Every finding on record at Liberty Home Care II, LLC

An onsite, unannounced recertification survey was conducted 12/2/25-12/3/25. No deficiencies to the Emergency Preparedness Plan were identified.

An onsite, unannounced recertification survey was conducted 12/2/25-12/3/25. Standard level deficiencies to the Medicare CoP were identified.

Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient's status at the time of assessment. This STANDARD is not met as evidenced by: Based on agency policy, clinical record review and staff interviews, the agency failed to ensure OASIS [The Outcome and Assessment Information Set- patient-specific standardized assessment] documentation was accurate for 2 of 7 records reviewed [ #3 and 4 ]. The findings included: The policy, Comprehensive Assessment/OASIS Collection, Encoding and Transmission [1/2025], was provided by the agency administrator on 12/3/25 at 1 pm. The policy stated, “...Each patient that is admitted to ______ [name of the agency] services will receive a patient-specific comprehensive assessment that accurately reflects the patient’s current health status...” 1. Patient # 3 had a Start of Care date of 11/11/25 with an admitting diagnosis of chronic obstructive pulmonary disease [COPD-lung condition]. Review of the clinical record revealed RN # 4 completed the OASIS [The Outcome and Assessment Information Set- patient-specific standardized assessment] on 11/11/25. Review of the OASIS documentation N0415 High Risk Drug Classes does not capture the use of Aspirin 81 mg [antiplatelet] as listed on the plan of care. During an interview with the agency administrator on 12/3/25 at 12:30 pm, the administrator confirmed the OASIS was inaccurate related to high-risk drug classes. 2. Patient # 4 had a Start of Care date of 10/18/25 with an admitting diagnosis of urinary tract infections. Review of the clinical record revealed RN # 4 completed the OASIS [The Outcome and Assessment Information Set- patient-specific standardized assessment] on10/18/25. Review of the OASIS documentation N0415 High Risk Drug Classes does not capture the use of Rivaroxaban 15 mg [anticoagulant] as listed on the plan of care. During an interview with the agency administrator on 12/3/25 at 12:30 pm, the administrator confirmed the OASIS was inaccurate related to high-risk drug classes.

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 direct observation, clinical record review and staff interviews, the Plan of Care failed to include all medications the patient was taking for 3 of 3 home visits [#5, 6 and 7]. The findings included: 1. Patient # 5 had a Start of Care date of 11/21/25 with an admitting diagnosis of hemiplegia [paralyzed on ½ side of the body] following non-traumatic subarachnoid hemorrhage [stroke] of right side. Review of the Plan of Care [POC] for the certification period 11/21/25-1/19/25 included orders for PT [physical therapy] 1 time a week for 2 weeks, 1 time every other week for 7 weeks. On 12/2/25 at approximately 12:30 pm a joint visit was made with PT # 2. During the visit, a medication review was conducted using the medication profile provided by the agency. The following discrepancy was noted: The medication profile listed Erythromycin 5 mg/gm ophthalmic ointment. The medication profile stated, “...1 drop in left eye every 4 hours...” During an interview with the daughter at the visit, the daughter stated, “Mama has already completed that medication. She doesn’t use it anymore.” During an interview with the agency clinical manager on 12/3/25 at approximately 2 pm, the manager confirmed the POC did not include all the current medications. 2. Patient # 6 had a Start of Care date of 10/31/25 with an admitting diagnosis of wedge compression fracture T 11-T 12 vertebra [front part of the eleventh or twelfth thoracic vertebra (mid-to-lower back) has collapsed, forming a wedge shape]. Review of the Plan of Care [POC] for the certification period 10/31/25-12/29/25 included orders for OT [occupational therapy] effective 11/10/25 1 time a week for 1 week, 1 time every other week for 5 weeks. On 12/3/25 at approximately at 10 am a joint visit was made with OT # 1. During the visit a medication review was conducted using a medication profile provided by the agency. The following discrepancy was noted: The medication profile listed Furosemide [fluid medication] 20 mg daily. During the home visit, the patient presented a medication bottle with instructions to take 2 tablets per day. During the interview with the patient, the patient stated, “I have been taking 2 pills each day for about 2 months.” During an interview with the agency clinical manager on 12/3/25 at approximately 2 pm, the manager confirmed the POC did not include all the current medications. 3. Patient # 7 had a Start of Care date of 9/13/25 with admitting diagnoses of venous insufficiency [leg veins have faulty valves, causing blood to pool, leading to symptoms like leg swelling, aching, heaviness, varicose veins, skin discoloration, itching, and, in severe cases, non-healing venous ulcers] and non-pressure chronic ulcer of other part of left foot. Review of the Plan of Care [POC] for the certification period 11/12/25-1/10/26 included orders for SN [skilled nursing] 1 time a week for 8 weeks. On 12/2/25 at 2 pm, a joint visit was made with RN # 5. During the visit, a medication review was conducted using a medication profile provided by the agency. The following discrepancies were noted: The patient reported taking Probiotic 1 capsule daily and Mag Oxide [supplement] 400 mg each day. Neither medication was included in the medication profile. The patient reported she has been using these medications since before being admitted to home health. During an interview with the agency clinical manager on 12/3/25 at approximately 2 pm, the manager confirmed the POC did not include all the current medications.

