Liberty Home Care

“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 agency policy, clinical record review, and staff interviews the agency failed to track and analyze adverse patient events for 2 of 2 patients that experienced falls. (Patients #11 and #17) Findings included: A policy, Non-Routine Events (revised 01/2021) was received on 01/24/2024 at approximately 8:30 AM from the agency director. The policy stated, “A non-routine event may include…: Any falls that have occurred since the last clinician visit…The non-routine event is documented on-line within 24-48 hours on the Non-Routine Event Form…The supervisor investigates the details of the event…” 1. Patient #11 was admitted on 12/01/2023 with a diagnosis of cellulitis (a bacterial infection of the skin) of the left lower limb. The plan of care for 12/01/2023-01/29/2024 included orders for skilled nurse (SN) visits 1 time a week for 1 week, 2 times a week for 8 weeks, and 3 prn (as needed) visits. For the SN visit of 12/22/2023 LPN #11 stated, “Pt [patient] reports she fell this am around 4 off the bed and had to go to the ER [emergency room]. There was no evidence of reporting or analyzing on the Non-Routine Event log. 2. Patient #17 was admitted on 01/12/2024 with a diagnosis of Pressure Ulcer (wound) of right buttock. A home visit was conducted on 01/23/2024 with registered nurse (RN) #5 at approximately 8:30 AM. The plan of care for 01/12/2023-03/11/2024 included orders for physical therapy (PT) visits 1 time a week for 1 week, 2 times a week for 2 weeks, and 1 time a week for 5 weeks and skilled nurse visits 0 times a week for 1 week, 1 time a week for 8 weeks, and 2 PRN (as needed) visits. For the PT visit of 01/16/2024 PT #3 stated, “Reports 1 fall since being home when CG [caregiver] found Pt. [patient] In [sic] floor…” There was no evidence of reporting or analyzing on the Non-Routine Event log. An interview was conducted on 01/24/2024 with LPN #11 at approximately 1:45 PM. LPN #11 stated, “Honestly, I don’t know if I completed the NRE [Non-Routine Event]. We do document in the NRE about a fall.” An interview was conducted on 01/24/2024 with PT #3 at approximately 12:40 PM. PT #3 stated, “Yes [remembers family reporting a fall]. I documented it into his chart and called the doctor’s office and had forgotten to do the NRE.” An interview was conducted on 01/24/24 at approximately 11:30 AM with the clinical manager. The clinical manager stated, “A fall is an NRE non-routine event for [agency name], that’s how they are tracked.””

“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 maintain clean equipment and dispose of a contaminated would dressing for 1 of 7 patients with conducted home visits (Patient #17) and the agency’s home health aide failed to perform hand hygiene after glove removal for 1 of 1 home health aide visits observed (Patient #14). Findings included: PolicyStat ID 10382835, last revised 09/21 and titled “Exposure Control Plan: Engineering and Work Practice Controls” was received on 01/24/24 at 8:30 AM from the agency director. This policy revealed, “If hands are not visibly soiled, the use of an alcohol-based hand rub for routinely decontaminating hands is the preferred method for hand hygiene in all of the following clinical situations…after removing gloves and other PPE [personal protective equipment]” Patient #14 was admitted to the agency 5/16/23 with diagnoses including left lower leg wound, congestive heart failure (heart does not pump blood efficiently), and chronic kidney disease. Plan of Care from 01/11/24 to 03/10/24 revealed orders for skilled nursing one time per week for one week and two times per week for eight weeks, and home health aide zero times per week for one week and one time per week for five weeks. A home visit, conducted by Employee #13, home health aide, was observed on 01/23/24. Employee #13 assisted Patient #14 with a chair bath and when the bath was complete, Employee #13 removed her gloves and assisted the patient with ambulation to the front room of the home. Employee #13 did not perform hand hygiene after she removed her gloves. In an interview on 01/24/24 at 1:31 PM, Employee #13 acknowledged that she did not perform hand hygiene after removing her gloves during the observed visit and stated that hand hygiene should be performed, “right after and right before” glove removal and glove placement. A policy, Bag technique, home care (revised 05/22/2023) was received on 01/24/2024 from the agency director at approximately 8:30 AM. The policy stated, “If a product is expired, is defective, or has compromised integrity, remove it from patient use.” A policy, Exposure Control Plan: Engineering and Work Practice Controls (revised 09/2021) was received on 01/24/2024 from the agency director at approximately 8:30 AM. The policy stated, “When working with patients, it is important for clinicians to keep company-issued devices clean and sanitized...” Patient #17 was admitted on 01/12/2024 with a diagnosis of Pressure Ulcer (wound) of right buttock. The plan of care for 01/12/2023-03/11/2024 included orders for skilled nurse visits 0 times a week for 1 week, 1 time a week for 8 weeks, and 2 PRN (as needed) visits and SN (skilled nurse) taught cg (caregiver) to perform pressure ulcer care to R (right) side of buttocks every 3-5 days. Cleanse wound with wound cleanser, apply hydrocolloid dressing using asceptic (sterile) technique. A home visit was conducted on 01/23/2024 with registered nurse (RN) #5 at approximately 8:30 AM. RN #4 performed a physical assessment on patient #17 and removed the contaminated gloves. The contaminated gloves came in contact with the documentation tablet (electronic device). RN #4 failed to disinfect the tablet. RN #4 completed wound care on patient #17. A clean dressing came into contact with the contaminated documentation tablet. RN #4 failed to dispose on the dressing. An interview with RN #4 on 01/23/2024 at approximately 9:30 AM revealed that RN #4 normally keeps the documentation tablet with the clean wound care supplies. An interview with the clinical manager was conducted on 01/23/2024 at approximately 9:35 AM. The clinical manager stated, “The tablet should have been cleaned [after contact with the dirty gloves] and the dressing should have been thrown out [after contact with the tablet].”

