Pasco/SW Home Health - Grand Junction

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to ensure skilled nursing (SN) services were provided in accordance with the plan of care for 1 of 3 patients reviewed (Patient #3). Findings include: AGENCY POLICY According to the agency policy titled, “Provision of Care and Record Management”, dated 4/21 (in pertinent parts), “The plan of care will be based upon the physician’s (or other authorized licensed independent practitioner’s) orders and will encompass the equipment, supplies, and services required to meet the patient’s needs.” 1. The clinical record for Patient #3 was reviewed on 3/31/26. Plan of care orders for the certification period dated 2/4/26 to 4/8/26 revealed a start of care date of 12/5/25; diagnoses included type 2 diabetes mellitus, morbid (severe) obesity, and bariatric surgery. Plan of care orders included skilled nursing (SN) visits twice a week for wound care, Peripheral Intravenous Central Catheter (PICC) line management, and instruction in diabetic care including diet, diabetic foot care, and blood glucose testing. a) The agency failed to ensure Patient #3 was receiving blood glucose testing or education on testing according to the plan of care. Review of the clinical record for Patient #3 revealed a SN visit note dated 2/9/26 by RN #1 failed to include blood glucose testing results or documentation of education provided on blood glucose testing. Review revealed a SN visit note dated 2/11/26 entered by RN #1 failed to reveal blood glucose testing or documentation showing education was provided to Patient #3 on blood glucose testing. Review of SN visit notes completed by RN #1 dated on 2/16/26, 2/18/26, 3/4/26, 3/16/26, 3/25/26, and 3/27/26 failed to reveal blood glucose testing or education on blood glucose testing was completed during these visits. Review of coordination notes entered by RN #1 on 2/16/26, 2/18/26, 2/28/26, 3/4/26, 3/26/26, and 3/27/26 failed to include a reason blood glucose testing or education for blood glucose testing was not completed during the visits completed by RN #1 for Patient #3. Review of SN visit notes completed by LPN #1 on 3/6/26 and 3/13/26 failed to include blood glucose testing results or documented education on blood glucose testing provided to Patient #3. Review of coordination notes dated 3/6/26 and 3/13/36 entered by LPN #1 gave the reason for not including blood glucose testing as does not check. During an interview conducted on 4/1/26 at 12:41 p.m., LPN #1 confirmed Patient #3’s blood glucose testing was not completed during the visits on 3/6/26 and 3/13/26. LPN #1 stated Patient #1 did not have a glucose monitor in the home that she was aware of. LPN #1 verbalized failure to notify the RN case manager or office of the missing glucose monitor. Further, LPN #1 revealed the missing glucose monitor was not documented in Patient #3’s record. An interview was completed on 4/1/26 at 12:00 p.m. with RN #1. RN #1 confirmed blood glucose testing was not concluded for Patient #3 during the visits indicated. RN #1 stated Patient #3 did not consider herself a diabetic. Interview revealed the plan of care was confirmed by the physician of record for Patient #3. Further, RN #3 acknowledged failure of not following the plan of care and poor documentation as to why the blood glucose testing was not completed. During an interview on 4/2/26 at 9:30 a.m., the agency admitted blood glucose testing was not completed per the plan of care for Patient #3. The agency confirmed the plan of care was signed by the physician and counted as physician orders.”