Every finding on record at Liberty Home Care

An onsite, unannounced recertification survey was conducted 03/04/24 to 03/06/24. No deficiencies to the Emergency Preparedness program were identified.

An onsite, unannounced recertification survey was conducted 03/04/24 to 03/06/24. 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 agency policy, direct observation, and staff interview, the agency failed to maintain an accurate medication list for 1 of 7 patients with home visits conducted during survey. (Patient #8) Findings included: PolicyStat ID 9464970, last approved 03/21 and titled “Medication Profile and Drug Regimen Review” was received from the agency director on 03/04/24 at 2:42 PM. This policy revealed, “A current listing of all medications the patient is using is maintained in the clinical record at all times…on every subsequent visit to the patient throughout the episode of care, the nurse…reviews the medication profile with the patient/caregiver to identify new, changed or discontinued medications [i.e. asks to see patient’s medications] …” Patient #8 was admitted to the agency 01/29/24 with diagnoses including hypertensive heart disease and heart failure. Plan of Care from 01/29/24 to 03/28/24 included orders for skilled nursing one time per week for nine weeks with two as needed (PRN). Employee #6, registered nurse, conducted a home visit on 03/05/24 which was observed during survey. During the visit, Employee #6 was observed reviewing Patient #8’s medications and comparing them to the agency’s medication profile. Patient #8’s medications were dispensed in “pill packets” and divided by the day and the time of day the medications were to be taken. During the medication review, Employee #6 noted several medications in the home that were not included on the agency’s medication list, including the following: Nitroglycerin (relaxes blood vessels and increases oxygen to the heart), Furosemide (reduces extra fluid in the body), Potassium (supplement often used with furosemide due to potential for potassium loss), Hydroxyzine (antihistamine used to treat anxiety, itching, nausea, and vomiting) Trazadone (used to treat depression), Propranolol (used to treat heart disease) Percocet (narcotic used to treat moderate to severe pain), Probiotic (supplement used to restore good bacteria in the body), Restasis (drops used for dry eyes) In an interview on 03/06/24 at 9:07 AM, Employee #6 stated that she would typically review patient medications “at least once per month” and stated “I had no idea that she [Patient #8] had all of those [medications] that she was taking … I am not sure what happened with that situation.” In an interview on 03/06/24 at 9:10 AM, Employee #1, agency director, stated that the expectation would be that the admitting clinician review patient medications and verify them with the physician’s office and stated “Each clinician should address medications on every visit…any changes…have they stopped something…any over-the-counter medications.”

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 agency policy, clinical record review, and staff interviews the agency failed to notify the physician of missed visits for 1 of 1 patient with fewer visit than ordered. (patient #4) Findings included: A policy, Plan of Care-CMS485 and Physician Orders was received on 03/12/2024 at 10:45 A.M. from the agency administrator. The policy stated, "If the Agency provides few visits than the physician orders, it has altered the plan of care and the physician must be notified." Patient #4 was admitted on 02/02/2023 with a diagnosis of Pressure ulcer (wound) of left buttock. The plan of care for 02/0/2023-04/02/2023 included orders for skilled nurse (SN) visits 1 time a week for 1 week, 2 times a week for 1 week, 1 time a week for 7 weeks, and 3 PRN (as needed). There were no SN visits from 02/04/2024 - 02/16/2024. There was no evidence in the clinical record of physician notification of missed visits. An interview was conducted on 03/06/2024 at approximately 9:00 A.M. with registered nurse (RN) #8. RN #8 stated, “It is my practice to contact the doctor’s [about missed visits]. I don’t see a note that I put it in there.” An interview was conducted on 03/06/2024 at approximately 9:05 A.M. the agency administrator. The agency administrator stated, “It [notification to the doctor of missed visits] should be there, at least 1 that week.”

