Every finding on record at Liberty Home Care, LLC

An unannounced onsite recertification survey was conducted 3/17/25-3/19/25. No deficiencies to the Emergency Preparedness Plan were identified.

An unannounced onsite recertification survey was conducted 3/17/25-3/19/25. Standard level deficiencies to the Medicare CoP were identified.

Make efforts to resolve the problem(s) CFR(s): 484.50(d)(5)(ii) (ii) Make efforts to resolve the problem(s) presented by the patient's behavior, the behavior of other persons in the patient's home, or situation; This ELEMENT is not met as evidenced by: Based on agency policy, clinical record review, and staff interviews the agency failed to make efforts to resolve the problem presented by the patient's behavior prior to discharging for cause for 1 of 1 patient discharged for cause [#2]. The findings included: The policy, Discharge and Transfer of Patients [01/2025], was provided by the agency administrator on 3/19/25 at 9:04 am. The policy stated, "...When the agency determines that the patient's (or other person's in the home) behavior is disruptive, abusive, or uncooperative...the following must be done before the patient is discharged: Hold a case conference to make a decision concerning discharge and document...Make efforts to resolve the big problem presented by the patient's behavior...Provide the patient and representative (if any), with contact information for other agencies...Document the problem and efforts made to resolve the problem, and enter this documentation into the electronic clinical record..." Patient # 2 had a Start of Care date of 12/1/23 with admitting diagnoses of encounter for adjustment and management of VAD [vascular access device-medical device inserted into a blood vessel to provide long term access for administration of medication, etc.] and bacteremia [bacteria in the bloodstream]. Review of the Plan of Care [POC] for the certification period 1/30/24-3/29/24 revealed a primary diagnosis of hemiplegia [paralysis of ½ of body] following a cerebral infarction [stroke]. The POC included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 4 weeks, 1 time a week for 4 weeks and PT [physical therapy] 1 time a week for 1 week, 2 times a week for 1 week, 1 time a week for 7 weeks. Review of the clinical record revealed missed visits for PT and SN on 2/9/24 and 2/12/24. Further review of the clinical record revealed the following documentation by RN # 2 on 2/12/24,” Call to physician office to report unable to contact patient since 2/6/24 to schedule PT. SN has not been able to make contact with patient or family since then either. Spoke with _____ [name] who verbalized understanding that ____ [name of agency] will be discharging patient from HH [home health] due to non-compliance and illegal drug seeking activities [unable to find information related to this in the clinical record]. SN reported that patient was at _____[name of emergency department] on 2/7/24...Patient will be discharged on Thursday or Friday...” Further review of the clinical record revealed RN # 6 conducted a routine visit on 2/13/24. RN # 2 discharged the patient on 2/16/24. The clinical record revealed no evidence that the agency made efforts to resolve the problems related to the missed visits or provided the patient with contact information related to other home health agencies/providers who might be able to provide care. During an interview with the agency administrator on 3/17/25 at approximately 3 pm, the administrator confirmed the clinical record did not include the required documentation related to discharge for cause.

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 skilled nurse failed to obtain labs in accordance with the physician's order for 1 of 1 patient with VAD [vascular access device-medical device inserted into a blood vessel to provide long term access for administration of medication, etc.] [#2]; and failed to obtain weekly weights for 1 of 1 patient with VAD [vascular access device-medical device inserted into a blood vessel to provide long term access for administration of medication, etc.] [#2.]; and provided wound care for 1 of 4 patients with a wound without an order for wound care [#3]; and the agency failed to report vitial signs outside a given parameter in accordance with the physician's order for 1 of 3 patients who received a home visit [#5]. The findings included: 4. Patient #5 had a Start of Care date of 1/12/2025 with an admitting diagnosis of Lymphedema (build up of fluid causing swelling, usually in arms and legs caused by a blockage in the lymphatic system). Review of the Plan of Care (POC) for the certification period 1/12/25-3/12/25 included orders for SN (skilled nurse) 2 times a week for 2 weeks, 1 time a week for 7 weeks. Further review of the POC revealed vital sign parameters as follows: “Notify physician of vital sign parameters out of range: Heart rate: greater than (>)100 bpm (beats per minute) or less than () 160mmHg or less than () 90 mmHg or less than ( RN #2 conducted home visits on 1/21/2025 and 2/14/2025. On 1/21/2025, RN #2 documented that patient had an O2 (oxygen) saturation (refers to the percentage of oxygen in the blood) of 91%. Documentation for the 2/14/2025 home visit revealed RN #2 documented a blood pressure of 164/90. Review of the clinical record revealed no evidence that the physician had been notified of the vital signs documented on 1/21/25 or 2/14/25. On 2/14/25, PT #1 conducted a home visit and documented a blood pressure reading of 220/70. PT #1 documented calling RN #2 with this blood pressure reading and that RN #2 stated they would notify MD. There was no evidence the PT or RN notified the physician of the blood pressure reading. On 2/21/2025, RN #2 conducted a home visit and documented the patient’s heart rate at 108. Review of the clinical record revealed no evidence that the physician was notified of this vital sign reading. An interview with the director on 3/19 at approximately 4 pm, confirmed there was no evidence the physician was notified of the vital signs outside the given parameters in accordance with the POC. 1A.Patient # 2 had a Start of Care date of 12/1/23 with admitting diagnoses of encounter for adjustment and management of VAD [vascular access device-medical device inserted into a blood vessel to provide long term access for administration of medication, etc.] and bacteremia [bacteria in the bloodstream]. Review of the Plan of Care for the certification period 12/1/23-1/29/24 included orders for SN [skilled nursing] 2 times a week for 1week,1 time a week for 8 weeks and “SN to obtain blood for BMP [basic metabolic panel and triglycerides each Monday...” On 1/9/24 a supplemental order was noted that stated, “Please make sure to add magnesium and phosphorous to weekly labs.” Review of the clinical record revealed lab work was obtained on 1/15/24, 1/22/24, 1/29/24, and 2/5/24. Further review of the clinical record revealed no lab results for magnesium or phosphorous. During an interview with the agency administrator on 3/17/25 at 3 pm, the administrator confirmed the nurses failed to obtain the blood for magnesium and phosphorous levels. 