Every finding on record at Liberty Home Care

An onsite recertification survey was conducted January 22, 2024 - January 24, 2024. No deficiencies to the Emergency Preparedness Program were identified.

An onsite recertification survey was conducted January 22, 2024 - January 24, 2024. Standard level deficiencies to the Medicare Conditions of Participation were identified.

Before discharge for cause HHA must: CFR(s): 484.50(d)(5) The HHA determines, under a policy set by the HHA for the purpose of addressing discharge for cause that meets the requirements of paragraphs (d)(5)(i) through (d)(5)(iii) of this section, that the patient's (or other persons in the patient's home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the HHA to operate effectively is seriously impaired. The HHA must do the following before it discharges a patient for cause: This ELEMENT is not met as evidenced by: Based on agency policy, clinical record review, and staff interview the agency failed to notify a patient/representative that a discharge from occupational therapy for cause (uncooperative for care) was being considered and failed to make efforts to resolve the problem for 1 of 1 patient that was discharged for cause. (patient #4) Findings included: A policy, Discharge and Transfer of Patients (revised 09/2021) was received on 01/24/2024 at approximately 8:30 AM from the agency director. The policy stated, “The following must be done before the patient is discharge: Advise the patient, representative [if any]… that a discharge for cause is being considered; Make efforts to resolve the problem(s) presented by the patients behavior…” Patient #4 was admitted on 03/14/2023 with a diagnosis of nondisplaced (in proper alignment) oblique (at an angle) fracture of the shaft of the right femur (upper thigh bone). The plan of care from 03/14/2023-05/12/2023 included orders for physical therapy 1 time a week for 9 weeks, medical social worker visits 1 time a week for 1-week, occupational therapy (OT) visits 1 time a week for 1 week, 0 times a week for 2 weeks and, 1 time week for 1 week. For the OT evaluation visit of 03/15/2023 OT #14 stated, “OT will see for 2 more visits once pain and anxiety is addressed to reassess for further OT needs.” On the OT visit on 04/06/2023 OT #14 stated, “OT discharge without visit… OT eval [evaluation] completed 03/15/2023. At the time patient was non-compliant with attempts with bed mobility.” There was no evidence in the clinical record that OT #14 informed the patient/representative that a discharge for cause was being considered or made efforts to resolve the problem.” OT #14 was not available for an interview. An interview was conducted with the agency director on 01/24/2024 at approximately 9:15 AM. The agency director stated, “There is no 48-hour notification of discharge and no signed order for OT discharge. They normally would call the doctor from the home, educate patient and caregiver, that they have to participate to meet goals, that should have happened prior to discharge.”

Immediate reporting of abuse by all staff CFR(s): 484.50(e)(2) Any HHA staff (whether employed directly or under arrangements) in the normal course of providing services to patients, who identifies, notices, or recognizes incidences or circumstances of mistreatment, neglect, verbal, mental, sexual, and/or physical abuse, including injuries of unknown source, or misappropriation of patient property, must report these findings immediately to the HHA and other appropriate authorities in accordance with state law. This ELEMENT is not met as evidenced by: Based on agency policy, clinical record review, and staff interviews the agency failed to without delay, report neglect of 1 of 1 patient living in an unsafe environment. (patient #4) Finding included: A policy, Reporting abuse and Neglect (revised 03/2021) was received on 01/24/2024 at approximately 8:30 AM from the agency director. The policy stated, “Neglect means failure to provide goods and services necessary to avoid physical harm…Immediately means as soon as possible but not to exceed 24 hours…Personnel with knowledge or reasonable suspicion of an abuse, neglect or exploitation violation will make an immediate report to the appropriate [i.e., Adult Protective Services…] protective services unit of the local Department of Social Services [DSS].” Patient #4 was admitted on 03/14/2023 with a diagnosis of nondisplaced (in proper alignment) oblique (at an angle) fracture of the shaft of the right femur (upper thigh bone). The home health referral order of 03/10/2023 stated, “Resident to discharge home on 03/13/2023 with Home health, Nursing, PT [physical therapy] and OT [occupational therapy] services. The plan of care from 03/14/2023-05/12/2023 included orders for physical therapy 1 time a week for 9 weeks, medical social worker visits 1 time a week for 1 week, occupational therapy (OT) visits 1 time a week for 1 week, 0 times a week for 2 weeks and, 1 time week for 1 week. For the skilled nurse visit of 03/17/2023 registered nurse (RN)#4 stated, “Family does not have a wheelchair ramp in home. Discussed with family that if the house caught on fire, how would patient get out of house without wheelchair and wheelchair ramp. Family unsure of how they would get patient out…” There was no evidence in the clinical record that RN#4 notified Adult Protective Service of the potential for harm. For the RN visit of 03/29/2023 RN #9 stated, “Also due to the inability of family to get out of the home and to use the hoyer lift [mechanical lift] to transfer the patient, there are safety concerns for the patient remaining at home. APS referral made…” An interview was conducted on 01/23/2024 at approximately 4:30 PM with RN#4. RN #4 stated, “She was a large woman, she had no way to get out to doctor appointments or get out if there was a fire.” An interview with RN#4 on 01/24/2024 at 9:45 AM revealed that RN #4 had an understanding that all staff are mandated reporters of abuse.

