Liberty Home Health Care, Inc.

“Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice’s ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This Standard is not met as evidenced by: Based on review of the Agency’s Emergency Preparedness Plan and staff interview, the Agency failed to ensure the Emergency Preparedness Plan was based on a facility and community risk assessment, utilizing an all-hazards approach. This has the potential to affect all Pts. served by the Agency. Findings include: 1. The Agency’s Emergency Preparedness Plan was reviewed on 08/28/25. The plan lacked a facility and community-based risk assessment, using an all- hazards approach for the years 2023 and 2024. 2. During an interview with the Director of Nursing and Office Coordinator on 08/28/25 at 3:00 PM, the confirmed the above finding was confirmed.”

“Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO’s Donation Service Area (DSA). This Standard is not met as evidenced by: Based on the review of the Agency’s Emergency Preparedness and Staff interview, the Agency failed to have a communication plan that included the required names and contact information. This has the potential to affect all patients who receive services from the Agency. Findings include: 1. The Agency’s Emergency Preparedness Plan was reviewed on 8/28/25. The plan lacked a communication plan that includes the updated list of the following requirements: Names and contact information for staff, entities providing service under arrangement, Patients’ Physicians, and Volunteers. 2. During an interview with the Director of Nursing on 8/28/25 at 3:00 PM, the above finding was confirmed.”

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on the clinical records reviewed and Staff interview, the Agency failed to ensure patient care as ordered in the plan of care, for 8 of 10 (Pts. #1, 4, 5, 9, 2, 7, 8 and 10) clinical records reviewed. 5. Pt. #2 was admitted to the Home Health Services on 07/14/25 with the diagnosis of Multiple Fractures of Ribs, Right side. The clinical record was reviewed on 08/27/25. The clinical record contained an admission order dated 07/14/25, that required, “Treatment orders: Wound care to right and left shin abrasions – RN to cleanse site with normal saline and pat dry, apply xeroform dressing (petrolatum gauze with 3% bismuth tribromophenate) to wound bed, cover with ABD (abdominal pad) and secure with kerlix gauze wrap and tape.” The Skilled Nurse Visit notes dated 07/17/25, 07/21/25, 07/24/25, 07/28/25 and 07/31/25 included documentation that the RN used “Mepilex” (absorbent foam dressing) for wound care instead of the xeroform dressing. The RN failed to follow the physician orders. 6. Pt. #7 was admitted to the Home Health Services on 07/11/25 with the diagnosis of Encounter for Attention to Gastrostomy and Type 2 Diabetes Mellitus with Other Oral Complications. The clinical record was reviewed on 08/27/25. The clinical record which included the POC effective 07/11/25, required, “SN to monitor blood sugar every visit and as needed and to notify MD with result of fasting BS (greater than) 200 mg/dl and of random BS 250 mg/dl. The Skilled Nursing Visit notes lacked documentation of blood glucose results for the following dates: 07/18/25, 07/26/25, 07/31/25 and 08/08/25. 7. Pt. #8 was admitted to the Home Health Services on 03/04/25 with the diagnosis of Encounter for Acute on Chronic Systolic (Congestive Heart Failure). The clinical record was reviewed on 08/28/25. The clinical record included the POC for the certification period of 05/03/25 to 07/01/25, which required, “PT to notify MD of:… Pulse greater than > 100 or less than 60… PT to assess weight every visit…” The following were listed in the PT notes: 05/05/25: (radial) =105, wt. = n/t (not taken) 05/09/25: (radial) = 109, wt. = n/t 05/12/25: (radial) = 104, wt. = n/t 05/16/25: (radial) = 107, wt. = n/t 05/19/25: (radial) = 105, wt. = n/t 05/23/25: (radial) = 109, wt. = n/t 05/25/25: (radial) = 107, wt. = n/t 05/30/25: (radial) = 102, wt. = n/t The PT failed to notify the physician of parameters that were out of range and failed to assess the patient’s weight. 8. Pt. #10 was admitted to the Home Health Services on 08/24/24 with the diagnoses of: Pneumonitis due to Inhalation of Food and Vomit. The clinical record was reviewed on 08/28/25. The clinical record contained a POC for the certification period of 08/14/24 to 10/12/24, that required, “SN to notify MD of…Pulse greater than 100 or less than 60…” The comprehensive assessment dated 08/14/24 included documentation “Pulse = 110…” The RN failed to notify the physician of the parameter that was out of range. 9. During interviews with the Director of Nursing and Office Coordinator/Acting Administrator on 08/27/25 at 2:00 PM and on 08/28/25 at 2:00 PM, the above findings were confirmed. Findings include: 1. Pt. #1 was admitted to the Home Health Services on 08/18/25 with the diagnosis of: Other Sequelae of Cerebral Infarction. The clinical record was reviewed on 08/26/25. The clinical record contained a POC dated 08/18/25, that required the SN to notify the physician if the blood pressure diastole was below 60. On 08/25/25 the SN failed to notify the physician of the blood pressure 102/54. 2. Pt. #4 was admitted to the Home Health Services on 07/07/25 with the diagnosis of: “Hyp Hrt & Chr Kdny dis w Hrt Fail and Stg 1-4 unsp Chr Kdny”. The clinical record was reviewed on 08/27/25. The clinical record contained a POC dated 07/07/25, that required the SN to notify the physician if the weekly weight was greater than 5 lbs/wk. On 07/17/25 the SN failed to weigh the patient. On 07/23/25 the SN weighed the patient as 147 lbs and failed to notify the physician of the 27 pounds weight gain. 3. Pt. #5 was admitted to the Home Health Services on 04/01/25 with the diagnoses of: Idiopathic Gout Multiple Sites and Heart Failure, Unspecified. The clinical record was reviewed on 08/27/25. The clinical record contained a recertification POC dated 05/31/25, that required the SN to assess the patient’s weight every visit and notify the physician if the weight was greater than 5 lbs/week. On 05/28/25 (recertification) the SN failed to weigh the patient. Each week from 05/31/25 thru the next recert 07/27/25, the SN failed to weigh the patient, as ordered in the POC. 4. Pt. #9 was admitted to the Home Health Services on 10/23/24 with the diagnosis of: Other Sequelae of Cerebral Infarction. The clinical record was reviewed on 08/27/25. The clinical record contained a recertification POC dated 02/20/25, that required the PT to evaluate. The PT failed to conduct the evaluation. The POC also required the SN to assess the vital signs. The SN failed to assess the pain on 04/3/25.”

