Every finding on record at Liberty Home Care

An onsite recertification and follow up survey was conducted 08/29/22 to 08/30/22. No deficiencies were identified to the Emergency Preparedness Program. ABH

An onsite recertification and follow up survey was conducted 08/29/22 to 08/30/22. Deficiencies to the Medicare Conditions of Participation were identified. ABH

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, clinical record review, virtual visit observations, and interviews with patients and staff the Plan of Care [POC] failed to include all medications/correct dose/strength the patient was using for 1 of 2 virtual visits [#3]; failed to include all pertinent diagnoses for 1 of 22 records [#11]; failed to include weight bearing restrictions for 1 of 22 records [#6]; failed to include indications/frequency for PRN [as needed] medications or visits for 1 of 22 records [#20]. The findings included: The policy, Medication Profile/Drug Regimen Review [3/2021], was provided by the agency director on 8/30/22 at 1:12 pm. The policy stated, “…At the time of a comprehensive assessment (SOC, ROC, or any follow-up time point) …the registered nurse or therapist will assess and document a thorough medication history. This history will include documentation of all prescription and non-prescription medications the patient is using…” The policy, Care Planning, Initial Care Plan and Updates to the Plan of Care [3/2021], was provided by the agency director on 8/30/22 at 1:12 pm. The policy stated, “…The Plan of Care also includes documentation of the following…All pertinent primary, secondary, and surgical diagnoses with dates of onset or exacerbation…The types of supplies and equipment required…Amount, frequency and duration of visits/services provided…Functional limitations…Activities Permitted…” Patient # 3 had a Start of Care date of 8/22/22 and admitting diagnosis of Other Shoulder Lesions, Right Shoulder. The Plan of Care [POC] for the certification period 8/22/22-10/20/22 included orders for OT [occupational therapy] 1 time a week for 1 week, 2 times a week for 2 weeks, 1 time a week for 2 weeks. A virtual visit was conducted on 8/29/22 at approximately 2:30 pm with OT # 1. During the visit a medication review was conducted using a medication profile provided by the agency. The following discrepancies were noted: The medication profile listed Pantoprazole [used for reflux] 1 tablet 2 times a day 30 minutes before meals. The medication profile did not include the strength of the medication. During an interview with OT # 1 during the virtual visit, the OT reported the strength of the medication was 30 mg. The medication profile listed Vitamin D3 [supplement] 25 mcg [micrograms] 1 tablet daily. An interview was conducted with Patient # 3 during the virtual visit. Patient # 3 stated she was taking Vitamin D3 50,000 units per week. During an interview the clinical manager on 8/30/22 at approximately 4:30 pm she confirmed the POC did not include all the medications the patient was taking. 2. Patient # 11 had a Start of Care date of 7/28/22 and admitting diagnoses of Essential Hypertension [high blood pressure] and Unsteadiness on feet. Review of the Plan of Care [POC] for the certification period 7/28/22 to 9/25/22 included orders for SN [skilled nursing] 1 time a week for 5 weeks, 1 time every other week for 4 weeks, 3 PRN [as needed] for medication issues or disease management and “…SN to assess other co-morbidities including diabetes…SN to minimize risk for hospitalization due to high risk [sic] hypertension and diabetes…SN to instruct patient on self-management program to include disease process…blood sugar monitoring, hypo/hyperglycemia management…” Review of the admission note dated 7/28/22 included the following information, “…Pt [patient] is deaf…Pt is also a diabetic but pt’s sister states it has been diet controlled for years and they don’t check his sugar regularly…”An interview was conducted with the clinical manager on 8/30/22 at approximately 2 pm. During the interview, she confirmed Diabetes should have been included in the diagnosis section of the POC. 3. Patient # 6 had a Start of Care date of 8/16/22 and admitting diagnosis of Displaced Oblique [bone is broken at an angle] Fracture of Shaft of Right Fibula [the outer and smaller one the 2 bones between the knee and ankle]. The Plan of Care [POC]for the certification period 8/16/22 to 10/14/22 included orders for PT [physical therapy] 2 times a week