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 home visit observation, agency policy, clinical record review, and staff interview, the agency failed to maintain an accurate medication profile for 1 of 7 home visits conducted (Patient #12). Findings included: PolicyStatID 9464970, last revised 03/21 and titled “Medication Profile and Drug Regimen Review, was received from the agency director on 01/24/24 at 12:00 PM. This policy revealed, “If a clinician is assessing the patient’s medications and the patient has a new prescription from a pharmacy (correctly labeled), then the clinician must update the medication profile…If the clinician is assessing the patient’s medications and the patient states that the physician has changed the dosage of a medication, a physician’s order is needed to cover the change in dosage. The clinician contacts the physician to verify the current dosage, documents this in the clinical record, enters a physician interim order for the changed dosage, updates the medication profile and then incorporates the changes onto the next Plan of Treatment.” Patient #12 was admitted to the agency on 12/06/23 with diagnoses including diabetes with foot ulcer (foot wound related to diabetes), congestive heart failure (heart is unable to pump blood efficiently), and chronic kidney disease. Plan of Care from 12/06/23 to 02/03/24 revealed orders for skilled nursing one time per week for nine weeks and occupational therapy one time per week for four weeks, effective 01/15/24. During a home visit observation on 01/23/24, Employee #7, occupational therapist, conducted a review of Patient #12’s medications. Patient #12 stated that she had been taking the following medications that were not listed on the agency’s medication profile: Eliquis (blood thinner), Humalog (insulin), Toujou (insulin) quick pen using a sliding scale (predetermined range of medication to be given based on test results), Toujou and nitroglycerin (used to treat chest pain, as needed. Additionally, the following medications were listed on the medication profile, that Patient #12 stated had been discontinued: Allopurinol (used to treat gout and kidney stones) 50 milligrams. Patient #12 stated that the medication changes discussed on 01/23/24 were not new and had been in effect for months to years. In an interview on 01/24/24 at 1:20 PM, Employee #7 stated, “I usually do it [medication reconciliation] every visit.” In an interview on 01/24/24 at approximately 1:25 PM, Employee #1, clinical manager, stated “That’s [medication reconciliation] supposed to be done every visit…If there are any discrepancies, a nurse contacts and reviews with the doctor.”

