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 clinical record review and staff interviews the agency failed to answer N0415 related to high risk medications correctly on the OASIS for 4 of 9 patient records reviewed [ #2, 4, 6 and 9]. The findings included: 1. Patient # 2 had a Start of Care [SOC] date of 2/8/24 with admitting diagnoses of pressure ulcer right buttock unstageable [type of ulcer that occurs when the base of a full-thickness pressure injury is hidden by slough or eschar, making it impossible to determine the ulcer’s depth] and pressure ulcer of sacral [lower back just above the tail bone] area stage II [ulcer that occurs when the outer layer of skin is partially lost]. Review of the Plan of Care [POC] for the certification period 2/8/24-4/8/24 included orders for SN [skilled nursing] 1 time a week for 8 weeks and PT [physical therapy] 1 time a week for 8 weeks. Review of the clinical record revealed RN # 3 completed the SOC OASIS [Outcome and Assessment Information Set-data collection tool used to collect and report assessment data] on 2/8/24. Review of the SOC OASIS N0415 [high risk drug classes-use and indication] revealed RN # 3 indicated the patient was not ordered any high-risk medications on the POC. Review of the POC revealed the patient was ordered cefpodoxime [antibiotic] and quetiapine [anti-psychotic] at the time of admission. RN # 3 completed a recertification OASIS on 4/6/24. Review of the POC for the certification period 4/8/24-6/6/24 included orders for SN 1 time a week for 6 weeks. The POC also included orders for cefpodoxime [antibiotic] and quetiapine [anti-psychotic]. RN # 3 completed the Discharge [DC] OASIS on 4/27/24. Review of N0415 indicated the patient was not ordered any high risk medications at the time of discharge. The RN failed to capture the use of the anti-psychotic and the use of the antibiotic. During an interview with RN # 1 on 6/18/24 at 11 am, RN # 1 confirmed the OASIS was inaccurate. 2. Patient # 4 had a Start of Care [SOC] date of 3/9/24 and an admitting diagnosis of orthopedic aftercare. Review of the Plan of Care [POC] for the certification period 3/9/24-5/7/24 included orders for PT [physical therapy] 1 time a week for 1 week, 2 times a week for 6 weeks. Review of the clinical record revealed PT # 4 completed the SOC OASIS [Outcome and Assessment Information Set-data collection tool used to collect and report assessment data] on 3/9/24. Review of the SOC OASIS N0415 [high risk drug classes-use and indication] revealed PT # 4 indicated the patient was not ordered any high-risk medications on the POC. Further review of the POC revealed the patient was ordered aspirin [antiplatelet-suppresses the number of platelets the body produces to reduce chances of blood clot formation] at the time of admission. PT # 4 completed the discharge [DC] OASIS on 4/17/24. Review of the DC OASIS documentation revealed PT # 4 failed to capture the use on an antiplatelet when answering N0415 at the time of discharge. During an interview with RN # 1 on 6/18/24 at approximately 12 noon, RN # 1 confirmed the OASIS was inaccurate. 3. Patient # 6 had a Start of Care [SOC] date of 12/7/23 and an admitting diagnosis of hemiplegia [paralysis of 1 half of body] following cerebral infarction [stroke] affecting left non-dominant side. Review of the Plan of Care [POC] for the certification period 12/7/23-2/24/24 included orders for PT [physical therapy] 1 time a week for 1 week, 2 times a week for 3 weeks, 1 time a week for 5 weeks and OT [occupational therapy] 1 time a week for 4 weeks, 0 times a week for 1 week, 1 time a week for 1 week. Review of the clinical record revealed PT # 5 completed the SOC OASIS [Outcome and Assessment Information Set-data collection tool used to collect and report assessment data] on 12/7/23. Review of the SOC OASIS N0415 [high risk drug classes-use and indication] revealed PT # 5 indicated the patient was ordered an anti-psychotic on the POC. Review of the clinical record revealed the patient was not ordered an anti-psychotic. Further review of the clinical record revealed PT # 4 completed the DC [discharge] OASIS on 1/31/24. Review of the OASIS question N0415 indicated the patient was only ordered an anti-coagulant [reduces clotting of blood]. PT # 4 failed to include the patient was ordered a hypoglycemic [lowers blood sugar] when answering N0415. During an interview with RN # 1 on 6/18/24 at approximately 11 am, RN # 1 confirmed the OASIS was not accurate. 4. Patient # 9 had a Start of Care [SOC] date of 5/30/23 with admitting diagnoses of chronic atrial fibrillation [abnormal heart rhythm] and type 2 diabetes with diabetic chronic kidney disease [diabetes damages blood vessels in the kidneys, leading the kidneys not function adequately]. Review of the Plan of Care [POC] for the certification period 5/30/23-7/28/23 included orders for PT [physical therapy] 1 time a week for 6 weeks and OT [occupational therapy] 1 time a week for 5 weeks. Review of the clinical record revealed PT # 4 completed the SOC OASIS [Outcome and Assessment Information Set-data collection tool used to collect and report assessment data] on 5/30/23. Review of the SOC OASIS N0415 [high risk drug classes-use and indication] revealed PT # 4 documented the patient was ordered a hypoglycemic [used to lower blood sugar]. However, further review of N0415 revealed PT # 4 failed to document the patient was ordered warfarin [anti-coagulant-thins the blood], olanzapine [anti-psychotic], and oxycodone [opioid-pain medication], as indicated on the POC. Review of the clinical record revealed PT # 4 completed the DC [discharge] OASIS on 7/7/24. Review of the documentation revealed the PT failed to include that the patient was ordered a hypoglycemic and anti-psychotic at the time of discharge when answering N0415. During an interview with RN # 1 on 6/18/24 at approximately 12 noon, RN # 1 confirmed the OASIS was inaccurate”

