Every finding on record at Liberty Home Care, LLC

Based on agency policy, clinical record review, and staff interviews, the agency failed to update the plan of care to include contact precautions (requirement to wear gloves and gowns to enter a patient’s room) for 1 of 1 patient requiring contact precautions. (Patient #1)Finding’s included: --- A policy, Care Planning: Initial Care Plan and Updates to the Plan of Care (revised 02/2025) received on 12/16/2025 at 12:20 PM from the agency administrator stated, “The comprehensive assessment must be updated and revised as frequently as the patient’s condition warrants… In addition, the patient is reassessed and the plan of care is reviewed/updated when: There is a significant change in the patient’s condition, diagnosis…”A policy, Exposure Control Plan: Isolation Precaution (revised 01/2025) received on 12/16/2025 at 12:20 PM from the agency administrator stated, “Health care workers and other hospice personnel use Transmission Bases Precaution with patients documented or suspected to be infected with highly transmittable or epidemiologically important pathogens for which additional precautions beyond Standard Precaution are needed to interrupt transmission.”Patient #1 was admitted on 09/26/2025 with a diagnosis of senile degeneration of the brain (severe mental decline). Patient #1 resided in a facility. The plan of care for 11/25/2025-01/23/2025 included orders for skilled nurse visits 1 time a week for 8 weeks with 3 PRN (as needed) and home health aide (HHA) visits 7 times a week for 7 weeks and 6 times a week for 1 week. Review of the clinical record revealed that on 12/05/2025 licensed practical nurse (LPN) #5 documented, “Upon arrival, noted contact precautions [requirement to wear gloves and gowns to enter a patient’s room] on patient’s door. Facility staff notified this nurse that patient was on contact precaution and being treated for shingles [contagious blistering rash].” Further review revealed that the HHA plan of care had not been updated to include contact precautions and HHA #7 completed visits on 12/08/2025, 12/09/2025, and 12/10/2025 and failed to document using contact precautions for personal care.During an interview conducted on 12/16/2025 at 1:43 PM LPN #5 stated, “I don’t think that I did [update the plan of care], as an LPN I don’t normally do that, I would normally notify the case manager or office. I did go to the office and tell [clinical manager’s #8’s name] …”During an interview conducted on 12/16/2025 at 1:49 PM clinical manager #8 stated, “She did come in and tell us. I asked her to make sure that [case manager’s name] is aware. We should update our care plan and start taking the proper precautions.”

Based on agency policy, clinical record review, and staff interviews, the agency failed to provide home health aide (HHA) services as ordered in the plan of care for 1 of 3 patients receiving HHA services (patient #1).Findings included: --- A policy, Physician Interim Orders (revised 02/2025), received on 12/169/2025 at 12:20 PM from the agency administrator stated, “All hospice services are provided under the supervision of the patient’s physician and in accordance with the physician’s orders and written plan of care…”Patient #1 was admitted on 09/26/2025 with a diagnosis of senile degeneration of the brain (severe mental decline). The plan of care for 11/25/2025-01/23/2025 included orders for home health aide (HHA) visits 7 times a week for 7 weeks and 6 times a week for 1 week. Review of the clinical record revealed that patient #1 did not receive HHA visits on 12/06/2025 or 12/07/2025. Further review revealed that there was no documentation for missed visits.An interview conducted on 12/16/2025 at approximately 12:00 revealed that the visits were not scheduled as ordered and the expectation is for all ordered visits to be scheduled.

Based on agency policy, clinical record review, and staff interview, the agency failed to conduct home health aide supervisory visits every 14 days for 1 of 3 patients with HHA visits ordered (patient #3).Findings included: --- A policy, Aide Supervisory Visits Hospice (revised 09/20/21), received on 12/16/2025 at 12:20 PM from the agency administrator stated, “An RN [registered nurse] makes a supervisory home visit to the patient’s residence no less frequently than every 14 days…”Patient #3 was admitted on 09/20/2025 with a diagnosis of senile degeneration of the brain (severe mental decline). The plan of care for 09/20/2025-11/18/2025 included orders for skilled nurse (SN) visits 2 times a week for 1 week, 1 time a week for 7 weeks, and 1 time a week for 4 weeks with 3 PRN (as needed) and home health aide (HHA) visits 5 times a week for 8 weeks. Review of the clinical record revealed that HHA supervisory visits were documented on 10/02/2025 and 11/11/2025 and no HHA supervisory visits were completed between 10/03/2025 and 11/10/2025.Registered nurse #4 was not available for an interview.An interview conducted on 12/16/2025 at 11:20 AM with the agency administrator revealed that the expectation is for the registered nurse to complete and document HHA supervisory visits at least every 14 days.

