Liberty Home Care LLC

“Responsibilities of skilled professionals CFR(s): 484.75(b) Standard: Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following: This Standard is not met as evidenced by: Based on agency policy, clinical record review, and staff interviews, the skilled nurse failed to measure the PICC [peripherally inserted central catheter- is a thin, flexible tube inserted into a vein in the upper arm and threaded into a larger vein near the heart] line measurements for 1 of 1 patient with a PICC line [#2]; and failed to obtain wound measurements/wound assessments for 2 of 4 patients with a wound [#4 The findings included: The policy, Peripherally Inserted Central Catheter [PICC] Dressing Change, Home Care [8/19/24], was provided by the agency administrator on 3/19/25 at approximately 9:04 am. The policy stated, “...Documentation associated with a PICC dressing change included: condition and length of the external catheter...” The policy, Wound Assessment [2/24/25], was provided by the agency administrator on 3/19/25 at approximately 9:04 am. The policy stated, “...A complete wound assessment is to be completed every visit and documented in the patient’s medical record. Wound measurements are to be taken at least one time every week and documented in the clinical record...” 1.Patient # 2 had a Start of Care date of 12/1/23 with admitting diagnoses of encounter for adjustment and management of VAD [vascular access device-medical device inserted into a blood vessel to provide long term access for administration of medication, etc.] and bacteremia [bacteria in the bloodstream]. Review of the Plan of Care for the certification period 12/1/23-1/29/24 included orders for SN [skilled nursing] 2 times a week for 1week,1 time a week for 8 weeks and “...SN to perform sterile dressing changes to R [right] IJ [sic] catheter weekly...” Review of the clinical record revealed 9 routine nursing visits were made from 12/1/24-1/29/24. Out of the nine [9] visits the SN failed to obtain PICC [peripherally inserted central catheter- is a thin, flexible tube inserted into a vein in the upper arm and threaded into a larger vein near the heart] line measurements for 7 of the 9 visits. During an interview with the agency administrator on 3/17/25 at 3 pm, the administrator confirmed the SN failed to obtain PICC line measurements in accordance with the agency policy. 2.Patient # 4 had a Start of Care date of 6/21/24 and admitting diagnoses of pressure ulcer or right buttock, stage 4 [ulcer involving full-thickness skin and tissue loss, exposing bone, muscle or tendons, and may show signs of infection-like pus, odor, and redness] and pressure ulcer of left buttock, stage 4. Review of the Plan of Care for the certification period 2/16/25-4/16/25 included orders for SN [skilled nursing] 1 time a week for 9 weeks and “SN to perform wound care to lower back/sacral area on weekly basis. Cleanse wound with dermal wound cleanser, cover and secure with ABD pad, tape...SN to perform pressure ulcer care to right ischium [hip bone area] at each visit...SN to perform pressure ulcer care to left ischium at each visit...” Review of the clinical record revealed no wound measurements for the week of 3/4/25. RN # 2 conducted a routine visit on 3/13/25. Review of the visit note revealed no wound assessments for that date. The RN documented wound care but no wound assessments. During an interview with the agency administrator on 3/17/25 at approximately 3 pm, the administrator stated, “We measure wounds weekly, and a wound assessment is due with each visit.” 3. Patient # 6 had a Start of Care [SOC] date of 1/18/25 with an admitting diagnosis of pressure ulcer of left buttock, stage 2 [partial thickness skin loss, presenting as a shallow open ulcer], pressure ulcer of right hip, stage 2, pressure ulcer of left hip, stage 2. Review of the Plan of Care [POC] for the certification period 1/18/25-3/18/25 included orders for SN [skilled nursing] 1 time a week for 1 week, 0 times a week for 1 week, 1 time week for 7 weeks. Review of the clinical record revealed RN # 7 completed the SOC OASIS [Outcome and Assessment Information Set-used by home health agencies to collect data on patients receiving skilled care] and documented the following information, “...Pt [patient] has two stage 2 wounds, and extensive excoriation/skin peeling on buttocks and thighs due to incontinence...” Further review of the clinical record revealed no wound assessments/measurements related to the two stage 2 pressure ulcers. RN # 2 conducted a routine visit on 1/29/25 and documented the following information, “...states that his pain increases when positioned onto left side to offload pressure to buttocks. Extreme maceration/excoriation noted to right hip and posterior thighs...” During an interview with the agency administrator on 3/19/25 at 3 pm, the administrator confirmed the RNs failed to obtain measurements or wound assessments or go into detail as to why the measurements/assessments were not obtained.”

