Liberty Home Care, LLC

“Track adverse patient events CFR(s): 484.65(c)(2) Performance improvement activities must track adverse patient events, analyze their causes, and implement preventive actions. This Standard is not met as evidenced by: Based on clinical record review and staff interviews, the agency failed to track and analyze an adverse event for 1 of 1 patient that had a fall with injury (patient #7). Findings included: Patient #7 was admitted on 03/06/2025 with a diagnosis of Paroxysmal atrial fibulation (irregular heartbeat causing poor blood flow). The plan of care for 05/05/2025-07/02/2025 included orders for skilled nurse (SN) visits 1 time a week for 9 weeks and, “SN to provide skilled assessment, identify and mitigate risk factors, provide instruction and reinforcement of teaching to prevent falls/injury.” A review of the clinical record revealed that during the registered nurse (RN) visit on 06/02/2025 RN #3 documented, “Patient had a fall yesterday… Patient went to [hospital name] ER [emergency room] where they found a left rib fracture.” Further review revealed that an incident/adverse event report was not completed. An interview conducted on 06/24/2025 at 11:47 AM with RN #3 revealed that RN #3 did not complete an incident report. An interview conducted on 06/24/2025 at approximately 12:15 PM with the agency administrator revealed that the expectation is for a NRE (non-routine event) form to be completed by the clinicians for review and investigation by clinical leadership.”

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on agency policy, observation, and staff interviews, the agency failed to perform hand hygiene prior to obtaining a blood sample for 1 of 1 patient requiring a PT/INR (test that measures how long it takes blood to clot) test. (patient #7) Findings included: A policy, Point-of-care testing, prothrombin time (PT) and internation normalized ratio (INR), home care (revised 11/18/2024), received on 06/24/2025 at 9:29 AM from the agency administrator stated, “Organize the equipment and supplies on a stable, level, clean surface... Perform hand hygiene.” A policy, Exposure Control Plan: Engineering and Work Practice Controls (revised 01/2025), received on 06/24/2025 at 9:29 AM from the agency administrator stated, “Hand hygiene… After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient”. Patient #7 was admitted on 03/06/2025 with a diagnosis of Paroxysmal atrial fabulation (irregular heartbeat causing poor blood flow). The plan of care for 05/05/2025-07/02/2025 included orders for skilled nurse (SN) visits 1 time a week for 9 weeks and, “SN to assess INR every week on Mondays. SN may perform finger-stick/venipuncture to obtain INR.” A home visit was conducted on 06/24/2025 at 2:18 PM with registered nurse (RN) #3 and the clinical manager. RN #3 performed hand hygiene, donned clean gloves, performed a skin assessment, handled the documentation tablet, and proceeded to obtain a blood sample for the INR test. RN #3 failed to remove gloves, perform hand hygiene, and don clean gloves after handling the tablet. During an interview conducted on 06/25/2025 at 11:44 AM RN #3 denied handling the documentation tablet prior to obtaining the blood sample and stated that they would perform hand hygiene and don clean gloves prior to obtaining a blood sample. On 06/24/2025 at approximately 12:00 PM the clinical manager confirmed that RN #3 failed to remove gloves, perform hand hygiene, and don a clean pair after handing the documentation tablet and obtaining a blood sample and should have.”

“Immediate reporting of abuse by all staff CFR(s): 484.50(e)(2) Any HHA staff (whether employed directly or under arrangements) in the normal course of providing services to patients, who identifies, notices, or recognizes incidences or circumstances of mistreatment, neglect, verbal, mental, sexual, and/or physical abuse, including injuries of unknown source, or misappropriation of patient property, must report these findings immediately to the HHA and other appropriate authorities in accordance with state law. This Element is not met as evidenced by: Based on agency policy, clinical record review, and staff interviews, the agency failed to report suspected abuse to the appropriate authorities for 1 of 1 patient reporting abuse (patient #7). Findings included: A policy, Reporting Abuse and Neglect (revised 03/2024) received on 06/25/2025 at 12:18 PM from the agency administrator stated, “Personnel with knowledge or reasonable suspicion of abuse/neglect or exploitation violation will make an immediate report by telephone to the appropriate (i.e., Adult Protective Services…) protective services unit of the local Department of Social Services (DSS).” Patient #7 was admitted on 03/06/2025 with a diagnosis of Paroxysmal atrial fabulation (irregular heartbeat causing poor blood flow). The plan of care for 05/05/2025-07/02/2025 included orders for skilled nurse (SN) visits 1 time a week for 9 weeks. A review of the clinical record revealed that during the registered nurse (RN) visit on 05/29/2025 RN #3 documented, “Patient describes how her spouse has been increasing defiant…, is progressively getting more irritable and has angry outburst towards the patient… Patient states that her spouses [sic] will grab her “hard by the arms” at time, that he often “yells in my face”… and “he corned [sic] me in the kitchen last night with a broom.” SN reminded patient that she also could call 911 should she felt [sic] that she was in physical jeopardy; patient states that she has considered that, but “I didn’t want to make him angrier” … SN notified [clinical manager’s name], Clinical Manager of conversation with patient. SN instructed SN to notify the patient’s PCP [primary care physician] to see if provider felt APS [adult protective services] was necessary…SN attempted to reach provider, but was only able ot [sic] leave a message…” On 05/30/2025 RN #3 documented, “SN made second attempt to reach [provider’s name]; no answer, voicemail left regarding the urgent need to reach her for concerns identified in last visit.” Further review revealed that there was no documentation that APS was notified. An interview conducted on 06/24/2025 at 11:47 AM with RN #3 revealed that APS had not been called, they understood that all clinicians are mandated reporters of abuse, and that a physician’s order is not necessary to report. An interview conducted on 06/24/2025 at 11:54 AM with the agency administrator revealed that all staff can report suspected abuse to APS, there is no need for a physician’s order to report, and this situation should have been reported.”