Track adverse patient events CFR(s): 484.65(c)(2) Performance improvement activities must track adverse patient events, analyze their causes, and implement preventive actions. This STANDARD is not met as evidenced by: Based on agency policy, clinical record review, and staff interviews the agency failed to track and analyze adverse patient events for 2 of 2 patients that experienced falls. (Patients #11 and #17) Findings included: A policy, Non-Routine Events (revised 01/2021) was received on 01/24/2024 at approximately 8:30 AM from the agency director. The policy stated, “A non-routine event may include…: Any falls that have occurred since the last clinician visit…The non-routine event is documented on-line within 24-48 hours on the Non-Routine Event Form…The supervisor investigates the details of the event…” 1. Patient #11 was admitted on 12/01/2023 with a diagnosis of cellulitis (a bacterial infection of the skin) of the left lower limb. The plan of care for 12/01/2023-01/29/2024 included orders for skilled nurse (SN) visits 1 time a week for 1 week, 2 times a week for 8 weeks, and 3 prn (as needed) visits. For the SN visit of 12/22/2023 LPN #11 stated, “Pt [patient] reports she fell this am around 4 off the bed and had to go to the ER [emergency room]. There was no evidence of reporting or analyzing on the Non-Routine Event log. 2. Patient #17 was admitted on 01/12/2024 with a diagnosis of Pressure Ulcer (wound) of right buttock. A home visit was conducted on 01/23/2024 with registered nurse (RN) #5 at approximately 8:30 AM. The plan of care for 01/12/2023-03/11/2024 included orders for physical therapy (PT) visits 1 time a week for 1 week, 2 times a week for 2 weeks, and 1 time a week for 5 weeks and skilled nurse visits 0 times a week for 1 week, 1 time a week for 8 weeks, and 2 PRN (as needed) visits. For the PT visit of 01/16/2024 PT #3 stated, “Reports 1 fall since being home when CG [caregiver] found Pt. [patient] In [sic] floor…” There was no evidence of reporting or analyzing on the Non-Routine Event log. An interview was conducted on 01/24/2024 with LPN #11 at approximately 1:45 PM. LPN #11 stated, “Honestly, I don’t know if I completed the NRE [Non-Routine Event]. We do document in the NRE about a fall.” An interview was conducted on 01/24/2024 with PT #3 at approximately 12:40 PM. PT #3 stated, “Yes [remembers family reporting a fall]. I documented it into his chart and called the doctor’s office and had forgotten to do the NRE.” An interview was conducted on 01/24/24 at approximately 11:30 AM with the clinical manager. The clinical manager stated, “A fall is an NRE non-routine event for [agency name], that’s how they are tracked.”

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 maintain clean equipment and dispose of a contaminated would dressing for 1 of 7 patients with conducted home visits (Patient #17) and the agency's home health aide failed to perform hand hygiene after glove removal for 1 of 1 home health aide visits observed (Patient #14). Findings included: PolicyStat ID 10382835, last revised 09/21 and titled “Exposure Control Plan: Engineering and Work Practice Controls” was received on 01/24/24 at 8:30 AM from the agency director. This policy revealed, “If hands are not visibly soiled, the use of an alcohol-based hand rub for routinely decontaminating hands is the preferred method for hand hygiene in all of the following clinical situations…after removing gloves and other PPE [personal protective equipment]” Patient #14 was admitted to the agency 5/16/23 with diagnoses including left lower leg wound, congestive heart failure (heart does not pump blood efficiently), and chronic kidney disease. Plan of Care from 01/11/24 to 03/10/24 revealed orders for skilled nursing one time per week for one week and two times per week for eight weeks, and home health aide zero times per week for one week and one time per week for five weeks. A home visit, conducted by Employee #13, home health aide, was observed on 01/23/24. Employee #13 assisted Patient #14 with a chair bath and when the bath was complete, Employee #13 removed her gloves and assisted the patient with ambulation to the front room of the home. Employee #13 did not perform hand hygiene after she removed her gloves. In an interview on 01/24/24 at 1:31 PM, Employee #13 acknowledged that she did not perform hand hygiene after removing her gloves during the observed visit and stated that hand hygiene should be performed, “right after and right before” glove removal and glove placement. A policy, Bag technique, home care (revised 05/22/2023) was received on 01/24/2024 from the agency director at approximately 8:30 AM. The policy stated, "If a product is expired, is defective, or has compromised integrity, remove it from patient use." A policy, Exposure Control Plan: Engineering and Work Practice Controls (revised 09/2021) was received on 01/24/2024 from the agency director at approximately 8:30 AM. The policy stated, "When working with patients, it is important for clinicians to keep company-issued devices clean and sanitized..." Patient #17 was admitted on 01/12/2024 with a diagnosis of Pressure Ulcer (wound) of right buttock. The plan of care for 01/12/2023-03/11/2024 included orders for skilled nurse visits 0 times a week for 1 week, 1 time a week for 8 weeks, and 2 PRN (as needed) visits and SN (skilled nurse) taught cg (caregiver) to perform pressure ulcer care to R (right) side of buttocks every 3-5 days. Cleanse wound with wound cleanser, apply hydrocolloid dressing using asceptic (sterile) technique. A home visit was conducted on 01/23/2024 with registered nurse (RN) #5 at approximately 8:30 AM. RN #4 performed a physical assessment on patient #17 and removed the contaminated gloves. The contaminated gloves came in contact with the documentation tablet (electronic device). RN #4 failed to disinfect the tablet. RN #4 completed wound care on patient #17. A clean dressing came into contact with the contaminated documentation tablet. RN #4 failed to dispose on the dressing. An interview with RN #4 on 01/23/2024 at approximately 9:30 AM revealed that RN #4 normally keeps the documentation tablet with the clean wound care supplies. An interview with the clinical manager was conducted on 01/23/2024 at approximately 9:35 AM. The clinical manager stated, "The tablet should have been cleaned [after contact with the dirty gloves] and the dressing should have been thrown out [after contact with the tablet].