for 4 weeks, 1 time a week for 3 weeks. The physician’s order indicated a weight bearing limit of “Touch down weight bearing on right lower extremity with boot on”. Review of the POC did not include the weight bearing restrictions or the use of the walking boot. An interview was conducted with the clinical manager on 8/30/22 at approximately 4:45 pm. During the interview, the clinical manager stated, “The information is on the OASIS [The Outcome and Assessment Information Set]. I don’t know why it didn’t pull to the POC.” 4. Patient # 20 had a Start of Care date of 7/20/22 and admitting diagnoses of Non-ST Elevation [NSTEMI] Myocardial Infarction [heart attack] and Heart Failure. The Plan of Care for the certification period 7/20/22 to 9/17/22 included orders for SN [skilled nursing] 1 visit every other week for 7 weeks, 3 PRN [as needed]. The PRN visits did not include the indication for the visit. The medication profile provided by the agency listed Voltaren [topical nonsteroidal anti-inflammatory gel] 1% Topical gel, 2 grams on back or affected joints as needed for pain. The order did not include a frequency for the PRN [as needed] medication. An interview was conducted with the clinical manager on 8/30/22 at approximately 4:30 pm. During the interview, she confirmed the PRN visits had no indication and the order for Voltaren had no frequency

Communication with all physicians CFR(s): 484.60(d)(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 and procedure, clinical record review, and staff interview the agency failed to coordinate care with the physician regarding vital signs outside of parameters for 6 of 22 records reviewed (#18,5, 8, 11, 14, and 20) incorrect weight bearing status for 1 of 4 physical therapy records reviewed (#5), reported lightheadedness for 1 of 5 discharged records (#15), and telemonitor vital signs outside of parameters for 1 of 5 discharged records reviewed (#15). Findings included: 2. Patient # 5 had a Start of Care date of 8/9/22 and admitting diagnosis of Hypo-osmolality [levels of electrolytes, proteins and nutrients in the blood are lower than normal] and Hyponatremia [low sodium]. Review of the Plan of Care of the certification period 8/9/22 to 10/7/22 included orders for PT [physical therapy] 1 time a week for 1 week, 2 times a week for 4 weeks, 1 time a week for 4 weeks and “Notify physician of vital sign parameters out of range….Diastolic [bottom number - relating to the phase of the heartbeat when the heart muscle relaxes and allows the chambers to fill with blood] greater than 90 or less than 60…Systolic blood pressure [top number - relating to the phase of the heartbeat when the heart muscle contracts and pumps blood from the chambers into the arteries ] greater than 160 or less than 90…” PTA [physical therapist assist] # 6 made a routine visit on 8/25/22 and documented a blood pressure reading of 96/50. During an interview with the clinical manager on 8/30/22 at approximately 4:30 pm, she confirmed the physician was not notified of the blood pressure reading. 3. Patient # 8 had a Start of Care date of 7/29/22 and an admitting diagnosis of Enterocolitis due Clostridium Difficile [C-diff-inflammation of the colon caused by the bacteria Clostridium difficile]. Review of the Plan of Care for the certification period 7/29/22 to 9/26/22 included orders for PT [physical therapy] 1 time a week for 1 week, 2 times a week for 3 weeks, 1 time a week for 4 weeks and “Notify physician of vital sign parameters out of range….Diastolic [bottom number – relating to the phase of the heartbeat when the heart muscle relaxes and allows the chambers to fill with blood] greater than 90 or less than 60…Systolic blood pressure [top number – relating to the phase of the heartbeat when the heart muscle contracts and pumps blood from the chambers into the arteries] greater than 160 or less than 90…” PT # 7 made a routine visit on 8/22/22. The clinical record for 8/22/22 included a blood pressure reading of 90/50. There was no evidence PT # 7 notified the physician of the blood pressure reading. An interview was conducted with the clinical manager on 8/30/22 at approximately 4:30 pm. During the interview she confirmed the physician was not notified of the blood pressure. 