Liberty Home Care II, LLC

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…

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…

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…

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…

Staff interview the agency failed to include all medications on the plan of care for 4 of 10 patients (#8, 3, 7 and 9); failed to include indications for PRN [as needed]/frequency of PRN medications for 2 of 10 patients [#1 and 7] ;failed to include all pertinent diagnoses/surgical procedures for 1…

The nurse failed to monitor blood sugar results for 2 of 4 patients with diabetes [#7 and 9]. The findings included: The policy, Care Planning: Initial Care Plan and Updates to the Plan of Care [3/21], was provided by the agency administrator on 12/5/22 at 3:50 pm.

The agency failed to document accurate wound assessment for 1 of 5 patients with a wound [#1]. The findings included: The policy, Wound Assessment [2/18/22], was provided by the agency administrator on 12/5/22 at 3:50 pm.

Staff interview the RN [registered nurse] failed to notify the physician of patient’s refusal to allow wound care for 1 of 5 patients with a wound [#1]; failed to notify physician of vital signs outside the given parameters for 2 of 10 patients [#3, 7];failed to notify the physician of new area of…

Other healthcare professional interviews the agency failed to provide care in accordance with the condition of skilled professional services for 6 or 14 patients (#9, 11, 3, 7, 10, and 4).

Home visits and interviews with staff the RN failed to change a PICC [peripherally inserted central catheter] Line Dressing using proper infection control for 1 of 1 patient with PICC line dressing change observed during home visit [#3]. The findings included: Patient # 3 had a Start of Care [SOC]…

Other healthcare professional interviews the agency failed to identify, accurately assess, and/or treat pressures ulcers for 2 of 14 records reviewed (#9 and 11); and to measure the external catheter length of a PICC [peripherally inserted central catheter] line for 1 of 1 patient with a PICC who…

Staff interviews the RN failed to provide the patient with a notice prior to discharging for cause for 1 of 1 patient discharged for cause from nursing services [#4]. The findings included: The policy, Discharge and Transfer of Patients [last revised 1/2018] was provided by the agency director on…

Patient/caregiver and staff interviews the Plan of Care [POC] failed to include all medications/doses the patient was using for 3 of 14 charts reviewed [#3, 4, 2] and failed to include frequency of dressing changes for 1 of 5 charts reviewed with dressing changes [#7]. The findings included: 1.…

The agency failed to obtain an order for thickened liquids for 1 of 1 patient that received thickened liquids (#10); to obtain a physician's order to apply ace wraps to lower legs for 1 of 1 patient [#4]; and to apply correct dressing to wound on the heel for 1 of 1 patient with diabetic ulcer to…

The agency failed to provide wound care as ordered in the plan of care for 1 of 5 patients with wounds (#9).

Staff interviews the Registered Nurse [RN] failed to provide accurate/clear documentation regarding a wound for 1 of 5 charts with a wound [#7]. The findings included: Patient # 7 had a Start of Care [SOC] date of 1/8/20 and diagnoses of Type 2 Diabetes Mellitus and Non-Pressure Chronic Ulcer of…

Staff interview the agency failed to communicate with the physician changes in skin integrity/wound appearance for 3 of 5 patients with wounds (#9, 10, 11); alterating the plan of care for 1 of 14 patients (#9); change in condition for 1 of 4 patients who received a home visit [#4]; and blood…