Every finding on record at Liberty Home Care II, LLC

An onsite recertification survey was conducted 1/16/24 to 1/17/24. No deficiencies to the Emergency Preparedness Program were identified.

An onsite recertification survey was conducted 1/16/24 to 1/17/24. 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 clinical record review and staff interviews, the Plan of Care [POC] failed to include all the required components on for 2 of 10 patients [#1 and 3] The findings included: 1. Patient # 1 had a Start of Care date of 10/27/22 and an admitting diagnosis of traumatic subdural hemorrhage with loss of consciousness [brain bleed]. Review of the clinical record revealed the Plan of Care [POC] was initiated on 10/27/22 by RN # 11. Review of the “Nutritional Requirements” section of the POC revealed “Other [Thickened liquids]”. The POC did not include the type of diet the patient should receive. The “Allergies” section of the POC indicated NKA [no known allergies]. Review of the referral information from the skilled nursing facility revealed the patient had an allergy to Celexa [antidepressant], Lexapro [antidepressant], Ultram [pain medication], and grass extracts. RN # 11 was no longer employed by the agency and unavailable for interview. During an interview with the agency administrator on 1/17/24 at approximately 2:30 pm, the administrator confirmed the POC was incomplete. 2. Patient # 3 had a Start of Care [SOC] date of 11/20/23 and an admitting diagnosis of chronic hepatic failure without coma [liver failure]. Review of the clinical record revealed RN # 1 initiated the Plan of Care on 11/20/23. Review of the POC on 1/16/24 revealed the Advance Directive section on the POC was blank. During an interview with the administrator and RN # 1 on 1/17/24 at approximately 2:30 pm, it was confirmed the POC was incomplete.

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 Registered Nurse applied a dressing to a wound without an order for 1 of 3 patients with a wound [#1]; and advised the caregiver to use Desitin [barrier cream] without an order for 1 of 3 patients with a wound [#1]. 1A. Patient # 1 had a Start of Care date of 10/27/22 and an admitting diagnosis of traumatic subdural hemorrhage with loss of consciousness [brain bleed]. Review of the Plan of Care [POC] for the certification period 10/27/22-12/25/22 included orders for SN [skilled nursing] 1 time a week for 1 week, 0 times a week for 1 week, 2 times a week for 2 weeks, 1 time a week for 5 weeks and home health aide 0 times a week for 2 weeks, 1 time a week for 5 weeks. A supplemental order was written on 12/1/22 for “SN to perform wound care to unstageable pressure ulcer to sacrum [lower spine], twice a week. Cleanse wound with saline, pat with gauze, apply hydrogel to eschar in wound, cover with foam dressing and secure with transparent dressing…” RN # 11 conducted a routine visit on 12/8/22 and documented the following information, “…Cleansed wound with saline, apply gauze with tape, awaiting supplies to arrive.” Further review of the clinical record revealed no evidence the RN obtained an order for gauze and tape until the original supplies arrived. RN # 11 was no longer employed by the agency and was unavailable for interview. An interview was conducted with the agency administrator on 1/17/24 at approximately 3 pm. During the interview the administrator confirmed there was no order for gauze and tape to be applied to the pressure ulcer. 1B. Patient # 1 had a Start of Care date of 10/27/22 and an admitting diagnosis of traumatic subdural hemorrhage with loss of consciousness [brain bleed]. Review of the Plan of Care [POC] for the certification period 10/27/22-12/25/22 included orders for SN [skilled nursing] 1 time a week for 1 week, 0 times a week for 1 week, 2 times a week for 2 weeks, 1 time a week for 5 weeks. Review of the clinical record revealed RN # completed a routine visit on 12/16/22. The RN documented the following information, “…Instructed _____ [caregiver’s name] to apply desitin [sic] [barrier cream] to buttocks if area is red…” Further review of the clinical record revealed no order for Desitin. RN # was no longer employed by the agency. An interview was conducted with the agency administrator on 1/17/24 at approximately 3 pm. During the interview, the administrator confirmed there was no order to apply Desitin.

