Every finding on record at Liberty Home Care, LLC

An unannounced onsite recertification survey was conducted October 9, 2023- October 10, 2023. Standard level deficiencies to the Medicare Conditions of Participation were identified.

An unannounced onsite recertification survey was conducted October 9, 2023-October 10, 2023. No deficiencies to the Emergency Preparedness Program were identified.

5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, and staff interview, the agency failed to conduct a medical social work evaluation as ordered for 1 of 2 records reviewed with orders for a social work evaluation (Patient #1). Findings included: PolicyStat ID 9662495, titled “Comprehensive Assessment/OASIS Collection, Encoding and Transmission, last reviewed 04/2021, was received from the agency director 10/10/23 at 3:52 PM. This policy revealed, “The comprehensive assessment will…meet the patient’s medical, nursing, rehabilitative, social, and discharge planning needs…” Patient #1 was admitted to the agency 08/30/23 with diagnoses including hypertensive heart disease and chronic obstructive pulmonary disease. Plan of care from 08/30/23 to 10/28/23 revealed orders for skilled nursing one time per week for two weeks, one time every other week for six weeks, and one time per week for one week. Referral documentation from 08/28/23 revealed, “Patient is in an assisted living facility and needs home health orders to be put in place because he wants to be discharged home…” and that Patient #1 was “trying to leave the nursing facility, but he needs someone to put in orders for Home Health and PCS [personal care services] …” The home health orders from 08/28/23 included orders for skilled nursing, physical therapy evaluation, and social work evaluation. Employee #10, registered nurse, conducted a skilled nursing assessment on 08/30/23. This visit note revealed documentation that Patient #1 had hip surgery over one year ago and while he was in a rehabilitation facility, his wife divorced him and would not allow him to return to the home they shared. This visit note also revealed that Patient #1 was unhappy living in the assisted living facility and stated that he wanted to be discharged to live with his son. Employee #10 informed Patient #1 that the medical social worker (MSW) would “get involved in this.” At the time of survey, there was no evidence in the clinical record that a medical social work evaluation was conducted. In an interview on 10/10/23 at 4:10 PM, Employee #9, covering agency director, stated that the expectation would be that the social worker makes the visit to evaluate the patient as ordered. Employee #7, social worker, was unavailable for interview at the time of survey.