4. Patient # 11 had a Start of Care [SOC] date of 8/1/22 and admitting diagnoses of Infection/Inflammation Reaction due to Right Knee Prosthesis and Other Streptococcal [type of bacteria] Arthritis. The Plan of Care for the certification period 8/1/22-9/29/22 included order for SN [skilled nursing] 1 time a week for 3 weeks, 2 PRN [as needed] for complications/concerns and “Notify physician of vital sign parameters out of range…Heart rate greater than 100 or less than 60…” RN # 2 completed the SOC on 8/1/22. Review of the visit note revealed a heart rate of 50. There was no evidence RN # 2 notified the physician of the heart rate. An interview was conducted the clinical manager on 8/30/22 at approximately 4:30 pm. During the interview she confirmed the physician was not notified of the heart rate. 5. Patient # 14 had a Start of Care date of 2/21/22 and admitting diagnoses of Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease and Hypertensive Chronic Kidney Disease. Review of the Plan of Care for the certification period 2/21/22 to 4/21/22 included orders for SN [skilled nursing] 1 time a day for 1 day, 1 time a week for 9 weeks, 3 PRN [as needed] for complication/med changes; PT [physical therapy] 1 time a day for 1 day, 2 times a week for 3 weeks, 1 time a week for 3 weeks and “Report findings to MD [medical doctor] if Diastolic [bottom number – relating to the phase of the heartbeat when the heart muscle relaxes and allows the chambers to fill with blood] is greater than 100 or less than 50…if systolic [top number - relating to the phase of the heartbeat when the heart muscle contracts and pumps blood from the chambers into the arteries ] is greater than 160 or less than 90…” The clinical record included the following blood pressure readings: 3/1/22 by RN # 3 - 177/86, 3/11/21 by PT # 4 - 70/44 and 90/54, 3/24/22 by RN # 3 – 98/63, 3/31/22 by RN # 3 – 187/88, 4/21/22 RN # 3 -96/64. There was no evidence the physician was notified of the blood pressures being outside the given parameters. An interview was conducted with the clinical manager on 8/30/22 at approximately 4:30 pm. During the interview she confirmed the physician was not notified. 6. Patient # 20 had a Start of Care date of 7/20/22 and admitting diagnoses of Non-ST Elevation [NSTEMI] Myocardial Infarction [heart attack] and Heart Failure. The Plan of Care for the certification period 7/20/22 to 9/17/22 included orders for SN [skilled nursing] 1 visit every other week for 7 weeks, 3 PRN [as needed], PT [physical therapy] 2 times a week for 3 weeks, 1 time a week for 6 weeks and ““Notify physician of vital sign parameters out of range….Diastolic [bottom number - relating to the phase of the heartbeat when the heart muscle relaxes and allows the chambers to fill with blood - ] greater than 90 or less than 60…Systolic blood pressure [top number - relating to the phase of the heartbeat when the heart muscle contracts and pumps blood from the chambers into the arteries] greater than 160 or less than 90…” The clinical record revealed the following blood pressure readings: 8/1/22 by PTA [physical therapy assistant] # 8 – 102/52, 8/3/22 by RN # 2 - 106/54, 8/5/22 by PTA # 8 – 102/52, 8/11/22 by PTA # 8 – 100/54, 8/21/22 by PTA # 8 – 100/58. There was no evidence the physician was notified of the blood pressure readings. An interview was conducted with the clinical manager on 8/30/22 at approximately 4:30 pm. During the interview, she confirmed the physician was not notified of the blood pressure readings. 7. Patient # 6 had a Start of Care date of 8/16/22 and admitting diagnosis of Displaced Oblique [bone is broken at an angle] Fracture of Shaft of Right Fibula [the outer and smaller one the 2 bones between the knee and ankle]. The Plan of Care for the certification period 8/16/22 to 10/14/22 included orders for PT [physical therapy] 2 times a week for 4 weeks, 1 time a week for 3 weeks. The physician’s order indicated a weight bearing limit of “Touch down weight bearing on right lower extremity with boot on”. Review of the clinical record revealed PT # 9 made a routine visit on 8/18/22 and documented the following, “…Patient reported pain at the ankle inside the boot, therapist removed the boot and noted swelling at the fx [fracture] site. Upon further questioning, therapist realized that patient has been putting more weight on the right LE [lower extremity] than recommended. Educated on proper weight bearing restrictions and recommended to schedule the appointment with surgeon if swelling persists or worsens.” PT # 9 made a second visit on 8/23/22. The following documentation was noted, “…Patient thought skin redness is from boot pressing against skin…Skin is warm and swollen because of improper weight bearing on right ankle…” There was no evidence PT # 9 notified the physician of his findings. An interview was conducted with the clinical manager on 8/30/22 at 4:45 pm. During the interview, she confirmed the physician was not notified. 