Liberty Home Care

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on agency policy, home visit observations, clinical record review, and staff interviews, the Start of Care comprehensive assessment failed to include a list of all medications for 1 of 6 patients with a home visit conducted. (patients #18). The findings included: A policy, Legal Aspects of Clinical Documentation, (revised 01/2025), was presented by the agency administrator on 6/4/2025 at 8:00 am. The policy stated, “Timeliness of clinical record documentation…admission assessment documentation will be submitted within 1 working day after the evaluation visit.” Patient #18 was admitted on 5/31/2025 with a diagnosis of Fracture of unspecified part of neck of left femur, initial encounter for closed fracture (left hip fracture). The plan of care for 5/31/2025-07/29/2025 included orders for PT (physical therapy) 1 time a week for 1 week, 2 times a week for 4 weeks and OT (occupational therapy) 1 time a week for 1 week for an OT evaluation. During a home visit on 6/3/2025 at approximately 1:15 pm with OT #11, a medication review was conducted and it was determined that the medications had not been added to the start of care comprehensive assessment by the admitting clinician (PT #13). An interview with the clinical manager was conducted on 6/3/2025 at approximately 3:45pm. When asked about what the expectation is for having a complete medication list in the clinical record at start of care, the clinical manager confirmed that the expectation is that the medications should be added on the start of care visit. PT #13 was not available for an interview, so the Administrator was interviewed on 6/4/2025 at 11:19 am and asked “what is the expectation on how long it should take to have meds entered at start of care?” The reply was “the whole start of care should be completed in the first 24 hours”.”

“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 agency policy, home visit observations, clinical record review, and staff interviews, the Plan of Care failed to include all/current medications for 3 of 6 patients who received a home visit (patients #6, 9, and 11). The findings included: A policy, Medication Profile and Medication Reconciliation, (revised 01/2025), was presented by the agency administrator on 6/4/2025 at 9:55 am. The policy stated, “The comprehensive assessment of the patient includes a review of all medications the patient is using…a current listing of all medications the patient is using is maintained in the clinical record at all times.” 1.Patient #6 was admitted on 5/2/2025 with a diagnosis of Unspecified intracapsular fracture of left femur, subsequent encounter for closed fracture with routine healing (a healing left hip fracture). The plan of care for 5/2/2025-6/30/2025 included orders for occupational therapy visits 2 times a week for 2 weeks and 1 time a week for 3 weeks. During a home visit on 6/2/2025 at approximately 4:00 pm with COTA (Certified Occupational Therapy Assistant) #8, a medication review was conducted using a medication list provided by the agency and the following discrepancies were noted: The medication list did not include Vitamin B-12 (used to treat and prevent anemia, which is a condition in which the blood does not have enough healthy red blood cells)1000mcg monthly, Furosemide (used to treat fluid retention) 20mg daily, and Actos (used to control blood sugar levels) 30 mg daily. The patient confirmed that she is taking these medications. Metformin (used to control blood sugar levels) 500mg was listed as once a day. The patient stated that they took this medication twice a day. During an interview on 6/4/2025 at 10:13 am, when asked “how often do you do a complete medication review?” COTA #8 stated “I do a med review each visit” and confirmed that the plan of care was incorrect. 2.Patient #9 was admitted on 4/28/2025 with a diagnosis of Acute pulmonary edema (fluid in the lungs, making it difficult to breathe). The plan of care for 4/28/2025-6/26/2025 included orders for PT (physical therapy) 1 time a week for 9 weeks. During a home visit on 6/3/2025 at approximately 12:30 pm with PT #10, a medication review was conducted using a medication list provided by the agency and the following discrepancies were noted: The medication list did not include Trelegy (a combination of inhaled medications used to treat asthma and chronic obstructive pulmonary disease) 1 puff daily, Vitamin D2 (used for strengthening bones and teeth) 1.25 mcg 1 time a week, and Prednisone (steroid used treat inflammation and help with immune response) 10 mg every other day. The patient confirmed they are taking these medications. Fluoxetine (used to treat depression) 20 mg was listed as 3 capsules daily. The patient stated they are taking 2 capsules daily. Breo Ellipta (a combination of inhaled medications used to treat asthma and chronic obstructive pulmonary disease) 1 puff daily, Famotidine (used to treat excess stomach acid) 20mg 2 times daily, Miralax (used to treat constipation) 17g daily, and Omeprazole (used to treat excess stomach acid) 40 mg daily had been discontinued and were still on the agency medication list. During an interview on 6/4/2025 at 11:57 am, when asked “how often do you do a complete medication review?” PT #10 stated “I ask about meds each visit. Therapy does a complete med review at reassessment (30 days). I also do it when there are med interactions or new or discontinued meds”. PT #10 confirmed that the plan of care was incorrect. 3.Patient #11 was admitted on 8/6/2024 with a diagnosis of Encounter for adjustment and management of VAD (vascular access device which provides access to the blood stream, allowing for repeated long-term infusions of medications, fluids, or blood products or for blood sampling). The plan of care for 6/2/2025-7/31/2025 included orders for SN (skilled nurse) 1 time a week for 9 weeks. During a home visit on 6/3/2025 at approximately 9:00 am with RN (registered nurse) #7, a medication review was conducted using a medication list provided by the agency and the following discrepancies were noted: Acyclovir (anti-viral) 800 mg was listed as 1 tablet 2 times a day on the medication list. The patient stated they are taking ½ a tablet 2 times a day. Atorvastatin (used to lower cholesterol) 20 mg at bedtime, Diltiazem (used to treat high blood pressure) 120 mg 1 capsule daily, Hydralazine (used to treat high blood pressure) 25 mg every 8 hours as needed for systolic blood pressure greater than 160 or diastolic blood pressure greater than 100, Remeron (used to treat depression) 15 mg at bedtime, and Telmisartan (used to treat high blood pressure) 20 mg ½ tablet daily had been discontinued and were still on the agency medication list. During an interview on 6/4/2025 at 10:48 am, when asked “how often do you do a complete medication review?” RN #7 stated “I do one each visit” and confirmed that the plan of care was incorrect. The Administrator, on 6/4/2025 at 10:14 am, was asked “What is the expectation on how often a complete med review should be done?” She replied, “obviously, to pull them (medication bottles) out each visit.””