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, home visits, staff interviews, the agency failed to include all medications in the plan of care for 1 of 3 patients with home visits (Patient #7). Findings included: A policy, Medication Profile and Drug Regimen Review (revised 03/2021) was received from the agency director (#9) on 10/10/2023 at approximately 12:30 P.M. The policy stated, “A current list of all medications the patient is using is maintained in the clinical record at all times.” Patient #7 was admitted on 04/21/2023 with diagnoses of pressure ulcer of sacral region (area between the hip bone and pelvis), stage 4, diabetes mellitus type 2 (DM II), and congestive heart failure. The plan of care for 08/19/2023-10/17/2023 included orders for skilled nurse (SN) visits 0 times a week for 1 week, 1 time a week for 9 weeks, and 3 PRN (as needed) and SN to perform medication review each skilled nursing visit and reconcile medications as needed. A home visit was conducted on 10/10/2023 at approximately 10:00 A.M. with RN #7. A comprehensive medication review found that patient #7 had been prescribed Albuterol (breathing treatment) 2.5mg/3mL via nebulizer as needed, duloxetine (anti-depressant) 30mg daily, furosemide (diuretic) 20mg daily, and Trulicity (DM II) 0.75mg/0.5mL 0.5mL every 7 days. RN #7 acknowledged that the medications were not included in the plan of care. Patient #7 stated that the Trulicity was prescribed 3-4 months ago. Patient #7 stated that he has been taking Albuterol, duloxetine, and furosemide for years. An interview was conducted with RN #7 on 10/10/2023 at approximately 11:50 A.M. RN #7 stated that she “tries to do (complete medication review every visit). I haven’t notice them (the new meds) before.” An interview was conducted with the agency director (#9) on 10/10/2023 at approximately 12:00 P.M. The agency director stated that a complete medication review should be conducted at every nurse visit.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on agency policy, clinical record review, and staff interviews the agency failed to notify the physician of a change in patient status for 1 of 4 patients with wounds (Patient #2), failed to notify the physician of a missed social work evaluation as ordered for 1 of 2 records reviewed with orders for a social work evaluation (Patient #1), and failed to notify the physician that the patient’s respiratory symptoms were not improving for 1 of 11 records reviewed (Patient #10). Findings included: PolicyStat ID 9010481, titled “Coordination and Communication Activities, last reviewed 12/2021, was received from the agency director 10/10/23 at 3:52 PM. This policy revealed, “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 patient’s condition…missed visits and failure to follow the plan of care… lack of achievement of home care goals/outcomes…” 1. Patient #1 was admitted to the agency 08/30/23 with diagnoses including hypertensive heart disease and chronic obstructive pulmonary disease. Plan of care from 08/30/23 to 10/28/23 revealed orders for skilled nursing one time per week for two weeks, one time every other week for six weeks, and one time per week for one week. Referral documentation from 08/28/23 revealed, “Patient is in an assisted living facility and needs home health orders to be put in place because he wants to be discharged home…” and that Patient #1 was “trying to leave the nursing facility, but he needs someone to put in orders for Home Health and PCS [personal care services] …” The home health orders from 08/28/23 included orders for skilled nursing, physical therapy evaluation, and social work evaluation. Employee #10, registered nurse, conducted a skilled nursing assessment on 08/30/23. This visit note revealed documentation that Patient #1 had hip surgery over one year ago and while he was in a rehabilitation facility, his wife divorced him and would not allow him to return to the home they shared. This visit note also revealed that Patient #1 was unhappy living in the assisted living facility and stated that he wanted to be discharged to live with his son. Employee #10 informed Patient #1 that the medical social worker (MSW) would “get involved in this.” At the time of survey, there was no evidence in the clinical record that a social work evaluation was conducted and there was no evidence that the physician was notified that the social work evaluation was not conducted. In an interview on 10/10/23 at 3:30 PM, Employee #6, clinical manager, stated that the visit was being moved from week to week. Employee #6 stated that the way in which the visits were being moved in the electronic system did not alert the clinical manager and that was the reason there was no communication with the physician. In an interview on 10/10/23 at 4:10 PM, Employee #9, covering agency director, stated that the expectation would be that the social worker makes the visit to evaluate the patient as ordered and that if the visit was not conducted or moved at the patient’s request, the physician would be notified, and this information would be documented in the clinical record. Employee #7, social worker, was unavailable for interview at the time of survey. 2. Patient #10 was admitted to the agency 09/06/23 with diagnoses including bacterial pneumonia and diabetes. Plan of care from 09/06/23 to 11/04/23 revealed orders for skilled nursing one time per week for two weeks, one time every other week for six weeks, and one time per week for one week, and physical therapy one time per week for one week, two times per week for two weeks, and one time per week for one week. Employee #8, registered nurse, conducted a skilled nursing visit on 09/12/23. This visit note revealed, “Pt’s [patient’s] lower lobes are diminished and sn [skilled nurse] called [name of primary care physician] …but office closed for lunch…sn advised pt that she probably needs another chest x-ray to make sure pneumonia is getting better or worse. Pt informed sn that [name of hospital] was to schedule her an appt [appointment] for one but she hasn’t received a call from anyone. Pt has an appt with pcp [primary care physician] today at 2pm and informed to ask pcp if he would schedule a chest x-ray. Sn will also f/u [follow-up].” There was no evidence in the clinical record that Employee #8 followed up with the physician’s office. On 09/18/23 Employee #11, physical therapist, wrote a missed physical therapy visit note that stated, “Dgt [daughter] stated that pt was admitted to [name of hospital] last Friday [09/15/23] …” In an interview on 10/10/23 at 3:35 PM Employee #6, clinical manager, confirmed that there was no evidence of follow-up after the 09/12/23 in the clinical record and stated, “they’re supposed to call again, and a communication note is supposed to be entered.” Employee #8 was unavailable for interview at the time of survey. A policy, Coordination and Communication Activities was received on 10/20/2023 from the agency director (#9) at approximately 3:52 P.M. The policy stated, “Home Health staff will maintain on-going communication with all physicians…that address the following…significant changes in the patient’s condition.” Patient #2 was admitted on 06/09/2023 with a diagnosis of sequelae of cerebral infarction (residual effects after a disruption of blood flow to the brain) the plan of care for 06/09/2023-08/07/2023 included orders for skilled nurse (SN) visits 1 time a week for 2 weeks, 1 every other week for 6 weeks, 1 time a week for 1 week, and 3 PRN (as needed) and SN to assess integumentary (skin) status, identify any signs and symptoms of impaired skin integrity, report significant changed to physician. The SN visit of 06/14/2023 RN #3 stated, “Pt has pressure ulcers to bilateral elbows and sacrum [area between the hip bone and pelvis].” There was no evidence of physician notification or orders for care. The SN visit of 06/21/2023 RN #3 stated, “Pt [patient] has pressure ulcers to bilateral elbows and sacrum.” There was no evidence of physician notification or orders for care. An interview was conducted on 10/10/2023 at approximately 12:14 P.M. with the agency director (#9) The agency director stated, “Wounds should have measurements 1 time a week, be assessed every visit, and notify the doctor for orders.”