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 RN documented a left intrajugular central line [a type of central venous catheter [CVC] inserted into the internal jugular vein in the neck which allows for long-term access to the central venous circulation] was flushed with heparin [anticoagulant] for 1 of 1 patient with a left intrajugular central line [# 2 ]. The findings included: Patient # had a Start of Care date of 1/20/25 with admitting diagnoses of post-surgical malabsorption [condition that exists when a person is unable to absorb nutrients after a surgical procedure and encounter for adjustment and management of VAD [vascular access device- a medical tool, like a tube or port, inserted into a vein to provide long-term or repeated access to the bloodstream for delivering meds, fluids, nutrition, or drawing blood]. Review of the Plan of Care for the certification period 1/20/25-3/20/25 included orders for SN [skilled nursing] 1 time a week for 9 weeks and “...SN to perform sterile dressing changes to left IJ [intrajugular] and [sic] central line [a type of central venous catheter (CVC) inserted into the internal jugular vein in the neck, which allows for long-term access to the central venous circulation] Q [every] Monday...Upon blood return, inject 10 cc of normal saline slowly into the catheter...Flushed [sic] with 0.9% sodium chloride [normal saline] 10 cc...”Review of the clinical record revealed RN # 5 conducted routine visits on 1/27/25, 2/3/25, 2/10/25 and documented, “...Flushed with 0.9 % NS [normal saline] and 5,000 units Heparin [anticoagulant] 5 cc...” Further review of the clinical record revealed there was no order to use a Heparin Flush. During an interview with the agency administrator on 12/3/25 at 12:30 pm, the administrator stated, “She didn’t use heparin. That is what happens when we use a template for documentation.”

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interviews the home health aide care plan failed to included "Bleeding Precautions" under the safety section for 1 of 1 patient receiving home health aide services who was receiving an anticoagulant {#4]. The findings included: Patient # 4 had a Start of Care date of 10/18/25 with an admitting diagnosis of urinary tract infections. Review of the Plan of Care [POC] for the certification period 10/18/25-12/16/25 included orders for SN [skilled nursing] 1 time a week for 3 weeks, HHA [home health aide] 1 time a week for 3 weeks. Further review of the POC revealed the patient order taking Rivaroxaban 15 mg [anticoagulant]. The aide care plan was completed by RN # 4 on 10/18/25. Review of the safety precautions on the aide care plan did not include “Bleeding Precautions.” During an interview with the agency administrator on 12/3/25 at 12:30 pm, the administrator confirmed the aide care plan should have included bleeding precautions.