1B. Patient # 2 had a Start of Care date of 12/1/23 with admitting diagnoses of encounter for adjustment and management of VAD [vascular access device-medical device inserted into a blood vessel to provide long term access for administration of medication, etc.] and bacteremia [bacteria in the bloodstream]. Review of the Plan of Care for the certification period 12/1/23-1/29/24 included orders for SN [skilled nursing] 2 times a week for 1week,1 time a week for 8 weeks and “SN to monitor weekly weights”. Review of the clinical record revealed a weight of 133 was documented on 12/1/24. Further review of the clinical record revealed no weekly weights were obtained after the weight on 12/1/24. During an interview with the agency administrator on 3/17/25 at approximately 3 pm, the administrator confirmed the SN failed to obtain the weekly weight for the patient. 3. Patient # 3 had a Start of Care date of 8/24/24 with an admitting diagnosis of type 2 diabetes mellitus with hypoglycemia [low blood sugar level]. Review of the clinical record revealed the patient was admitted to _________ [name of hospital] on 9/3/24 for “low blood sugar” and was discharged home on 9/6/24. The Resumption of Care [ROC-comprehensive assessment completed after patient has had inpatient stay] visit was conducted on 9/7/24 by RN # 2. RN # 2 documented the following information, “...Patient has bandaid to right forearm, states that he got the injury when he fell, dressing changed using same products that are currently in use, Xeroform gauze and bandaid applied...” Review of the clinical record revealed no order for wound care to the right forearm. During an interview with the agency administrator on 3/17/25 at approximately 3 pm, the administrator confirmed there was no order for wound care.

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 skilled nurse failed to measure the PICC [peripherally inserted central catheter- is a thin, flexible tube inserted into a vein in the upper arm and threaded into a larger vein near the heart] line measurements for 1 of 1 patient with a PICC line [#2]; and failed to obtain wound measurements/wound assessments for 2 of 4 patients with a wound [#4 The findings included: The policy, Peripherally Inserted Central Catheter [PICC] Dressing Change, Home Care [8/19/24], was provided by the agency administrator on 3/19/25 at approximately 9:04 am. The policy stated, "...Documentation associated with a PICC dressing change included: condition and length of the external catheter..." The policy, Wound Assessment [2/24/25], was provided by the agency administrator on 3/19/25 at approximately 9:04 am. 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..." 1.Patient # 2 had a Start of Care date of 12/1/23 with admitting diagnoses of encounter for adjustment and management of VAD [vascular access device-medical device inserted into a blood vessel to provide long term access for administration of medication, etc.] and bacteremia [bacteria in the bloodstream]. Review of the Plan of Care for the certification period 12/1/23-1/29/24 included orders for SN [skilled nursing] 2 times a week for 1week,1 time a week for 8 weeks and “...SN to perform sterile dressing changes to R [right] IJ [sic] catheter weekly...” Review of the clinical record revealed 9 routine nursing visits were made from 12/1/24-1/29/24. Out of the nine [9] visits the SN failed to obtain PICC [peripherally inserted central catheter- is a thin, flexible tube inserted into a vein in the upper arm and threaded into a larger vein near the heart] line measurements for 7 of the 9 visits. During an interview with the agency administrator on 3/17/25 at 3 pm, the administrator confirmed the SN failed to obtain PICC line measurements in accordance with the agency policy. 2.Patient # 4 had a Start of Care date of 6/21/24 and admitting diagnoses of pressure ulcer or right buttock, stage 4 [ulcer involving full-thickness skin and tissue loss, exposing bone, muscle or tendons, and may show signs of infection-like pus, odor, and redness] and pressure ulcer of left buttock, stage 4. Review of the Plan of Care for the certification period 2/16/25-4/16/25 included orders for SN [skilled nursing] 1 time a week for 9 weeks and “SN to perform wound care to lower back/sacral area on weekly basis. Cleanse wound with dermal wound cleanser, cover and secure with ABD pad, tape...SN to perform pressure ulcer care to right ischium [hip bone area] at each visit...SN to perform pressure ulcer care to left ischium at each visit...” Review of the clinical record revealed no wound measurements for the week of 3/4/25. RN # 2 conducted a routine visit on 3/13/25. Review of the visit note revealed no wound assessments for that date. The RN documented wound care but no wound assessments. During an interview with the agency administrator on 3/17/25 at approximately 3 pm, the administrator stated, “We measure wounds weekly, and a wound assessment is due with each visit.” 3. Patient # 6 had a Start of Care [SOC] date of 1/18/25 with an admitting diagnosis of pressure ulcer of left buttock, stage 2 [partial thickness skin loss, presenting as a shallow open ulcer], pressure ulcer of right hip, stage 2, pressure ulcer of left hip, stage 2. Review of the Plan of Care [POC] for the certification period 1/18/25-3/18/25 included orders for SN [skilled nursing] 1 time a week for 1 week, 0 times a week for 1 week, 1 time week for 7 weeks. Review of the clinical record revealed RN # 7 completed the SOC OASIS [Outcome and Assessment Information Set-used by home health agencies to collect data on patients receiving skilled care] and documented the following information, “...Pt [patient] has two stage 2 wounds, and extensive excoriation/skin peeling on buttocks and thighs due to incontinence...” Further review of the clinical record revealed no wound assessments/measurements related to the two stage 2 pressure ulcers. RN # 2 conducted a routine visit on 1/29/25 and documented the following information, “...states that his pain increases when positioned onto left side to offload pressure to buttocks. Extreme maceration/excoriation noted to right hip and posterior thighs...” During an interview with the agency administrator on 3/19/25 at 3 pm, the administrator confirmed the RNs failed to obtain measurements or wound assessments or go into detail as to why the measurements/assessments were not obtained.

Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This ELEMENT is not met as evidenced by: Based on clinical record review and staff interviews the skilled nurse educated the patient to apply topical creme without a physician's order for 1 of 4 patients with a wound [#6]. The findings included: Patient # 6 had a Start of Care [SOC] date of 1/18/25 with an admitting diagnosis of pressure ulcer of left buttock, stage 2 [partial thickness skin loss, presenting as a shallow open ulcer], pressure ulcer of right hip, stage 2, pressure ulcer of left hip, stage 2. Review of the Plan of Care [POC] for the certification period 1/18/25-3/18/25 included orders for SN [skilled nursing] 1 time a week for 1 week, 0 times a week for 1 week, 1 time week for 7 weeks. Review of the SOC OASIS [Outcome and Assessment Information Set-used by home health agencies to collect data on patients receiving skilled care] revealed RN # 7 documented the following information, “...Pt [patient] wife states orange barrier cream is not working. SN recommends A & D ointment to skin to create barrier and promote healing...” Review of the clinical record revealed no physician’s order to A & D ointment. During an interview with the agency administrator on 3/19/25 at 3:30 pm the administrator confirmed the RN should not have recommended the A & D without a physician’s order.

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 skilled nurse failed to individualize interventions by not removing information that was not applicable from the interventions template for 2 of 2 patients with nursing orders who received home visits. (#3 and #5). The findings included: 1.Patient #3 had a Start of Care date of 2/14/2025 with an admitting diagnosis of right leg cellulitis (bacterial infection of the skin). Review of the Plan of Care (POC) for the certification period 2/14/25-4/14/25 included orders for SN (skilled nurse) 1 time a week for 3 weeks, 1 time every other week for 5 weeks. Review of the medical record revealed that on 3/13/2025, LPN #3 documented under interventions that “SN instructed patient/caregiver regarding heart failure status and self-management program” and “SN instructed patient/caregiver regarding self-management of Peripheral Vascular Disease”. 2.Patient #5 had a Start of Care date of 1/12/2025 with an admitting diagnosis of Lymphedema (build up of fluid causing swelling, usually in arms and legs caused by a blockage in the lymphatic system). Review of the Plan of Care (POC) for the certification period 1/12/25-3/12/25 included orders for SN (skilled nurse) 2 times a week for 2 weeks, 1 time a week for 7 weeks. Further review of the clinical record revealed all SN visit notes reviewed for this patient, (1/12/25 – 3/7/25), the following was documented in the intervention portion of the SN narrative: “SN instructed patient/caregiver regarding heart failure ( a chronic condition in which the heart doesn’t pump blood as well as it should) status and self-management program” and “SN instructed patient/caregiver regarding self-management of Peripheral Vascular Disease” (a condition in which narrowed blood vessels reduce blood flow to the limbs). Review of the clinical record revealed no diagnosis of heart failure or PVD. An interview with the director on 3/19 at approximately 4 pm, confirmed that peripheral vascular disease and heart failure sections of the template were not removed from the interventions section of the nursing narrative.

A recertification survey was conducted March 21, 2022-March 23, 2022. No deficiencies identified to the Emergency Preparedness Program.

A recertification survey was conducted March 21, 2022-March 23, 2022. Standard level deficiencies to the Medicare Conditions of Participation were identified. A complaint investigation was also conducted. The complaint was substantiated and a standard level deficiency was 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 policy review, clinical record review and staff interviews the Plan of Care [POC] failed to include all medications the patient was using at the time of admission for 1 of 2 records with a PICC [peripherally inserted central catheter] line [#5]. Findings include: Patient # 5 had a Start of Care [SOC] date of 1/24/22 and an admitting diagnosis of Discitis [an infection in the intervertebral disc space]. A review of the Plan of Care [POC] for the certification period 1/24/22 to 3/24/22 revealed orders for SN [skilled nursing] 1 time a day for 1 day, 1 time a week for 9 weeks and “IV-Access type: PICC : PICC [peripherally inserted central catheter]…Flush line with 20 ml normal saline then 3 ml heparin 100 units per ml…” A review of the clinical record revealed normal saline nor heparin were included on the medications at the SOC. An interview was conducted with the agency administrator on 3/23/22 at approximately 11 am. During the interview the administrator confirmed the normal saline and the heparin should have been included on the POC. A policy, "Care Planning: Initial Care Plan and Updates to the Plan of Care" revised 3/2021, was provided by the agency director on 3/22/22 at 12:10 p.m. The policy stated, "The plan of care also included documentation of the following...All current prescription and over-the-counter medications".

