Liberty Home Care

“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 record review and interview, the agency failed to include objectively measurable goals on the plan of care to use in determining the patient’s progress towards obtaining the goals throughout the course of care in 5 of 8 (P-3, P-4, P-6, P-7, P-8) records reviewed. Findings included: P-6: The Start of Care (SOC) was dated 2/6/2025. The patient was admitted to homecare following a hospital discharge on 2/5/2025. The Plan of Care (POC) for the Certification Period 2/6/2025 to 4/6/2025 identified a primary diagnosis of Flu due to influenza virus with other respiratory manifestations, Metabolic Encephalopathy, Mild Cognitive Impairment, Muscle Weakness, Difficulty Walking, Hypertension, Acute Respiratory Failure, and Diabetes type 2. The patient was receiving Skilled Nursing (SN) services 1xweekx1, 2xweekx2,1xweekx1; and Physical Therapy (PT) services 2xweekx3,1xweekx4. Upon review of the record on 2/18/2025, it was noted the goals on the POC were not objectively measurable to determine the patient’s progress towards achieving the goals. Examples included: “Patient will demonstrate correct-insulin prep/admin technique; demonstrate glucose testing {sic}; Patient/Caregiver will verbalize knowledge regarding correct uses of all new/changed medications; Patient/caregiver will be able to describe/demonstrate proper use of oxygen therapy. These goals are not objectively measurable to determine the patient’s progress towards obtaining the goals. P-7: The Start of Care (SOC) was dated 8/13/2024. The Plan of Care (POC) for the certification period 8/13/2024 to 10/11/2024 identified diagnoses of Diabetes type 2 (DM2), Muscle Weakness, Unspecified Dementia, Hypotension, Difficulty Walking, and Essential Primary Hypertension. Upon review of the record, it was noted the goals on the POC were not objectively measurable to determine the patient’s progress towards achieving the goals. Examples included: “Patient/Caregiver will demonstrate correct insulin prep/admin technique” {sic}; Demonstrate glucose testing”{sic}; Patient/caregiver will verbalize knowledge regarding correct uses of all new/changed medications insulin by 8/23/24”{sic}; “Patient/caregiver will identify and reduce respiratory risk factors.” These goals are not objectively measurable to determine the patient’s progress towards obtaining the goals. P-8: The Start of Care was dated 2/6/2025. The Plan of Care (POC) for the certification period 2/6/25 to 4/6/2025 identified diagnoses of Aftercare following Joint Replacement Surgery, Pain in Right Knee, Generalized Muscle Weakness, Difficulty Walking, Congestive Heart Failure (CHF), Atrial Fibrillation (A-Fib), and Hypertension (HTN). This patient was receiving Skilled Nurse services 1wk1, 2wk1, and 1wk2; Physical Therapy 2wk3, 1wk5; Occupational Therapy 1wk1, 2wk3. Upon review of the record, it was noted the goals were not objectively measurable to determine the patient’s progress towards obtaining the goals. Examples included: “Patient/Caregiver will verbalize knowledge regarding correct use of all new/changed medications by 3/1/2025; Patient/caregiver will be knowledgeable of clean techniques/sterile technique/aseptic technique; patient/caregiver will understand proper infection control as demonstrated by proper hand washing, proper and safe disposal of sharps and waste materials; universal precautions. These goals are not objectively measurable to determine the patient’s progress towards obtaining the goals. P-4: This 71-year-old patient was admitted to home care on 1/23/25 with diagnoses of chronic venous insufficiency and chronic venous ulcers. The patient received once weekly nursing visits from 1/23/25 through 2/14/25. During record review on 2/19/25, it was noted that the 1/23/25 plan of care listed the following goal for this patient: Patient/caregiver will demonstrate correct insulin preparation/administration technique and demonstrate glucose testing. The patient’s medications listed on the plan of care did not include insulin or oral diabetic medications. A joint provider surveyor home visit with the physical therapist was conducted on 2/19/25 at 1:00 p.m. The patient stated she is not a diabetic, is not on insulin or any medications for diabetes, and does not check her blood glucose levels. These were not appropriate goals for this patient. The findings were reviewed with and acknowledged by Adm-1 and CM-1 during an interview on 2/20/25 at 12:45 p.m. P-3: This 69-year-old patient was admitted to home care on 1/27/25 with diagnoses of non-pressure ulcers to the lower extremities, peripheral vascular disease, congestive heart failure, and diabetes. Skilled nursing visits are ordered twice weekly for four weeks, then weekly for four weeks. During record review on 2/19/25, it was noted that the plan of care listed the following goal, “patient/caregiver will be able to describe/demonstrate proper use of oxygen therapy.” There is no evidence the patient is using oxygen therapy. This finding was reviewed with and acknowledged by the administrator (Adm-1) and the clinical manager (CM-1) during an interview on 2/20/25 at 1:15 p.m.”

“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 record review and interview, the agency failed to ensure a detailed discharge summary was sent to the physician within 5 business days of discharge for 1 (P-5) of 2 discharge records reviewed, resulting in a lack of information to ensure continuity of care. Findings include: P-5: This patient was admitted to home care on 12/11/24 with diagnoses of diabetes type 2 and skin infection on middle and ring fingers of both hands. During record review on 2/20/25, it was noted that the patient was discharged from agency services on 12/31/24. There was no evidence that a detailed discharge summary report was sent to the physician within 5 days of the patient’s discharge. The findings were reviewed with and acknowledged by the administrator (Adm-1) and the clinical manager (CM-1) during an interview on 2/20/25 at 12:45 p.m.”