Based on agency policy, clinical record review, and staff interviews the IDG [interdisciplinary group] failed to project visit frequencies for the next 15 days for 17 of 27 patients [ #22, 24, 4, 7, 11, 12, 14, 15, 16, 17, 18, 19, 21, 25, 26, 27, and 1]. The findings included:The policy, Interdisciplinary Group and Coordination of Care [01/25], was provided by the agency director on 4/23/25 at 3:02 pm. The policy stated, "...The IDG conducts team conferences and participates in developing and updating the plan of care. The IDG reviews the effectiveness of the plan of care including progress toward goals as the patients [sic] condition indicates and not less frequently than every 15 days..." --- 14.  Patient #25 had a start of care date of 1/7/25 with a terminal diagnosis of senile degeneration of brain (decline in brain function associated with age). Review of the Plan of  Care for the certification period of 4/17/25-7/15/25 included orders for  SN (skilled nursing) 1 time a week for 11 weeks; hospice aide 3 times a week for 12 weeks, 2 times a week for 1 week; MSW (medical social worker) 2 times a month for 1 month, 2 times a month for 1 month, 2 times a month for 1 month; Spiritual Counselor 1 time a month for 1 month, 2 times a month for 2 months, 1 time a month for 1 month. Review of the clinical record revealed the agency conducted an IDG (interdisciplinary group) meeting on 4/23/25. Review of the IDG minutes revealed no visit projections for the next 15 days by the Spirit Counselor. 15. Patient #26 had a start of care date of 1/20/25 with a terminal diagnosis of pulmonary fibrosis (chronic lung disease where lung tissue becomes damaged and scarred). Review of the Plan of Care for the certification period of 3/21/25-5/19/25 included orders for  SN (skilled nursing) 1 time a week for 8 weeks; hospice aide 3 times a week for 8 weeks; MSW (medical social worker) 1 time a month for 2 months; Spiritual Counselor 1 time a month for 1 month, 2 times a month for 2 months, 1 time a month for 1 month. Review of the clinical record revealed the agency conducted IDG (interdisciplinary group) meetings on 3/26/25, 4/9,25, and 4/23/25. Review of the IDG minutes revealed no visit projections for the next 15 days by the MSW or the Spiritual Counselor for any of these 3 meetings. 16. Patient #27 had a start of care date of 3/29/25 with a terminal diagnosis of progressive supranuclear ophthalmoplegia (a rare, incurable brain disorder that causes deterioration of brain cells). Review of the Plan of Care for the certification period of 3/29/25-6/26/25 included orders for  SN (skilled nursing) 2 times a week for 3 weeks, 1 time a week for 10 weeks; MSW (medical social worker) 1 time a month for 1 months, 2 times a month for 2 months; Spiritual Counselor 3 times a month for 1 month, 4 times a month for 2 months. Review of the clinical record revealed the agency conducted IDG (interdisciplinary group) meetings on 4/9/25 and 4/23/25. Review of the IDG minutes revealed no visit projections for the next 15 days by the MSW on 4/9/25 and no visit projections for the next 15 days by the Spiritual Counselor on 4/23/25. 17.  Patient #1 had a start of care date of 9/17/24 with a terminal diagnosis of unspecified protein/calorie malnutrition (a state of insufficient intake of both protein and calories). Review of the Plan of Care for the certification period of 9/17/24-11/15/24 included orders for  SN (skilled nursing) 1 time a week for 1 week, 2 times a week for 1 week,1 time a week for 7 weeks; hospice aide 2 times a week for 1 week, 3 times a week for 7 weeks,2 times a week for 1 week; MSW (medical social worker) 1 time a week for 1 week, 1 time a month for 2 months. Review of the clinical record revealed the agency conducted IDG (interdisciplinary group) meetings on 9/25/24, 10/9/24, and 10/23/24. Review of the IDG minutes revealed no visit projections for the next 15 days by the MSW for any of these 3 meetings.     1.       Patient #22 had a start of care date of 11/18/22 with a terminal diagnosis of Parkinson’s [a progressive neurological disorder that affects movement]. Review of the Plan of Care for the certification period 3/7/25-5/5/25 included orders for SN [skilled nursing] 1 time a week for 9 weeks; hospice aide 4 times a week for 9 weeks; MSW [medical social worker] 2 times a month for 2 months. Review of the clinical record revealed the agency conducted IDG [interdisciplinary group] meetings on 3/26/25 and 4/9/25. Further review of the clinical record revealed no visit projections for the next 15 days by the MSW for either meeting.2.    Patient # 24 had a start of care date of 7/25/24 with a terminal diagnosis of senile degeneration of the brain [decline in mental functioning associated with old age]. Review of the Plan of Care for the certification period 3/22/25-5/20/25 included orders for SN [skilled nursing] 1 time a week for 9 weeks; hospice aide 5 times a week for 9 weeks; MSW [medical social worker] 2 times a month for 2 months; Volunteer 1 time a month for 1 month. Review of the clinical record revealed the agency conducted IDG [interdisciplinary group] meetings on 3/12/25, 3/26/25, and 4/9/25. Review of the clinical record revealed no visit projections for the next 15 days by the MSW on 3/12/25 or 3/26/25 meetings. Further review revealed no visit projections for the next 15 days by the Volunteer for any of the meetings.3.      Patient # 4 had a start of care date of 5/8/24 with a terminal diagnosis of hypertensive heart and chronic kidney disease without heart failure [uncontrolled high blood pressure damages the heart]. Review of the Plan of Care for the certification episode 8/6/24-11/3/24 included orders for SN [skilled nursing] 1 time a week for 13 weeks; MSW [medical social worker] 2 times a month for 3 months; Volunteer 1 time a month for 3 months. Review of the clinical record revealed the agency conducted IDG [interdisciplinary group] meetings on 8/13/24, 8/27/24, 9/10/24, and 9/24/24. Review of the IDG minutes revealed no visit projections for the next 15 days by the volunteer or the MSW for 8/13/24, 8/27/24 or 9/10/2. The patient expired on 9/12/24.4.      Patient # 7 had a start of care date of 11/7/24 with a terminal diagnosis of chronic obstructive pulmonary disease [COPD-a lung condition]. Review of the Plan of Care for the certification period 11/7/24-2/5/25 included orders for SN [skilled nursing] 2 times a week for 3 weeks, 1 time a week for 10 weeks; MSW [medical social worker] 1 time a week for 1 week, 1 time a month for 1 month, 2 times a month for 2 months; Spiritual Counselor 1 time a week for 1 week, 1 time a month for 1 month.  Review of the clinical record revealed the agency conducted IDG [interdisciplinary group] meetings 11/20/24 and 12/11/24. Further review of the clinical record revealed no visit projections for the next 15 days for the 11/20/24 meeting by the MSW or the Spiritual Counselor. The patient passed away on 12/3/24.5.      