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on agency policy review, clinical record review and staff interviews the agency failed to follow the Plan of Care [POC] related to dressing changes for 3 of 7 records with a wound [#16, 6, and 13]; failed to follow the POC related to PICC [peripherally inserted central catheter] line measurements for 1 of 1 records with a PICC line (#16); failed to report blood sugars outside the given parameters for 1 of 5 records with a diagnosis of Diabetes Mellitus (#16); failed to obtain lab work for 1 of 1 discharged records with an order for INR [international normalized ration-measures the amount of time it will take the blood to clot] and BMP [basic metabolic panel] (#5). Findings include: 1A. Patient # 16 had a Start of Care [SOC] date of 1/28/22 and admitting diagnoses of Other Streptococcal Arthritis [left knee], Type 2 Diabetes Mellitus with foot ulcer and Non-pressure Chronic Ulcer of Right heel and midfoot limited to breakdown of skin. A review of the Plan of Care [POC] for the certification period 1/28/22 to 3/28/22 revealed orders for SN [skilled nursing] 1 time a day for 1 day, 2 times a week for 6 weeks, 1 time a week for 3 weeks, 2 PRN [as needed] for signs and symptoms of complications and “Wound # 5- Diabetic Ulcer- anterior left knee: HHSN [home health skilled nurse] to irrigate wound gently with normal saline apply protectant to skin surrounding affected area. Allow to dry. Apply silver gel or medical honey to wound bed including any undermining…Apply petroleum gauze and dry clean dressing, secure with gauze wrap…Change dressing every 2-3 days and as needed…” A review of the SN Clinical Note [Care Plan section-under the not performed section] dated 1/31/22 and completed by RN # 3 revealed the RN did not complete the wound care but Patient/caregiver completed the dressing changes. Further review of the documentation revealed no evidence the RN notified the physician that she did not complete the wound care. RN # 3 was not available for interview. An interview was conducted with the agency administrator on 3/23/22 at approximately 9:30 am. During the interview the administer confirmed the physician was not notified related to the POC not being followed for the SN to do the dressing changes on the days a visit was made. On 1/31/22 RN # 3 obtained an order for wound care, “Wound 1- Diabetic Ulcer- plantar right heel- clean foot with soap and water or normal saline. Cover wound with medihoney [sic] gel, 4x4 gauze pad and secure with roll [sic] gauze. Change dressing 3 times a week, CG [caregiver] may change dressing in absence or SN. SN to change dressing weekly for assessment and observation including measurements. Wound 2- Traumatic – anterior left knee. Cleanse wound with normal saline or wound cleanser, pat dry. Cover wound with silver polymer [sic] foam and secure with tape or roll [sic] gauze Change dressing 3 times a week, CG [caregiver] may change dressing in absence or SN. SN to change dressing weekly for assessment and observation including measurements. Wound 4 – Pressure Injury – posterior right gluteus maximus -Cleanse wound with soap and water or normal saline. Pat dry. Cover with sacral foam dressing, change every 3 days or PRN if soiled or dislodged. CG [caregiver] may change dressing in absence or SN. SN to change dressing weekly for assessment and observation including measurements. Wound 3-Pressure Injury – posterior left gluteus maximus --Cleanse wound with soap and water or normal saline. Pat dry. Cover with sacral foam dressing, change every 3 days or PRN if soiled or dislodged. CG [caregiver] may change dressing in absence or SN. SN to change dressing weekly for assessment and observation including measurements.” A review of the Skilled Nurse Clinical Note dated 2/4/22 [Care Plan section-under the not performed section] and completed by RN # 3 revealed the RN did not complete and of the wound care but Patient/caregiver completed the dressing changes. RN #3 was not available for interview. An interview was conducted with the agency administrator on 3/23/22 at approximately 10 am. During the interview the administrator confirmed RN # 3 failed to follow the physician’s order related to dressing changes. 1B. Patient # 16 had a Start of Care [SOC] date of 1/28/22 and admitting diagnoses of Other Streptococcal Arthritis [left knee], Type 2 Diabetes Mellitus with foot ulcer and Non-pressure Chronic Ulcer of Right heel and midfoot limited to breakdown of skin. A review of the Plan of Care [POC] for the certification period 1/28/22 to 3/28/22 revealed orders for SN [skilled nursing] 1 time a day for 1 day, 2 times a week for 6 weeks, 1 time a week for 3 weeks, 2 PRN [as needed] for signs and symptoms of complications and “Administer IV using SASH [Saline-Administration-Saline-Heparin] Method. IV-Access Type: PICC [peripherally inserted central catheter] …Measure arm circumference weekly in cm [centimeters]…Measure catheter length every visit…” A review of the SN Clinical notes revealed no catheter length measurement for 1/28/22 or 2/4/22. Further review of the clinical record revealed no arm circumference for the week of 2/4/22, 2/7/22, 2/14/22, 2/21/22 or 3/7/22. An interview was conducted with the agency administrator on 3/3/22 at approximately 10:30 am. During the interview the administrator confirmed the PICC line measured in accordance with the POC. 1C. Patient # 16 had a Start of Care [SOC] date of 1/28/22 and admitting diagnoses of Other Streptococcal Arthritis [left knee], Type 2 Diabetes Mellitus with foot ulcer and Non-pressure Chronic Ulcer of Right heel and midfoot limited to breakdown of skin. A review of the Plan of Care [POC] for the certification period 1/28/22 to 3/28/22 revealed orders for SN [skilled nursing] 1 time a day for 1 day, 2 times a week for 6 weeks, 1 time a week for 3 weeks, 2 PRN [as needed] for signs and symptoms of complications and “…Report findings to MD if Blood Glucose greater than 300 or less than 65…” A