8A. Patient # 15 had a Start of Care date of 9/9/21 and admitting diagnoses of COVID 19, Adult Failure to Thrive and Heart Failure. Review of the Plan of Care [POC] for the certification period 9/9/21 to 11/7/21 included orders for PT [physical therapy] 1 time a day for 1 day, 1 time a week for 1 week, 2 times a week for 3 weeks, 1 time a week for 1 week. On 9/16/21 PTA # 10 made a routine visit and documented the following information, “…blood pressure at rest 97/57; blood pressure sitting, after activity 112/88…Patient required to site and rest between standing exercises due to complaints of being lightheaded. Patient reports it passed when she sat down and rested…” There was no evidence PT # 10 notified the physician of the blood pressure readings or the patient’s complaints of being lightheaded. An interview was conducted with the clinical manager on 8/30/22 at approximately 4:50 pm. During the interview, she confirmed PT # 10 did not notify the physician of the findings. 8B. Patient # 15 had a Start of Care date of 9/9/21 and admitting diagnoses of COVID 19, Adult Failure to Thrive and Heart Failure. Review of the Plan of Care [POC] for the certification period 9/9/21 to 11/7/21 included orders for SN [skilled nursing] 1 time a day for 1 day, 2 times a week for 1 week, 1 time a week for 8 weeks, 4 PRN [as needed] for exacerbation of disease/CP [cardiopulmonary] assessment and “Report telemonitor systolic [top number - relating to the phase of the heartbeat when the heart muscle contracts and pumps blood from the chambers into the arteries] blood pressure less than 90 or greater than 180, Diastolic [bottom number - relating to the phase of the heartbeat when the heart muscle relaxes and allows the chambers to fill with blood] blood pressure less than 40 or greater than 90, heart rate less than 50 or greater than 120…”Review of the telemonitoring records included the following readings: 10/20/21 blood pressure of 174/97, 10/23/21 blood pressure of 166/93, 10/28/21 heart rate of 136, 11/3/21 blood pressure of 172/96 and 167/96 with heart rate of 118, 11/5/21 blood pressure of 172/97. There was no evidence the physician was notified of the telemonitor readings. An interview was conducted with the clinical manager on 8/30/22 at approximately 4:45 pm. During the interview, the clinical manager confirmed the physician was not notified. A policy, “Coordination of Care”, approved 12/2020 was received from the agency administrator on 08/30/22 at 9:35 a.m. The policy stated…significant changes in the patient’s condition, including findings that are outside of established reporting parameters” … The policy, Telemonitoring Protocol [3/2021], was provided by the agency administrator on 8/30/22 at approximately 3:30 pm. The policy stated, “…It is the responsibility of the primary clinician/designee to review the telemonitoring data to make a clinical judgement regarding the patient’s condition and respond accordingly…” 1.Patient #18 had a SOC (start of care) of 07/25/22 and included diagnoses of essential hypertension, polymyalgia (inflammatory disorder), hypothyroidism (low thyroid), and long-term use of aspirin. The plan of care for 07/25/22 -09/22/22 had orders for physical therapy for 2 times a week for 4 weeks, and 1 time a week for 5 weeks. Physical therapy to provide skilled assessment, teaching/training, and reinforcement of teaching to properly assess, manage and mitigate pain. Orders for discipline and treatment: notify physician of vital sign parameters out of range: heart rate: greater than 100 or less than 60, temperature greater than 100 or less than 95, respiration: greater than 24 or less than 12, oxygen saturation: less than 88, systolic blood pressure: greater than 160 or less than 90, and diastolic blood pressure: greater than 90 or less than 60. Review of the physical therapist assistant visit note for 08/03/22 revealed Patient #18 blood pressure was 120/58. No documentation was in the record that the physician was notified of these findings. Interview with the agency administrator on 08/30/22 at 2:01 p.m. revealed, “No, she didn’t notify the doctor, it was hardcoded into the new system, and we were getting use to the new system”.