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 for missed visits for 1 of 3 patients with a wound (#2), notify the physician of a blood pressure out of parameters for 1 of 10 patients (#1), and notify the physician of wound care performed not as ordered for 1 of 3 patients with a wound (#1). 2. Patient # 1 had a Start of Care date of 10/27/22 and an admitting diagnosis of traumatic subdural hemorrhage with loss of consciousness [brain bleed]. Review of the Plan of Care [POC] for the certification period 10/27/22-12/25/22 included orders for SN [skilled nursing] 1 time a week for 1 week, 0 times a week for 1 week, 2 times a week for 2 weeks, 1 time a week for 5 weeks; PT [physical therapy] 2 times a week for 3 weeks, 1 time a week for 3 weeks, 0 times a week for 1 week, 1 time a week for 1 week and “Notify physician of vital sign parameters out of range “…systolic [top number] blood pressure greater than 160 or less than 90 and diastolic [bottom number] greater than 90 or less than 60…” Review of the clinical record revealed PT # 12 conducted a visit on 10/31/22 and documented a blood pressure reading of 98/57. RN # 11 completed a routine visit on 12/5/22 and documented a blood pressure reading of 96/42. There was no evidence the physician was notified either blood pressure reading. PT # 12 nor RN # 11 were available for interviews. During an interview with the agency administrator on 1/17/24 at approximately 3 pm, the administrator confirmed the physician was not notified of either blood pressure reading. 3. Patient # 1 had a Start of Care date of 10/27/22 and an admitting diagnosis of traumatic subdural hemorrhage with loss of consciousness [brain bleed]. Review of the Plan of Care [POC] for the certification period 10/27/22-12/25/22 included orders for SN [skilled nursing] 1 time a week for 1 week, 0 times a week for 1 week, 2 times a week for 2 weeks, 1 time a week for 5 weeks. A supplemental order was written on 12/1/22 for “SN to perform wound care to unstageable pressure ulcer to sacrum [lower spine], twice a week. Cleanse wound with saline, pat with gauze, apply hydrogel to eschar in wound, cover with foam dressing and secure with transparent dressing…” RN # 11 conducted a routine visit on 12/2/22 and documented the following information related to wound care, “No s/s [signs/symptoms] infection noted. Demonstrated correct wound care technique for spouse to observe. Care not performed. Caregiver performed care…” There is no evidence the physician was notified the RN did not complete wound care. RN # 11 was no longer employed by the agency. During an interview with the agency administrator on 1/17/24 at approximately 3 pm, the administrator confirmed the physician was not notified the RN did not complete the wound care. Findings included: A policy, “Coordination and Communication Activities”, revised 12/2020 was received from the Agency Director on 01/17/24 at 11:17 a.m. The policy stated, “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: missed visits and failure to follow the plan of care… if a visit is missed and there is a deviation from the plan of care that cannot be made up in the week the visit is due, notify the certifying physician/or MD representative”. 1.Patient #2 had a SOC (start of care) of 01/28/23 and included diagnoses of atherosclerosis of native arteries (build of up cholesterol) of right leg with ulcer of other part of foot, raynaud’s syndrome (reduced blood flow) without gangrene. The plan of care for 01/28/23 had orders for skilled nursing 1 time a week for 9 weeks. Review of the skilled nurse missed visit note for 03/17/23 revealed that the note was marked no for physician notification of the missed visit. Review of the skilled nurse communication note for 03/23/23 revealed unable to reach patient no documentation was in the record that the physician was notified of the missed visit. Interview with the agency director on 01/17/24 at 1:32 p.m., revealed, “I don't see that they documented that the physician was notified on the coordination notes”.

