Liberty Home Care, LLC

“Discharge Planning CFR(s): 484.58(a) Standard: Discharge planning. An HHA must develop and implement an effective discharge planning process. For patients who are transferred to another HHA or who are discharged to a SNF, IRF or LTCH, the HHA must assist patients and their caregivers in selecting a post-acute care provider by using and sharing data that includes, but is not limited to HHA, SNF, IRF, or LTCH data on quality measures and data on resource use measures. The HHA must ensure that the post-acute care data on quality measures and data on resource use measures is relevant and applicable to the patient’s goals of care and treatment preferences. This Standard is not met as evidenced by: Based on agency policy, clinical record review, and employee interview, the agency failed to coordinate discharge planning with the patient and/or caregiver and physician for 1 of 3 discharge records reviewed. (Patient #8) Findings included: Policy 10359749, titled “Discharge and Transfer of Patients” and last revised 09/2021, revealed, “The case manager involves the physician/NPP, other staff, and the patient/family in identifying and planning for continuing care needs after discharge from home health services…” and “The patient/family/representative receives notification of the intent to terminate home health services at least 48 hours before discharge…At the time of discharge, patients receive written and verbal instructions regarding any resources available to meet continuing care needs…” Patient #8 was admitted to the agency 03/18/24 with diagnoses including urinary tract infection, pressure ulcer of right heel, hypothyroidism (under-active thyroid gland), and atrial fibrillation (irregular heart rhythm). Plan of Care (POC) from 03/18/24 to 05/16/24 revealed orders for skilled nursing one time per week for two weeks with two as needed (PRN). POC from 05/17/24 to 07/15/24 revealed orders for skilled nursing zero times for one week, one time per week for eight weeks, zero times for one week, and three PRN; physical therapy zero times for one week, two times per week for four weeks, and occupational therapy one time per week for one week, zero times for three weeks, and one time per week for one week. On 05/14/24 at 11:09 AM Employee #4, registered nurse, conducted a recertification visit. On 05/16/24 at 9:52 AM, Employee #5, physical therapist conducted an assessment/evaluation visit and documented that Patient #8 would “benefit from resumption of PT [physical therapy] services to address ongoing functional impairment and promote return to PLOF [prior level of functioning] at least minimize burden of care on daughter-in-law and son. On 05/16/24 at 7:45 PM, Employee #5 conducted a discharge non-visit and noted that the patient “was hospitalized again for another UTI”. The discharge documentation took place prior to Patient #8 going to the emergency department with UTI symptoms and admission to the hospital on 05/19/24. There was no evidence that the agency provided 48-hour discharge notice or coordinated the discharge with the patient and/or caregivers or physician. On 06/11/24 at approximately 1:00 PM, Employee #5 stated that he conducted the assessment visit on 05/16/24 with plans to continue physical therapy services but he was later contacted by the office and told to complete a discharge non-visit due to Patient #8’s hospitalization. On 06/11/24 at approximately 1:05 PM, Employee #1, agency director, stated that the patient and/or family were notified of the agency’s discharge and inability to readmit by the hospital’s case manager and stated that that documentation should have been in the clinical record regarding that care coordination.”

“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 follow accepted standards of practice to prevent the transmission of infection for 2 of 6 patients with home visits. (Patients #6, #13) Findings included: A policy, Exposure Control Plan; Engineering and Work Practice Controls (revised 09/2021) was received on 11/28/2023 at approximately 9:30 A.M. from the Regional Clinical Manager. The policy stated, “Hand Hygiene…Before and after having direct contact with patients… if moving from a contaminated body site to another… after removing gloves…” A policy, Exposure Control Plan: Cleaning and Disinfection Reuseable equipment (revised 10/2021) was received on 11/28/2023 at approximately 9:30 A.M. from the regional clinical manager. The policy stated, “Cleaning and Disinfection of the Point of Care Computer Device…When working with patients, it is important for the clinicians to keep their computers clean and sanitized.” Patient # 6 was admitted on 11/09/2023 with a diagnosis of aftercare following a surgical amputation (removal of a body part). The plan of care for 11/09/2023-01/07/2024 included orders for skilled nurse (SN) visits 1 time a week for 1 week, 1 time a week for 8 weeks, and 2 PRN (as needed) and, SN to complete wound care to left 4th toe amputation site. A home visit was conducted with LPN #4 on 11/27/2023 at approximately 3:00 P.M. LPN #4 donned clean gloves, removed the soiled dressing from the wound, removed the dirty gloves and donned clean gloves. LPN #4 failed to perform hand hygiene before donning clean gloves. LPN #4 disinfected the bandage scissors, removed the dirty gloves, and donned clean gloves. LPN #4 failed to perform hand hygiene before donning clean gloves. LPN #4 placed the documentation tablet on a visibly soiled chair. LPN #4 removed