An onsite recertification survey was conducted 12/5/22-12/6/22. No deficiencies to the Emergency Preparedness Program were identified. ABH

An onsite recertification survey was conducted on 12/5/22-12/6/22. 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 policy review, client record review, and staff interview the agency failed to include all medications on the plan of care for 4 of 10 patients (#8, 3, 7 and 9); failed to include indications for PRN [as needed]/frequency of PRN medications for 2 of 10 patients [#1 and 7] ;failed to include all pertinent diagnoses/surgical procedures for 1 of 10 patients [#3] ; failed to include frequency for a dressing change for 1 of 4 patients with a wound [#9]. Findings included: 2. Patient # 1 had a Start of Care [SOC] date of 10/27/22 and admitting diagnoses of Pressure Ulcer of Left Hip, Stage 4 [deep wound reaching the muscle, ligaments, or bone] and Intestinal Malabsorption [disorder characterized by inadequate absorption of nutrients in the small intestines]. Review of the Plan of Care [POC] for the certification period 10/27/22 to 12/25/22 included orders for SN [skilled nursing] 1 time a week for 9 weeks and 2 PRN [as needed] for complications or labs. Review of the medication section of the POC included Oxycodone-Acetaminophen [pain medication] 7.5 mg/325 mg [milligrams]. 1 tablet every 6 hours PRN [as needed] and Narcan [used to reverse opioid overdose] 4 mg per 0.1 ml nasal spray. 1 spray PRN overdose. There was no indication for the use of the Oxycodone-Acetaminophen or any frequency [how often] the Narcan could be administered. RN # 5 was not available for interview. During an interview with the administrator on 12/6/22 at approximately 11:30 am, the administrator confirmed the POC [medications] should have included the indications and frequency. 3A. Patient # 3 had a Start of Care date of 11/21/22 and an admitting diagnosis of Other Specified Functional Intestinal Disorders. Review of the Plan of Care [POC] for the certification period 11/21/22 to 1/19/23 revealed orders for SN [skilled nurse] 2 times a week for 1 week, 1 time a week for 1 week, 3 PRN [as needed] for ileostomy [a stoma constructed by bringing the end or loop of the small intestine out onto the surface of the skin…Intestinal contents pass out the ileostomy] care and “SN to instruct patient/caregiver on management of ileostomy include stoma care, s/s [signs/symptoms] of complications to report, application of ostomy device, emptying pouch, infection control …” Review of the Admission Narrative on the POC revealed the following documentation by RN # 6, “…she had a subtotal colectomy [removal of majority of colon] with end ileostomy for colonic inertia[abnormal passage of waste through the digestive system…Patient has a past medial history of Barrett’s Esophagus [damage to the lower portion of the tube that connects the mouth and stomach], Coronary Artery Disease [CAD], and COPD [chronic obstructive pulmonary disease-lung disease]…” The POC [diagnosis section] did not include a diagnosis or surgical procedure related to the new ileostomy. During an interview with the administrator on 12/6/22 at 11:30 am, the administrator confirmed the POC should have included the other diagnoses related to the POC. 3B. Patient # 3 had a Start of Care date of 11/21/22 and an admitting diagnosis of Other Specified Functional Intestinal Disorders. Review of the Plan of Care [POC] for the certification period 11/21/22 to 1/19/23 revealed orders for SN [skilled nurse] 2 times a week for 1 week, 1 time a week for 1 week, 3 PRN [as needed] for ileostomy [a stoma constructed by bringing the end or loop of the small intestine out onto the surface of the skin…Intestinal contents pass out the ileostomy] care. Further review of the POC revealed the nutritional requirement section was blank [no diet]. Review of the medications section of the POC revealed Cyanocobalamin [B 12] 100 mcg/ml. Inject 1 ml every 28 days. Review of the hospital discharge dated 11/20/22 revealed the Cyanocobalamin should have been entered as 1000 mcg/ml. During an interview with RN # 6 on 12/6/22 at 11:00 am, RN # 6 stated, “It should have been 1000 mcg per ml. It was a typo.” 4A. Patient # 7 had a Start of Care [SOC] date of 10/19/22 and admitting diagnoses of Bipolar Disorder, Type 2 Diabetes Mellitus with Diabetic Neuropathy [nerve damage] and Chronic Obstructive Pulmonary Disease [COPD-lung disease]. Review of the Plan of Care [POC] for the certification period 10/19/22 to 12/17/22 revealed orders for SN [skilled nursing] 1 time a week for 4 weeks, 1 time every other week for 5 weeks, 4 PRN [as needed] for medication management, falls, respiratory complications. Review of the POC Homebound Narrative revealed the following documentation, “…Patient is exhibiting a considerable and taxing effort to leave home due to dyspnea…has history of chronic respiratory failure, on O2 [oxygen] at 2 liters per minute as needed…” Further review of the medication section of the POC revealed oxygen was not included in the POC. RN # 5 completed the POC and was not available for interview. An interview was conducted with the agency administrator on 12/6/22 at 11:30 am. During the interview, the administrator confirmed oxygen was not included in the POC and should have been listed as a medication. 