review of the SN Clinical note dated 1/31/22 by RN # 3 revealed a blood sugar of 305. A review of the SN Clinical note dated 2/4/22 by RN # 3 revealed a blood sugar of 429. Further review of the clinical noted revealed no evidence the RN contacted the MD to report the blood sugar readings for either date. RN # 3 was not available for interview. An interview was conducted with the agency administrator on 3/23/22 at approximately 9:30 am. During the interview the administrator confirmed there was no evidence the RN contacted the physician. RN # 3 was not available for an interview. An interview was conducted with the agency administrator on 3/23/22 at approximately 10:30 am. During the interview the administrator confirmed the physician was not notified of the blood sugar reading in accordance with the POC. 2. Patient # 5 had a Start of Care [SOC] date of 1/24/22 and an admitting diagnosis of Discitis [an infection in the intervertebral disc space]. A review of the Plan of Care [POC] for the certification period 1/24/22 to 3/24/22 revealed orders for SN [skilled nursing] 1 time a day for 1 day, 1 time a week for 9 weeks. A review of the clinical record revealed Patient # 5 was admitted to _____[name of hospital] on 1/26/22 for an Acute GI Bleed. The patient remained inpatient from 1/26/22 until 2/2/22. A review of the ROC [Resumption of Care] orders revealed SN orders for 1 time a week for 6 weeks and SN to “obtain INR [international normalized ration-measures the amount of time it will take the blood to clot] and BMP [basic metabolic panel] weekly.” Further review of the clinical record revealed the patient received SN visits on 2/7/288, 2/14/22, 2/21/22, 2/28/22 and 3/8/22 [for discharge]. There is no evidence the INR or the BMP were obtained weekly in accordance with the resumption of care orders. An interview was conducted with the agency administrator on 3/23/22 at approximately 11 am. During the interview the administrator stated, “The order was on the ROC paperwork. It looks like the nurse failed to pull it over to the orders.” 3. Patient #6 was admitted on 10/12/21 with diagnoses of aftercare following surgery for neoplasm and squamous cell carcinoma of skin, scalp, and neck. The Plan of Care (POC) for 2/9/22-4/9/22 included orders for skilled nursing (SN) weekly for eight weeks; wound care to two sites on the anterior scalp as follows: 1. CG/SN to wash hands 2. With gloves, remove outer dressing to scalp, VERY slowly due to tenderness. 3. Cut kerlex gauze to fit size of open wounds on scalp. 4. Apply hydrogel to wounds cover with formed gauze. 5. Cover scalp with cushion dressing for protection. 6. Place stockinette over head to hold dressing in place…” On the SN visit for 2/16/22, RN #4 documented, “SN cleaned wound well.” On the 3/16/22, RN #___ Morgan documented, “Wounds on scalp were cleaned very well this visit as there were some scab like areas and “booger” looking areas, removed and cleaned…SN encouraged patient and CG [caregiver] to be sure to clean wound and surrounding hair well.” The wound care orders did not include orders to cleanse wound. An interview with the clinical director on 3/23/22 at 10:05 a.m. confirmed there were no orders to cleanse the wounds. An interview with RN #4 on 3/23/22 at 1:20 p.m. confirmed she had used saline to cleanse the wounds. The interview also confirmed there were no orders to cleanse the wounds. 4. Patient #13 was admitted on 12/31/21 with diagnoses of aftercare following surgery for a neoplasm and malignant neoplasm of cardia [between stomach and esophagus]. The Plan of Care (POC) for 12/31/21-2/28/22 included orders for skilled nursing (SN) weekly for eight weeks. The POC included the feeding for Vital 1.5 (no amount listed); also stated to flush the feeding tube with “50 ml flush before and after feedings and every 6 hours.” The visit note on 1/6/22 stated, “Advised patient to report nausea, if appetite picks up during the day feeding may need to be adjusted at night. Educated patient and caregiver that if when doing feeding, if patient becomes nauseated and started dry heaving or vomiting to hold feeding and notified [sic] HHSN/MD [home health skilled nurse/physician]. May hold feeding for hour until nausea resolves and start back…Flushing every 4-6 hours…” There was no evidence of a physician order for patient to hold feedings or to flush every 4 hours. An interview with the clinical director on 3/23/22 at 10:30 a.m. confirmed there were no orders to hold feedings and the flush orders was after before and after feedings and every 6 hours.

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 policy review, clinical record review, and staff interview, the agency failed to notify the physician of changes in patient’s condition for 5 of 17 patients (#6, 7, 13, 15, and 12); and to advise the physician the patient was dosed with wife’s insulin for 1 of 5 records with diabetes [#16] Findings include: 5. Patient # 12 had a Start of Care [SOC] date of 12/18/21 and admitting diagnoses of PVD [Peripheral Vascular Disease- progressive circulation disorder] and Diabetes Mellitus. A review of the Plan of Care [POC] for the certification period 12/18/21 to 1/27/22 revealed orders for SN [skilled nursing] 1 time a day for 1 day, 1 time a week for 9 weeks. A review of the clinical record revealed RN # 5 completed the SOC assessment. Further review of the clinical record revealed the following documentation, “…Patient had cardiac cath [sic] done prior to discharge, inserted via left groin via left groin…SN noted a blister to left groin to the right of insertion of where catheter was inserted. Patient advised to leave this blister alone and let it heal on its own…” Further review of the clinical record revealed no evidence the RN contacted the physician about the blister. RN # 5 was not available for interview. An interview was conducted with the agency administrator on 3/23/22 at approximately 10:15 am. During the interview the administrator confirmed there was no evidence the physician was notified. 