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on agency policy, observation, and staff interviews the agency failed to follow accepted standards of practice to prevent the transmission of infection for 1 of 3 patients with home visits. (Patient #7) Findings included: A policy, Bag Technique, Home Care (revised 05/22/2023) was received on 10/10/2023 at approximately 12:34 P.M. from the agency director (#9). The policy stated, “Place a non-wheeled bag on a flat surface that appears clean and dry… Using a fluid-impermeable pad as a barrier between the bag and the patient’s home demonstrates respect for the patient’s property and health by reducing the risk of contamination.” A policy, Wound Assessment, Home Care was received on 10/10/2023 at approximately 12:34 P.M. from the agency director. The policy stated, “Organize equipment and supplies on a clean surface.” Patient #7 was admitted on 04/21/2023 with diagnoses of pressure ulcer of sacral region (area between hip bone and pelvis), stage 4, diabetes mellitus type 2 (DM II), and congestive heart failure. The plan of care for 08/19/2023-10/17/2023 included orders for skilled nurse (SN) visits 0 times a week for 1 week, 1 time a week for 9 weeks, and 3 PRN (as needed) and SN eval (evaluate) Teach wound care… QOD (every other day). A home visit was conducted on 10/10/2023 at approximately 10:00 A.M. with RN #7. RN #7 moved the patient’s personal items on the bedside table and placed the clinical bag on the table. RN #7 failed to disinfect the table or place a fluid-impermeable pad under the clinical bag. RN #7 removed the wound care supplies and bandage scissors from the patient’s supply, placed the bandage scissors on the patient’s bed and set up the bandages on the back of the patient’s legs. RN #7 failed to place a fluid-impermeable pad under the supplies. RN #7 used the scissors to cut sterile bandages 2 times and placed the scissors on the patient’s bed in between use. RN #7 failed to disinfect the scissors after picking them up off the bed. An interview was conducted with RN #7 on 10/10/2023 at approximately 11:50 A.M. RN # 7 stated “It depends on the home [When asked about the use of a fluid-impermeable barrier under the clinical bag] RN #7 stated that it is her normal practice to use the patient’s legs and bed to set up wound care supplies without the use of a barrier. An interview was conducted with the agency director (#9) on 10/10/2023 at approximately 11:55 A.M. The agency director stated, “There should be on a barrier [under the clinical bag].” The agency director stated, “Clean supplies should be laid on a chux [fluid-impermeable barrier]”

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 agency failed to include wound assessments for 1 of 4 patients with wounds. (Patient #2) Findings included: A policy, Wound Assessment, home care (revised 02/20/2023) was received on 10/10/2023 at approximately 12:34 P.M. from the agency director (#9). 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…” Patient #2 was admitted on 06/09/2023 with a diagnosis of sequelae of cerebral infarction (residual effects after a disruption of blood flow to the brain) the plan of care for 06/09/2023-08/07/2023 included orders for skilled nurse (SN) visits 1 time a week for 2 weeks, 1 every other week for 6 weeks, 1 time a week for 1 week, and 3 PRN (as needed) and SN to assess integumentary (skin) status, identify any signs and symptoms of impaired skin integrity, report significant changed to physician. The SN visit of 06/14/2023 RN #3 stated, “Pt [patient] has pressure ulcers to bilateral elbows and sacrum.” There was no evidence of wound staging, assessment, or measurements. The SN visit of 06/21/2023 RN #3 stated, “Pt has pressure ulcers to bilateral elbows and sacrum.” There was no evidence of wound staging, assessment, or measurements. An interview was conducted with RN #3 on 10/10/2023 at approximately 12:03 P.M. RN #3 stated, “Wounds should be assessed and measured weekly, if we have orders and should be measured and documented at least weekly there are no orders.” An interview was conducted on 10/10/2023 at approximately 12:14 P.M. with the agency director (#9). The agency director (#9) stated, “Wounds should have measurements 1 time a week, be assessed every visit, and notify the doctor for orders.”