4B. Patient # 7 had a Start of Care [SOC] date of 10/19/22 and admitting diagnoses of Bipolar Disorder, Type 2 Diabetes Mellitus with Diabetic Neuropathy [nerve damage] and Chronic Obstructive Pulmonary Disease [COPD-lung disease]. Review of the Plan of Care for the certification period 10/19/22 to 12/17/22 revealed orders for SN [skilled nursing] 1 time a week for 4 weeks, 1 time every other week for 5 weeks, 4 PRN [as needed] for medication management, falls, respiratory complications. The POC [medication section] included Trazodone [antidepressant] 50 mg 1 tablet 2 times a day PRN [as needed]. There were no indications for the use of the Trazodone. The POC also included Zinc Oxide [barrier cream] 20% topical ointment. 1 application PRN [as needed]. There were no indications for the use of the zinc oxide. An interview was conducted with the agency administrator on 12/6/22 at 11:30 am. During the interview, the administrator confirmed the medications failed to include indications. 5A. Patient # 9 had a Start of Care date of 5/4/21. Review of the Plan of Care [POC] for the certification period 4/29/22 through 6/27/22 included diagnoses of Type 2 Diabetes Mellitus with Foot Ulcer, Non-Pressure Chronic Ulcer of Left Heel and Midfoot with Fat Layer Exposed, Type 2 Diabetes Mellitus with Diabetic Neuropathy [nerve damage],Essential Hypertension and Long Term [current] use of Insulin. The POC included orders for SN [skilled nursing] 0 times for 1 week, 2 times a week for 8 weeks, 1 time a week for 1 week, 4 PRN [as needed] for wound care/complications and “SN to perform wound care to left calcaneus [heel]. Cleanse wound with Dakin’s 0.25%. Apply zinc cream to peri-wound. Apply Gentamicin cream to wound base. Cover with Aquacel AG or equivalent, cover with rolled gauze, wrap with elastic bandage and secure with tape using aseptic technique. SN may teach patient/caregiver to perform wound care.” Further review of the POC revealed no frequency for the dressing change. RN # 4 was not available for interview. An interview was conducted with the agency administrator on 12/6/22 at 11:30 am. During the interview, the administrator confirmed the wound care order did not include the dressing change frequency. 5B. Patient # 9 had a Start of Care date of 5/4/21. Review of the Plan of Care [POC] for the certification period 4/29/22 through 6/27/22 included diagnoses of Type 2 Diabetes Mellitus with Foot Ulcer, Non-Pressure Chronic Ulcer of Left Heel and Midfoot with Fat Layer Exposed, Type 2 Diabetes Mellitus with Diabetic Neuropathy [nerve damage], Essential Hypertension and Long Term [current] use of Insulin. The POC included orders for SN [skilled nursing] 0 times for 1 week, 2 times a week for 8 weeks, 1 time a week for 1 week, 4 PRN [as needed] for wound care/complications and “SN to perform wound care to left calcaneus [heel]. Cleanse wound with Dakin’s 0.25%. Apply zinc cream to peri-wound. Apply Gentamicin cream to wound base. Cover with Aquacel AG or equivalent, cover with rolled gauze, wrap with elastic bandage and secure with tape using aseptic technique. SN may teach patient/caregiver to perform wound care [no frequency for the dressing change].” Review of the POC [medication section] revealed Dakin’s [used to cleanse wound], zinc oxide [barrier cream] and Gentamicin [antibiotic] cream were not included in the POC [medication section]. An interview was conducted with the agency administrator on 12/6/22 at 11:30 am. During the interview, the administrator confirmed the Dakin’s, zinc oxide and Gentamicin should have been included in the POC [medication section]. Review of a policy “Care Planning: Initial Care Plan and Updates to the Plan of Care”, revised 03/2021 was received from the agency administrator on 12/05/22 at 3:52 p.m. The policy stated,” … the plan of care also includes documentation of the following…all current prescription and over the counter medications…all pertinent primary, secondary and surgical diagnoses with dates of onset or exacerbation…amount, frequency, and duration of visits/services to be provided…”. 1.Patient #8 was admitted on 10/13/22 with diagnoses of type 2 diabetes with hypoglycemia without coma, unspecified convulsions (seizures), chronic kidney disease stage 3, and unspecified diastolic congestive heart failure. Review of the start of care oasis visit on 10/13/22 revealed the patient was on oxygen therapy, but it was not included on the plan of care. Interview with the administrator on 12/06/22 at 12:24 p.m. revealed “I see it on the referral, I don’t see it on the plan of care”.