6. Patient # 16 had a Start of Care [SOC] date of 1/28/22 and admitting diagnoses of Other Streptococcal Arthritis [left knee], Type 2 Diabetes Mellitus with foot ulcer and Non-pressure Chronic Ulcer of Right heel and midfoot limited to breakdown of skin. A review of the Plan of Care [POC] for the certification period 1/28/22 to 3/28/22 revealed orders for PT [physical therapy] 1 time a day for 1 day, 2 times a week for 2 weeks, 1 time a week for 2 weeks. A review of the PT Clinical Note dated 1/28/22 revealed the following documentation, “Random finger stick: 436. Patient’s spouse administered 15 units of her own insulin to the patient because patient does not have his own insulin as of the moment [sic]. PT instructed patient’s wife not to do this again unless ordered by patient’s physician…” A review of the clinical record revealed no evidence the physician was notified of this. An interview was conducted with the agency administer on 3/23/22 at approximately 9:30 am. The administrator confirmed the physician was not notified of the wife dosing Patient 16 with her insulin. A policy, “Coordination and Communication Activities” revised 6/2018, was provided by the agency director on 3/22/22 at 12:10 p.m. The policy stated, “In order to assure the development and coordination of a coordinated plan of care, communication with all physicians involved in the patient’s plan of care (i.e. physicians wo give orders that are directly related to home health services) is necessary…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: a. Significant changes in the patient’s condition, including findings that are outside of established reporting parameters b. Any revision to the plan of care due to a change in patient health status… g. Lack of achievement of home care goals/outcomes within the specified time h. Changes in expected response to treatment or medication i. Changes in caregiver support of the home environment j. Patient’s response to care/outcome of or services” 1. Patient #6 was admitted on 10/12/21 with diagnoses of aftercare following surgery for neoplasm and squamous cell carcinoma of skin, scalp, and neck. The Plan of Care (POC) for 2/9/22-4/9/22 included orders for skilled nursing (SN) weekly for eight weeks. During the skilled nursing visit on 3/2/22, RN #4 documented, “Patient reports trouble swallowing intermittently. Patient still looking for PCP [primary care provider], but does have appt [appointment] with her old doctor at the new location in _______. Recommended she ask for referral to have swallow study.” There was no evidence the nurse communicated swallowing difficulty to the physician. There was no other documentation related to swallowing difficulty through the 3/16/22 visit. An interview the RN #4 on 3/23/22 at 1:30 p.m. confirmed the physician was not notified of the patient’s report of intermittent swallowing difficulty. 2. Patient #7 was admitted on 1/4/22 with diagnoses of pressure ulcer left heel stage 4, pressure ulcer of other site stage 1, and cellulitis of left lower limb. The Plan of Care (POC) for 1/4/22-3/4/22 included orders for skilled nursing one time for one week, then two times weekly for eight weeks. The POC for 3/5/22-5/3/22 included orders for skilled nursing twice weekly for nine weeks. On 1/28/22, RN #4 conducted a visit. The visit note stated, “Talked with patients [sic] daughter as she is still in town, she test [sic] positive for COVID 10 days ago and is still testing positive therefore she can not fly. Patent [sic] states he tested last week and was negative, this is new information to SN as patient has no [sic] verbalized any symptoms. Patient states he has noted [sic] to be more tired and winded…SN advised him to get home test if can [sic] for COVID…” The RN conducted a follow-up phone call and patient alerted the nurse the COVID-19 home test was positive. The RN instructed the patient to increase vitamin c and protein. There was no evidence that physician was notified. An interview was conducted with RN #4 on 3/23/22 on 1:50 p.m. The RN stated the physician was notified, but confirmed there was no evidence of the physician was notified. 3. Patient #13 was admitted on 12/31/21 with diagnoses of aftercare following surgery for a neoplasm and malignant neoplasm of cardia [between stomach and esophagus]. The Plan of Care (POC) for 12/31/21-2/28/22 included orders for skilled nursing (SN) weekly for eight weeks. On 1/25/22 the LPN conducted a visit. The visit note stated, “pt [patient] states surgeons [sic] nutritionist called him and pt was to have decreased his tube feeding to 2 cartons as of his visit 2 weeks ago but surgeon did not tell him and his sister did not hear anything regarding that as well…” There was no evidence that the physician was communicated with to verify the change in the tube feedings. An interview with the clinical director on 3/23/22 at 10:30 a.m. confirmed the physician should have been notified to receive an updated order. The interview confirmed there was no evidence of physician notification. 4. Patient #15 was admitted on 2/1/22 with diagnoses of COVID-19, pneumonia, and acute respiratory failure with hypoxia. The Plan of Care (POC) for 2/1/22-4/1/22 included orders for skilled nursing one time visit; physical therapy two times per week for two weeks, then weekly for four weeks; and occupational therapy two times per week for one week, one time per week for two weeks, two times per week for two weeks, then on time per week for one week. On 2/11/22 the occupational therapy assistant (OTA) conducted a visit and found patient to have pain reported as a 10 out of 10 under left breast. The OTA called RN and EMS. The caregiver declined transport to the hospital. There was no evidence the patient’s physician was notified of the pain. An interview with the clinical director on 3/23/22 at 10:45 a.m. revealed the clinical manager or the administrator should have been notified and they would have notified the physician.

