Every finding on record at Liberty Healthcare Group, LLC

Based on agency policy, clinical record review, and staff interviews, the agency failed to assess reported pain for 1 of 3 patients reporting pain. (patient #8)Findings included: --- Findings included:A policy, Rights and Responsibilities (revised 08/2021), received on 04/15/2025 at 10:19 AM stated, “Patients have the right: … To receive effective pain management and symptom control…”Patient #8 was admitted on 02/28/2024 with a diagnosis of Parkinson’s disease (a progressive neurological disorder). The plan of care for 05/28/2024-07/29/2024 included orders for skilled nurse visits 5 times a week for 12 weeks with 1 PRN (as needed), effective 07/21/2024 SN visits 6 times a week for 1 week, and MSW (medical social work) visits 2 times a month for 3 months.During the MSW visit on 07/04/2024 MSW #5 documented, “Yes [patient is experiencing pain] Patient reports that her knees hurt… MSW notified LPN [licensed practical nurse #6’s name] … Patient reports that she can’t wait until the pain stops.” Further review revealed that there was no documentation of a nurse following up on reports of pain. Further review revealed that on 07/17/2024 MSW #5 documented, “Yes [patient is experiencing pain] Patient reports that her knees hurt. [Facility LPN name] reports that the patient complains of legs hurting everyday [sic].” Further review revealed that there was no documentation of a nurse following up on the report of pain.LPN #6 was not available for an interview.During an interview conducted on 04/15/2025 at 8:45 AM MSW #5 stated, “They [patient #6] weren’t really in pain [on 07/04/2025] that was an error on my behalf. She was having pain [on 07/17/2025]. No, I didn’t notify the case manager that day, because I spoke with [facility nurse’s name] at facility.During an interview conducted on 04/15/2025 at approximately 9:30 AM the agency director stated, “All staff are educated to report unmanaged pain. A nurse will follow up and address it.”

Based on agency policy, clinical record review, and staff interviews, the agency failed to include all prescribed medications in the clinical record for 1 of 1 patient with a skilled nurse home visit conducted. (patient #3)Findings included: --- Patient #3, a resident of facility, was admitted on 02/15/2024 with a diagnosis of Neurocognitive disorder with Lewy bodies (a progressive disorder affecting mental function). The plan of care for 02/09/2025-04/09/2025 included orders for skilled nurse visits 2 times a week for 8 weeks, 1 time a week for 1 week and 3, 2, 1 PRN (as needed). A home visit was conducted on 04/15/2025 at 8:00 AM with registered nurse (RN) #7. A comprehensive medication review revealed that the facility had an order from 03/26/2025 for “Morphine Sulfate (concentrate) Solution 20mg/mL [milligrams per milliliter] Give 0.25 mL by mouth every 4 hours as need for pain or dyspnea [shortness of breath]. Review of the hospice medication list revealed that morphine sulfate was not included in the plan of care.An interview conducted on 04/15/2025 at 9:36 AM with RN #7 revealed that a complete medication review should be conducted at every skilled nurse visit.During an interview conducted on 04/15/2025 at 11:19 AM the administrator stated, “The expectation is that the visiting nurses compare medications at each visit.”

Based on agency policy, clinical record review, and staff interviews, the agency failed to implement personal protective equipment precautions for 1 of 1 patient with an infectious disease. (patient #6)Findings included: --- A policy, Communicating Transmission Based Precautions (revised 12/2005), received on 04/15/2025 at 10:26 AM from the agency administrator stated, “The first employee with knowledge of the need for Transmission Based Precautions must ensure that the clinical record indicates that the patient is on Transmission Based Precautions…”Patient #6 was admitted on 08/22/2024 with a diagnosis of Alzheimer’s Disease (progressive disorder that affects the brain). The plan of care for 08/22/2024-09/04/2024 included orders for skilled nurse visits 1 time a week for 1 week and 2 times a week for 12 weeks. Review of the clinical record revealed that on 08/27/2024 licensed practical nurse (LPN) #6 documented, “Patient is COVID positive [a contagious disease caused by a virus requiring additional precautions].” Further review revealed that there was no documentation of transmission-based precautions being implemented.LPN #6 was not available for interview.An interview conducted on 04/15/2025 at 9:47 AM with the clinical manager revealed that the virus was not documented on the infection report.During an interview conducted on 04/15/2025 at 4:00 PM the administrator stated, “They [nurses] should notify the provider. The staff working with the patient should be notified. Precautions are implemented based on the infectious process. PPE [personal protective equipment] for Covid positive includes shoe covers, N95 respirator [disposable filtering facepiece], gown, and gloves.”

Based on agency policy and staff interviews, the agency failed to document on-going efforts to recruit and retain volunteers.Findings included: --- A policy, Volunteer Recruitment, Retention and Recognition (revised 03/2021) received on 04/14/2025 at 2:52 PM stated, “Regional Volunteer Program Manager will document efforts to recruit, retain and recognize appropriate and trained volunteers…”An interview conducted on 04/14/2025 at approximately 3:00 PM with the Regional Volunteer Program Manager revealed that there was no documentation of efforts to recruit volunteers.

Based on agency policy, hospice volunteer program cost savings report review, and staff interviews, the agency failed to provide volunteers to equal 5 percent of total patient care hours.Findings included: --- A policy, Volunteer Statistical Information (revised 03/2021), received on 04/14/2025 at 2:52 PM from the agency director stated, “Volunteer hours of service must equal 5 % of all patient care hours provided as hands on care by hospice staff.”The volunteer program cost savings report received on 04/14/2025 at 1:30 PM from the administrator had documentation of the “% of Volunteer/Staff hours” as “,1% [less than 1 percent].An interview conducted on 04/14/2025 at approximately 3:00 PM with the Regional Volunteer Program Manager revealed that the agency had 1 administrative volunteer.