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 Registered Nurse failed to complete a wound assessment and obtain measurements for 2 of 3 patients with a wound [#1 and #2]. The findings included: The policy, Wound Assessment, Home Care [2/20/23], was provided by the agency administrator on 1/17/24 at approximately 3 pm. The policy stated, “… A complete wound assessment is to be completed every visit and documented in the patient’s medical record. Wound measurements are to be taken at least one time every week and documented in the clinical record…” Patient # 1 had a Start of Care date of 10/27/22 and an admitting diagnosis of traumatic subdural hemorrhage with loss of consciousness [brain bleed]. Review of the Plan of Care [POC] for the certification period 10/27/22-12/25/22 included orders for SN [skilled nursing] 1 time a week for 1 week, 0 times a week for 1 week, 2 times a week for 2 weeks, 1 time a week for 5 weeks. Review of the clinical record revealed RN # 11 conducted a routine visit on 11/29/22. Review of the clinical record revealed the RN identified a pressure injury. RN # 11 documented, “…New unstageable pressure ulcer to sacrum with eshcar [sic] noted during skilled nurse visit…” RN # 11 conducted a routine visit on 12/2/23 and documented the following information, “…New unstageable pressure ulcer to sacrum with yellow slough noted during skilled nurse visit…” Further review of the clinical record revealed no wound assessment or measurements were obtained until 1/5/23. RN # 11 was no longer employed with the agency. During an interview with the agency administrator on 1/17/24 at approximately 3 pm, the administrator confirmed the RN should have documented wound measurements when the wound was identified and documented a wound assessment with each visit. 2.Patient #2 had a SOC (start of care) of 01/28/23 and included diagnoses of atherosclerosis of native arteries (build of up cholesterol) of right leg with ulcer of other part of foot, raynaud’s syndrome (reduced blood flow) without gangrene. The plan of care for 01/28/23 had orders for skilled nursing 1 time a week for 9 weeks. Review of the skilled nurse visit for the week of 03/06/23 revealed measurements were not documented in the record. Interview with the agency director on 01/17/24 at 1:32 p.m., revealed, “I don’t see any measurements in the visits that were made”.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on clinical record review and staff interviews the Registered Nurse failed to document the type of wound care completed when a new pressure injury was noted for 1 of 3 patients with a wound [#1]. The findings included: Patient # 1 had a Start of Care date of 10/27/22 and an admitting diagnosis of traumatic subdural hemorrhage with loss of consciousness [brain bleed]. Review of the Plan of Care [POC] for the certification period 10/27/22-12/25/22 included orders for SN [skilled nursing] 1 time a week for 1 week, 0 times a week for 1 week, 2 times a week for 2 weeks, 1 time a week for 5 weeks. Review of the clinical record revealed RN # 11 conducted a routine visit on 11/29/22. Review of the clinical record revealed the RN identified a pressure injury during that visit. RN # 11 documented, “…New unstageable pressure ulcer to sacrum with eshcar [sic] noted during skilled nurse visit… Spouse stated he had not seen that wound. I reviewed pressure relief techniques with patient and caregiver, instructed caregiver to encourage patient to reposition every two hours, Keep perineal area clean and dry. Both verbalized understanding. Instructed caregiver to report any changes in patient’s condition to agency. Patient mobilize [sic] independently in manual wheelchair, observe [sic] patient stand from wheelchair independently, AFO [type of brace] boot present to left lower leg… He voiced his concern with patient continuing to eat and drink things within [sic] liquids despite being instructed not to do so. Patient has short-term memory loss issues due to TBI [traumatic brain injury]. Still nursing notified Dr. _____ [name of physician] of new pressure ulcer, obtain[sic] verbal orders for wound care. Skilled nurse ordered wound care supplies from _______ [name of supply company].” RN # 11 conducted a routine visit on 12/2/23 and documented the following information, “…New unstageable pressure ulcer to sacrum with yellow slough noted during skilled nurse visit… Spouse stated he had not seen that wound. I reviewed pressure relief techniques with patient and caregiver, instructed caregiver to encourage patient to reposition every two hours, Keep perineal area clean and dry. Both verbalized understanding. Instructed caregiver to report any changes in patient’s condition to agency. Patient mobilize [sic] independently in manual wheelchair, observe [sic] patient stand from wheelchair independently, AFO [type of brace] boot present to left lower leg… He voiced his concern with patient continuing to eat and drink things within [sic] liquids despite being instructed not to do so. Patient has short-term memory loss issues due to TBI [traumatic brain injury]. Still nursing notified Dr. _____ [name of physician] of new pressure ulcer, obtain verbal orders for wound care. Skilled nurse ordered wound care supplies from _______ [name of supply company].” Further review of the clinical record revealed the treatment order was written on 12/1/22 and the next visit was made on 12/2/22. RN # 11 was no longer employed by the agency and was not available for interview. During an interview with the agency administrator on 1/17/24 at approximately 3 pm, the administrator confirmed the clinical record does not specify if or what type of treatment was completed when the RN identified the wound on 11/29/22.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on agency policy, clinical record review and staff interviews the home health aide plan of care failed to include all the required patient care instructions for 1 of 2 patients receiving aide services [#1]. The findings included: The policy, Home Health Aide Care Plan and Documentation [reviewed 4/21], was provided by the agency administrator on 1/22/24 at approximately 10 am. The policy stated, “…The Home Health Aide is assigned to a specific patient…with written patient care instructions…”. Patient # 1 had a Start of Care date of 10/27/22 and an admitting diagnosis of traumatic subdural hemorrhage with loss of consciousness [brain bleed]. Review of the Plan of Care [POC] for the certification period 10/27/22-12/25/22 included orders for SN [skilled nursing] 1 time a week for 1 week, 0 times a week for 1 week, 2 times a week for 2 weeks, 1 time a week for 5 weeks and home health aide 0 times a week for 2 weeks, 1 time a week for 5 weeks. Review of the clinical record revealed RN # 4 completed the aide care plan on 10/28/22. Review of the aide care plan revealed the following sections were blank: allergies, nutritional status, culture beliefs, safety precautions, mental/cognitive status, activities permitted, functional limitations and psychosocial status. RN # 4 was no longer employed by the agency. During an interview with the agency director on 1/17/24 at approximately 2:30 pm, the administrator confirmed the aide care plan did not include all the required elements.