Patient # 11 had a start of care date of 3/21/25 with a terminal diagnosis of other lymphoid leukemia not having achieved remission [cancer of the blood]. Review of the Plan of Care for the certification period of 3/21/25-6/18/25 included orders for  SN [skilled nursing] 3 times a week for 12 weeks, 2 times a week for 1 week; hospice aide 5 times a week for 12 weeks, 3 times a week for 1 week; MSW [medical social worker] 1 time a week for 1 week then 1 time a month for 1 month, 5 times a month for 1 month, 4 times a month for 1 month, 1 time a month for 1 month; Spiritual Counselor 1 time a week for 1 week then 2 times a month for 1 month, 2 times a month for 1 month [sic], 1 time a month for 1 month; Volunteer Coordinator 1 time a week for 1 week then 1 time a month for 1 month. Review of the clinical record revealed the agency conducted IDG [interdisciplinary group] meetings on 4/1/25 and 4/15/25. Review of the IDG minutes revealed no visit projections for the next 15 days by the Spirit Counselor or the Volunteer for either meeting.6.      Patient # 12 had a start of care date of 3/13/25 with a terminal diagnosis of Alzheimer’s Disease with early onset. Review of the Plan of Care for the certification period 3/13/25-6/10/25 included orders for SN [skilled nursing] 1 time a week for 14 weeks; hospice aide 2 times a week for 12 weeks, 1 time a week for 1 week; MSW [medical social worker] 1 time a month for 1 month, 2 times a month for 2 months, 1 time a month for 1 month; Spiritual Counselor 1 time a day for 1 day, 1 time a month for 1 month, 2 times a month for 2 month, 1 time a month for 1 month. . Review of the clinical record revealed the agency conducted IDG [interdisciplinary group] meetings on 3/20/25, 4/3/25, and 4/17/25. Review of the IDG minutes for those dates revealed no visit projections for the next 15 days by the MSW or the Spiritual Counselor for any of the IDG meetings.7.      Patient # 14 had a start of care date of 4/10/25 and a terminal diagnosis of malignant neoplasm of supralottis [cancer of the voice box]. Review of the Plan of Care for the certification period 4/10/25-7/8/25 included orders for SN [skilled nursing] 1 time a week for 9 weeks, 1 time a week for 3 weeks; hospice aide 1 time a week for 12 weeks; MSW [medical social worker] 1 time a month for 1 week, 2 times a month for 2 months, 1 time a month for 1 month. Review of the clinical record revealed the agency conducted an IDG [interdisciplinary group] meeting on 4/15/25. Review of the minutes for that meeting revealed no visit projections for the next 15 days by the MSW.8.      Patient # 15 had a start of care date of 3/13/54 with a terminal diagnosis of malignant neoplasm [cancer] of the pancreas. Review of the Plan of Care for the certification period 3/13/25-6/10/25 included orders for SN [skilled nursing] 3 times a week for 12 weeks; hospice aide 3 times a week for 1 week, 7 times a week for 12 weeks; MSW [medical social worker] 1 time a month for 1 month, 2 times a month for 2 months, 1 time a month for 1 month; Spiritual Counselor 1 time a month for 1 month, 2 times a month for 2 months, 1 time a month for 1 month. Review of the clinical record revealed the agency conducted IDG [interdisciplinary group] meetings on 4/2/25 and 4/16/25. Review of the IDG minutes revealed no visit projections for the next 15 days by the MSW for the 4/2/25 meeting.9.      Patient # 16 had a start of care date of 4/2/25 with a terminal diagnosis of sepsis [infection of the blood]. Review of the Plan of Care for the certification period 4/2/25-6/30/25 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 12 weeks; hospice aide 2 times a week for 1 week, 5 times a week for 12 weeks, 1 time a week for 1 week; MSW [medical social worker] 2 times a month for 3 months; Spiritual Counselor 2 times a month for 3 months.  Review of the clinical record revealed the agency conducted an IDG [interdisciplinary group] meeting on 4/16/25. Review of the minutes for that meeting revealed no visit projections for the next 15 days by the MSW or the Spiritual Counselor.10. Patient # 17 had a start of care date of 3/31/25 and a terminal diagnosis of congestive heart failure [heart is unable to pump effectively]. Review of the Plan of Care for the certification period 3/31/25-6/28/25 revealed orders for SN [skilled nursing] 2 times a week for 3 weeks, 1 time a week for 8 weeks; hospice aide 2 times a week for 12 weeks; MSW [medical social worker] 3 times a month for 3 months. Review of the clinical record revealed the agency conducted an IDG [interdisciplinary group] meeting on 4/2/25. Review of the minutes for that meeting revealed no visit projections for the next 15 days by the MSW.11. Patient # 18 had a start of care date of 3/19/25 with a terminal diagnosis of Alzheimer’s Disease. Review of the Plan of Care for the certification period 3/19/25-6/16/25 included orders for SN [skilled nursing] 2 times a week for 2 weeks, 1 time a week for 10 weeks; hospice aide 1 time a week for 1 week, 5 times a week for 12 weeks, 1 time a week for 1 week; MSW [medical social worker] 2 times a month for 2 months, 1 time a month for 1 month. Review of the clinical record revealed the agency conducted IDG [interdisciplinary group] meetings on 3/25/25 and 4/8/25. Review of the clinical record revealed no visit projections for the next 15 days by the MSW during the IDG meeting on 3/25/25.12. Patient # 19 had a start of care date of 3/26/25 with a terminal diagnosis of hypertensive heart and chronic kidney disease with heart failure [high blood pressure affects the heart’s pumping ability and affects blood vessels in the kidneys]. Review of the Plan of Care for the certification period 3/26/25-5/24/25 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 1 week, 1 time a week for 7 weeks; hospice aide 2 times a week for 1 week, 5 times a week for 8 weeks; MSW [medical social worker] 2 times a month for 1 month; Spiritual Counselor 2 times a month for 2 months. Review of the clinical record revealed the agency conducted IDG [interdisciplinary group] meetings on 4/1/25 and 4/15/25. Review of the IDG minutes revealed no visit projections for the next 15 days by the MSW or the Spiritual Counselor for either meeting.13. Patient # 21 had a start of care date of 3/14/25 with a terminal diagnosis of chronic lymphocytic leukemia of B-cell [cancer of the blood]. Review of the Plan of care for the certification period 3/14/25-6/11/25 included orders for SN [skilled nursing] 2 times a week for 2 weeks, 1 time a week for 11 weeks; hospice aide 5 times a week for 12 weeks, 3 times a week for 1 week; Medical social worker 1 time a week for 1 week, 1 time a month for 1 month, 3 times a month for 2 months, 1 time a month for 1 month; Spiritual Counselor 1 time a week for 1 week, 2 times a month for 2 months, 1 time a month for 1 month. Review of the clinical record revealed the agency conducted IDG [interdisciplinary group] meetings on 3/25/25 and 4/8/25. Review of the IDG minutes revealed no visit projections for the next 15 days by the Spirit Counselor or the MSW for either meeting.During an interview with the agency director on 4/24/25 at approximately 11 am, the director stated, "They [IDG team] know they have to say if they expect to see the patient within the next 15 days. We used to do that."