Development and evaluation of plan of care CFR(s): 484.75(b)(2) Development and evaluation of the plan of care in partnership with the patient, representative (if any), and caregiver(s); This ELEMENT is not met as evidenced by: Based on policy and procedure review, clinical record review, and staff interview, the agency failed to conduct comprehensive wound assessments for 5 of 7 patients with wounds (#6, 7, 8, 9 and 16). Findings include: 4. Patient # 9 had a Start of Care [SOC] date of 2/4/22 and diagnoses of Type 2 Diabetes Mellitus with foot ulcer and non-pressure chronic ulcer of other part of right foot with unspecified severity. A review of the Plan of Care [POC] for the certification period 2/4/22 to 4/4/22 revealed orders for SN [skilled nursing] 1 time a day for 1 day, 1 time a week for 9 weeks, 2 PRN [as needed] for signs and symptoms of complications and “Wound 1- Diabetic ulcer-plantar right 3rd metatarsal-HHSN [home health skilled nurse] to cleanse diabetic ulcer to plantar surface of right foot with normal saline or soap and water. Pat dry. Apply aquacel ag. Cover with hydrophilic foam dressing. Wound care 3 times per week. Patient/CG [caregiver] to perform on days no SNV [skilled nursing visit] and prn soilage…” A review of the clinical record revealed RN # 2 completed the SOC Oasis [Outcome and Assessment Information Set] on 2/4/22. A review of the SN Clinical note revealed no wound assessment was completed. RN # 4 also visited the patient on 2/7/22. A review of the SN Clinical Note revealed no wound assessment. RN # 4 documented on 2/9/22 the wound was healed. RN # 4 was not available for interview. An interview was conducted with the agency administrator on 3/23/22 at 10:30 am. During the interview the administrator stated, “Wounds are supposed to be assessed [to include the wound bed, wound edges, etc] weekly. I do not see any wound assessments in the chart.” 5. Patient # 16 had a Start of Care [SOC] date of 1/28/22 and admitting diagnoses of Other Streptococcal Arthritis [left knee], Type 2 Diabetes Mellitus with foot ulcer and Non-pressure Chronic Ulcer of Right heel and midfoot limited to breakdown of skin. A review of the Plan of Care [POC] for the certification period 1/28/22 to 3/28/22 revealed orders for SN [skilled nursing] 1 time a day for 1 day, 2 times a week for 6 weeks, 1 time a week for 3 weeks, 2 PRN [as needed] for signs and symptoms of complications and “Wound # 5- Diabetic Ulcer- anterior left knee: HHSN [home health skilled nurse] to irrigate wound gently with normal saline apply protectant to skin surrounding affected area. Allow to dry. Apply silver gel or medical honey to wound bed including any undermining…Apply petroleum gauze and dry clean dressing, secure with gauze wrap…Change dressing every 2-3 days and as needed…” A review of the SN Clinical Note dated 1/28/22 and completed by RN # 2 revealed wound measurements of 2 cm [centimeters] in length by 2 cm wide by 0.2 cm deep. Further review of the SN Clinical Note revealed no assessment of the wound/wound bed. RN # 2 was not available for interview. An interview was conducted with the agency administer on 3/23/22 at approximately 9:30 am. During the interview the administrator confirmed there was no wound assessment in accordance with agency policy. On 1/31/22 RN # 3 obtained orders for new areas of breakdown. The orders were as follows: “Wound 1- Diabetic Ulcer- plantar right heel- clean foot with soap and water or normal saline. Cover wound with medihoney [sic] gel, 4x4 gauze pad and secure with roll [sic] gauze. Change dressing 3 times a week, CG [caregiver] may change dressing in absence or SN. SN to change dressing weekly for assessment and observation including measurements. Wound 2- Traumatic – anterior left knee. Cleanse wound with normal saline or wound cleanser, pat dry. Cover wound with silver polymer [sic] foam and secure with tape or roll [sic] gauze Change dressing 3 times a week, CG [caregiver] may change dressing in absence or SN. SN to change dressing weekly for assessment and observation including measurements. Wound 4 – Pressure Injury – posterior right gluteus maximus -Cleanse wound with soap and water or normal saline. Pat dry. Cover with sacral foam dressing, change every 3 days or PRN if soiled or dislodged. CG [caregiver] may change dressing in absence or SN. SN to change dressing weekly for assessment and observation including measurements. Wound 3-Pressure Injury – posterior left gluteus maximus --Cleanse wound with soap and water or normal saline. Pat dry. Cover with sacral foam dressing, change every 3 days or PRN if soiled or dislodged. CG [caregiver] may change dressing in absence or SN. SN to change dressing weekly for assessment and observation including measurements.” A review of the SN Clinical Note dated 2/4/22 by RN # 3 revealed no wound measurements or assessment of any of the wounds. A review of the clinical record revealed RN # 4 made a routine visit on 2/7/22 and 2/10/22 [week of 2/7/22]. Further review of the clinical record revealed no wound assessments for the week of 2/7/22 or 2/14/22. A review of the SN Clinical Note revealed RN # 4 made a routine visit on 2/21/22 and 2/24/22. A review of the clinical record revealed no wound assessments on any of the wounds for the week of 2/21/22. Routine visits were made on 2/28/22, 3/7/22, 3/15/22 and the patient was discharged on 3/17/22. There are no wound assessments for the week of 2/28/22, 3/7/22 or 3/17/22. RN’s # 3 and 4 were unavailable for interview. An interview was conducted with the agency administrator on 3/23/22 at approximately 9:30 am. During the interview the administrator confirmed the SN failed to assess the wounds in accordance with agency policy. Patient #6 was admitted on 10/12/21 with diagnoses of aftercare following surgery for neoplasm and squamous cell carcinoma of skin, scalp, and neck. The Plan of Care (POC) for 2/9/22-4/9/22 included orders for skilled nursing (SN) weekly for eight weeks; wound care to two sites on the anterior scalp as follows: 1. CG/SN to wash hands 2. With gloves, remove outer dressing to scalp, VERY slowly due to tenderness. 3. Cut kerlex gauze to fit size of open wounds on scalp. 4. Apply hydrogel to wounds cover with formed gauze. 5. Cover scalp with cushion dressing for protection. 