Exclusive Health Services Inc.

“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 record review and interview, the agency failed to ensure the patient plan of care was complete and included all required elements for 1 (Patient #5) of 4 patients whose reviewed record included the primary diagnosis of Diabetes Mellitus Type-2 (high blood sugar levels due to either the body’s inability to produce enough insulin or its inability to properly use insulin). The POC did not include blood sugar parameters or instructions when to notify the physician of an abnormal low or abnormal high blood sugar reading. This failure potentially placed the patient at risk of a decline in health status when an abnormally low or high blood sugar reading was not reported to the physician or addressed. FINDINGS INCLUDE: Patient #5: Record review revealed a POC dated 03/10/2025 to 05/11/2025 with a SOC date 09/10/2024. The POC included, “… Primary Diagnosis: Type 2 Diabetes Mellitus. Medications for diabetes mellitus included: Metformin 500 milligrams, 2 tablets taken orally twice a day and Sitagliptin 100 milligrams, 1 tablet taken orally every day. The physician ordered the SN to visit the client once a month. The POC did not include instructions for the SN to notify the physician of a blood sugar reading out of parameters. A comprehensive reassessment completed by the Administrator/DON on 03/07/2025, included on page 24, “… SKILLED INTERVENTIONS: … randomly checked patient finger stick blood sugar with a result of 190 ….” A SN visit completed by the Administrator/DON on 03/14/2025 included on page 2, “… Random blood sugar 177 …” A SN visit completed by LVN B on 04/14/2025 included on page 2, “… Random blood sugar 198 …” A comprehensive reassessment completed by the Administrator/DON on 05/07/2025, included on page 12, “… Random blood sugar result 174 …” In an interview with the Administrator/DON on 05/28/2025 at 12:15 PM, the surveyor reviewed the findings and asked why the POC did not include blood sugar parameters for the SN to report a low or high blood sugar to the physician. The Administrator/DON reviewed the patient’s record and stated, “it (blood sugar parameters) should be on there, we are checking the blood sugar.” The surveyor asked why blood sugar parameters were not on the POC. The Administrator/DON stated, “the information must not have transferred from the comprehensive assessment over to the POC, the (blood sugar) parameter should be on the POC.” Agency policy, dated 05/02/2024, quoted in part, “Plan of Care, PC. 35, Purpose: To ensure that care provided is appropriately planned in a timely manner to meet the patient’s/client’s specific needs and problems. … Policy: I. The Agency will use data/information gathered during patient/client assessments in the care planning process which involves the identification of patient/client goals, actions or interventions that will resolve or alleviate the patient’s/client’s problems and/or needs. … III. … The Plan of Care must specify the care and services necessary to meet the patient/client-specific needs as identified in the comprehensive assessment, … A. The individualized Plan of Care must include the following: … 10. All … treatments; … 14. Patient/client specific interventions … and 17. Any additional items the Agency or physician and/or non-physician practitioner may choose to include. …””