Choice Homecare

“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: This is a continuing deficiency from (Event Id: 5DFA0-H1/ 10/19/22). Based on record review and interview, the agency failed to ensure the plan of care contained patient specific interventions and education, and safety measures to protect against injury for 1 of 7 patients (Patient #4) records reviewed for plans of care, in that: Patient #4’s POC did not include diabetic precautions as a safety measure for her diagnosis of Type II Diabetes (a condition when the body is unable to use insulin [a hormone excreted by the pancreas] correctly and sugar builds up in the blood). This failure could place patients at risk of not receiving proper care/instruction leading to complications and hospitalization. Findings included: Record review of Patient #4’s POC dated 7/27/25- 9/24/25 indicated a SOC date of 1/28/25, and indicated she was 66 years old with diagnosis including Type II Diabetes (a condition when the body is unable to use insulin [a hormone excreted by the pancreas] correctly and sugar builds up in the blood) with diabetic peripheral angiopathy (a serious complication that affects blood vessels which can cause leg pain and ulcers [a wound caused by poor circulation]), unstageable pressure ulcer (wound caused by pressure to the skin for an extended period of time) of the right hip, and severe obesity (disease involving having too much body fat). The POC indicated Patient #4 was ordered skilled nursing visits twice a week for one week, once a week for one week, three times a week for one week, two times a week for five weeks, and once a week for one week. The POC did not include diabetic precautions as a safety measure. During a telephone interview on 9/9/25 at 3:45 pm, RN A said she was responsible for completing the plan of care for Patient #4. RN A said diabetic patients should have diabetic precautions listed as a safety measure on their plan of care. RN A said Patient #4 should definitely have diabetic precautions on her plan of care. RN A said diabetic precautions not being listed on Patient #4’s plan of care must have been an oversight. RN A said if safety measures were not listed on the patient’s plan of care the patient may not know signs or symptoms to report, they could run into diabetic issues and not know what to do, and other staff would not know what was going on with the patient. During an interview and record review on 9/9/25 at 4:10 pm, the Supervising Nurse said the RN that does the start of care was responsible for completing the plan of care for the patient. The Supervising Nurse said diabetic precautions should be listed as a safety measure on the plan of care. The Supervising Nurse reviewed Patient #4 plan of care dated 7/27/25- 9/24/25 and said Patient #4 was diabetic. The Supervising Nurse said diabetic precautions were not listed as a safety measure on Patient #4’s plan of care dated 7/27/25- 9/24/25. The Supervising Nurse said diabetic precautions should have been listed on Patient #4’s plan of care. The Supervising Nurse said if safety measures were not identified on the patient’s plan of care the patient would be at risk of a safety hazard. During a telephone interview on 9/10/25 at 9:00 am, Patient #4 said she was diabetic. Patient #4 said she checks her blood sugar regularly. Patient #4 said the agency nurses have not been discussing her diabetes with her because her blood sugars have been good. During an interview on 9/10/25 at 9:58 am, the Alternate Administrator said the RN field clinician who does the start of care was responsible for completing the plan of care. The Alternate Administrator said diabetic precautions and anything related to the patient’s diagnosis should be listed as a safety measure on the plan of care. The Alternate Administrator said diabetic precautions should have been listed as a safety measure on Patient #4’s plan of care. The Alternate Administrator said if safety measures were not on the patient’s plan of care clinicians would not know to treat it and provide education to the patient/family/care givers. During an interview on 9/10/25 at 10:15 am, the Administrator/Alternate Supervising Nurse said the RN was responsible for completing the plan of care. The Administrator/Alternate Supervising Nurse said diabetic precautions should be listed as a safety measure on the patient’s plan of care. The Administrator/Alternate Supervising Nurse said diabetic precautions should have been listed as a safety measure on Patient #4’s plan of care. The Administrator/Alternate Supervising Nurse said if safety measures were not included on the plan of care the clinician would not have awareness as to what to check for and education would not be provided to the patient. Record review of a Plan of Care policy dated 05/02/24 indicated “…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 interventions that will resolve or alleviate the patient’s/client’s problems and/or needs. … Procedure… The individualized 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: 1. All pertinent diagnoses … 11. Safety measures to protect against injury … 12. A description of the patient’s/client’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors … 14. Patient/client-specific interventions and education…””