6. Place stockinette over head to hold dressing in place…” The visit note on 2/16/22 did not include an assessment of wound #1 on the anterior scalp. The note stated the wound #2 on the anterior scalp “has bone exposed and measured 3cm x 5cm.” The visit note on 2/23/22 stated, “Patients [sic] wounds on scalp are showing improvement.” However, there was no assessment of the wounds documented. On 3/2/22, there were no wound assessments documented. On 3/9/22, the nurse documented, “…wounds on scalp look good, no ss [signs or symptoms] of infection noted. Patient reports daughter as [sic] been cleaning pus spots [sic].” There was no documentation of which wound had the “pus spots.” There was no other wound assessment evident. On 3/16/22, the nurse stated, “Wounds on scalp were cleaned very well this visit as there were some scab like areas and “booger” looking areas, removed and cleaned.” No other wound assessment noted. An interview was conducted with RN #4 on 3/23/22 at 1:30 p.m. The interview confirmed there was no evidence of a comprehensive wound assessment. 2. Patient #7 was admitted on 1/4/22 with diagnoses of pressure ulcer left heel stage 4, pressure ulcer of other site stage 1, and cellulitis of left lower limb. The Plan of Care (POC) for 1/4/22-3/4/22 included orders for skilled nursing one time for one week, then two times weekly for eight weeks. The POC for 3/5/22-5/3/22 included orders for skilled nursing twice weekly for nine weeks. The start of care note identified three wounds. Stage 4 pressure injury posterior right gluteus maximus measuring 2.0 cm x 2.5 cm x 2.5 cm with a moderate amount of serous, tan colored drainage.Stage 1 pressure injury right knee measuring 0.5 cm x 0.5 cm x 0.1 cmStage 2 pressure injury posterior left heel measuring 2.5 x 4.0 cm x 1.3 cm with the wound base 100% slough (dead tissue) with a moderate amount of serous tan drainage. The note also stated, “Patient’s right ischium has bone visible in wound.” Between 1/4/22 and 3/21/22, for 23 of 23 visits, the comprehensive wound assessments for each wound were not complete. An interview with RN #4 was conducted on 3/23/22 at 1:50 p.m. The RN confirmed that the assessments were missing the required elements. 3. Patient #8 was admitted on 11/1/21 with a diagnosis for and encounter for fitting and adjustment of urinary device. The Plan of Care (POC) for 3/1/22-4/9/22 included orders for weekly nursing visits; and to perform wound care to a surgical wound on the anterior left lower abdominal quadrant—cleanse with normal saline and apply foam adhesive dry dressing. A visit was conducted on 3/2/22 by the RN. The wound measured 0.5 cm x 0.5 cm x0.3 cm. There was no evidence of any further wound assessment. On 3/8/22, the nurse’s visit note stated “Incisional site midabdomen [sic] dressing clean dry intact [sic]. Assessed site. No signs or symptoms of infection. Patient spouse performed dressing change after patient showered this morning.” There was no documentation of the findings of the wound assessment. An interview with the clinical director on 3/23/22 at 10:10 a.m. confirmed the wound assessment was not complete.

Patient, caregiver, and family counseling CFR(s): 484.75(b)(4) Patient, caregiver, and family counseling; This ELEMENT is not met as evidenced by: Based on policy review, clinical record review and staff interview the agency failed to follow up on a phone call from the patient/caregiver for 1 of 1 patients that required a follow-up phone call (#13). Findings include: A policy, “Coordination and Communication Activities” revised 6/2018, was provided by the agency director on 3/22/22 at 12:10 p.m. The policy stated, “…will engage the patient, family and physician in care planning and the care delivery process...Coordination activities may include, but are not limited to...Activities that involve the patient, representative, and/or caregiver as appropriate in establishing and updating the plan of care." Patient #13 was admitted on 12/31/21 with diagnoses of aftercare following surgery for a neoplasm and malignant neoplasm of cardia [between stomach and esophagus]. The Plan of Care (POC) for 12/31/21-2/28/22 included orders for skilled nursing (SN) weekly for eight weeks. The start of care visit was conducted by RN #5 on 12/31/21. The visit note stated, “SN reviewed POC including VF (visit frequency), POC goals, discharge planning and OT (occupational therapy).” A communication note on 1/4/22 revealed the caregiver called the agency and stated a nurse was supposed to come to the home on Tuesday and Thursday (1/4/22 and 1/6/22). The note further revealed there was no plan of care for the on-call nurse to refer to. The on-call nurse called RN #5. RN #5 confirmed she would call the patient. There was no evidence of follow-up with the patient/caregiver until the nurse visit on 1/6/22. An interview with the clinical director on 3/23/22 at 10:30 a.m. confirmed there was no evidence the RN called the patient/family as requested.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review and staff interviews the agency failed to complete a transfer summary [transfer from home health to in-patient hospital stay] for 2 of 4 discharged records #5 and 11). The findings included: The policy, Discharge and Transfer of Patients [revised date 9/2021], was provided by the agency administrator on 3/23/22 at approximately 1 pm. The policy stated, “…The transfer or discharge is necessary for the patient’s welfare because the agency and the physician/NPP who is responsible for the home health plan of care agree that the agency can no longer meet the patient’s needs, based on the patient’s acuity. The agency must arrange a safe and appropriate transfer to other care entities when the needs of the patient exceed the agency’s capabilities…” 1. Patient # 5 had a Start of Care [SOC] date of 1/24/22 and an admitting diagnosis of Discitis [an infection in the intervertebral disc space]. A review of the Plan of Care [POC] for the certification period 1/24/22 to 3/24/22 revealed orders for SN [skilled nursing] 1 time a day for 1 day, 1 time a week for 9 weeks. A review of the clinical record revealed Patient # 5 was admitted to _____[name of hospital] on 1/26/22 for an Acute GI Bleed. The patient remained inpatient from 1/26/22 until 2/2/22. Further review of the clinical record revealed no evidence a transfer summary was completed. During an interview with the agency administrator on 3/23/22 at approximately 11 am, the administrator confirmed no transfer summary was completed in accordance with the agency policy. 2. Patient # 11 had a Start of Care [SOC] date of 12/29/21 and an admitting diagnosis of Tuberculosis of the Spine. A review of the Plan of Care [POC] for the certification period 12/29/21 through 1/16/22 revealed SN [skilled nursing] orders for 1 time a day for 1 day, 1 time a week for 8 weeks, 2 PRN [as needed] for signs and symptoms of complications. A review of the clinical record revealed Patient # 11 was admitted to the hospital on 2/21/22. Further review of the clinical record revealed no transfer summary was completed. An interview was conducted with the agency administrator on 3/23/22 at approximately 11:30 am. During the interview the administrator confirmed there was no transfer summary in the clinical record.