“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 observation, clinical record review, and patient interview the agency failed to review all current medications for 1 of 1 patients that received a home visit (#1). Findings included: 1.Patient #1 was admitted on 04/6/24 with a diagnosis of fracture (break) of the humerus (arm). The plan of care for 06/5/24 to 08/3/24 included the following orders: physical therapy 1 time a week for 9 weeks and occupational therapy 1 time a week for 9 weeks. A home visit was conducted on 6/17/24 at 1:45 p.m. with the physical therapist assistant. A review of current medications was conducted with the patient during the home visit. The review revealed the following discrepancy: Ibuprofen 200mg tablets- take 1 as needed for pain was not listed on the medication profile. Per interview with the patient “I took 2 ibuprofen about 2 hours ago for my headache, I take them once in a while for pain”.”

“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 policy review, client record review, and staff interview the agency failed to include all vital signs as ordered on the plan of care for 1 of 9 records reviewed (#5); and failed to include correct visit frequencies for 1 of 9 charts (#1). Findings included: 2. Patient # 2 had a Start of Care [SOC] date of 2/8/24 with admitting diagnoses of pressure ulcer right buttock unstageable [type of ulcer that occurs when the base of a full-thickness pressure injury is hidden by slough or eschar, making it impossible to determine the ulcer’s depth] and pressure ulcer of sacral [lower back just above the tail bone] area stage II [ulcer that occurs when the outer layer of skin is partially lost]. Review of the Plan of Care [POC] for the certification period 2/8/24-4/8/24 included orders for SN [skilled nursing] 1 time a week for 8 weeks. Review of the clinical record revealed RN # 3 made a SOC visit on 2/8/24 and a routine visit on 2/10/24 [2 times that week]. Review of the clinical record revealed no order for a second visit the week of 2/8/24. During an interview with RN # 1 on 6/18/24, the RN confirmed there was no physician’s order for the 2nd visit. Review of a policy “Admission Initial and Comprehensive Assessment and Development of the Plan of Care”, revised 05/2022 was received from the agency director on 06/17/24 at approximately 1:00 p.m. The policy stated,” … the plan of care will include… all treatment orders…”. 1. Patient #5 had a SOC (start of care) of 03/15/24 and included diagnoses of fall, fracture (break), type 2 diabetes, and hypertension. The plan of care 3/15/24 to 5/13/24 included orders for skilled nursing 1 time for 1 week, 2 times a week for 1 week, and 1 time a week for 7 weeks. Review of the skilled nursing note for 4/12/24 revealed the only vital sign documented was respiration (breathing measurement) of 16. No other vital signs were documented in the note. Interview with agency administrator on 6/18/24 at 12:06 p.m. confirmed the only vital sign in the nursing visit note was the respiration of 16.”

“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 agency failed to follow physician’s orders for wound care [referral] for 1 of 1 patient with a wound [#2]. The findings included: Patient # 2 had a Start of Care [SOC] date of 2/8/24 with admitting diagnoses of pressure ulcer right buttock unstageable [type of ulcer that occurs when the base of a full-thickness pressure injury is hidden by slough or eschar, making it impossible to determine the ulcer’s depth] and pressure ulcer of sacral [lower back just above the tail bone] area stage II [ulcer that occurs when the outer layer of skin is partially lost]. Review of the Plan of Care [POC] for the certification period 2/8/24-4/8/24 included orders for SN [skilled nursing] 1 time a week for 8 weeks and “SN to perform pressure ulcer care to right buttocks. Cleanse/irrigate wound with wound cleaner [sic], apply xeroform cover and secure...SN to perform pressure ulcer care to left buttock [sacral], daily. Cleanse/irrigate wound with wound cleaner [sic], apply xeroform. Cover with foam dressing...” Review of the clinical record revealed referral orders dated 2/7/24 from _____ [name of physician]. The referral included the following wound care orders, “Gently cleanse wounds with VASHE wound cleanser. Then continue to cover wounds with mepilex border to coccyx and right buttocks. Change Monday, Wednesday and Friday and PRN [as needed] for soiling...” Further review of the clinical record revealed no evidence the RN notified the physician to obtain the orders for the xeroform which the nurse applied at the time of admission. RN # 3 was not available for interview. During an interview with RN # 1 on 6/18/24 at 11 am, the RN confirmed the nurse failed to follow the physician’s order for wound care.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: Based on policy review, client record review, and staff interview the agency failed to provide home health aide supervision for 1 of 2 home health aide records reviewed (#5). Findings included: Review of policy “Home Health Aide Supervisory Visits”, revised 12/2016 was received from agency administrator on 06/18/24 at 10:28 a.m. The policy stated,” …makes a supervisory visit to all patients receiving home health aide services no less frequently than every 14 days, with or without the aide present…” Patient #5 had a SOC (start of care) of 03/15/24 and included diagnoses of fall, fracture (break), type 2 diabetes, and hypertension. Home health aide orders were for 1 time a week for 7 weeks. Review of the weekly home health aide visits revealed a supervisory visit was completed on 4/5/24 by the physical therapist and was not completed again until 4/26/24. Interview with agency administrator on 6/18/24 at 12:08 p.m. confirmed the aide supervisory visits were not done appropriately.”