An onsite recertification and follow up survey was conducted 07/06/21 to 07/07/21. No deficiencies were identified to the Emergency Preparedness Program. ABH

An onsite recertification and follow up survey was conducted 07/06/21 to 07/07/21. Deficiencies were identified to the Medicare Conditions of Participation. The following tag was put back into compliance: G337. ABH

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 interviews the agency failed to coordinate care with the physician for a blood sugar outside of parameters for 1 of 2 patients (#3) with diabetes. Findings included: A policy, “Coordination and Communication Activities”, revised 06/2018 was received from the Clinical Director on 07/07/21 at 9:53 a.m. The policy stated, “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, including finding that are outside of established reporting parameters”. Patient #3 had a SOC (start of care) of 01/14/2021 and included diagnoses of pressure ulcer of right buttock, stage 4; encounter for change or removal of nonsurgical wound dressing; type 2 diabetes, chronic kidney disease stage 3, and chronic diastolic heart failure. Review of SN (skilled nurse) visit by Employee #2 for visit 03/24/21 revealed that Patient #3 had a blood sugar of 341. Review of SN visit by Employee #3 for visit 4/14/21 revealed that Patient #3 had a blood sugar of 326. Further review of the clinical record confirmed the physician was not notified of the blood sugars outside of parameters on both visits. Staff Interview with Employee #3 on 7/7/21 at 9:46 a.m., revealed, “ I did not notify the doctor as it was early in the day, they rechecked the blood sugar before the visit ended and it was below the parameter, but I failed to document it”. Interview with Employee #2 on 7/7/21 at 9:56 a.m. revealed, “I did not notify the doctor; her daughter was there, and she just got her morning dose of insulin”.

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 follow the plan of care as ordered by the physician for skilled nursing visits for 1 of 6 patients with skilled nursing (#2). Findings include: A policy, “Initial Care Plan and Updates to the Plan of Care” revised 03/21 was provided by the Clinical Director on 07/07/21 at 9:53 a.m. The policy stated, “ …the plan of care also includes documentation of the following…amount, frequency and duration of visits/services to be provided”. Patient #2 was admitted on 05/14/21 with diagnoses of type 2 diabetes mellitus, essential hypertension, urinary tract infection, and other chronic pain. The plan of care (POC) for 05/14/21-07/12/21 included orders for skilled nursing visits for 1 day 1, and 1 time a week for 8 weeks. Review of the clinical record revealed skilled nursing visits were conducted on the following dates: 05/14/21, 06/02/21, 06/08/21,06/16/21, 06/23/21, and 06/30/21 . No nursing visits are in the record for the week of 5/17/21 or the week of 05/24/21. An interview with the Administrator on 7/7/21 at 9:49 a.m., revealed “ I didn’t find where there were any missed visits in the record for those weeks”.