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 interviews the LPN [licensed practical nurse] failed to report new skin breakdown to the RN [registered nurse] for 1 of 6 records with a wound [#5]. The findings included: The policy, Coordination and Communication Activities [12/2020], was provided by the agency administrator on 8/30/2022 at approximately 9:38 am. The policy stated, “…Home health staff will maintain ongoing communication and coordination of care or services…Communication regarding significant changes in the patient’s overall plan of care. The content and results of all coordination activities are documented in the clinical record. This documentation includes but is not limited to the following information: The names of all persons involved in the coordination activity. What was discussed during the coordination activity. The outcome of the coordination activity [i.e. changes in the current plan of care…] …” Patient # 5 had a Start of Care date of 8/9/22 and admitting diagnosis of Hypo-osmolality [levels of electrolytes, proteins and nutrients in the blood are lower than normal] and Hyponatremia [low sodium]. Review of the Plan of Care of the certification period 8/9/22 to 10/7/22 included orders for SN [skilled nursing] 1 time a week for 4 weeks, 1 time every other week for 5 weeks, 5 PRN [as needed] for foley catheter concerns, wound concerns, medications changes. Review of the clinical record revealed LPN # 5 made a routine visit on 8/22/22. The clinical note included the following documentation by LPN # 5, “…Patient has new pressure areas noted to both heels today. Foam dressing applied to feet. Notified PCP [primary care physician] of the new wounds…” LPN # 5 documented the following measurements: Left heel 5 cm [centimeters] x 5 cm, 100% necrotic [dead tissue] wound bed and right heel 2.2 cm x 1 cm, 100% necrotic wound bed. There was no evidence the LPN communicated her findings with the RN.

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 policy review, client record review, and staff interview the clinical record failed to include wound measurements for 1 of 6 records with wounds (#17). Findings included: Review of policy “Wound Assessment, Home Care, revised 02/18/2022 was received from the agency administrator on 08/30/22 at 9:38 a.m. The policy stated,” …wound measurements are to be taken at least one time every week and documented in the clinical record” … Patient #17 had a SOC (start of care) of 08/14/21 and included diagnoses of type 2 diabetes with foot ulcer, non- pressure chronic ulcer of left heel and midfoot, pressure ulcer of left buttock, stage 1, and encounter for change or removal of non-surgical dressing. Skilled nursing frequency orders were 1 time a week for 1 week, and 2 times a week for 1 week, and 3 times a week for 3 weeks. Orders for skilled nursing were to evaluate and treat pressure ulcer management/teaching. Skilled nursing was to apply betadine daily to left posterior heel and cover with dry gauze and secure with rolled gauzed and loose ae bandage. Review of skilled nursing notes for dates of 08/18/21, 08/20/21, 08/25/21, and 08/27/21 revealed measurements for wound #1 were not obtained for the week of 08/24/21. Interview with the agency administrator on 08/30/22 at 1:55 p.m. revealed, “I don’t see any wound measurements for that week for wound #1”.