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 agency policy, clinical record review and staff interview, the nurse failed to monitor blood sugar results for 2 of 4 patients with diabetes [#7 and 9]. The findings included: The policy, Care Planning: Initial Care Plan and Updates to the Plan of Care [3/21], was provided by the agency administrator on 12/5/22 at 3:50 pm. The policy stated, “…Each patient will receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs…The agency has a responsibility to obtain physician orders prior to the initiation of care and to notify the physician of any changes in the patient’s condition…” 1. Patient # 7 had a Start of Care [SOC] date of 10/19/22 and admitting diagnoses of Bipolar Disorder, Type 2 Diabetes Mellitus with Diabetic Neuropathy [nerve damage] and Chronic Obstructive Pulmonary Disease [COPD-lung disease]. Review of the Plan of Care for the certification period 10/19/22 to 12/17/22 revealed orders for SN [skilled nursing] 1 time a week for 4 weeks, 1 time every other week for 5 weeks, 4 PRN [as needed] for medication management, falls, respiratory complications and “Notify the physician of vital sign parameters out of range:…Fasting blood sugar greater than 200 or less than 70…Random blood sugar greater than 300 or less than 70…” Review of the clinical record revealed the patient received 5 SN visits. There were no blood sugar readings documented for 4 of the 5 visits. During an interview with the administrator on 12/6/22 at 11:30 am, the administrator confirmed the SN did not monitor the blood sugar readings. 2. Patient # 9 had a Start of Care date of 5/4/21. Review of the Plan of Care [POC] for the certification period 4/29/22 through 6/27/22 included diagnoses of Type 2 Diabetes Mellitus with Foot Ulcer, Non-Pressure Chronic Ulcer of Left Heel and Midfoot with Fat Layer Exposed, Type 2 Diabetes Mellitus with Diabetic Neuropathy [nerve damage], Essential Hypertension and Long Term [current] use of Insulin. The POC included orders for SN [skilled nursing] 0 times for 1 week, 2 times a week for 8 weeks, 1 time a week for 1 week, 4 PRN [as needed] for wound care/complications and “SN to monitor blood sugar levels to assess efficacy of medication and dietary therapy, coordinate care with physician for need to change plan of care…”Review of the clinical record revealed RN # 4 made 14 SN visits from 4/29/22 through 6/16/22 [patient transferred to the hospital]. Further review of the clinical record revealed 9 of the 14 visits did not have blood sugar results recorded. RN # 4 was not available for interview. During an interview with the agency administrator on 12/6/22 at 11:30 am, the administrator confirmed the RN failed to monitor blood sugars.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on agency policy, clinical record review and staff interview, the agency failed to document accurate wound assessment for 1 of 5 patients with a wound [#1]. The findings included: The policy, Wound Assessment [2/18/22], was provided by the agency administrator on 12/5/22 at 3:50 pm. The policy stated, “…Red, the color of healthy granulation tissue, indicates normal healing. When a wound begins to heal, a layer of pale pink granulation tissue covers the wound bed…” Patient # 1 had a Start of Care [SOC] date of 10/27/22 and admitting diagnoses of Pressure Ulcer of Left Hip, Stage 4 [deep wound reaching the muscle, ligaments, or bone] and Intestinal Malabsorption [disorder characterized by inadequate absorption of nutrients in the small intestines]. Review of the Plan of Care for the certification period 10/27/22 to 12/25/22 included orders for SN [skilled nursing] 1 time a week for 9 weeks and 2 PRN [as needed] for complications or labs. Review of the clinical record revealed RN # 5 completed the SOC OASIS [The Outcome and Assessment Information Set] on 10/27/22. Review of the wound care section of the OASIS revealed the following documentation by RN # 5, “…Wound #1 Great Trochanter [bony prominence near the end of the femur] , Left Pressure Ulcer - Stage 4 [Full Thickness] [tissue loss with exposed bone, tendon or muscle]… Length: 0.8 cm Width: 1.2 cm Depth: 0.4 cm…Tissue Type: Granulation Tissue [a new connective tissue which includes microscopic blood vessels] Granulation: 100%...” RN # 5 was not available for interview. During an interview with the administrator on 12/6/22 at 11:30 am, she confirmed a stage 4 pressure ulcer could not have 100% granulation as documented by RN # 5.