“Make efforts to resolve the problem(s) CFR(s): 484.50(d)(5)(ii) (ii) Make efforts to resolve the problem(s) presented by the patient’s behavior, the behavior of other persons in the patient’s home, or situation; This Element is not met as evidenced by: Based on agency policy, clinical record review, and staff interviews the agency failed to make efforts to resolve the problem presented by the patient’s behavior prior to discharging for cause for 1 of 1 patient discharged for cause [#2]. The findings included: The policy, Discharge and Transfer of Patients [01/2025], was provided by the agency administrator on 3/19/25 at 9:04 am. The policy stated, “...When the agency determines that the patient’s (or other person’s in the home) behavior is disruptive, abusive, or uncooperative...the following must be done before the patient is discharged: Hold a case conference to make a decision concerning discharge and document...Make efforts to resolve the big problem presented by the patient’s behavior...Provide the patient and representative (if any), with contact information for other agencies...Document the problem and efforts made to resolve the problem, and enter this documentation into the electronic clinical record...” Patient # 2 had a Start of Care date of 12/1/23 with admitting diagnoses of encounter for adjustment and management of VAD [vascular access device-medical device inserted into a blood vessel to provide long term access for administration of medication, etc.] and bacteremia [bacteria in the bloodstream]. Review of the Plan of Care [POC] for the certification period 1/30/24-3/29/24 revealed a primary diagnosis of hemiplegia [paralysis of ½ of body] following a cerebral infarction [stroke]. The POC included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 4 weeks, 1 time a week for 4 weeks and PT [physical therapy] 1 time a week for 1 week, 2 times a week for 1 week, 1 time a week for 7 weeks. Review of the clinical record revealed missed visits for PT and SN on 2/9/24 and 2/12/24. Further review of the clinical record revealed the following documentation by RN # 2 on 2/12/24,” Call to physician office to report unable to contact patient since 2/6/24 to schedule PT. SN has not been able to make contact with patient or family since then either. Spoke with _____ [name] who verbalized understanding that ____ [name of agency] will be discharging patient from HH [home health] due to non-compliance and illegal drug seeking activities [unable to find information related to this in the clinical record]. SN reported that patient was at _____[name of emergency department] on 2/7/24...Patient will be discharged on Thursday or Friday...” Further review of the clinical record revealed RN # 6 conducted a routine visit on 2/13/24. RN # 2 discharged the patient on 2/16/24. The clinical record revealed no evidence that the agency made efforts to resolve the problems related to the missed visits or provided the patient with contact information related to other home health agencies/providers who might be able to provide care. During an interview with the agency administrator on 3/17/25 at approximately 3 pm, the administrator confirmed the clinical record did not include the required documentation related to discharge for cause.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on clinical record review and staff interviews, the skilled nurse failed to obtain labs in accordance with the physician’s order for 1 of 1 patient with VAD [vascular access device-medical device inserted into a blood vessel to provide long term access for administration of medication, etc.] [#2]; and failed to obtain weekly weights for 1 of 1 patient with VAD [vascular access device-medical device inserted into a blood vessel to provide long term access for administration of medication, etc.] [#2.]; and provided wound care for 1 of 4 patients with a wound without an order for wound care [#3]; and the agency failed to report vitial signs outside a given parameter in accordance with the physician’s order for 1 of 3 patients who received a home visit [#5]. The findings included: 4. Patient #5 had a Start of Care date of 1/12/2025 with an admitting diagnosis of Lymphedema (build up of fluid causing swelling, usually in arms and legs caused by a blockage in the lymphatic system). Review of the Plan of Care (POC) for the certification period 1/12/25-3/12/25 included orders for SN (skilled nurse) 2 times a week for 2 weeks, 1 time a week for 7 weeks. Further review of the POC revealed vital sign parameters as follows: “Notify physician of vital sign parameters out of range: Heart rate: greater than (>)100 bpm (beats per minute) or less than () 160mmHg or less than () 90 mmHg or less than ( RN #2 conducted home visits on 1/21/2025 and 2/14/2025. On 1/21/2025, RN #2 documented that patient had an O2 (oxygen) saturation (refers to the percentage of oxygen in the blood) of 91%. Documentation for the 2/14/2025 home visit revealed RN #2 documented a blood pressure of 164/90. Review of the clinical record revealed no evidence that the physician had been notified of the vital signs documented on 1/21/25 or 2/14/25. On 2/14/25, PT #1 conducted a home visit and documented a blood pressure reading of 220/70. PT #1 documented calling RN #2 with this blood pressure reading and that RN #2 stated they would notify MD. There was no evidence the PT or RN notified the physician of the blood pressure reading. On 2/21/2025, RN #2 conducted a home visit and documented the patient’s heart rate at 108. Review of the clinical record revealed no evidence that the physician was notified of this vital sign reading. An interview with the director on 3/19 at approximately 4 pm, confirmed there was no evidence the physician was notified of the vital signs outside the given parameters in accordance with the POC. 1A.Patient # 2 had a Start of Care date of 12/1/23 with admitting diagnoses of encounter for adjustment and management of VAD [vascular access device-medical device inserted into a blood vessel to provide long term access for administration of medication, etc.] and bacteremia [bacteria in the bloodstream]. Review of the Plan of Care for the certification period 12/1/23-1/29/24 included orders for SN [skilled nursing] 2 times a week for 1week,1 time a week for 8 weeks and “SN to obtain blood for BMP [basic metabolic panel and triglycerides each Monday...” On 1/9/24 a supplemental order was noted that stated, “Please make sure to add magnesium and phosphorous to weekly labs.” Review of the clinical record revealed lab work was obtained on 1/15/24, 1/22/24, 1/29/24, and 2/5/24. Further review of the clinical record revealed no lab results for magnesium or phosphorous. During an interview with the agency administrator on 3/17/25 at 3 pm, the administrator confirmed the nurses failed to obtain the blood for magnesium and phosphorous levels. 