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 follow accepted standards of practice to prevent the transmission of infection for 2 of 7 patients with home visits. (Patients #12 and 16.) Findings included: A policy, Bag technique, home care (revised 05/22/2023) was received on 03/05/2024 at approximately 10:00 A.M. from the agency administrator. The policy stated, “Never place any dirty or soiled items into the bag.” Patient #12 was admitted on 02/26/2024 with a diagnosis of hypoglycemia (low glucose in the blood stream). The plan of care for 02/26/2024-04/25/2024 included orders for skilled nurse visits 2 times a week for 1 week, 1 time a week for 1 week, 1 every other week for 7 weeks, and 2 PRN (as needed) visits. A home visit was conducted with registered nurse (RN) #8 on 03/05/2024 at approximately 9:00 A.M. RN #8 placed a dirty barrier pad into the clinical bag. An interview was conducted on 03/05/2024 at approximately 9:40 A.M. with the clinical manager. The clinical manager stated, “[the expectation is] to discard [barrier pad] in the trash.” The clinical manager was unable to state if the dirty barrier pad should be discarded in the home. 2. PolicyStat ID 10382835, last reviewed 09/2022, titled “Exposure Control Plan: Engineering and Work Practice Controls” was received from the agency director on 03/06/24 at 11:00 AM. This policy revealed, “If hands are not visibly soiled, the use of an alcohol-based hand rub…is the preferred method for hand hygiene in all of the following clinical situations…if moving from a contaminated body site to a clean body site during patient care…” Patient #16 was admitted to the agency on 02/26/24 with diagnoses including hypertension (high blood pressure) and encounter following left knee replacement surgery. Plan of Care from 02/26/24 to 04/25/24 included orders for a home health aide two times per week for four weeks. Employee #4, home health aide, conducted a home visit on 03/05/24, and was observed assisting Patient #16 with a chair bath. Patient #16 was observed removing the disposable brief that she was wearing prior to her chair bath and handing the used brief to Employee #4. Employee #4 was observed taking the used brief from Patient #16, while wearing gloves, and disposing of it in the garbage. Employee #4 was next observed applying soap and water to a clean, dry washcloth and handing it to Patient #16 to use for washing her face. Employee #4 did not remove her gloves and perform hand hygiene between handling the used brief and assisting Patient #16 with a clean washcloth. In an interview on 03/06/24 at 10:16 AM, Employee #4 stated that she would normally have removed her gloves and performed hand hygiene after handling used patient under garments prior to helping the patient with cleaning her face.

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 agency policy, clinical record review, and staff interview, the agency’s skilled nurses failed to document upper-arm circumference measurements and failed to document external catheter length measurements for 1 of 1 clinical record reviewed of a patient with a peripherally inserted central catheter (PICC) (Patient #6). Findings included: A document last updated 08/21/23, titled, “Lippincott Procedures-Peripherally inserted central catheter (PICC) dressing change”, was received from the agency director on 03/04/24 at 2:42 PM. This policy revealed, “Use a sterile tape measure or the incremental markings on the catheter to measure the external length of the catheter from hub to skin entry…Measure upper-arm circumference when clinically indicated to assess for the presence of edema and deep vein thrombosis…” Patient #6 was admitted to the agency 11/09/23 with diagnoses including disruption of wound, methicillin susceptible staph infection, bacteremia, and pancreatic cancer. Plan of care (POC) from 01/08/24 to 03/07/24 revealed orders for skilled nursing three times per week for eight weeks, two times per week for one week, and three as-needed (PRN). Employee #7, licensed professional nurse (LPN), conducted skilled nursing visits on 01/08/24, 01/10/24, and 01/17/24 and documented PICC dressing changes on those dates. There was no documented evidence in the clinical record that an upper-arm circumference was measured during any of these visits. Employee #6, registered nurse (RN) conducted a skilled nursing visit on 01/15/24 and documented a PICC dressing change. There was no documented evidence in the clinical record that the external catheter length or an upper-arm circumference was measured during this visit. In an interview on 03/06/24 at 8:59 AM, Employee #7 stated, “It [upper-arm circumference] was measured…I don’t know why I didn’t put it in [clinical record] …I don’t how I missed that…” In an interview on 03/06/24 at 9:05 AM, Employee #6 stated, “Honestly, I probably just forgot to write them down that day…” and verbally confirmed the standard practice of documenting external catheter length and upper-arm circumference measurements with each PICC dressing change. In an interview on 03/06/24 at 9:12 am, Employee #1, agency director, stated that the external catheter length and upper-arm circumference measurements should be documented “weekly…with dressing change…”