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on agency policy, clinical record view and staff interview the RN [registered nurse] failed to notify the physician of patient’s refusal to allow wound care for 1 of 5 patients with a wound [#1]; failed to notify physician of vital signs outside the given parameters for 2 of 10 patients [#3, 7];failed to notify the physician of new area of skin breakdown for 1 of 5 patients with a wound [#7]; failed to notify the physician of decline in wound status in 1 of 5 patients with a wound [#1]; failed to notify the physician when no caregiver was available to assist with dressing changes for 1 of 5 patients with a wound [#9]; failed to notify the physician when 1 of 1 discharged patients had emergency room visits related to hyperglycemia [high blood sugar] [#9]; failed to notify physician when patient had no means to monitor blood sugars for 1 of 2 discharged patients [#9]. The findings included: The policy, Coordination and Communication [12/20], was provided by the agency administrator on 12/5/22 at 3:50 pm. 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 findings that are outside of established reporting parameters…If the patient or patient representative refuses care…All coordination and communication with the physician …failure to follow the plan of care must be documented in the clinical record…” 1. Patient # 1 had a Start of Care [SOC] date of 10/27/22 and admitting diagnoses of Pressure Ulcer of Left Hip, Stage 4 [deep wound reaching the muscle, ligaments, or bone] and Intestinal Malabsorption [disorder characterized by inadequate absorption of nutrients in the small intestines]. Review of the Plan of Care [POC] for the certification period 10/27/22 to 12/25/22 included orders for SN [skilled nursing] 1 time a week for 9 weeks and 2 PRN [as needed] for complications or labs and “SN to perform pressure ulcer care to left hip. Cleanse/irrigate wound with wound cleaner [sic], pack with silver impregnated dressing, cover and secure with bordered dressing, using aseptic technique…SN to perform care once a week…” Review of the clinical record revealed RN # 6 made a routine visit on 11/22/22 for wound care. The clinical record revealed no wound assessment or wound care. RN # 6 documented, “Wound care not provided. Patient refused.” During an interview with RN # 6 on 12/6/22 at 11:00 am, the RN stated, “I didn’t tell the physician the patient refused the wound care.” 2. Patient # 3 had a Start of Care date of 11/21/22 and an admitting diagnosis of Other Specified Functional Intestinal Disorders. Review of the Plan of Care [POC] for the certification period 11/21/22 to 1/19/23 revealed orders for SN [skilled nurse] 2 times a week for 1 week, 1 time a week for 1 week, 3 PRN [as needed] for ileostomy[a stoma constructed by bringing the end or loop of the small intestine out onto the surface of the skin…Intestinal contents pass out the ileostomy] care and “Notify physician of vital sign parameters out of range: Heart rate greater than 100 or less than 60…Pain level greater than 6…Diastolic [bottom number] blood pressure greater than 90 or less than 60…Systolic [top number] greater than 160 or less than 90…” RN # 6 completed the SOC visit dated 11/21/22. Review of the documentation revealed a heart rate of 103 and a pain level of 7/10. During an interview with RN #6 on 12/6/22 at 11:00 am the RN stated, “I didn’t notify the physician of the heart rate or the pain level.” 3A. Patient # 7 had a Start of Care [SOC] date of 10/19/22 and admitting diagnoses of Bipolar Disorder, Type 2 Diabetes Mellitus with Diabetic Neuropathy [nerve damage] and Chronic Obstructive Pulmonary Disease [COPD-lung disease]. Review of the Plan of Care for the certification period 10/19/22 to 12/17/22 revealed orders for SN [skilled nursing] 1 time a week for 4 weeks, 1 time every other week for 5 weeks, 4 PRN [as needed] for medication management, falls, respiratory complications and “Notify the physician of vital sign parameters out of range: Heart rate greater than 100 or less than 60…Pain level greater than 6…Diastolic [bottom number] blood pressure greater than 90 or less than 60, Systolic [top number] blood pressure greater than 160 or less