant changes in the patient’s condition…” Patient #9 was admitted to the agency on 09/15/22 with diagnoses including pericardial effusion (buildup of fluid in the space around the heart), cardiac tamponade (a condition that occurs when the fluid sac around the heart fills with fluid), and atrial fibrillation (an irregular heart rhythm). Plan of Care from 09/15/22 to 11/13/22 included orders for skilled nursing 1 time per week for 4 weeks, physical therapy 1 time per week for 8 weeks, and occupation therapy 1 time per week for 3 weeks. On 09/23/22, Employee #6, a registered nurse, wrote a communication note which read, “Patients [sic] husband called to report patient was having shortness of breath of and difficulty breathing, instructed him to call 911 for EMS (emergency medical services) to take her to ED (emergency department). He said he would do so.” There was no evidence that the physician was notified regarding this communication. On 09/27/22, Employee #4, a licensed practical nurse, conducted a skilled nursing visit. The respiratory portion of this visit note included “cough, productive” with “dull yellow color/dime size” sputum and a comment “lungs clear”. The documented visit narrative revealed, “…Heart rate at 116, but regular, no shortness of breath noted…resp (respirations) WNL (within normal limits)…patient states that she can feel when her heart is racing which makes her dizzy, instructed patient to call 911 next time she feels her hear racing and dizzy feeling, so that she can be checked out, patient and husband verbalized understanding…” There was no documentation regarding the 09/23/22 call or documented evidence of follow-up to address the reported symptoms from 09/23/22. On 09/29/22, Employee #5, an occupational therapist, conducted an occupational therapy visit. The subjective (patient reported) portion of this visit note included “I just feel terrible all over” and the narrative assessment portion revealed, “Patient is participating more in self care tasks overall since last visit, however reports more issues with SOB (shortness of breath). Patient has had to cancel medical appointment this week due to feeling poorly…” There was no documented evidence of follow-up or care coordination to address Patient #9 feeling “terrible all over” or that Patient #9 reported increased issues with shortness of breath. On 09/29/22, Employee #2 a physical therapy assistant, conducted a physical therapy visit. The subjective (patient reported) portion of this visit note included, “Patient reports her stomach cont (continues) to hurt a lot. She reports not feeling well at all…Patient reports poor appetite...” There was no documented evidence that Employee #2 reported to anyone that Patient #9 stated her stomach hurt and that Patient #9 stated she did not feel well. In an interview on 11/15/22 1:55 pm, Employee #1, Regional Clinical Manager, was asked what the expectations of clinicians with a change in condition or new symptoms were reported. Employee #1 stated, “That they would notify the doctor or at least document that they [the patient and/or caregivers] were told what to do when they were having symptoms.”

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on agency policy, clinical record review and staff interviews the Home Health Aide (HHA) failed to provide services that were included the plan of care for 1 of 1 patient receiving HHA services. (patient #5) Findings included: A policy, Home Health Aide, revised 06/2021, was received from the clinical manager on 11/15/22 at 2:07 P.M. The policy stated, the HHA is expected to, “Follow the aide care plan appropriate to the patient's needs and condition as developed and assigned by the Registered Nurse or Licensed Therapist.” … Patient #5 was admitted on 10/28/22 with a diagnosis of venous insufficiency chronic and a chronic leg ulcer. The Plan of Care for 10/28/22-12/26/22 included orders for skilled nurse visits 1 time a week for 10 weeks and Home Health Aide (HHA) visits 2 times a week for 8 weeks starting week the week of 10/30/22. The HHA Plan of Care included orders for the HHA to document temperature, pulse rate, respirations, and blood pressure (vital signs) with parameters (guidelines) on what to report to the nurse case manager. For 2 of 2 HHA visits completed between 11/04/22-11/14/22 HHA #3 documented the vital signs as “N/A” (not applicable). There was no evidence that vital signs were obtained according to the plan of care. An interview was conducted with HHA #2 on 11/15/22 at approximately 9:00 A.M. HHA #2 stated, “I take the vital signs then try to go back and document. Sometimes I forget.” An interview was conducted with the Clinical Manager on 11/15/22 at approximately 9:15 A.M. The Clinical Manger stated, it is the expectation that vital signs, “will be done on all patients that it’s assigned and documented.”