Jcare Home Health Agency LLC

“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 observation, record review and interview the agency failed to ensure the individualized plan of care for 2 patients (ID 1 and 2) of 7 failed to include the following: All pertinent diagnoses and all medications and treatments. Patient 1’s POC failed to contain the medication insulin (a hormone that regulates blood sugar and allows cells in the body to function). Patient 2’s POC failed to include the diagnosis of diabetic foot wounds (open sores on the feet of individual with diabetes) and wound care treatment orders. This failure potentially subjected patients to poor health outcomes and a lack of quality care. Review of Patient 1’s POC dated 05/19/2025 to 07/17/2025 found diagnoses of Multiple fractures of ribs bilaterally (broken rib bones on both sides of the rib cage), Transverse Fracture of the shaft of the humerus (a break in the long bone of the upper arm), Contusion of the head (bruise of the brain by trauma to the head), history of falling, Urinary Incontinence (involuntary leakage of urine), Diabetes Mellitus type 2 (condition where the body has trouble controlling blood sugar and using it for energy), Hypertension (high blood pressure), Dementia (brain disorder with memory and behavioral changes).The POC included orders for nursing care once a week for nine weeks and physical therapy twice a week for 6 weeks. Medications listed included Metformin and oral (by mouth) medication to treat diabetes. The medications list did not include any insulin medications or orders. During a visit to Patient 1’s home on 07/09/2025 at 12:30 PM the surveyor observed Patient 1’s insulin injection pens which were stored in the refrigerator. The family member for Patient 1 stated Patient 1 was on multiple insulins and the oral medication Metformin to manage his blood sugar. Review of Patient 1’s physician summary of care and referral for home health services to the agency dated 05/08/2025 included a list of current medications prescribed to Patient 1 which included multiple types of insulin with various orders as follows: Novolog Flex pen (a fast acting insulin) – inject 20 units under the skin four times daily before meals and at bedtime, Insulin glargine (Basaglar Kwik Pen u-100 Insulin) (a long acting insulin) – inject 40 units under the skin at bedtime, and Insulin glargine (Lantus Solostar U-100 insulin) (a different type of long acting insulin) – Inject 42 units under the skin at bedtime, and another order for Novolog Flex pen (a fast acting insulin) – inject 18 units under the skin three times daily with meals. Review of Patient 1’s start of care assessment dated 05/19/2025 by RN A failed to document Patient 1’s insulin dependent status. Review of additional orders in Patient 1’s record revealed no clarification or updates on Patient 1’s insulin medication orders. During an interview on 07/11/2025 at 11:47 AM with RN A the surveyor asked about Patient 1’s Plan of Care not having insulin listed as a current medication. RN A stated she just did the start of care assessment for Patient 1 as the patient was staying at his family members house while recovering and the family member was managing the medications. The surveyor asked if the policy and procedures for start of care visits included review of the current medications list from the doctor or referral source. RN A stated that was the usual process. RN A stated they did not know why the insulin was not listed in the assessment and plan of care. RN A stated maybe the information from the referral or doctors’ office wasn’t in the patient record at the time of the start of care and RN A would have documented the medications provided by the family member. The surveyor asked if RN A had contacted the physician to clarify the medication orders. RN A stated they had not. RN A stated the case was transferred to another case manager and RN A stated RN A was scheduled to see Patient 1 the week of 4th of July and the patient was moving from one family members home to another home. RN A stated they were scheduled to see Patient 1 this week and RN A would clarify the medication orders. RN A stated they did not know what the outcome for the patient was and if they were on insulin, it should be on the POC. Review of Patient 2’s POC dated 08/10/2024 to 10/08/2024 found diagnoses of: Type 2 Diabetes Mellitus with Hyperglycemia (condition where the body has trouble controlling blood sugar and using it for energy resulting in higher than normal blood sugar), Hyperlipidemia (high blood fats), Hypo-osmolality and hyponatremia (closely related conditions where the body has too little sodium in the blood and blood water), Urinary tract infections (infections of bladder and / urinary tract organs), long term use of oral hypoglycemic drugs (many months or years taking medications to help the body mange blood sugar levels), and long term use of insulin (many months or years taking supplemental insulin to help the body manager blood sugar levels and the cells use blood sugar for energy). Skilled nursing care was ordered once a week for nine weeks. Orders for care included orders for the nurse to perform an inspection of patient’s lower extremities every visit and report any alteration in skin integrity to physician. The POC did not include any diagnosis of diabetic foot ulcers, and no orders for assessment and care of Patient 2’s diabetic foot ulcers. Review of Patient 2’s recertification assessment dated 08/08/2024 by the DON / RN B found two wounds documented with measurements on Patient 2’s foot. The assessment failed to include wound care provided or coordination of care with another provider for the wound care to the two assessed wounds. Review of skilled nursing visit notes by LVN A on 08/14/2024 and 08/21/2024 documented wound care was done by a wound clinic. On 08/29/2024 LVN A documented there were no wound care orders. On 09/04/2024 LVN A documented the patient would be referred for wound management. The record contained a physician order dated 09/10/2024 for wound care to the patient’s diabetic foot wounds to be provided by the MD and the patient was referred to skilled rehabilitation facility for wound care to the diabetic foot wounds. There was no documentation of wound care treatment orders and care in the record from 08/10/2024 to discharge on 09/10/2024. LVN A was not a current employee of the agency, the surveyor attempted on 07/10/2025 at 1:45PM to interview LVN A and the phone number was not a working number. The surveyor was unable to interview this nurse. On 07/10/2025 at 2PM the surveyor attempted to interview the DON/RN B. The DON answered the call and stated she was in the hospital and was not available to interview. On 07/15/2025 the Alternate DON at 03:17PM, and again at 03:45PM. The Alternate DON was seeing patients an unavailable for an interview. On 07/15/2025 the surveyor interviewed the Administrator at 3:20PM. The surveyor reviewed the findings for Patient’s 1 and 2. The Administrator stated the policy was to include all pertinent diagnoses, medications including insulin, and all treatment orders for wounds. The Administrator stated the staff should have included this information in the patient’s plan of care. The Administrator stated the DON reviewed the assessments and plans of care after the nurse submitted them. The Administrator stated they should have put the diagnoses, insulin and treatment orders on the plans of care. The Administrator stated they missed it, and the patients could have had issues because of the mistakes. The Administrator stated the wounds were not new that the patient had the wounds, and an outside wound provider was caring for the wounds. The Administrator stated this should be evident in the treatment plan and medical records. Agency policy titled “Plan of Care PC.9” dated “030119” read in part: “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- 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 intervention’s that will resolve or alleviate the patient’s/client’s problems and/or needs…The individualized plan of care must include the following: All pertinent diagnoses… the types of services, supplies and equipment requires…all medications and treatments…””