Based on agency policy review, clinical record review, and staff interviews, the nurse failed to measure and accurately describe wounds for 2 out of 6 patients with wounds (#1 and #13).The policy, Wound Assessment, Home Care revised 2/24/2025, was provided by the agency administrator 04/23/2025 at 3:44 pm. The policy stated, “A comprehensive wound assessment is necessary during every visit and documented in the patient’s medical record. Wound measurements are to be taken at least one time every week…Documentation associated with wound assessment includes…size in length, width, and depth.”CMS (Centers for Medicare and Medicaid Services) follow best practice guidelines revised April 2016, that are outlined by the NPUAP (National Pressure Ulcer Advisory Panel), which state, “If the pressure ulcer has ever been classified at a higher numerical stage than what is observed now, it should continue to be classified at the higher numerical stage.” --- 1.Patient #1 had a start of care date of 9/17/24 with a terminal diagnosis of unspecified protein/calorie malnutrition (a state of insufficient intake of both protein and calories). The Plan of Care (POC) for the certification period of 9/17/24-11/15/24 included orders for SN (skilled nursing) 1 time a week for 1 week, 2 times a week for 1 week, 1 time a week for 7 weeks and “Stage IV pressure ulcer (full thickness skin and tissue loss, exposing muscle, tendon, or bone) left heel…monitor the site of impaired skin integrity at least weekly for size/measurements…”. Review of the clinical record revealed that on the admission comprehensive assessment on 9/17/24, RN#1 documented the patient had a stage IV pressure ulcer on his left heel that measured 6 x 6 [sic] and a stage II pressure ulcer (partial thickness skin loss) on right heel that measured 2 x 0.5 [sic]. Further review of the documentation revealed no wound depth for either area. On 9/25/24, RN #2 documented the patient had a stage IV pressure ulcer on left heel that measured 6.3 x 5.3 x 0.7 [sic] with undermining (the separation of the skin edge from the underlying tissue, creating a pocket beneath the wound’s surface) of 0.5 cm between 11o’clock and 12 0’clock (area of wound is broken down into segments that correspond to a clock face) and a stage 1 pressure ulcer on right heel that measured 0.9 cm x 1cm. (previously documented as a stage II). Review of the documentation revealed RN #2 back staged (the incorrect practice of downgrading the stage of a pressure ulcer as it heals) the ulcer on the right heel to a stage I. On 10/2/24, RN #2 documented that the patient had a stage III pressure ulcer(wound penetrates through the top layers of skin and into the underlying fatty tissue) on his left heel (previously documented as a stage IV) that measured 6.2 x 5.2 [sic] with undermining 0.5cm between 11o’clock and 12 o’clock. Review of the documentation on 10/2/24 indicated the RN back staged the stage IV on the left heel to a stage III.On 10/7/24, RN #2 documented that the patient had a stage III pressure ulcer on the left heel that measured 6.2 x 5.2 [sic]. This wound was previously staged as a stage IV on the initial assessment on 9/17/2024. Further review of the documentation revealed that no depth or undermining measurements were documented and there was no mention of any other wounds, and that RN #2 back staged the stage IV on the left heel to a stage III. On 10/14/24, RN #2 documented that the patient had a stage 1 pressure ulcer on right heel (stage II on the original assessment on 9/17/2024) that measured 0.5 x 0.7 [sic] and a stage III pressure ulcer (stage IV on the initial assessment on 9/17/2024) on left heel that measured 6.2 x 5.2 [sic]. Further review of the documentation revealed that no depth or undermining measurements were documented, and that RN #2 back staged the stage IV on the left heel to a stage III.On 10/21/24, RN #2 documented only a stage III (stage IV on initial assessment on 9/17/2024) pressure ulcer on left heel that measured 6.2 x 5.2 [sic]. No depth or undermining measurement documented. During an interview with the agency director on 4/27/25 at approximately 11 am, the director confirmed the RNs failed to measure wounds in accordance with the agency policy.2. Patient #13 had a start of care date of 3/28/2025 with a terminal diagnosis of malignant neoplasm (cancerous tumor) of connective and soft tissue of the head, face, and neck. The Plan of Care (POC) for the certification period of 3/28/2025-6/25/2025 included orders for SN (skilled nursing) 5 times a week for 1 week, 3 times a week for 11 weeks, 2 times a week for 1 week and “Perform wound care to left leg. Cleanse/irrigate affected areas with wound cleanser, apply 4x4, and wrap with Kerlix. For head angiosarcoma, clean gently with wound spray, apply xeroform, a 4x4 gauze, and an abdominal pad. Cover and secure with tape or kerlix using aseptic technique.” On the admission comprehensive assessment on 9/17/24, RN#3 documented, “Angiosarcoma (a rare and aggressive cancerous tumor) of scalp serosanguinous (a combination of clear fluid and blood) weeping of large circular slightly raised area on left side of scalp”. Left leg “there is a 5cm x 2.5 [sic], a 5cm x 1.5 [sic], a ½ [sic] x 1 cm, and another small circular area”. RN #3 failed to record the depth of these wounds. On 3/30/2025, RN #4 documented wound #1 as scalp wound “Back-Upper Cranial, Left, Head” that measured 4 x 4 x 0.1 [sic], wound #2 as ulcer “Left – Lower leg, Distal, Left Lower Leg that measured 5 x 2.5 x 0.1 [sic], wound #3 as ulcer “Front-Lower leg, Distal, Left Lower leg” that measured 5 x 1.5 x 0.1 [sic], and wound #4 as ulcer ““Front-Lower leg, Distal, Left Lower leg” that measured 1.2 x 1 x 0.1 [sic].On 4/10/2025, RN #6 documented wound #1 as “Front-Lower leg, Distal, Left lower leg”, wound #2 as “Front-Lower leg, Distal, Right lower leg”, and wound #3 “Back-Upper Cranial, Left, Head”.  Review of the clinical record revealed that no wound measurements were documented during the week of 4/6/2024 – 4/12/2024.During an interview with the agency director on 4/24/25 at approximately 11:15 am, the director confirmed that the location/area of the wounds were inconsistent.