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 agency failed to complete skilled nurse notes for 1 of 8 active patients. (Patient #5) Finds included: Patient # 5 was admitted on 09/12/2023 with a diagnosis of infection/inflammation reaction due to internal left knee prosthetic (artificial joint). The plan of care for 09/12/2023-11/10/2023 included orders for skilled nurse visits 1 time a week for 9 weeks and 3 PRN (as needed). A clinical record review was completed on 10/09/2023 at approximately 3:00 P.M. The skilled nurse visits of 09/25/2023, 09/26/2023, and 10/02/2023 conducted by RN #3 had incomplete clinical notes. An interview was conducted on 10/10/2023 at approximately 12:03 P.M. with RN #3. RN #3 stated, “[Agency name] allows 24 hours to complete documentation.” An interview was conducted with the agency director #9 on 10/10/2023 at approximately 12:14 P.M. Agency director #9 indicated that clinical staff had 24 hours to complete documentation.

An onsite recertification survey was conducted 03/22/21 to 03/23/21. No deficiencies were identified to the Emergency Prepardeness Program. ABH

An onsite recertification and follow up survey was conducted 03/22/21 to 03/23/21. Deficiencies to the Medicare Conditions of Participation were identified. The following tag was put back into compliance: G 536. ABH

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 interviews the agency failed to follow the plan of care as ordered by the physician for physical therapy services for 1 of 5 patients with physical therapy (#4). Findings include: A policy, "Care Planning : Initial Care Plan and Updates to the Plan of Care" revised 03/21 was provided by the administrator on 03/22/21 at 4:58 p.m. The policy stated, " ...the plan of care also includes documentation of the following: amount, frequency and duration of visits/services to be provided ..." 1. Patient #4 was admitted on 01/08/21 with a diagnoses of fracture of metatarsal bone, major depressive disorder, nicotine dependence, and long-term use of aspirin . The Plan of Care (POC) for 01/08/21-03/08/21 included orders for physical therapy 1 day1 and 2 times a week for 6 weeks. Orders for physical therapy were to provide fall prevention instruction, interventions to monitor and mitigate pain, telehealth video visits are being provided for emphasis on home exercise program independence and compliance, therapeutic exercise/muscle reeducation and transfer training. Review of the clinical record revealed physical therapy visits were conducted on the following dates: 01/08/21, 01/12,21, 01/14,21, 01/19/21, 01/21/21,01/26/21, 01/28/21, 02/02/21, 02/04/21, 02/11/21, 02/16/21, and 02/18/21. Further review of the record revealed no visit was conducted on 02/09/21 as ordered by the physician. An interview with Employee #4 on 3/23/21 at 8:48 a.m. revealed "it was supposed to be a video visit by _______physical therapy assistant". Interview with Employee #9 on 3/23/21 at 9:03 a.m. revealed "I don't see a call log /missed visit for 2/9/21, I didn't do one".

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on policy review, client record review, and staff interview the agency failed to measure wounds for 1 of 2 patients with wounds (#3). Findings included: Review of a policy "Wound Assessment, Photography, and Documentation", revised 08/15 was received from the administrator on 03/22/21 at 3:33 p.m. The policy stated," ....the nurse will measure wounds weekly and in accordance with payor source requests ....". 1. Patient #1 was admitted on 12/19/20 with diagnoses of encounter for surgical aftercare following surgery on the circulatory system, presence of aortocoronary bypass graft, essential hypertension, restless legs syndrome, and mild cognitive impairment. The plan of care for 12/19/20 to 02/16/21 had orders for skilled nursing 3 times a week for 1 day 1, 2 times a week for 2 weeks, 1 time a week for 7 weeks with 2 as needed visits. Orders for skilled nursing to perform wound care to surgical wounds 1-6 as follows- gently cleanse area with mild soap and water, pat dry and paint with betadine swab 3 times a daily and leave open to dry. Caregiver to perform on days skilled nurse doesn't visit. Review of skilled nursing notes for dates of 12/19/20, 12/20/20, 12/26/20, 12/28/20, 01/01/21, 01/06/21, 01/11/21, 01/18/21, 01/25/21, 01/28/21, 02/01/21, 02/10/21 revealed wound measurements were not obtained for the weeks of 12/21/20, 12/28/20, and 01/11/21. Interview with Employee #8 on 3/23/21 at 9:25 a.m. revealed " I have measurements here in my notebook, but they are not in the record". Interview with Employee #3 on 3/23/21 at 9:30 a.m. revealed " if they are seen 2 times a week, I usually don't measure, I didn't look back to see if they were measured". Interview with the Employee #2 on 3/23/21 at 9:32 a.m. revealed "he had surgical wounds that were sutured together, I forgot to measure".