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on agency policy, clinical record review, and staff interviews the agency failed to provide an on-going interdisciplinary assessment for 1 of 5 discharged patient. (patient #4) Findings included: A policy, Reporting Abuse and Neglect (revised 03/2021) was received on 01/24/2024 at approximately 8:30 AM from the agency director. The policy stated, “Following a report of abuse and neglect to DSS [Department of Social Services], the social worker/social work assistant will follow-up with an immediate visit to the patient’s home… The social work visit is scheduled within 24 hours of the report to DSS.” Patient #4 was admitted on 03/14/2023 with a diagnosis of nondisplaced (in proper alignment) oblique (at an angle) fracture of the shaft of the right femur (upper thigh bone). The plan of care from 03/14/2023-05/12/2023 included orders for medical social worker (MSW) visits 1 time a week for 1 week and MSW to assess psychosocial issues that impact healthcare, need for counseling, financial health, need for access to community resources and long-term care planning. MSW #12 conducted a telephone assessment on 03/17/2023. On 03/20/2023 MSW #12 conducted a telephone visit. MSW #12 stated, “SW [social worker] made referral to CAP [Competitive Acquisition Program] and has a list of ramp resources.” For the RN visit of 03/29/2023 RN #9 stated, “Also due to the inability of family to get out of the home and to use the hoyer lift [mechanical lift] to transfer the patient, there are safety concerns for the patient remaining at home. APS referral made…” There was no evidence in the clinical record of MSW completing an in person visit or having continued involvement with patient #4. An interview was conducted with MSW #12 on 01/24/2024 at approximately 1:00 PM. MSW #12 revealed that MSW #12 was not involved with patient #4 or her family after the telephone call on 03/20/2023. An interview was conducted with the agency director on 01/24/2024 at approximately 1:15 PM. The agency director stated, “We should have done a home visit [MSW, after APS referral].

An unannounced onsite recertification survey was conducted 8/9/21-8/11/21. No deficiencies to the Emergency Preparedness Plan 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 review, clinical record review, virtual visits and interviews with staff, patients and caregivers the Plan of Care failed to include all current/correct medications for 5 of 7 charts who had virtual visits [#5, 6, 8, 3 and 10]. The findings included: 5. Patient #3 was admitted on 7/27/21 with a diagnosis of a urinary tract infection and was receiving IV antibiotics. The Plan of Care (POC) for 7/27/21-9/24/21 included orders for skilled nursing 1 time for 1 day, then weekly for 8 weeks. The POC included the medication “Percocet 1 tablets oral 4 times a day for pain, PRN [as needed] pain.” A telephone visit was conducted with patient and RN #9 on 8/10/21 at 9:10 a.m. The RN confirmed the Percocet dose was not on the POC but should be 10/325 mg. 6. Patient #10 was admitted on 2/9/21 with a diagnosis of a complete traumatic amputation at elbow level. The Plan of Care (POC) for 8/8/21-10/6/21 included orders for skilled nursing 3 times per week for 1 week, 5 times per week for 1 week, then 7 times per week for 1 week. A virtual home visit was conducted on 8/10/21 at 2:05 p.m. A review of the medications list on the POC revealed the following discrepancies: Dilaudid 2 mg every 4 hours as needed for pain. The patient stated he had not taken Dilaudid “for a while”Duloxetine 60 mg daily for pain. The patient stated he had not taken “for a while’Gabapentin 900 mg 3 times daily for neuropathic pain. The patient stated he was taking 300 mg every 6 hours since approximately 6/8/21Methocarbamol 500 mg 3 times per day. The patient stated he was no longer taking this Potassium chloride 10 mEqs daily. The patient stated he was taking 10 mEqs 2 tablets daily “for years”Senna 2 tablets 2 times per day for constipation. The patient stated he had not taken since he stopped the narcotic pain medication. The POC also failed to include the following medications:Tylenol 500 mg as needed—taking since approximately February 2021Vitamin C 500 mg 2 tabs dailyVitamin D3 50 mcg 1 time daily “for a while”The policy, Care Planning - Initial Care Plan and Updates to the Plan of Care with a revised date of 5/20, was provided by the agency