“Before discharge for cause HHA must: CFR(s): 484.50(d)(5) The HHA determines, under a policy set by the HHA for the purpose of addressing discharge for cause that meets the requirements of paragraphs (d)(5)(i) through (d)(5)(iii) of this section, that the patient’s (or other persons in the patient’s home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the HHA to operate effectively is seriously impaired. The HHA must do the following before it discharges a patient for cause: This Element is not met as evidenced by: Based on agency policy, clinical record review, and staff interview the agency failed to notify a patient/representative that a discharge from occupational therapy for cause (uncooperative for care) was being considered and failed to make efforts to resolve the problem for 1 of 1 patient that was discharged for cause. (patient #4) Findings included: A policy, Discharge and Transfer of Patients (revised 09/2021) was received on 01/24/2024 at approximately 8:30 AM from the agency director. The policy stated, “The following must be done before the patient is discharge: Advise the patient, representative [if any]… that a discharge for cause is being considered; Make efforts to resolve the problem(s) presented by the patients behavior…” Patient #4 was admitted on 03/14/2023 with a diagnosis of nondisplaced (in proper alignment) oblique (at an angle) fracture of the shaft of the right femur (upper thigh bone). The plan of care from 03/14/2023-05/12/2023 included orders for physical therapy 1 time a week for 9 weeks, medical social worker visits 1 time a week for 1-week, occupational therapy (OT) visits 1 time a week for 1 week, 0 times a week for 2 weeks and, 1 time week for 1 week. For the OT evaluation visit of 03/15/2023 OT #14 stated, “OT will see for 2 more visits once pain and anxiety is addressed to reassess for further OT needs.” On the OT visit on 04/06/2023 OT #14 stated, “OT discharge without visit… OT eval [evaluation] completed 03/15/2023. At the time patient was non-compliant with attempts with bed mobility.” There was no evidence in the clinical record that OT #14 informed the patient/representative that a discharge for cause was being considered or made efforts to resolve the problem.” OT #14 was not available for an interview. An interview was conducted with the agency director on 01/24/2024 at approximately 9:15 AM. The agency director stated, “There is no 48-hour notification of discharge and no signed order for OT discharge. They normally would call the doctor from the home, educate patient and caregiver, that they have to participate to meet goals, that should have happened prior to discharge.””

“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 without delay, report neglect of 1 of 1 patient living in an unsafe environment. (patient #4) Finding included: A policy, Reporting abuse and Neglect (revised 03/2021) was received on 01/24/2024 at approximately 8:30 AM from the agency director. The policy stated, “Neglect means failure to provide goods and services necessary to avoid physical harm…Immediately means as soon as possible but not to exceed 24 hours…Personnel with knowledge or reasonable suspicion of an abuse, neglect or exploitation violation will make an immediate report to the appropriate [i.e., Adult Protective Services…] protective services unit of the local Department of Social Services [DSS].” Patient #4 was admitted on 03/14/2023 with a diagnosis of nondisplaced (in proper alignment) oblique (at an angle) fracture of the shaft of the right femur (upper thigh bone). The home health referral order of 03/10/2023 stated, “Resident to discharge home on 03/13/2023 with Home health, Nursing, PT [physical therapy] and OT [occupational therapy] services. The plan of care from 03/14/2023-05/12/2023 included orders for physical therapy 1 time a week for 9 weeks, medical social worker visits 1 time a week for 1 week, occupational therapy (OT) visits 1 time a week for 1 week, 0 times a week for 2 weeks and, 1 time week for 1 week. For the skilled nurse visit of 03/17/2023 registered nurse (RN)#4 stated, “Family does not have a wheelchair ramp in home. Discussed with family that if the house caught on fire, how would patient get out of house without wheelchair and wheelchair ramp. Family unsure of how they would get patient out…” There was no evidence in the clinical record that RN#4 notified Adult Protective Service of the potential for harm. For the RN visit of 03/29/2023 RN #9 stated, “Also due to the inability of family to get out of the home and to use the hoyer lift [mechanical lift] to transfer the patient, there are safety concerns for the patient remaining at home. APS referral made…” An interview was conducted on 01/23/2024 at approximately 4:30 PM with RN#4. RN #4 stated, “She was a large woman, she had no way to get out to doctor appointments or get out if there was a fire.” An interview with RN#4 on 01/24/2024 at 9:45 AM revealed that RN #4 had an understanding that all staff are mandated reporters of abuse.”