“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 the clinical records reviewed and Staff interview, the Agency failed to ensure all the plan of care requirements for 4 of 10 (Pts. # 3, 9, 7 and 10) clinical records reviewed. 3. Pt. #7 was admitted to the Home Health Services on 07/11/25 with the diagnosis of Encounter for Attention to Gastrostomy. The clinical record was reviewed on 08/27/25. The clinical record included the POC effective 07/11/25. The POC lacked The POC lacked documentation of interventions and caregiver education for the care of the Gastrostomy tube. The POC also lacked documentation of supplies, treatment, and procedure for the care of the skin surrounding the ostomy. 4. Pt. #10 was admitted to the Home Health Services on 08/24/24 with the diagnoses of: Pneumonitis due to Inhalation of Food and Vomit. The clinical record was reviewed on 08/28/25. The clinical record included the POC for the certification period of 08/14/24 to 10/12/24. The POC lacked documentation of interventions and caregiver education for the care of the Gastrostomy tube. The POC lacked documentation of supplies, treatment, and procedure for the care of the skin surrounding the ostomy. The POC also lacked documentation of the type of gastrostomy feeding, the dose and the frequency of the feedings. 5. During interviews with the Director of Nursing and Office Coordinator/Acting Administrator on 08/27/25 at 2:00 PM and on 08/28/25 at 2:00 PM, the above findings were confirmed. Findings include: 1. Pt. #3 was admitted to the Home Health Services on 07/28/25 with the diagnosis of: Multiple Sclerosis. The clinical record was reviewed on 08/27/25. The clinical record contained a POC dated 07/28/25 that required the diabetic medication Metformin 500mg 2 times a day. The POC lacked the diagnosis for the use of Metformin. 2. Pt. #9 was admitted to the Home Health Services on 10/23/24 with the diagnosis of: Other Sequelae of Cerebral Infarction. The clinical record was reviewed on 08/27/25. The clinical record contained a recertification POC dated 02/20/25, that lacked the ST orders to evaluate and treat 02/24/25 thru 04/16/25.”

“Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This Element is not met as evidenced by: Based on the home visit observations and Staff interview, the Agency failed to ensure the Clinical Manager’s contact information in 4 of 10 (Pts. #1, 2, 3 and 4) clinical records reviewed. 2. During an interview conducted with the Director of Nursing and Office Coordinator on 08/29/25 at 9:15 AM, the above findings were confirmed. Findings include: 1.On 08/26/25 and 08/28/25, home visits were conducted. It was observed the home folders lacked documentation regarding the contact information of the Clinical Manager for the following: Pt. #1 SOC 08/18/25 Pt. #2 SOC 07/14/25 Pt. #3 SOC 07/28/25 Pt. #4 SOC 07/07/25”