dirty gloves and failed to perform hand hygiene prior to handling the documentation tablet. Patient #6 handled the tablet and stylus to sign for the visit. LPN #4 failed to disinfect the tablet prior to providing it to the patient. LPN #4 failed to disinfect the stylus and tablet after the patient handled it. An interview was conducted with LPN #4 on 11/29/2023 at approximately 1:45 P.M. LPN #4 stated, “Hand hygiene should be done before doing any patient care and after patient care, when going in and out of my bag, and I would normally do hand hygiene with glove changes. I put the tablet in the chair with a cushion, there’s supposed to be a barrier. I clean and sanitize tablet before I go into a patient’s house.” An interview was conducted on 11/27/2023 at approximately 4:15 P.M. with the clinical manager. The clinical manager stated, “Hand hygiene should occur between glove changes. The tablet should be placed on a clean surface and cleaned after use.” Patient #13 was admitted to the agency on 10/27/23 with diagnoses including chronic obstructive pulmonary disease (COPD-chronic lung disease), hypertensive heart disease with heart failure (high blood pressure with heart disease), and obstructive sleep apnea (a condition in which breathing is interrupted multiple times during sleep). Plan of Care from 10/27/23 to 12/25/23 revealed orders for physical therapy one time per week for eight weeks effective 10/30/23. Employee #5, physical therapist, was observed conducting a home visit on 11/28/23. During the visit, Employee #5 placed the electronic tablet used for documentation on the patient’s bed between tasks. In an interview on 11/29/23 at 1:20 PM, Employee #5 stated that he would not typically place the electronic tablet on a patient’s bed and that he would typically place it on his lap or on top of his clinical bag. In an interview on 11/29/23 at 1:20 PM, Employee #1, agency director, stated “They should not [place the electronic tablet on a patient’s bed]””

“5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient’s immediate needs, but no later than 5 calendar days after the start of care. This Element is not met as evidenced by: Based on clinical record review and staff interviews the agency failed to complete the comprehensive assessments within 5 days for 2 of 5 discharged patients (#3, #10) and 2 of 6 patients with home visits conducted (#6, #17), and 1 of 9 records reviewed without home visits (#8). Findings included: 3. Patient # 10 was admitted on 10/21/23 with diagnoses of pressure ulcer of the left heel and a fractured femur (thigh bone). The plan of care for 10/21/23-12/19/23 included orders for skilled nurse (SN) visits 1 time a week for 10 weeks and 3 PRN (as needed), home health aide visits (HHA) 1 time a week for 5 weeks, and speech therapy (ST) visits 1 time a week for 1 week and 1 time a week for 6 weeks. The referral for home health care included physician orders for SN, ST, physical therapy (PT), occupational therapy (OT), and medical social worker (MSW) visits. The initial PT assessment was conducted on 11/01/2023, 11 days after the start of care (SOC). The initial MSW assessment was conducted on 11/02/2023, 12 days after the SOC. The initial ST assessment was conducted on 11/06/2023, 16 days after the SOC. There was no evidence in the clinical record of an OT assessment. There was no documented reason that the assessments were not completed within 5 days. 4. Patient #6 was admitted 11/09/2023 with a diagnosis of aftercare following a surgical amputation (removal of a body part) of left toe (removal. The home health referral included orders for skilled nursing (SN), physical therapy, (PT) occupational therapy (OT), and home health aide (HHA). The plan of care for 11/09/2023-01/07/2023 included orders for SN visits 1 time a week for 1 week, 1 time a week for 8 weeks, and 2 PRN (as needed), PT 1 time a week for 2 weeks, 2 times a week for 2 weeks, 1 time a week for 1 week, and HHA 0 times a week for 1 week and 1 time a week for 8 weeks. There was no evidence in the clinical record that the OT conducted an assessment. 5. Patient #17 was admitted on 11/19/2023 with a diagnosis of cutaneous (relating to the skin) abscess of back. The home health referral included orders for skilled nursing (SN), physical therapy (PT), occupational therapy (OT), and home health aide (HHA) visits. The plan of care for 11/19/2023-01/17/2023 included orders for SN 2 times a week for 8 weeks, 1 time a week for 1 week, and 2 PRN (as needed) and PT 1 time a week for 9 weeks. Patient #17 declined HHA visits. There was no evidence in the clinical record that an OT assessment was conducted. An interview was conducted on 11/29/23 at approximately 12:00 P.M. The agency director stated, “We [agency name] want the initial assessments [for all disciplines] to be completed within 48 hours of the start of care, definitely within 5 days or the doctor should be notified.” 