Choice Homecare

“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 observation, interview, and record review, the agency failed to ensure each patient received the services written in an individualized plan of care for 1 of 3 patients. LVN E failed to check a patient’s blood glucose (sugar) level during a home visit. (Patient #7). This failure could result in undetected hyperglycemia (high blood sugar), hypoglycemia (low blood sugar), failure to treat complications of diabetes, and hospitalization. Findings included: Record review of Patient #7’s plan of care for certification period 11/24/24 to 1/22/25 indicated he was a 71 year old male with diagnoses including diabetes mellitus (a chronic disease that occurs when the body doesn’t produce enough insulin or can’t use insulin properly), long term use of insulin, bipolar disorder (a serious mental illness that causes unusual shifts in mood), and schizophrenia (a serious mental condition involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion, and a sense of mental fragmentation). The plan of care indicated Patient #7 was to receive skilled nurse visits once every 8 weeks. The plan of care indicated Patient #7 was legally blind. The plan of care indicated the skilled nurse was to check Patient #7’s blood sugar every visit. During observation of Patient #7’s home visit on 12/12/24 at 10:00 a.m., LVN E performed a physical assessment and provided patient teaching related to signs and symptoms of high and low blood sugar levels. LVN E removed Patient #7’s continuous glucose monitor (CGM; a wearable device that tracks blood sugar levels in real time) and applied a new CGM. LVN E did not check Patient #7’s blood sugar levels and did not check the read-out of the CGM for a blood sugar value. LVN E did not ask Patient #7 what his blood sugar was or had been at any point in time. The home visit ended before the new CGM had started working. During an interview outside Patient #7’s home on 12/12/24 at 10:30 a.m., LVN E said she knew what care to provide by reviewing the plan of care for each patient. During the interview, Patient #7 came to the door and called out to LVN E that his blood sugar was 81 milligrams per deciliter (mg/dl; a unit of measurement used to the results of blood glucose tests), and she encouraged him to eat. LVN E said other than Patient #7 reporting his blood sugar to her, she had not checked his blood sugar during the visit. After reviewing the order for the skilled nurse to check Patient #7’s blood sugar each visit, LVN E said, “I understand,” but did not explain why she had not checked Patient #7’s blood sugar during the visit. During an interview with the Administrator on 12/12/24 at 2:36 p.m., she said nurses should know what care to provide for a patient by reviewing the plan of care. She said that if Patient #7 was unwilling or unable to check his blood sugar the nurse should do it every visit. The Administrator said if LVN E did not check Patient #7’s blood sugar, she could not know if his blood sugar was controlled or whether the physician needed to be notified. Record review of a visit note dated 12/12/24 at 3:49 p.m., written by LVN E, indicated Patient #7 was diabetic and that his blood sugars were monitored daily. The note did not indicate who was monitoring Patient #7’s blood sugar. During a telephone interview on 12/13/24 at 10:34 a.m., LVN E said she did not review Patient #7’s plan of care before the home visit on 12/12/24. She said Patient #7’s CGM was working and that she could have checked his blood sugar before changing it, but she did not. LVN E said she did not check Patient #7’s blood sugar because she was nervous. LVN E said she remembered a recent in-service where “we talked about blood sugars, but I don’t remember what was said.” LVN E said the purpose of monitoring a patient’s blood sugar was to make sure the patient was within the parameters established by the physician and to determine if further interventions were needed. LVN E said it was not possible to know what a patient’s blood sugar level was without checking it. LVN E said “I know I was wrong for not checking it. That is on me for not doing it, not on the company for what they taught.” Record review of a Skilled Nursing Competency Checklist, dated 8/13/24, indicated LVN E had demonstrated satisfactory competence in skills including: · Reviews Plan of Care prior to care · Performs services as ordered · Home glucose monitoring · Use, care and teaching of glucose monitoring system Record review of an in-service attendance roster and training content, dated 9/24/24, indicated topics covered included Emergency Preparedness, a fire drill, and blood sugar checks at visit if indicated. The roster indicated LVN E had attended the in-service. The training content indicated most people who are diabetic need their blood sugar level tested at least once per day. The training content indicated a physician must set the acceptable ranges for blood sugars for each person, and when a blood sugar falls outside that range the doctor must be notified as soon as possible. During an interview on 12/13/24 at 11:02 a.m., the Regional Director of Operations said the agency had initiated a Performance Improvement Project on 9/25/23 related to blood sugars not being regularly checked when ordered. She said charts were being audited on an ongoing basis until compliance had been achieved. During an interview on 12/13/24 at 11:44 a.m., the Regional Director of Operations said the audits were not adequate to ensure the plan of care was implemented as intended, and that she felt more follow up was needed. Record review of an agency policy titled Plan of Care, dated 5/2/24, indicated “each patient must receive the home health services that are written in an individualized Plan of Care…” Record review of an agency policy titled Implementing Care and Treatment, dated 5/2/24, indicated the purpose of the policy was to ensure patient care and treatment were provided as identified in the care planning process. The policy also indicated: · Agency staff providing patient care and treatment will be competent to the level of care and treatment needed, and the care provided will be within the frequency parameters established in the plan of care. · The agency is responsible for patient care and must conduct and provide all services rendered to patients.”