administrator on 8/11/21.The policy stated, “…The plan of care also includes…specific physician orders to provide care requiring the administration of medication…” 1. Patient # 5 had a Start of Care [SOC] date of 7/21/21 and an admitting diagnosis of unspecified intracap. fracture of right femur. A review of the Plan of Care [POC] for the certification period 7/21/21 to 9/18/21 revealed orders for SN [skilled nursing] 1 time a day for 1 day; 1 time a week for 8 weeks, PT [physical therapy] 1 time a day for 1 day; 1 time a week for 8 weeks; OT [occupational therapy] 1 time a day for 1 day; 1 time a week for 2 weeks; 1 time a week for 1 week; 1 time a week for 3 weeks. On 8/10/21 a virtual visit was conducted. During the visit a medication review was conducted. The POC failed to include the following medication: Docusate Sodium 100 mg 2 times per day. During an interview with the patient she reported taking docusate for "about 2 years". On 8/11/21 at approximately 12:15 pm an interview was conducted with the agency administrator. The administrator confirmed the POC failed to include all the medications the patient was taking. 2. Patient # 6 had a Start of Care [SOC] date of 4/7/21 and an admitting diagnosis of encounter for surgical aftercare following surgery on the circulatory system. A review of the Plan of Care for the certification period 8/5/21 to 10/3/21 revealed orders for SN [skilled nursing] 1 time a week for 1 week; 2 times a week for 9 weeks; 4 PRN [as needed] for dressing changes, complications or med changes. On 8/10/21 a virtual visit was conducted. During the visit a medication review was conducted. The following discrepancies were noted during the review: the POC listed Hydrocodone 325 mg/5 mg 1 tablet every 6 hours as needed for pain and Fish Oil 1,000 mg daily . During an interview with the caregiver the caregiver advised, “He doesn’t take either one of those medications any longer.” On 8/11/21 at approximately 11:45 am an interview was conducted with the agency administrator . During the interview, the agency administrator confirmed the POC did not include the correct/current medications. 3. Patient # 8 had a Start of Care [SOC] date of 7/22/21 and an admitting diagnosis of gastrointestinal hemorrhage [unspecified]. A review of the Plan of Care [POC] for the certification period 7/22/21 to 9/19/21 revealed orders for OT [occupational therapist] 1 time a day for 1 day and 1 time a week for 7 weeks. On 8/10/21 a virtual visit was conducted with the occupational therapist. During the visit a medication review was conducted. The POC failed to include Novolin [insulin] 10 units every am and Humalog [insulin] as needed based on sliding scale. On 8/11/21 at approximately 11:30 am an interview was conducted with the agency administrator . During the interview, the agency administrator confirmed the POC did not include all the current medications. 4. Patient # 11 had a Start of Care [SOC] date of 6/18/21 and admitting diagnoses of Type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene and Type 2 diabetes mellitus with other specified complication. A review of the Plan of Care [POC]/Physician’s orders for the certification period 6/18/21 to 8/16/21 revealed orders for SN [skilled nursing] 1 time a day for 1 day; 1 time a day for 1 day; 3 times a week for 3 weeks and 3 PRN [as needed] for wound assessment. On 8/10/21 a virtual visit was conducted. During the visit, a medication review was performed. The following discrepancies were noted during the review: The POC listed Novolog [insulin] 100 units/mL 15 units 3 times per day. During the interview with the patient, he reported he took 20 units 3 times per day. The following medications were listed on the POC - B Complex [supplement] 1 tablet daily, Furosemide 40 mg 2 times per day and Metformin Hydrochloride ER [diabetic medication] 500 mg 2 times per day. During the interview the patient reported, “I don’t take those medicines any more.” On 8/11/21 at approximately 12 pm an interview was conducted with the agency administrator. During the interview, the administrator confirmed the POC did not include the current/correct medications the patient was taking.