1. Patient #3 was admitted to the agency on 06/25/23 with diagnoses including Type 2 diabetes, chronic obstructive pulmonary disease (COPD-chronic lung disease), and chronic pressure ulcers of the right and left heels. The Plan of Care included an admission narrative which revealed, “Discharged to home from rehab with referral to [agency name] for SN [skilled nurse] teaching, PT [physical therapy] for mobility strength exercises, and gait training, OT [occupational therapy] for ADL [activities of daily living] teaching, and MSW [medical social work] to help with getting additional resources…This SN [skilled nurse] contacted [name of primary care physician] office for VO [verbal order] for SOC [start of care] SN, PT, OT, and MSW orders were requested…” An order dated 06/26/23 revealed, “Pt [patient] and cg [caregiver] interested in additional resources if they qualify… specifically meals on wheels. VO [verbal order] received from [name or primary care provider] office for MSW order.” On 07/05/23, Employee #11, medical social worker, entered a communication note that read, “SW [social worker] had a delay in completing assessment due to being able [sic] to reach patient/family by phone. MD/staff notified.” There was no documented evidence of attempts to reach Patient #3 or her family within the five-day allowance for completion of the comprehensive assessment in the clinical record. In an interview on 11/29/23 at 11:55 AM, Employee #11 stated that she would typically document any attempts to reach the patient or family in the clinical record and “…If it [documentation of attempts to reach the patient or family] is not there [in the clinical record], then clearly that documentation isn’t there…” In an interview on 11/29/23 at 11:55 AM, Employee #1, agency director, confirmed that there was no documentation in the clinical record of attempts to reach the patient or family within the five-day allowance for completion of the comprehensive assessment. 2. Patient #8 was admitted to the agency on 10/30/23 with diagnoses including cirrhosis of the liver (a type of liver damage), Type 2 diabetes, and chronic kidney disease. Plan of Care from 10/30/23 to 12/28/23 revealed orders for physical therapy (one time per week for two weeks, two times per week for one week, one time per week for two weeks, two times per week for two weeks, and one time per week for two weeks effective 10/30/23) and medical social worker (one time per month for one month effective 10/30/23). The medical social work (MSW) assessment was conducted 11/21/23, which was outside of the five-day allowance for completion of the comprehensive assessment. In an interview on 11/29/23 at 11:42 AM, Employee #1, agency director, acknowledged that the medical social worker assessment was not conducted timely and stated that the initial order was entered into the computer system incorrectly, which allowed the visit timeframe to fall outside of the five-day allowance for completion of the comprehensive assessment. There was no evidence that the physician was notified of the delayed medical social work assessment.”

“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, clinical record review, observation, and patient and staff interviews, the agency failed to include all medications in the comprehensive assessment for 1 of 6 patients with home visits conducted. (patient #12). Findings included: A policy, Medication Profile and Drug Review (revised 03/2021) was received on 11/29/2023 at approximately 12:00 P.M. from the agency director. The policy stated, “On each visit, the therapist: Assesses/documents the following on each subsequent visit (asks to see medications): Med (New/changed/discontinued meds)…Updates the medication profile.” Patient #12 was admitted on 10/02/2023 with diagnoses of encounter for change or removal of surgical dressing, high blood pressure, and chronic obstructive pulmonary disorder (COPD). The plan of care (POC) included orders for physical therapy (PT) 1 time a week for 1 week, 2 times a week for 2 weeks, and 1 time a week for 6 weeks. A home visit was conducted on 11/27/2023 at approximately 2:15 P.M. with PT #3. A comprehensive medication review found discrepancies as follows: Fluoxetine (treats depression) 20mg oral capsule 1 capsule 1 time daily was included in the POC. Patient #12 stated, “I have not taken that for months.” Azithromycin (antibiotic urinary tract infection prevention) 250mg capsule 1 tab (tablet) 3 times a week was not included in the POC. Patient #12 stated, “I have been on that for months.” Nebivolol (treats high blood pressure) 2.5mg tablet 1 tablet daily was omitted from the POC. Patient #12 stated, “I’ve been on that a good long time.” Breztri Aeroshere Inhalation Aerosol (treats COPD) 2 puffs BID (2 times daily) was omitted from the POC. Patient #12 was unable to recall how long ago it was prescribed. Furosemide (reduces excess fluid) 20mg oral tablet 1 tablet daily was included on the POC. Patient #12 stated, “I take those 3 times a week as needed, for months.” Klor-Con (potassium chloride) (prevents low potassium related to furosemide use) 10 meq (milliequivalent) tablets 1 tablet 3 times a week as needed with the furosemide was omitted from the POC. Patient #12 stated, “I take those 3 times a week as needed, for months.” Cyanocobalamin (vitamin B-12) 100 MCG/mL Injectable Solution 1mL intramuscular (IM) monthly was omitted from the POC. Patient #12 stated, “That’s been years.” Dexlansoprazole (treats acid reflux) 60 mg oral delayed release capsule 1 time daily was included in the POC. Patient #12 stated, “That was replaced with famotidine [treats acid reflux] 6 months ago.” An interview was conducted on 11/29/2023 with PT #3 at approximately 1:00 P.M. PT #3 stated, “Well, I do them [comprehensive medication review] every visit.” An interview was conducted on 11/27/23 at 3:16 PM with the Clinical Manager. The clinical manager stated, “It [complete medication reconciliation] should be done every visit by all disciplines. They [medication discrepancies] should be clarified with the doctor.””