Based on agency policy, clinical record review, and staff interviews the agency failed to update the plan of care to reflect patient/family goals for 1 of 1 patient with a request. (patient #1) Findings included: --- A policy, Care Planning: Initial Care Plan and Updates to the Plan of care (revised 03/2024), received on 01/28/2025 at 10:30 AM from the agency administrator stated, ";The plan of care is reviewed/updated when: ... Requested by the patient." Patient #1 was admitted on 06/24/2023 with a diagnosis of Alzheimers Disease (progressive disease that destroys mental function). The plan of care (POC) for 11/15/2024-01/13/2025 included orders for skilled nurse visits 1 time a week for 9 weeks and 3 PRN (as needed). Review of the clinical record revealed on 11/22/2024 registered nurse (RN) #7 stated, ";Request mask to be worn in the home." Further review of the clinical record revealed that the POC had not been updated to reflect the request. During an interview conducted on 01/28/2025 at 10:03 AM RN #7 stated, ";That would probably be a good idea [to update the POC]. During an interview on 01/28/2025 at 10:15 AM the agency administrator stated, ";I would expect it [request to wear mask] to be on the plan of care and documented that the IDG [interdisciplinary group] was made aware."

Based on agency policy, clinical record review, and staff interviews, the agency failed to provide home health aide and/or registered nurse visits as ordered for 3 of 3 patients. (#1,2, and 3) Findings included: --- A policy Assessment: Ongoing and Reassessment (revised 10/2022) received on 01/28/2025 at approximately 8:30 AM from the agency administrator stated, ";Hospice personnel provide ongoing services to the patient/family in accordance with a written plan of care..." Patient #1 was admitted on 06/24/2023 with a diagnosis of Alzheimers Disease (progressive disease that destroys mental function). The plan of care for 11/15/2024-01/13/2025 included orders for hospice aide (HHA) visits 1 time a week for 1 week, 5 times a week for 8 weeks, and 4 times a week for 1 week. Review of the clinical record revealed that on 01/09/2025 HHA #3 stated, ";Spoke with patient [sic] daughter [daughters name] to let her know I wouldnt be there today." Further review of the clinical record revealed that during the week of 12/22/2024-12/28/2024 4 of 5 ordered HHA visits were conducted. 2. Patient #2 was admitted on 09/17/2024 with a diagnosis of senile degeneration of the brain. The plan of care for 12/16/2024-03/15/2025 included orders for hospice aide (HHA) visits 3 times a week for 13 weeks. Review of the clinical revealed a missed visit from 12/25/2024 were HHA #6 stated, ";Holiday PTO [paid time off] day." and a missed visit from 12/27/2024 HHA #6 stated, ";PTO Time Off." Further review of the clinical record reveal that no HHA visits were conducted during the week of 12/22/2024-12/28/2024. 3. Patient #3 was admitted on 11/18/2024 with a diagnosis of amyotrophic lateral sclerosis (a nervous system disease that weakens muscles and impacts physical functioning). The plan of care for 11/18/2024-02/15/2025 included orders for skilled nurse (SN) visits 2 times a week for 2 weeks and 1 time a week for 11 weeks and hospice aide (HHA) visits 2 times a week for 12 weeks. Review of the clinical record revealed a missed visit from 11/29/2024 were registered nurse (RN) #4 stated, ";This nurse stated to patient and her caregiver that she was taking time off today and that another nurse would not be able to cover..." and a missed visit from 11/29/2024 were HHA #6 stated, ";PTO time off." Further review of the clinical record reveal that 1 of 2 ordered SN visits and 1 of 2 HHA visits were conducted during the week of 11/24/2024-11/30/2024. During an interview conducted on 01/27/2025 at 1:30 PM the agency administrator stated, ";We have to meet the frequency of the patients, the case manager contacts the family to let them know that the aide is off, offer another aide, or allow them to refuse."