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on agency policy, clinical record review and staff interviews the agency failed to include all medication allergies for 1 of 7 patients with home visits conducted. (Patient #14) Findings included: A policy Care Planning: Initial Care Plan and Updates to the Plan of Care was received on 03/05/2024 at 2:37 P.M. from the agency administrator. The policy stated, “The plan of care also includes documentation of the following: … Allergies.” Patient #14 was admitted on 02/13/2024 by registered nurse (RN) #3 with a diagnosis of fracture of the sacrum (bony structure connected to the pelvis), the plan of care for 02/13/2024-04/12/2024 included orders for skilled nurse visits 1 time a week for 2 weeks, 1 every other week for 7 weeks, and 2 PRN (as needed) visits and occupational therapy (OT) visits 1 time a week for 3 weeks. A home visit was conducted on 03/05/2024 with OT #5. Patient #14 reported a new rash with itching. OT #5 completed a full medication review. Patient #14 stated that they began taking an acetaminophen (analgesic pain reliever) 250mg and ibuprofen (NSAID anti-inflammatory) 125mg over the counter medication. The Office Clinic Note Physician Final Report dated 12/27/2023 stated, “Allergies… NSAIDs”. The history and physical report dated 12/22/2023 from patient #14’s hospital stated, “Allergies NSAIDs”. There was no evidence in the clinical record of patient #14 having an allergy to NSAIDs. An interview was conducted on 03/06/2024 at approximately 10:17 A.M. with RN #3. RN #3 stated, “We go by their record, and I ask about food/dye allergies. I’m not sure if I had that [history and physical from hospital]” An interview was conducted with the clinical manager on 03/06/2024 at approximately 10:45 A.M. The clinical manager stated, “They [admitting clinicians] are provided all of the referral information that we [agency] receive. “They [admitting clinicians] should ask the patient what the allergies are, look at the referral, if there is a difference confirm with the PCP [primary care physician].

