Liberty Home Care II, LLC

“Based on agency policy, clinical record review, and staff interviews, the agency failed to include treatment orders on the plan of care for 1 of 1 patient requiring a Trilogy (a mechanical device used to assist with breathing) (#8).Findings included: A policy, Admission and Initial Comprehensive Assessment and Development of the Plan of Care (revised 02/2025), received on 05/19/2025 at 12:27 PM from licensed practical nurse #13 stated, “Agency staff receiving or verifying a referral will try to obtain the following baseline information: … Treatment orders.”Patient #8 was admitted on 08/18/2023 with diagnoses of chronic obstructive pulmonary disease and chronic respiratory failure. The plan of care for 04/09/2025-06/07/2025 included orders for skilled nurse visits 1 time a week for 9 weeks with 8 PRN (as needed). Review of the clinical record revealed that on 04/18/2025 clinical manager #8 documented, “has been using Trelegy [sic] every night.” Further review revealed that the Trilogy machine was not included in the plan of care.During an interview conducted on 05/20/2025 at 9:10 AM clinical manager #8 stated, “I would have expected that [Trilogy machine] to be included in the plan of care.””

“Based on agency policy, clinical record review, and staff interviews, the agency failed to coordinate care with the physician’s for 2 of 3 patients who are not taking medications as ordered. (#8 & 22)Finidngs included: A policy, Case Management, Coordination and Communication Activities (revised 11/2020) received on 05/21/2025 at 12:00 PM from the agency director stated, “Hospice staff maintains ongoing communication with the physician… that addressed the following, at a minimum: … Changes have occurred regarding … medications…”A policy, Clinical Record Content (revised 02/2025) received on 05/19/2025 at 12:27 PM from licensed practical nurse #13 stated, “Each time a patient is seen a clinical note is documented that includes: …Discussions with physician’s or other persons involved…”Patient #8 was admitted on 08/18/2023 with diagnoses of chronic obstructive pulmonary disease and chronic respiratory failure. The plan of care for 04/09/2025-06/07/2025 included orders for skilled nurse visits 1 time a week for 9 weeks with 8 PRN (as needed). Review of the clinical record revealed that on 05/07/2025 clinical manager #8 documented, “Patient is refusing the use of Zyprexa [antipsychotic medication] … Patient has not performing [sic] breathing treatment.” Further review revealed no documentation that the physician was notified. 2. Patient #22 was admitted on 02/26/2025 with a diagnosis of hypertensive heart disease (high blood pressure) and chronic kidney disease with heart failure. The plan of care for 02/26/2025-05/26/2025 included orders for skilled nurse visits 2 times a week for 13 weeks with 4 PRN (as needed). Review of the clinical record revealed that on 04/17/2025 registered nurse #15 documented, “Patient had started on a new medication (Neurontin) [treats nerve pain] … Discussed with wife, who feels more comfortable holding the medication.” Further review revealed no documentation that the physician was notified that order was not followed.”