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on agency policy, clinical record review, and staff interviews, the agency included inaccurate information for 2 of 19 clinical records. (patients # 5 & 8) Finding included: A policy, Legal Aspects of Clinical Documentation (revised 01/2025) received on 06/04/2025 at 8:00 AM from the agency administrator stated, “Chart [document] completely, concisely and accurately.” 1. Patient #5 was a male, admitted on 02/01/2024 with a diagnosis of urinary tract infection. The plan of care for 02/01/2024-03/31/2025 included orders for physical therapist (PT) visits 1 time a week for 1 week, 2 times a week for 3 weeks, and 1 time a week for 2 weeks. Inaccurate documentation included the following: A. Review of the clinical record revealed that on 02/01/2024 PT #6 documented, “Hospitalized for lower GI [gastrointestinal] bleed Bishop [sic] presents the Physical Therapy live in a one level apartment…” An interview conducted on 06/04/2025 at 12:49 PM with PT #6 revealed that the patient was not a Bishop and the patient not physical therapy lived in a one level apartment. PT #6 stated, “My accent causes a problem with dictation.” B. Review of the clinical record revealed that on 02/16/2025 PT # 6 documented, “Visit cancelled, she has too much pain.” An interview conducted on 06/05/2025 at 12:49 PM with PT #6 revealed that patient #5 was a male and did not identify as female. PT #5 stated, “Maybe it’s supposed to be he.” 2. Patient # 8 was admitted on 05/13/2025 with a diagnosis of Unspecified chronic otitis, externa, bilateral (inflammation of the external auditory canal lasting more than 3 months). The plan of care for 05/13/2025-07/11/2025 included orders for skilled nurse (SN) visits 1 time a week for 9 weeks with 2 PRN (as needed) and physical therapist (PT) visits 1 time a week for 1 week, 2 times a week for 3 weeks, 1 time a week for 1 week. On 05/13/2025 registered nurse (RN) #14 documented “recent diagnosis of malignant otitis exterior [serious infection that spreads from the outer ear canal into the skull]. Inaccurate documentation included the following: A. Review of the clinical record revealed that on 05/13/2025 RN #14 documented, “had PICC [peripherally inserted central catheter, tube inserted into a vein in the arm] placed in left chest.” Further review revealed that patient #8 had a central line 9tube inserted near the heart for medication delivery) placed in the left chest. Review of the clinical record revealed that 3 of 3 SN visits conducted by RN# 5 included documentation of PICC line care. An interview conducted on 06/04/2025 at 1:07 PM with RN #5 revealed that patient #8 had a central line in the left chest. B. Review of the clinical record revealed that on 01/09/2025 PT #6 documented, Endocrine/Hematologic “cancer.” Further review revealed that patient #8 did not have a diagnosis of cancer. During an interview conducted on 06/04/2025 at 12:49 PM PT #6 denied documenting endocrine/hematologic cancer and stated, “It was just cancer, I think it was triggered by the word malignant.” An interview conducted on 06/04/2025 at approximately 12:55 with the agency director revealed that PT#6 did document endocrine/hematologic cancer. C. Review of the clinical record revealed that on 05/21/2025 occupational therapist (OT) #11 documented, “Hospitalized for acute malignant otitis tumor of left ear.” Further review revealed that patient #8 did not have a tumor of the left ear. During an interview conducted on 06/04/2025 at 11:48 AM OT #11 stated, “I couldn’t find where I got that, when I saw malignant, I added that.” During an interview conducted on 06/04/25 at 12:38 PM the agency administrator stated, “My expectation is that they don’t add or presume any diagnoses. The documentation should be accurate.””