“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 home visit observation, agency policy, clinical record review, and staff interview, the agency failed to maintain an accurate medication profile for 1 of 7 home visits conducted (Patient #12). Findings included: PolicyStatID 9464970, last revised 03/21 and titled “Medication Profile and Drug Regimen Review, was received from the agency director on 01/24/24 at 12:00 PM. This policy revealed, “If a clinician is assessing the patient’s medications and the patient has a new prescription from a pharmacy (correctly labeled), then the clinician must update the medication profile…If the clinician is assessing the patient’s medications and the patient states that the physician has changed the dosage of a medication, a physician’s order is needed to cover the change in dosage. The clinician contacts the physician to verify the current dosage, documents this in the clinical record, enters a physician interim order for the changed dosage, updates the medication profile and then incorporates the changes onto the next Plan of Treatment.” Patient #12 was admitted to the agency on 12/06/23 with diagnoses including diabetes with foot ulcer (foot wound related to diabetes), congestive heart failure (heart is unable to pump blood efficiently), and chronic kidney disease. Plan of Care from 12/06/23 to 02/03/24 revealed orders for skilled nursing one time per week for nine weeks and occupational therapy one time per week for four weeks, effective 01/15/24. During a home visit observation on 01/23/24, Employee #7, occupational therapist, conducted a review of Patient #12’s medications. Patient #12 stated that she had been taking the following medications that were not listed on the agency’s medication profile: Eliquis (blood thinner), Humalog (insulin), Toujou (insulin) quick pen using a sliding scale (predetermined range of medication to be given based on test results), Toujou and nitroglycerin (used to treat chest pain, as needed. Additionally, the following medications were listed on the medication profile, that Patient #12 stated had been discontinued: Allopurinol (used to treat gout and kidney stones) 50 milligrams. Patient #12 stated that the medication changes discussed on 01/23/24 were not new and had been in effect for months to years. In an interview on 01/24/24 at 1:20 PM, Employee #7 stated, “I usually do it [medication reconciliation] every visit.” In an interview on 01/24/24 at approximately 1:25 PM, Employee #1, clinical manager, stated “That’s [medication reconciliation] supposed to be done every visit…If there are any discrepancies, a nurse contacts and reviews with the doctor.””

“Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This Element is not met as evidenced by: Based on agency policy, clinical record review, and staff interviews the agency failed to provide an on-going interdisciplinary assessment for 1 of 5 discharged patient. (patient #4) Findings included: A policy, Reporting Abuse and Neglect (revised 03/2021) was received on 01/24/2024 at approximately 8:30 AM from the agency director. The policy stated, “Following a report of abuse and neglect to DSS [Department of Social Services], the social worker/social work assistant will follow-up with an immediate visit to the patient’s home… The social work visit is scheduled within 24 hours of the report to DSS.” Patient #4 was admitted on 03/14/2023 with a diagnosis of nondisplaced (in proper alignment) oblique (at an angle) fracture of the shaft of the right femur (upper thigh bone). The plan of care from 03/14/2023-05/12/2023 included orders for medical social worker (MSW) visits 1 time a week for 1 week and MSW to assess psychosocial issues that impact healthcare, need for counseling, financial health, need for access to community resources and long-term care planning. MSW #12 conducted a telephone assessment on 03/17/2023. On 03/20/2023 MSW #12 conducted a telephone visit. MSW #12 stated, “SW [social worker] made referral to CAP [Competitive Acquisition Program] and has a list of ramp resources.” For the RN visit of 03/29/2023 RN #9 stated, “Also due to the inability of family to get out of the home and to use the hoyer lift [mechanical lift] to transfer the patient, there are safety concerns for the patient remaining at home. APS referral made…” There was no evidence in the clinical record of MSW completing an in person visit or having continued involvement with patient #4. An interview was conducted with MSW #12 on 01/24/2024 at approximately 1:00 PM. MSW #12 revealed that MSW #12 was not involved with patient #4 or her family after the telephone call on 03/20/2023. An interview was conducted with the agency director on 01/24/2024 at approximately 1:15 PM. The agency director stated, “We should have done a home visit [MSW, after APS referral].”