1B. Patient # 2 had a Start of Care date of 12/1/23 with admitting diagnoses of encounter for adjustment and management of VAD [vascular access device-medical device inserted into a blood vessel to provide long term access for administration of medication, etc.] and bacteremia [bacteria in the bloodstream]. Review of the Plan of Care for the certification period 12/1/23-1/29/24 included orders for SN [skilled nursing] 2 times a week for 1week,1 time a week for 8 weeks and “SN to monitor weekly weights”. Review of the clinical record revealed a weight of 133 was documented on 12/1/24. Further review of the clinical record revealed no weekly weights were obtained after the weight on 12/1/24. During an interview with the agency administrator on 3/17/25 at approximately 3 pm, the administrator confirmed the SN failed to obtain the weekly weight for the patient. 3. Patient # 3 had a Start of Care date of 8/24/24 with an admitting diagnosis of type 2 diabetes mellitus with hypoglycemia [low blood sugar level]. Review of the clinical record revealed the patient was admitted to _________ [name of hospital] on 9/3/24 for “low blood sugar” and was discharged home on 9/6/24. The Resumption of Care [ROC-comprehensive assessment completed after patient has had inpatient stay] visit was conducted on 9/7/24 by RN # 2. RN # 2 documented the following information, “...Patient has bandaid to right forearm, states that he got the injury when he fell, dressing changed using same products that are currently in use, Xeroform gauze and bandaid applied...” Review of the clinical record revealed no order for wound care to the right forearm. During an interview with the agency administrator on 3/17/25 at approximately 3 pm, the administrator confirmed there was no order for wound care.”

“Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This Element is not met as evidenced by: Based on clinical record review and staff interviews the skilled nurse educated the patient to apply topical creme without a physician’s order for 1 of 4 patients with a wound [#6]. The findings included: Patient # 6 had a Start of Care [SOC] date of 1/18/25 with an admitting diagnosis of pressure ulcer of left buttock, stage 2 [partial thickness skin loss, presenting as a shallow open ulcer], pressure ulcer of right hip, stage 2, pressure ulcer of left hip, stage 2. Review of the Plan of Care [POC] for the certification period 1/18/25-3/18/25 included orders for SN [skilled nursing] 1 time a week for 1 week, 0 times a week for 1 week, 1 time week for 7 weeks. Review of the SOC OASIS [Outcome and Assessment Information Set-used by home health agencies to collect data on patients receiving skilled care] revealed RN # 7 documented the following information, “...Pt [patient] wife states orange barrier cream is not working. SN recommends A & D ointment to skin to create barrier and promote healing...” Review of the clinical record revealed no physician’s order to A & D ointment. During an interview with the agency administrator on 3/19/25 at 3:30 pm the administrator confirmed the RN should not have recommended the A & D without a physician’s order.”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on clinical record review and staff interviews the skilled nurse failed to individualize interventions by not removing information that was not applicable from the interventions template for 2 of 2 patients with nursing orders who received home visits. (#3 and #5). The findings included: 1.Patient #3 had a Start of Care date of 2/14/2025 with an admitting diagnosis of right leg cellulitis (bacterial infection of the skin). Review of the Plan of Care (POC) for the certification period 2/14/25-4/14/25 included orders for SN (skilled nurse) 1 time a week for 3 weeks, 1 time every other week for 5 weeks. Review of the medical record revealed that on 3/13/2025, LPN #3 documented under interventions that “SN instructed patient/caregiver regarding heart failure status and self-management program” and “SN instructed patient/caregiver regarding self-management of Peripheral Vascular Disease”. 2.Patient #5 had a Start of Care date of 1/12/2025 with an admitting diagnosis of Lymphedema (build up of fluid causing swelling, usually in arms and legs caused by a blockage in the lymphatic system). Review of the Plan of Care (POC) for the certification period 1/12/25-3/12/25 included orders for SN (skilled nurse) 2 times a week for 2 weeks, 1 time a week for 7 weeks. Further review of the clinical record revealed all SN visit notes reviewed for this patient, (1/12/25 – 3/7/25), the following was documented in the intervention portion of the SN narrative: “SN instructed patient/caregiver regarding heart failure ( a chronic condition in which the heart doesn’t pump blood as well as it should) status and self-management program” and “SN instructed patient/caregiver regarding self-management of Peripheral Vascular Disease” (a condition in which narrowed blood vessels reduce blood flow to the limbs). Review of the clinical record revealed no diagnosis of heart failure or PVD. An interview with the director on 3/19 at approximately 4 pm, confirmed that peripheral vascular disease and heart failure sections of the template were not removed from the interventions section of the nursing narrative.”