Based on agency policy, clinical record review, and staff interviews, the agency failed to notify the physician of missed visits for 3 of 3 patients with missed visits. (patients # 1, 2, and 3) Findings included: --- A policy, Coordination and Communication Activities (revised 03/2024), received on 01/28/2025 at 8:30 AM from the agency administrator stated, ";If a visit is missed due to an agency scheduling problem and staff is not available to provide or make up the visit in the week it is due, notify the MD/MD representative." Patient #1 was admitted on 06/24/2023 with a diagnosis of Alzheimers Disease (progressive disease that destroys mental function). The plan of care for 11/15/2024-01/13/2025 included orders for hospice aide (HHA) visits 1 time a week for 1 week, 5 times a week for 8 weeks, and 4 times a week for 1 week. Review of the clinical record revealed that on 01/09/2025 HHA #3 stated, ";Spoke with patient [sic] daughter [daughters name] to let her know I wouldnt be there today." Further review of the clinical record revealed that during the week of 12/22/2024-12/28/2024 4 of 5 ordered HHA visits were conducted. There was no evidence in the clinical record of the physician being notified. 2. Patient #2 was admitted on 09/17/2024 with a diagnosis of senile degeneration of the brain. The plan of care for 12/16/2024-03/15/2025 included orders for hospice aide (HHA) visits 3 times a week for 13 weeks. Review of the clinical revealed a missed visit from 12/25/2024 were HHA #6 stated, ";Holiday PTO [paid time off] day." and a missed visit from 12/27/2024 HHA #6 stated, ";PTO Time Off." Further review of the clinical record reveal that no HHA visits were conducted during the week of 12/22/2024-12/28/2024. There was no evidence in the clinical record of the physician being notified. 3. Patient #3 was admitted on 11/18/2024 with a diagnosis of amyotrophic lateral sclerosis (a nervous system disease that weakens muscles and impacts physical functioning). The plan of care for 11/18/2024-02/15/2025 included orders for skilled nurse (SN) visits 2 times a week for 2 weeks and 1 time a week for 11 weeks and hospice aide (HHA) visits 2 times a week for 12 weeks. Review of the clinical record revealed a missed visit from 11/29/2024 were registered nurse (RN) #4 stated, ";This nurse stated to patient and her caregiver that she was taking time off today and that another nurse would not be able to cover..." and a missed visit from 11/29/2024 were HHA #6 stated, ";PTO time off." Further review of the clinical record revealed that only 1 of 2 ordered SN visits and 1 of 2 HHA visits were conducted during the week of 11/24/2024-11/30/2024. There was no evidence in the clinical record of the physician being notified.

Based on agency policy, clinical record review, and staff interviews the agency failed to provide pain management to a patient with unmanaged pain. (patient # 3) Findings included: --- A policy, Rights and Responsibilities (revised 08/2021) was received on 07/15/2024 at 1:49 from the clinical manager. The policy stated, ";Patients have the right... To received effective pain management..." Patient #3 was admitted on 01/10/2024 with a diagnosis of Alzheimers disease. Patient #3 was a resident of an assisted living facility (ALF). The plan of care for 01/10/2024-04/08/2024 included orders for skilled nurse visits 1 time a week for 1 week. An incident report was completed by registered nurse (RN) #4 on 01/14/2024 for a fall that occurred 01/11/2024. RN #4 stated, ";Patient laid on her right side and [sic] still screaming in pain..." There was no evidence in the clinical record of the RN #4 of obtaining orders for pain management. RN #4 was not available for an interview. An interview was conducted on 07/15/24 at approximately 1:30 PM with the clinical manager. The clinical manager stated, ";My expectation would be for the nurse to obtain orders for effective pain management. We [hospice agency] are responsible for managing the patients symptoms."

Based on agency policy, clinical record review, and staff interviews the agency failed to conduct the Chaplain assessment within 5 days of the start of care for 1 of 2 patients. (patient #2) Finding included: --- A policy, Spiritual Assessment and Services (revised 05/2022) was received on 07/15/2024 at 3:25 P.M. from the clinical director. The policy stated, ";A comprehensive assessment of spiritual needs related to the terminal illness will be completed..., within five (5) days..." Patient # 2 was admitted on 05/03/2024 with a diagnosis of Malignant carcinoid tumor of the bronchus and lung (lung cancer). The plan of care for 05/03/2024- 05/14/2024 included orders for nursing visits 2 times a week for 12 weeks and 3 PRN (as needed) and medical social worker visits 2 times a month for 2 months and 3 PRN. Patient #2 was discharged on 05/14/2024. There was no evidence in the clinical record of patient #2 declining Chaplain visits. There was no evidence in the clinical record of a Chaplain conducting an initial assessment. An interview was conducted 07/15/24 at 3:00 P.M. with the agency Chaplain. The Chaplain stated, ";I have 5 days to complete initial assessment. When she first came on to hospice, they did not elect for Chaplain services, I was added later." An interview was conducted on 07/15/2024 at approximately 3:05 P.M with the clinical manager. The clinical manager stated, ";Usually within 5 days of admission [conduct the Chaplain assessment, the admitting nurse will discuss elective services and the family/patient will decide if they want those services from admission. They [admitting nurse] should document that the services were discussed and if they are elected."

Based on the agencys patient and caregiver handbook, clinical record review, and staff interviews, the agency failed to conduct a physical assessment after a patient experienced a fall. (patient #2) Findings included: --- The Hospice Patient & Caregiver Handbook was received on 07/15/2024 at 10:30 A.M. from the clinical manager. The handbook stated, ";NURSE ... Provides on-call service (24 hours a day 7 days a week for unexpected situations that arise). Assesses pain, symptoms, nutritional status, bowel function, safety..." Patient #3 was admitted on 01/10/2024 with a diagnosis of Alzheimers disease. Patient #3 was a resident of an assisted living facility (ALF). The plan of care for 01/10/2024-04/08/2024 included orders for skilled nurse visits 1 time a week for 1 week. An incident report was completed by registered nurse (RN) #4 on 01/14/2024 for a fall that occurred 01/11/2024. RN #4 stated, ";Patient laid on her right side and [sic] still screaming in pain..." There was no evidence in the clinical record of the RN #4 of performing a physical assessment. RN #4 was not available for an interview. An interview conducted on 07/15/2024 at approximately 1:00 P.M. with the clinical manager revealed that the expectation is for the RN to perform a physical assessment after an incident.