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on clinical record review and staff interviews the agency failed to follow the Plan of Care related to oxygen orders for 2 of 17 charts [# 12 and 1 ]. The findings included: 2. Patient #1 was admitted on 6/18/21 with diagnoses of atherosclerotic heart disease, hypertensive heart disease, and chronic diastolic congestive heart failure. The Plan of Care for 6/18/21-8/16/21 included orders for physical therapy 1 time on day 1, 2 times per week for 3 weeks, 1 time on 7/23, then weekly for 4 weeks. The POC also included oxygen 3 liters per minute via nasal cannula. On 6/22/21, 6/24/21, 6/30/21 the physical therapy assistant documented the patient was using oxygen at 2 liters. On 7/3/21, the physical therapy assistant documented the patient was using oxygen at 2.5 liters. An interview with Employee #6 on 8/11/21 at 2:30 p.m. confirmed the oxygen should be 3 liters per minute. Patient # 12 had a Start of Care [SOC] date of 7/12/21 and an admitting diagnosis of encounter for surgical aftercare following surgery on the digestive system. A review of the Plan of Care for the certification period 7/12/21 to 9/9/21 revealed orders for SN [skilled nursing] 1 time a day for 1 day; 1 time a week for 8 weeks and 2 PRN [as needed] for complications/med changes and PT [physical therapy] 1 time a day for 1 day; 2 times a week for 4 weeks; 1 time a week for 4 weeks. Further review of the plan of care revealed an order for Oxygen 2.5 liters/min inhalation continuous for dyspnea. A review of the clinical record revealed the following information: During the PT and SN visit on 8/3/21 both disciplines documented the patient was using 3 liters of oxygen. On 8/5/21 and 8/6/21 the PTA documented the patient was using oxygen at 3 liters. On 8/12/21 at approximately 2 pm an interview was conducted with RN # 6. During the interview the RN confirmed the POC was not followed related to the oxygen setting.

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 interviews the agency failed to obtain an order for Epson Salt Soaks for 1 of 7 patients who received a virtual visit [#5]. The findings included: Patient # 5 had a Start of Care [SOC] date of 7/21/21 and an admitting diagnosis of unspecified intracap. fracture of right femur. A review of the Plan of Care [POC] for the certification period 7/21/21 to 9/18/21 revealed orders for SN [skilled nursing] 1 time a day for 1 day; 1 time a week for 8 weeks; and apply skin prep to the right heel daily. A review of the clinical record revealed during the SN visit on 7/29/21 RN # 9 documented, “…at this time patient has been informed to soak foot in Epson salt daily…” Further review of the clinical record does not include an order for Epson salt soaks to the right heel. An interview was conducted with RN # 6 on 8/11/21 at approximately 1 pm. During the interview RN # 6 confirmed the clinical record did not contain an order for Epson salt soaks.

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 clinical record review and staff interviews the agency failed to notify the physician of changes in the patient's condition for 2 of 17 charts [# 1 and 16]. The findings included: 2. Patient #1 was admitted on 6/18/21 with diagnoses of atherosclerotic heart disease, hypertensive heart disease, and chronic diastolic congestive heart failure. The Plan of Care for 6/18/21-8/16/21 included orders for physical therapy 1 time on day 1, 2 times per week for 3 weeks, 1 time on 7/23/21, then weekly for 4 weeks; and home health aide time per week for 4 weeks, the beginning on 7/25/21 1 time per week for 4 weeks. The physical therapy note on 6/18/21 revealed the patient’s blood pressure was 80/50 but came up to 100/70 after activity. The physical therapy note on 6/22/21 revealed “some” nausea. On 6/24/21, the PTA documented the patient reported diarrhea from the previous days and “generally not feeling well today.” On 6/30/21, the patient’s blood pressure, during the physical therapy visit, was 90/55. The note also stated, “No pain just feeling weak…Reports she took medication to help with diarrhea does not know the name of what she took.” The home health aide visited on 7/1/21 and documented a blood pressure of 92/56. On 7/6/21, the physical therapy visit note stated, “…Pt walked out of her bathroom with 3L O2 and RW [rolling walker]. O2 sats at 81%, noted breathing through mouth. Improved O2 sats to 93% after long rest break and deep breathing.” The patient’s blood pressure was noted to be 95/55. The documentation revealed the patient had some diarrhea, was short of breath “with minimal activity” and had dizziness “once in a while.” The patient was admitted to the hospital on 