than 90…” Review of the SOC visit completed by RN # 5 on 10/19/22, revealed the following documentation, “ blood pressure 178/86…” There was no evidence the RN notified the physician of the blood pressure being out of the given parameters. RN # 5 was not available for interview. An interview was conducted with the agency administrator on 12/6/22 at 11:30 am. During the interview the administrator confirmed the physician was not notified of the blood pressure being outside the given parameters in accordance with the POC. 3B. Patient # 7 had a Start of Care [SOC] date of 10/19/22 and admitting diagnoses of Bipolar Disorder, Type 2 Diabetes Mellitus with Diabetic Neuropathy [nerve damage] and Chronic Obstructive Pulmonary Disease [COPD-lung disease]. Review of the Plan of Care for the certification period 10/19/22 to 12/17/22 revealed orders for Physical therapy [PT] 1 time a week for 1 week, 2 times a week for 3 weeks, 1 time a week for 5 weeks and “Notify the physician of vital sign parameters out of range…Pain level greater than 6…” Review of the clinical record revealed PT # 7 completed the evaluation on 10/19/22 and documented a pain level of 7 in the bilateral lower extremities and the right shoulder. There was no evidence the PT notified the physician of the pain level being outside the parameter. During an interview with PT # 7 on 12/6/22 at 10:30 am, PT # 7 confirmed he did not notify the physician of the pain level being outside the given parameter. 3C. Patient # 7 had a Start of Care [SOC] date of 10/19/22 and admitting diagnoses of Bipolar Disorder, Type 2 Diabetes Mellitus with Diabetic Neuropathy [nerve damage] and Chronic Obstructive Pulmonary Disease [COPD-lung disease]. Review of the Plan of Care [POC] for the certification period 10/19/22 to 12/17/22 revealed orders for SN [skilled nursing] 1 time a week for 4 weeks, 1 time every other week for 5 weeks, 4 PRN [as needed] for medication management, falls, respiratory complications. Review of the clinical record revealed RN # 4 made a routine visit on 11/4/22. Further review of the clinical record revealed the following documentation, “…Patient observed sitting in the recliner…Pt [patient] stood up using walker and became SOB [short of breath] …Pt has 3+ pitting edema to BLE [bilateral lower extremities] and right leg has [sic] weeping…Pt reports having sore to buttocks. SN observed buttocks was [sic] red and very small open area 0.1 cm x 0.1 cm x 0.1 cm…” RN # 4 was not available for interview. An interview was conducted with the agency administrator on 12/6/22 at 11:30 am. During the interview, the administrator stated, “I can’t find any evidence the nurse notified the physician of the open area or the 3+ pitting edema.” 4. Patient # 1 had a Start of Care [SOC] date of 10/27/22 and admitting diagnoses of Pressure Ulcer of Left Hip, Stage 4 [deep wound reaching the muscle, ligaments, or bone] and Intestinal Malabsorption [disorder characterized by inadequate absorption of nutrients in the small intestines]. Review of the Plan of Care for the certification period 10/27/22 to 12/25/22 included orders for SN [skilled nursing] 1 time a week for 9 weeks and 2 PRN [as needed] for complications or labs and “SN to perform pressure ulcer care to left hip. Cleanse/irrigate wound with wound cleaner, pack with silver impregnated dressing, cover and secure with bordered dressing…” Review of the clinical record revealed the following wound measurements: 11/8/22 – 1.2 cm x 0.8 cm x 0.4 cm. The wound had purulent [drainage that may be a symptom of infection that may be white, yellow, or brown] drainage, no undermining [significant erosion occurs underneath the outwardly visible wound margins resulting in more extensive damage beneath the skin surface] or tunneling [the wound extends from the skin surface to various underlying tissues]; 11/15/22- 1.2 cm x 0.8 cm x 0.4 cm. The wound bed was covered with 100% slough [white or yellow material in the wound bed] and the wound had purulent drainage; 11/29/22 – 1 cm x 1.5 cm x 0.4 cm. The wound had a faint odor and had undermining present of 1.3 cm from the 6 o’clock-9 o’clock position and tunneling of 1.5 cm at the 3 o’clock position. An interview was conducted with RN # 6 pm 12/6/22 at 11:00 am. During the interview, RN # 6 confirmed the physician was not notified of the decline in the status of the wound. stated. During an interview with the agency director on 12/6/22 at 11:30 am, the administrator confirmed the RN should have notified the physician. 