Based on agency policy review, clinical record review and staff interviews the agency failed to document a grievance/complaint of a caregiver for 1 of 1 discharged records [#1]. The findings included: The policy, Client Concerns [revised date 9/2021], was provided by the agency director on 5/23/22 at 5:02 pm. The policy stated, "Patients have the right to voice grievances/complaints regarding treatment or care that is [or fails to be] furnished and lack of respect of property by anyone who is furnishing care/services on behalf of the agency. Clients have the right to have complaints heard, reviewed, and if possible, resolved without concern or fear of reprisal discrimination, or unreasonable interruption of care or services ...Hospice staff will listen to concerns voices by clients and/or client representatives and will complete an on-line client concern Report within 24 hours of receipt of the concern ...The person assigned to investigate the concern will review the concern within 48 hours of receipt and will initiate a problem solving process ...Informs the client that the concern has been received and is being investigated and documents the date and time the client was notified. Investigation must be initiated, and client must be contacted no later than 72 hours after the initial compaint [sic]/concern was received by hospice staff ..." Patient # 1 had a Start of Care [SOC] date of 3/1/21 and a terminal diagnosis of Senile Degeneration of the Brain. A review of the Plan of Care [POC] for the certification period 3/1/22 to 4/29/22 included orders for SN [skilled nursing] 1 time a week for 9 weeks, 4 PRN [as needed] for exacerbation of disease/dressing changes; aide 2 times a week for 1 week, 3 times a week for 8 weeks; MSW [medical social worker] 2 times a month for 2 months. A review of the Patient Note Section of the clinical record revealed an entry for 4/8/22 at 10:36 am by RN # 14 revealed the following documentation, "Appointment for April 8, 2022 [sic] cancelled on April 8, 2022 [sic] by _____[name of nurse] because "Other". Writer arrives at home at scheduled time, spouse is not home but is contacted by caregiver in the home and phone is brought out to write. Spouse refuses to allow the writer in the home without her being home. Spouse yells at writer stating that's [sic] she is sick and tired of the writer arriving and waiting on the HCA [aide] to assist with care of the patient. Spouse refuses to allow the writer into the home to assess and provide wound care." During an interview with RN # 12 on 5/25/22 at approximately 10 am, the RN stated, "I called the wife after ____ [name of RN # 14] contacted me. She was clearly upset and cussing. She said she was tired of the nurse waiting on the aide to get to the home to help the RN with her job." A review of the agency's complaint log did not include any entry for 4/8/22 or any entry for Patient # 1 for the time frame of 3/1/22-4/8/22. During an interview with RN # 13 on 5/25/22 at approximately 10:15 am the RN confirmed this incident should have been included in the complaint log.

Based on clinical record review and staff interviews the agency failed to update the comprehensive assessment related to changes in the patient's condition for 1 of 18 records reviewed [#4]. The findings included: Patient # 4 had a Start of Care [SOC] date of 4/9/22 and an admitting diagnosis of Abnormal Weight Loss. A review of the Plan of Care [POC] for the certification period 4/9/22 to 7/7/22 included orders for SN [skilled nursing] 1 time a day for 1 day, 1 time a week for 13 weeks, 2 PRN [as needed] for change in condition. A review of the clinical record revealed the caregiver [cg] called the after-hours line on 4/16/22 to report "the patient was passing blood rectally and she had 4 BM's [bowel movements] yesterday." RN # 5 returned the cg's call and advised the cg that the patient could go to the emergency room since the bloody stools were not related to her hospice diagnosis. There was no evidence in the clinical record that RN # 5 notified the physician of the patient "passing blood." In an interview with RN # 5 on 5/25/22 at approximately 9 am the RN stated, "we discussed the call in the next morning meeting. I did not tell the MD [physician] and the report was not talked about in IDT [interdisciplinary team] minutes. On 4/26/22 RN # 8 made a routine visit. A review of the visit note revealed the following documentation, " ...swelling noted in bilateral legs and abdomen ..." An interview was conducted with RN # 8 on 5/25/22 at approximately 9:15 am. During the interview the RN stated, "It was just edema not pitting edema. I didn't see any reason to call the physician." Further review of the IDT [interdisciplinary team] notes dated 4/29/22 revealed no mention of the rectal bleeding or the assessment which included "swelling in bilateral legs and abdomen".