7/6/21-7/13/21. The hospital discharge summary revealed hemoglobin 5.9 upon hospital admission. The patient was admitted due to gastrointestinal bleed [GI]. The note stated, “Patient reports symptoms started about 2 weeks ago and have progressively worsened. She reports associated nausea, dark, loose stool, and bright red blood per rectum on tissue paper. She also reports associated fatigue, loss of appetite, SOB [shortness of breath] and palpitations…she was found to have upper gi bleed and underwent EDG with GI, clips were placed and no active bleed was noted. We discontinued her Eliquis due to her significant gi bleed requiring 3 units prbc [packed red blood cells].” There was no evidence the physician was notified of the low blood pressure, nausea, diarrhea, or the drop in oxygen saturation. An interview with Employee #6 was conducted on 8/11/21 at 2:30 p.m.. The interview revealed there was no evidence the physician was notified of the low blood pressure, the nausea, diarrhea, or drop in oxygen saturation. 3. Patient #16 was admitted on 8/12/20 with a diagnosis of hypertensive heart and chronic kidney disease with heart failure and stage 5 kidney disease. The Plan of Care (POC) for 8/12/20-10/10/20 included orders for skilled nursing visits 1 time for 1 day then weekly for 8 weeks; physical therapy 1 time for 1 days, 2 times per week for 3 weeks, then 1 time per week for 2 weeks; occupational therapy 1 time for 1 day, 1 time the week of 8/24/20, then 1 time the week of 9/6/20, and home health aide weekly for 4 weeks. On 8/26/20, the physical therapy assistant [PTA] sent a coordination note the RN that stated, “[patient] is forgetful about taking her meds. Can you please assist patient with setting up a medi planner.” The RN visited on 8/28/20. The visit note stated, “CM [case manager] updated pill box set up, pt has 2 medications not put in pill box due to patient having to monitor blood pressure prior to taking it, as this time patient does not have a blood pressure cuff patient said she would obtain one.” The PTA visited on 8/31/20 at 10:00 a.m. The patient reported medication compliance, but PTA stated, “she [patient] states she hasn’t taken her meds yet.” On 9/2/20 PTA visited the “Patient reports compliance with medications however, Medi planner still full from when nurse filled it. Patient took morning meds from mediplanner while PTA was in the home.” On 9/9/20 the PTA documented that patient had not take meds that day. The PT conducted a PT discharge visit on 9/11/20. The PT stated, “Patient has not taken her medicines yesterday or today. Patient has a Medhi [sic] planner but apparently is taking meds from the bottles ad lib…” An interview with Employee #6 was conducted on 8/11/21 at 2:30 p.m. The interview revealed there was no evidence the physician was notified of medication non-compliance.

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 clinical record review and staff interviews the clinical record failed to include PICC [peripherally inserted central catheter] line measurements for 1 of 1 charts with a PICC line [#2]. The findings included: Patient # 2 had a Start of Care [SOC] date of 6/24/21 with an admitting diagnosis of Type 2 diabetes mellitus with specified complications. A review of the Plan of Care [POC] for the certification period 6/24/21 to 8/22/21 revealed orders for SN [skilled nursing] 1 time a day for 1 day; 1 time a week for 1 week; 3 times a week for 5 weeks; 3 times a week for 1 week; 2 times a week for 1 week; 1 time a week for 1 week. A review of the nursing care plan revealed the following information, “…measure arm circumference weekly in cm [centimeter] and measure catheter [PICC] length every visit…” A review of the clinical record revealed the arm circumference was measured at the time of admission on 6/24/21 and on 7/19/21 in inches. No further arm circumference measurements were obtained. Further review of the clinical record revealed no catheter length measurements were obtained in 21 of 21 visits from 6/24/21 thru 8/9/21. A telephone interview was conducted with RN # 8 on 8/11/21 at approximately 10:30 am. During the interview the RN stated, “I really didn’t see a place to chart any measurements” . An interview was conducted the agency administrator on 8/11/21 at approximately 2 pm. During the interview the administrator confirmed the clinical record did no include PICC line measurements and/or arm circumference measurements.