“Based on agency policy, observation, and staff interviews, the agency failed to follow agency procedures to prevent the spread of infection for 3 of 5 conducted home visits. (patients #1, 3,19)Findings included: A policy, Bag technique, home care (revised 05/20/2024) received on 05/19/2025 at 4:00 PM from the clinical manager stated, “Perform hand hygiene before entering the bag… Never place any soiled or dirty items into the bag, Clean and disinfect reusable items according to your agency’s guidelines… Place a nonwheeled bag on a flat surface that appears clean and dry.”A policy, Hand Hygiene (revised 08/19/2024) received on 05/19/2025 at 4:00 PM from the clinical manager stated, “An alcohol-based hand rub is appropriate for decontaminating the hands: … after contact with the patient… after contact with inanimate objects in the patient’s environment…”Patient #1 was admitted on 11/23/2024 with a diagnosis of congestive heart failure and was a resident of a skilled nursing facility. The plan of care for 02/21/2025-05/21/2025 included orders for home health aide (HHA) 3 times a week for 1 week, 2 times a week for 1 week, and 5 times a week for 8 weeks. During a home visit conducted on 05/20/2025 at 8:00 AM HHA #3 placed the clinical bag on a chair, on top of the patient’s shoes.During an interview conducted on 05/21/2025 at 8:32 AM HHA #3 stated, “I didn’t notice the shoes under my bag. No, I would not normally place the bag on shoes.”During an interview on 05/21/2025 at 8:34 AM the agency administrator stated, “They [clinical bags] should be placed on a clean surface.” 2. Patient #3 was admitted on 10/09/2024 with a diagnosis of abnormal weight loss and was a resident of a skilled nursing facility. The plan of care for 05/07/2025-07/05/2025 included orders for medical social work (MSW) visits 1 times a month for 2 months with 2 PRN (as needed). During a home visit conducted on 05/20/2025 at 1:30 PM MSW #4 placed the documentation tablet on the patient’s cloth chair then moved the tablet to the patient’s bedside table, documented on the tablet and placed the tablet into the clinical bag without sanitizing the tablet. MSW #3 touched personal items throughout the patient’s room and failed to perform hand hygiene prior to reaching into the clinical bag.An interview conducted on 05/21/2025 at 8:37 AM with MSW#3 revealed that MSW #3 was not aware that cloth furniture is not considered clean, that hand hygiene must be performed prior to entering the clinical bag, and the documentation tablet should be cleaned prior to placing it in the clinical bag. 3. Patient #19 was admitted on 05/01/2025 with a diagnosis of abnormal weight loss and was a resident of an assisted living facility. The plan of care for 05/01/2025-07/29/2025 included orders for skilled nurse visits 1 time a week for 10 weeks. During a home visit conducted on 05/20/2025 at 2:00 PM licensed practical nurse (LPN) #9 placed a stethoscope on the patient’s bed and failed to sanitize the stethoscope prior to placing it in the clinical bag.LPN #9 was not available for an interview.During an interview on 05/20/2025 at approximately 2:30 PM the clinical manager stated, “They [staff] should clean the equipment before putting it back in the bag.”During an interview conducted on 05/21/2025 at 8:49 AM the agency administrator stated, “The expectation is that any staff member will sanitize their hands before they go into their clinical bag. Any equipment should be cleaned and sanitized before it goes back into the bag.””

“Based on agency policy, clinical record review, and staff interviews, the agency failed to document responses to medications for 2 of 2 facility patients with unmanaged symptoms. (patient #1, 21)Findings included: A policy, Clinical Record Content (revised 02/2025) received on 05/19/2025 at 12:27 PM from licensed practical nurse #13 stated, “Each hospice record will contain the following information, at a minimum: … A description of the patient’s condition … including response to medication, symptom management…”Patient #1 was admitted on 11/23/24 with a diagnosis of congestive heart failure (condition in which the heart doesn’t pump enough blood). The plan of care for 02/21/2025-05/21/2025 included orders for skilled nurse visits 1 time a week for 1 week, 2 times a week for 8 weeks, 8 PRN (as needed), and “skilled nurse observation of S/SX UTI [signs and symptoms of urinary tract infection].” Review of the clinical record revealed that on 04/14/2025 registered nurse (RN) #16 documented, “Facility staff suspect UTI d/t [due to] pts [patient’s] behavior… Nurse [facility nurse’s name] states they have already notified the facility provider and is waiting for a response. Plan for next 2 weeks is possibly treat UTI.” Further review revealed that there was no follow-up documentation.During an interview conducted on 05/21/2025 at 8:51 AM RN #16 stated, “I didn’t see her for 16 days [after the suspected UTI]. I didn’t feel like she had a UTI. Yes [normally communicates concerns to the licensed practical nurse [to follow-up]. 2. Patient #21 was admitted on 01/16/2025 with a diagnosis of chronic obstructive pulmonary disease (lung disease that blocks air flow). The plan of care for 04/16/2025- 07/14/2025 included orders for skilled nurse (SN) visits 2 times a week for 8 weeks with 3 PRN (as needed) and “SN to assess exacerbations… that present themselves.” Review of the clinical record revealed that during the SN visit on 04/29/2025 registered nurse (RN) #14 documented, “Patient appears to be having an anxiety attack… Patient was assisted to bed, and encouraged to rest after receiving PRN dose of morphine… Will follow-up tomorrow.” Further review revealed that there was no follow-up documentation.During an interview conducted on 05/21/25 at 9:12 AM RN #14 stated, “I’m sure that I did [follow-up], it looks like another nurse saw her for me, I don’t remember. I do [normally document my follow-up]. I do know that I was there with her on 04/30 I did see her, I think that I just didn’t chart it.”During an interview on 05/21/2025 at 9:18 AM the agency administrator stated, “If an issue it identified, then it should be followed up on based on company policy or the limit that they set and document it.””