Liberty Home Care II, LLC

“Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient’s status at the time of assessment. This Standard is not met as evidenced by: Based on agency policy, clinical record review and staff interviews, the agency failed to ensure OASIS [The Outcome and Assessment Information Set- patient-specific standardized assessment] documentation was accurate for 2 of 7 records reviewed [ #3 and 4 ]. The findings included: The policy, Comprehensive Assessment/OASIS Collection, Encoding and Transmission [1/2025], was provided by the agency administrator on 12/3/25 at 1 pm. The policy stated, “...Each patient that is admitted to ______ [name of the agency] services will receive a patient-specific comprehensive assessment that accurately reflects the patient’s current health status...” 1. Patient # 3 had a Start of Care date of 11/11/25 with an admitting diagnosis of chronic obstructive pulmonary disease [COPD-lung condition]. Review of the clinical record revealed RN # 4 completed the OASIS [The Outcome and Assessment Information Set- patient-specific standardized assessment] on 11/11/25. Review of the OASIS documentation N0415 High Risk Drug Classes does not capture the use of Aspirin 81 mg [antiplatelet] as listed on the plan of care. During an interview with the agency administrator on 12/3/25 at 12:30 pm, the administrator confirmed the OASIS was inaccurate related to high-risk drug classes. 2. Patient # 4 had a Start of Care date of 10/18/25 with an admitting diagnosis of urinary tract infections. Review of the clinical record revealed RN # 4 completed the OASIS [The Outcome and Assessment Information Set- patient-specific standardized assessment] on10/18/25. Review of the OASIS documentation N0415 High Risk Drug Classes does not capture the use of Rivaroxaban 15 mg [anticoagulant] as listed on the plan of care. During an interview with the agency administrator on 12/3/25 at 12:30 pm, the administrator confirmed the OASIS was inaccurate related to high-risk drug classes.”

“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 direct observation, clinical record review and staff interviews, the Plan of Care failed to include all medications the patient was taking for 3 of 3 home visits [#5, 6 and 7]. The findings included: 1. Patient # 5 had a Start of Care date of 11/21/25 with an admitting diagnosis of hemiplegia [paralyzed on ½ side of the body] following non-traumatic subarachnoid hemorrhage [stroke] of right side. Review of the Plan of Care [POC] for the certification period 11/21/25-1/19/25 included orders for PT [physical therapy] 1 time a week for 2 weeks, 1 time every other week for 7 weeks. On 12/2/25 at approximately 12:30 pm a joint visit was made with PT # 2. During the visit, a medication review was conducted using the medication profile provided by the agency. The following discrepancy was noted: The medication profile listed Erythromycin 5 mg/gm ophthalmic ointment. The medication profile stated, “...1 drop in left eye every 4 hours...” During an interview with the daughter at the visit, the daughter stated, “Mama has already completed that medication. She doesn’t use it anymore.” During an interview with the agency clinical manager on 12/3/25 at approximately 2 pm, the manager confirmed the POC did not include all the current medications. 2. Patient # 6 had a Start of Care date of 10/31/25 with an admitting diagnosis of wedge compression fracture T 11-T 12 vertebra [front part of the eleventh or twelfth thoracic vertebra (mid-to-lower back) has collapsed, forming a wedge shape]. Review of the Plan of Care [POC] for the certification period 10/31/25-12/29/25 included orders for OT [occupational therapy] effective 11/10/25 1 time a week for 1 week, 1 time every other week for 5 weeks. On 12/3/25 at approximately at 10 am a joint visit was made with OT # 1. During the visit a medication review was conducted using a medication profile provided by the agency. The following discrepancy was noted: The medication profile listed Furosemide [fluid medication] 20 mg daily. During the home visit, the patient presented a medication bottle with instructions to take 2 tablets per day. During the interview with the patient, the patient stated, “I have been taking 2 pills each day for about 2 months.” During an interview with the agency clinical manager on 12/3/25 at approximately 2 pm, the manager confirmed the POC did not include all the current medications. 3. Patient # 7 had a Start of Care date of 9/13/25 with admitting diagnoses of venous insufficiency [leg veins have faulty valves, causing blood to pool, leading to symptoms like leg swelling, aching, heaviness, varicose veins, skin discoloration, itching, and, in severe cases, non-healing venous ulcers] and non-pressure chronic ulcer of other part of left foot. Review of the Plan of Care [POC] for the certification period 11/12/25-1/10/26 included orders for SN [skilled nursing] 1 time a week for 8 weeks. On 12/2/25 at 2 pm, a joint visit was made with RN # 5. During the visit, a medication review was conducted using a medication profile provided by the agency. The following discrepancies were noted: The patient reported taking Probiotic 1 capsule daily and Mag Oxide [supplement] 400 mg each day. Neither medication was included in the medication profile. The patient reported she has been using these medications since before being admitted to home health. During an interview with the agency clinical manager on 12/3/25 at approximately 2 pm, the manager confirmed the POC did not include all the current medications.”

“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 RN documented a left intrajugular central line [a type of central venous catheter [CVC] inserted into the internal jugular vein in the neck which allows for long-term access to the central venous circulation] was flushed with heparin [anticoagulant] for 1 of 1 patient with a left intrajugular central line [# 2 ]. The findings included: Patient # had a Start of Care date of 1/20/25 with admitting diagnoses of post-surgical malabsorption [condition that exists when a person is unable to absorb nutrients after a surgical procedure and encounter for adjustment and management of VAD [vascular access device- a medical tool, like a tube or port, inserted into a vein to provide long-term or repeated access to the bloodstream for delivering meds, fluids, nutrition, or drawing blood]. Review of the Plan of Care for the certification period 1/20/25-3/20/25 included orders for SN [skilled nursing] 1 time a week for 9 weeks and “...SN to perform sterile dressing changes to left IJ [intrajugular] and [sic] central line [a type of central venous catheter (CVC) inserted into the internal jugular vein in the neck, which allows for long-term access to the central venous circulation] Q [every] Monday...Upon blood return, inject 10 cc of normal saline slowly into the catheter...Flushed [sic] with 0.9% sodium chloride [normal saline] 10 cc...”Review of the clinical record revealed RN # 5 conducted routine visits on 1/27/25, 2/3/25, 2/10/25 and documented, “...Flushed with 0.9 % NS [normal saline] and 5,000 units Heparin [anticoagulant] 5 cc...” Further review of the clinical record revealed there was no order to use a Heparin Flush. During an interview with the agency administrator on 12/3/25 at 12:30 pm, the administrator stated, “She didn’t use heparin. That is what happens when we use a template for documentation.””

“Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This Element is not met as evidenced by: Based on clinical record review and staff interviews the home health aide care plan failed to included “Bleeding Precautions” under the safety section for 1 of 1 patient receiving home health aide services who was receiving an anticoagulant {#4]. The findings included: Patient # 4 had a Start of Care date of 10/18/25 with an admitting diagnosis of urinary tract infections. Review of the Plan of Care [POC] for the certification period 10/18/25-12/16/25 included orders for SN [skilled nursing] 1 time a week for 3 weeks, HHA [home health aide] 1 time a week for 3 weeks. Further review of the POC revealed the patient order taking Rivaroxaban 15 mg [anticoagulant]. The aide care plan was completed by RN # 4 on 10/18/25. Review of the safety precautions on the aide care plan did not include “Bleeding Precautions.” During an interview with the agency administrator on 12/3/25 at 12:30 pm, the administrator confirmed the aide care plan should have included bleeding precautions.”