Based on policy review, client record review, and staff interview the agency failed to provide a patient specific adl (activity of daily living) regarding a bath of 2 of 15 patients with a home care aide (#14 and #7), and incorrect oxygen settings/no flow rate for 2 of 15 home care aide care records reviewed (#7 and #12). Findings included: Review of policy "Aide Care Plan and Documentation", revised 11/2020 was received from the agency director on 05/25/22 at 8:17 a.m. The policy stated," ...completing all parts and providing the aide with all necessary information to carry out his/her duties safely ...acceptable documentation includes tub bath or shower ...". 1.Patient #14 was admitted on 03/24/2022 with diagnoses parkinson's disease, dementia, hypothyroidism, and heart failure. The plan of care for 03/24/22 to 06/21/22 had orders for skilled nursing 1 day 1, 2 times a week for 2 weeks, and 1 time a week for 11 weeks; home care aide 2 times a week for 13 weeks. Review of the home health aide care plan revealed the aide was to assist with partial/complete bath. Review of the home care aide visits notes for 03/29/22, 03/31/22, 04/05/22, 04/08/22, 04/11/22, 04/13/22, 04/15/22, 04/18/22, 04/20/22, 04/22/22, 04/25/22, 04/27/22, 04/29/22, 05/02/22, 05/04/22, 05/06/22, 05/09/22, 05/11/22, 05/13/22, 05/16/22, 05/18/22, 05/20/22, and 05/23/22 revealed documentation of partial/complete bath was performed. Further record review revealed the aide care plan was not patient specific for which type of bath to be performed. Interview with agency director on 5/24/22 at 5:18 p.m. revealed, " it should be one or the other on the aide care plan they can't choose what to do, it's a system issue". 2. Patient # 7 had a Start of Care [SOC] date of 4/8/22 and a terminal diagnosis of Unspecified Systolic Congestive Heart Failure. A review of the Plan of Care [POC] for the certification period 4/8/22 to 7/6/22 included orders for SN [skilled nursing] 1 time a day for 1 day, 2 times a week for 2 weeks, 1 time a week for 11 weeks; aide 5 times a week for 13 weeks to assist with housekeeping and personal hygiene. A review of the clinical record revealed RN # 15 completed the aide care plan on 4/12/22. The HCA orders on the POC included the following, "Assist with partial or complete bad" and "Oxygen Precautions". During an interview with RN # 13 on 5/24/22 at approximately 4 pm the RN stated, "The nurses know they have to specify which type of bath the patient is to get." Further review of the POC revealed the patient was using oxygen at 2 liters per minute via nasal cannula. The aide POC did not include what the oxygen setting should have been set to. 3. Patient # 12 had a Start of Care [SOC] date of 4/28/22 and a terminal diagnosis of Unspecified Combined Systolic and Diastolic Congestive Heart Failure. A review of the Plan of care for the certification period 4/28/22 to 7/26/22 revealed orders for SN [skilled nursing] 1 time a day for 1 day; aide 5 times a week for 1 week, 1 time a week for 1 week, 2 times a week for 12 weeks for housekeeping and personal hygiene and "Oxygen 2 liters/min inhalation continuous for shortness of breath by trach collar". A review of the aide plan of care orders revealed the following order "Observe oxygen precautions" and "Oxygen at 3 liters continuously". An interview was conducted with RN # 9 on 5/25/22 at approximately 10:30 am. During the interview the RN stated, "The oxygen should be set at 2 liters and not 3 liters. We will correct that now." The RN confirmed the oxygen setting was incorrect on the aide care plan.

Based on agency policy review, clinical record review and staff interviews the agency failed to notify The Division of Health Service Regulation [DHSR] of a discharge for cause for 1 of 1 discharged records [#1]. The findings included: The policy, Discharge from Hospice Services for Reasons Other than Death [revised date 2/2021], was provided by the agency director on 5/23/22 at 5:02 pm. The policy stated, " ...c. discharge for cause: There may be extraordinary circumstances in which hospice would be unable to continue to provide hospice care to a patient ... ________[name of agency] makes every effort to resolve these problems satisfactorily before it considers discharge an option. All efforts to resolve the problem must be documented in detail in the patient's clinical record ...in NC ...hospice must notify the Medicare Contractor and the State Survey Agency of the circumstances surrounding the impending discharge ..." Patient # 1 had a Start of Care [SOC] date of 3/1/21 and a terminal diagnosis of Senile Degeneration of the Brain. A review of the Plan of Care [POC] for the certification period 3/1/22 to 4/29/22 included orders for SN [skilled nursing] 1 time a week for 9 weeks, 4 PRN [as needed] for exacerbation of disease/dressing changes; aide 2 times a week for 1 week, 3 times a week for 8 weeks; MSW [medical social worker] 2 times a month for 2 months. A review of the clinical record revealed patient # 1 was discharged on 4/8/22 due to "the safety of hospice personnel was compromised ...patient's spouse [sic] behavior is disruptive, abusive and uncooperative to the extent that delivery of care to the patient or the ability of the hospice to operate effectively is seriously impaired." A review of the Patient Note completed by RN # 14 and dated 4/8/22 at 10:36 am revealed the following information, "Appointment for April 8, 2022 [sic] cancelled [sic] on April 8, 2022 [sic] by _____[name of nurse] because "Other". Writer arrives at home at scheduled time, spouse is not home but is contacted by caregiver in the home and phone is brought out to write. Spouse refuses to allow the writer in the home without her being home. Spouse yells at writer stating that's [sic] she is sick and tired of the writer arriving and waiting on the HCA [aide] to assist with care of the patient. Spouse refuses to allow the writer into the home to assess and provide wound care." Further review of the clinical record revealed a Patient Note dated 4/8/22 at 4:09 pm by RN # 12. The Patient note stated, "Called _____ [name of physician] to inform him of events that occurred today resulting in request for live discharge due to disruptive, abusive or uncooperative behaviors as exhibited by the spouse ...Such behaviors have contributed to the impairment to safely deliver care to the patient ..." A review of the clinical record to include the IDT [interdisciplinary team] minutes dated 3/7/22, 3/22/22 and 4/5/22 revealed no documentation related to aggressive, abusive, or disruptive behavior. During an interview with RN # 12 on 5/25/22 at approximately 10 am the RN stated, "The issues started way before the discharge of the patient. The wife was "bullying" the staff. When the nurse called me to inform me of the wife's behavior, I called the wife. She was clearly upset and was cursing. This was not the first time she had done this." [The agency was not able to provide this surveyor with any documentation related to unacceptable behavior by the wife]. During an interview with RN # 11 on 5/25/22 at approximately 9:30 am the RN stated, "We notified ACHC [accrediting organization] that we had discharged the patient due to the wife's behavior." An interview was conducted with RN # 12 on 5/25/22 at 10 am [RN # 12 was acting as manager in charge while RN # 11 was out of the office]. During the interview RN # 12 stated, "I emailed or faxed DHSR [Division of Health Service Regulation]. I saw the email just the other day." The RN was unable to provide the surveyor with any proof the agency had notified DHSR of the discharge for cause in an accordance with Centers for Medicare and Medicaid Services State Operations Manual Chapter 2-The certification Process - 2082 - Discharge from Hospice Care (Rev. 73, Issued: 12-02-11 Effective: 12-02-11, Implementation: 12-02-11).