Liberty Healthcare Services, LLC

“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 medical record review and staff interview, the agency failed to ensure the individualized plan of care included the types of services and frequency and duration of visits to be made for one of three patients reviewed (Patient #3). This could affect all patients receiving services from the agency. The census was 31. Findings include: Review of the medical record for Patient #3 revealed a plan of care dated 02/22/24 to 04/21/24 revealed no care orders. This was verified by Staff A on 04/24/24 at 12:45 PM.”

“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 interviews, medical record reviews, and document review, the agency failed to ensure all services were administered only as ordered by a physician for two of three patients reviewed (Patients #2 and #3). This had the potential to affect all patients receiving services from the agency. The census was 31. Findings include: Review of the medical record for Patient #2 revealed a plan of care dated 02/22/24 to 04/21/24 with orders for home health aide services four times a week for two hours each visit. Review of the medical record revealed four home health aide visits per week for three hours each visit and one home health aide visit each week for two hours each visit from 03/18/23 through 04/12/24. The medical record lacked documentation of physician orders to increase the amount of home health aide services. This was verified by Staff A on 04/24/24 at 12:45 PM. Review of the medical record for Patient #3 revealed a plan of care dated 02/22/24 to 04/21/24 revealed no care orders. The medical record contained five home health aide visits for a total of 14 hours per week from 03/18/24 through 04/14/24. The medical record contained documentation the home health aide frequency was five visits per week up to 14 hours each week that was effective 02/22/24; however this was not on the plan of care. This frequency was not documented as a verbal order or on a physician’s order form that had been sent to or received from the physician. This was verified by Staff A on 04/24/24 at 12:45 PM.”

“Investigate complaints made by patient CFR(s): 484.50(e)(1)(i) (i) Investigate complaints made by a patient, the patient’s representative (if any), and the patient’s caregivers and family, including, but not limited to, the following topics: This Element is not met as evidenced by: Based on document review and staff interview, the agency failed to investigate complaints made by the patient’s representative for one of one complaints reviewed (Patient #2). This could affect all patients receiving services from the agency. The census was 12. Findings include: On 01/30/24 at 10:45 A.M. Staff A presented a third party oversight entity investigation document and reported this was an investigation completed by the third party oversight entity and it had been cleared. A review of the documentation from third party oversight entity revealed it was a request for documents from the agency’s investigation. An interview with Staff A confirmed this was not the investigation and she stated she would look for email communication from the entity staff to find an investigation. On 01/30/24 at 11:08 A.M. Staff A provided a copy of a final report of an investigation by a third party oversight entity. Review of this report revealed no aide services were provided for Patient #2 on multiple dates and the agency did not make the required notifications to Patient #2, his back-up staff, or the Case Manager (CM) on those missed dates. Further review revealed the agency only provided one of two hours of care that Patient #2 was approved to receive on 11/07/22, 11/18/22, and 11/19/22 and only 45 minutes on 06/20/23, and there was no record of appropriate notifications to the CM staff, Patient #2, or his staff back-up. Further review revealed the aide staff and the patient signed the forms at the next scheduled shift on “several dates” between 11/07/22 and 11/01/23, and the aide did not mark tasks as completed or not completed on the 08/03/23, 08/04/23, and 10/01/23 time sheets. The aide wrote the date 02/27/23 instead of the actual date of care on 09/27/23 on the aide time sheet, and the aide documented tasks were completed on 09/26/23 and 09/29/23 when no services were provided on those dates. The aide did not indicate the year services were provided or if the time was AM/PM on aide time sheets from 10/30/23 to 11/01/23. Further review revealed the agency did not document if the individual refused personal care, the agency offered to complete personal care, or communication with the CM regarding notifications of the individual refusing personal care. An interview with Staff A at the time of review confirmed the third party oversight entity report was accurate, and the agency did fail to provide services as listed in the final report. Further interview revealed Staff A contacted third party oversight entity and explained the situation was caused because of staff shortages. That was all the agency staff did to investigate/resolve this issue, but Staff A felt that was enough. On 01/30/24 at 11:35 A.M. an interview with Staff A and Staff B revealed they could not find any complaint log or agency investigation.”

“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 medical record review and staff interview, the agency failed to ensure the individualized plan of care included the types of services and frequency and duration of visits to be made for one of three patients reviewed (Patient #2). This could affect all patients receiving services from the agency. The census was 12. Findings include: On 01/30/24 at 12:50 P.M. a review of Patient #2’s medical record revealed the physician ordered plan of care for the certification period dated 11/07/22 to 01/05/23 and 03/07/23 to 05/05/23 revealed no care orders. Review of the physician ordered plan of care for the certification period dated 07/05/23 to 09/02/23 revealed no orders for services even though the physician signed the plan of care and noted that the patient has not kept appointments and the physician cannot complete the order form until the patient “comes in.” The physician ordered plan of care for the certification period dated 09/03/23 to 11/01/23 revealed no orders for services. An interview with Staff A and Staff B during the record review confirmed the lack of orders on the available physician ordered plans of care.”

“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 interviews, medical record reviews, and document review, the agency failed to ensure all services were administered only as ordered by a physician for one of three patients reviewed (Patient #2). This had the potential to affect all patients receiving services from the agency. The census was 12. Findings include: On 01/30/24 at 12:50 P.M. a review of Patient #2’s medical records revealed there were no orders for services listed on the physician ordered plans of care that were reviewed, and even though some aide time sheets were noted in the medical record there were no orders to review for comparison. A review of the physician ordered plan of care for the certification period dated 11/07/22 to 01/05/23 and 03/07/23 to 05/05/23 revealed no care orders. Review of the physician ordered plan of care for the certification period dated 07/05/23 to 09/02/23 revealed no orders for services even though the physician signed the plan of care and noted that the patient has not kept appointments and the physician cannot complete the order form until the patient “comes in.” The physician ordered plan of care for the certification period dated 09/03/23 to 11/01/23 revealed no orders for services. Further medical record review revealed some timesheets were in the medical record and some missed visit reports were in the medical record, but they could not be compared to the physician orders because no orders could be found in the medical record. Interview with the Staff A and Staff B at the time of the review confirmed there were no other locations where the physician orders could be. Both reported there were no electronic records that would include additional information. Further interview with the Staff A and Staff B revealed the orders that the agency staff followed came from the CM Waiver staff orders and those had been the orders that had been followed since Staff A started working at the agency in 2022.”