An onsite recertification survey was conducted 6/28/21-6/30/21. No deficiencies to the Emergency Preparedness Plan was 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 agency policy review, clinical record review and interviews with staff/patients/caregivers the Plan of Care failed to include all current medications/dosages the patient was using for 4 of 5 patients with virtual visits [#7, 3, 6 and 8]. The findings included: 2. Patient #3 was admitted on 9/10/20 with diagnoses of pressure ulcer left buttock, sacral region, and right buttock (all stage 4—full thickness tissue loss) and multiple sclerosis. The Plan of Care for 5/8/20-7/6/21 included orders for skilled nursing visits weekly for 9 weeks. Medications included Lasix 20 mg every other day for fluid retention. A virtual visit was conducted on 6/29/21 at approximately 9 a.m. Interview with the caregiver during the visit revealed the patient was taking Lasix 20 mg daily. The caregiver said the Lasix had not been every other day; always daily. An interview with RN #1 on 6/30/21 at 8:30 a.m. confirmed the patient was taking Lasix daily. 3. Patient #6 was admitted on 5/10/19 with a diagnosis of quadriplegia. The Plan of Care (POC) for 6/28/21-8/26/21 included orders for skilled nursing visits weekly for 9 weeks. Medications included Baclofen 10 mg 3 times a day for muscle spasms. A virtual home visit was conducted on 6/29/21 at 9:50 a.m. Interview with the caregiver during the visit revealed the patient was taking Baclofen 10 mg 2 pills 2 times per day and had taken this dose “for years.” An interview with RN #4 on 6/30/21 at 9:30 a.m. revealed the medication dose was not correct on the POC. 4. Patient #8 was admitted on 2/4/20 with diagnoses of pressure ulcer left buttock and hypertensive heart disease with heart failure. The Plan of Care (POC) for 5/29/21-7/27/21 included orders for skilled nursing visits weekly for 4 weeks then every 2 weeks for 4 weeks. A virtual home visit was conducted on 6/29/21 at 11:45 a.m. Interview with the patient during the visit revealed the patient was taking Imodium as needed for loose stools and had been taking this for years. The patient confirmed that last dose of Imodium was taken on 6/29/21. An interview with RN #2 on 6/30/21 at 9:15 a.m. revealed the RN “thought it [Imodium] was on there [the POC].” The policy, Medication List and Medication Review [revised date of 12/20], was provided by the agency administrator on 7/13/21. The policy stated, “Purpose-To establish a process for reviewing the patient’s drug regimen in order to maintain a current list of the patient’s medications…Procedure-At the time of a comprehensive assessment…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…On every subsequent visit to the patient throughout the episode of care, the nurse reviews the medication profile w the patient/caregiver to identify new, changed or discontinued medications…” 1. Patient # 7 had a Start of Care [SOC] date of 3/26/21 with admitting diagnoses of postprocedural hematoma of a genitourinary system and encounter for change or removal of surgical wound dressing. A review of the Plan of Care [POC] for the certification period 5/25/21 to 7/23/21 revealed orders for SN [skilled nursing] 1 time a week for 9 weeks. On 6/29/21 a virtual visit was conducted with Patient # 7 and RN # 8. During the visit a medication review was conducted using a medication profile provided by the agency. The medication profile did not list Eliquis [blood thinner] 2.5 mg 2 times per day. During an interview with the patient she confirmed she was taking Eliquis 2.5 mg 2 times per day. On 6/30/21 a telephone interview was conducted with RN # 8. During the interview RN # 8 confirmed the POC failed to include Eliquis.

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 clinical record review and staff interview, the RN instructed patient on medications outside of the Plan of Care for 1 of 5 discharged records reviewed (#13). Findings include: Patient #13 was admitted on 6/24/20 with a diagnosis of type 2 diabetes. The Plan of Care (POC) for 12/21/20-2/18/21 included order for skilled nursing visits weekly for 3 weeks, then every 2 weeks for 6 weeks. The POC included insulin orders for Levemir 30 units subcutaneously once a day (at bedtime) for blood sugar. On 12/22/20, the blood glucose was 289. The visit note stated, “All medications assessed. Drug regimen reviewed. All medication is complied with as ordered…” On 12/29/20, the visit note stated, “Patient’s glucometer battery dead and patient has been unable to measure glucose. Patient unable to locate lancets. SN [skilled nurse] instructed patient to purchase battery and locate lancet. Patient verbalized understanding. States has not check [sic] bgl [blood glucose level] since last SN visit. Teaching related to same.” On 1/5/21 from 12:24 p.m. – 1:23 p.m. the RN visited patient in the home. The RN documented, “BGL elevated; states did not take insulin last night. No sliding scale insulin in home for administration. Glucometer states glucose “HI”. Patient instructed to be seen in ER. SN instructed patient to administer insulin available and skip dose tonight. Patient does not have sliding scale insulin available. Unable to contact pcp [primary care physician]. Patient refuses to be seen in ER at this time. States may go later. Teaching related to the same.” On 1/5/21, a patient note was made at 3:23 p.m. that stated, “…MD notified of elevated BGL and recommendations to be seen the ER. Also discussed glucometer strips out of date from health department. States more than likely bgl off due to same. Order for Random BGL to be drawn…” On 1/6/21, the RN conducted a home visit to obtain the random blood glucose level via venipuncture. The visit note stated, “BGL remains “HI” on glucometer…” The patient’s glucose level on 1/6/21 was 834 (reference range 70-110). The patient was then seen in the emergency department. An interview with RN #1 on 6/30/21 at 8:30 a.m. confirmed there was no order to administer insulin during the 1/5/21 visit, nor to skip insulin that night. The RN was unsure if the patient had taken the insulin as instructed.