5A.Patient # 9 had a Start of Care date of 5/4/21. Review of the Plan of Care [POC] for the certification period 4/29/22 through 6/27/22 included diagnoses of Type 2 Diabetes Mellitus with Foot Ulcer, Non-Pressure Chronic Ulcer of Left Heel and Midfoot with Fat Layer Exposed, Type 2 Diabetes Mellitus with Diabetic Neuropathy [nerve damage], Essential Hypertension and Long Term [current] use of Insulin. The POC included orders for SN [skilled nursing] 0 times for 1 week, 2 times a week for 8 weeks, 1 time a week for 1 week, 4 PRN [as needed] for wound care/complications and “SN to monitor blood sugar levels to assess efficacy of medication and dietary therapy, coordinate care with physician for need to change plan of care…”Review of the clinical record revealed Patient # 9 presented to the ______ [name of hospital Emergency Room on 6/8/22. Review of hospital documentation revealed the following information, “…Presents to the ER today with high blood sugar. Patient reports he was unable to get his insulin from the pharmacy…went a few days without his insulin…EMS [emergency medical service] reports sugar was 437…Patient discharged home…” Review of the clinical record revealed RN # 4 made a visit on 6/9/22 and documented, “Pt [patient] reports being in the ER [emergency room] 6/8/22 for high blood sugar and hypertension. Pt states he is very frustrated due to an unplanned visit to ER, and this wound just isn’t healing [sic]. Unable to check pts [patient’s] blood sugar due to having a broken accu check machine [used for home monitoring of glucose]. Further review of the clinical record revealed RN # 4 made a routine visit on 6/13/22 and documented, “Pt states that he did not go to the _____ [name of the wound clinic on Friday due to not feeling well…Pt has new glucometer [used to check blood sugar] but is unable to use it due to missing part…” A routine visit was made by RN # 4 on 6/15/22. The following information was documented, “Walked into pt [patient]house…Pt appears pale and weak. Pt reports feeling week and having dizziness when trying to stand…Pt has been unable to check his blood sugar due to broken glucometer and was supposed to be using Dexcom [continuous glucose monitoring system that tracks glucose levels throughout the day and night. If glucose levels get too high or too low the patient is alerted] for continuous monitor but has been unable to get the applicator from the pharmacy…EMS [emergency medical service] arrived at pt home and pts [patient’s] blood sugar was 350…” RN # 4 was not available for interview. An interview was conducted with the agency administrator on 12/6/22 at 11:30 am. During the interview, the administrator confirmed the RN failed to inform the physician of the patient’s visits to the ER on 6/8/22, as well as the patient not having access to a method to monitor blood sugar. 5B. Patient # 9 had a Start of Care date of 5/4/21. Review of the Plan of Care [POC] for the certification period 4/29/22 through 6/27/22 included diagnoses of Type 2 Diabetes Mellitus with Foot Ulcer, Non-Pressure Chronic Ulcer of Left Heel and Midfoot with Fat Layer Exposed, Type 2 Diabetes Mellitus with Diabetic Neuropathy, Essential Hypertension and Long Term [current] use of Insulin. The POC included orders for SN [skilled nursing] 0 times for 1 week, 2 times a week for 8 weeks, 1 time a week for 1 week, 4 PRN [as needed] for wound care/complications and “SN to perform wound care to left calcaneus [heel]. Cleanse wound with Dakin’s 0.25%. Apply zinc cream to peri-wound. Apply Gentamicin cream to wound base. Cover with Aquacel AG or equivalent, cover with rolled gauze, wrap with elastic bandage and secure with tape using aseptic technique. SN may teach patient/caregiver to perform wound care.” Review of the clinical record revealed the patient received 13 SN visits for wound care from 4/29/22-6/16/22 [transferred to an inpatient facility]. Further review of the clinical record revealed the SN documented the patient had no caregiver available to assist with wound care for 13 of the visits. There was no evidence the physician was notified that the patient did not have a caregiver to assist with the dressing changes in accordance with the POC.