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 policy review, clinical record review, and staff interviews the agency failed to ensure coordination of care for 3 out of 9 patients who received skilled nursing care (#7, 8, 10). Findings include: A policy titled "Coordination of Care," provided by RN #1, revised 03/2018, stated, "All employees and contract staff are expected to coordinate patient care activities in accordance with the needs of the patient ...Home Health staff will maintain on-going communication with all physicians involved in the plan of care which includes verbal and/or written reports ..." Patient #7 had a start of care of 1/21/21 and a diagnosis of venous insufficiency. Review of the clinical record for the certification period of 1/21/2021-3/21/2021 revealed orders for a home health aide (HHA) to visit twice per week for 7 weeks. During the week of 2/24/2021, there was one home health aide visit documented (2/25/2021). On 2/29/2021 in a call log note, HHA #11 documented that the patient refused a visit. No documentation was found that HHA #1 alerted the case manager of the missed visit. Interview with RN #6, a clinical manager, on 3/23/21 at 8:52 am confirmed the missed visit and the lack of missed visit documentation. RN #6 stated, "Anytime our aide has a patient refuse or anything, they should notify the case manager. That should be documented." A policy titled "Central Venous Catheter Dressing Change, provided by RN #1 and last approved 09/2018, stated the following steps when changing a central line dressing: "Measure the external catheter length ...notify the physician of any unusual observations." Patient #8 had a SOC of 6/20/2020 and a diagnosis of orthopedic aftercare following surgical amputation, diabetic foot ulcer, and the presence of a PICC (peripherally inserted central catheter, an intravenous line used to administer medications). Review of the clinical record for the certification period of 6/20/2020-8/18/2020 revealed that skilled nursing was ordered once on 6/20/2020, then once per week for nine weeks, with three PRN (as needed) visits for IV complications. The orders included weekly PICC dressing changes. In visit notes recorded by RN #5, the length of the external PICC length was recorded as 1cm on 6/29/2020; one week later, on 7/6/2020, the external catheter length was 2cm. No documentation was found that the physician was notified of the change in length. In an interview with RN #5 on 3/23/2020 at 9:40 am, the nurse stated that for a 1cm difference in external catheter length, the doctor should be notified. The nurse stated, "I don't remember calling the doctor." Interview with RN#1, the Administrative Director, on 3/23/20 at 9:46am revealed, "I would expect the PICC measurement change to be called to the doctor." Interview confirmed there was no documentation that RN #5 notified the doctor of the change. Patient #10 had a start of care of 8/31/2020 and a diagnosis of Other Sequelae of Cerebral Infarct (residual effects of a stroke). A review of the plan of care for the certification period of 8/31/2020-10/29/2020 revealed orders for skilled nursing visits once on 8/31/2020, once per week for one week, twice per week for two weeks, and once every other week for six weeks. The plan of care specified that four visits would be completed as telehealth visits. Review of the clinical record revealed a call log dated 9/1/2020 that stated that the tablet issued to the patient for video visits had been stolen, and that RN #1, the Administrative Director, had been made aware. Review of the visit notes revealed missed video visit documentation for 9/29/2021 and 10/6/2021. Interview on 3/23/21 at 8:54am with RN #1 revealed she was aware of the stolen tablet. Review revealed, "I should have communicated that with the case manager. The missed video visits were because of the stolen tablet." RN #1 further stated that the appropriate course of action would be to "notify the doctor and then make the visits in person. I was made aware and I should have followed up."