Reliant at Home

“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 plan of care for 6 (Patient 1,2,3,4,5, and 6) of 17 patients failed to include patient-specific interventions, education, and appropriate individualized goals. The plans of care included skilled nurse interventions of “teaching/reinforcement regarding proper diabetic foot care”(a specific set of actions to reduce infections and injuries to the feet of those who have Diabetes [a chronic disorder in which the body has trouble controlling blood sugar and using it for energy]) for the patients who did not have a diagnosis of Diabetes. The plans of care for included goals of “Patient/Caregiver will verbalize / demonstrate ability to properly manage diabetic foot care.” This failure placed patients at risk of receiving inappropriate and unnecessary care. Review of Patient 1’s plan of care from 08/13/2024 to 10/11/2024 revealed no diagnosis of Diabetes. The POC documented orders for SN visits weekly for 5 weeks and then once every 2 weeks for 4 weeks. Orders included: Skilled Nurse to provide “teaching/reinforcement regarding proper diabetic foot care.” The POC included the goal of: “Patient/Caregiver will verbalize / demonstrate ability to properly manage diabetic foot care.” During a visit to the home of Patient 1 on 09/27/24 at 3:00 PM the surveyor observed Patient 1. Patient 1 stated his health issues including recent pneumonia, history of 2 heart attacks, arthritis, and a history of bladder cancer. Patient 1 stated he did not have diabetes. Review of Patient 2’s plan of care from 08/15/2024 to 10/13/2024 revealed no diagnosis of Diabetes. The POC documented orders for SN visits weekly for 1 week, twice a week for one week, and then once every 2 weeks for 6 weeks. Orders included: Skilled Nurse to provide “teaching/reinforcement regarding proper diabetic foot care.” The POC included the goal of: “Patient/Caregiver will verbalize / demonstrate ability to properly manage diabetic foot care.” During a visit to the home of Patient 2 on 09/27/24 at 1:45 PM the surveyor observed Patient 2. Patient 2 stated his health issues including knee problems and described being with the agency since June of 2024. Patient 2 stated he did not have diabetes. Review of Patient 3’s plan of care from 07/14/2024 to 09/11/2024 revealed no diagnosis of Diabetes. The POC listed kidney disease, heart disease, depression, bladder issues and a history of falling. The POC documented orders for SN visits weekly for 5 weeks and then once every 2 weeks for 4 weeks. The POC listed no medications prescribed for diabetes. Orders included: Skilled Nurse to provide “teaching/reinforcement regarding proper diabetic foot care.” The POC included the goal of: “Patient/Caregiver will verbalize / demonstrate ability to properly manage diabetic foot care.” Review of Patient 4’s plan of care from 06/23/2024 to 08/21/2024 revealed no diagnosis of Diabetes. The POC documented orders for SN visits twice weekly for one week and then once per week for 4 weeks. Orders included: Skilled Nurse to provide “teaching/reinforcement regarding proper diabetic foot care.” The POC included the goal of: “Patient/Caregiver will verbalize / demonstrate ability to properly manage diabetic foot care.” During a visit to the home of Patient 4 on 09/27/24 at 2:30 PM the surveyor observed Patient 4. Patient 4 stated her health issues including a recent skin tear on her arm that had healed, osteoporosis (a condition causing the bones to become weak and brittle) that caused her a lot of pain. Patient 4 stated she did not have diabetes. Review of Patient 5’s plan of care from 07/25/2024 to 09/22/2024 revealed no diagnosis of Diabetes. The POC documented orders for SN visits once weekly for 4 weeks and then once every two weeks for 4 weeks. Orders included: Skilled Nurse to provide “teaching/reinforcement regarding proper diabetic foot care.” The POC included the goal of: “Patient/Caregiver will verbalize / demonstrate ability to properly manage diabetic foot care.” During a visit to the home of Patient 5 on 09/27/24 at 3:27 PM the surveyor observed Patient 5. Patient 5 stated her health issues included seizures (uncontrolled jerking, loss of consciousness, blank stares, or other symptoms caused by abnormal electrical activity in the brain), asthma (a condition of inflamed airways making breathing difficult). Patient 5 stated she did not have diabetes. Review of Patient 6’s plan of care from 05/08/2024 to 07/06/2024 signed by RN A revealed no diagnosis of Diabetes. The POC listed Alzheimer’s (a progressive disease that destroys memory and other important mental functions), Dementia (a group of thinking and social symptoms that interferes with daily functioning), scoliosis (sideways curvature of the spine), chronic pain, asthma, urinary incontinence (loss of bladder control), and history of falling. The POC documented orders for SN visits 1 time per week for 2 weeks and then once every 2 weeks for 6 weeks. The POC listed no medications prescribed for diabetes. Orders included: Skilled Nurse to provide “teaching/reinforcement regarding proper diabetic foot care.” The POC included the goal of: “Patient/Caregiver will verbalize / demonstrate ability to properly manage diabetic foot care.” The record review found SN visits as ordered documented by LVN A until Patient 6 was discharged from the agency 06/24/2024. An interview was conducted with RN A on 09.30.2024 at 12:03 PM. The surveyor asked if the patients #1, #2, #3, #4, #5 and #6 had a diagnosis of diabetes. RN A looked up each patient and stated they were not diabetics. The surveyor asked about the orders for teaching diabetic foot care and the goals for diabetic foot care. RN A stated she was looking the patients up in the electronic medical record. RN A stated: “there’s certain measures that I was told that we have to pick on the 485… so when I pick the intervention for safety (the electronic medical record) automatically puts diabetic foot care on the plan of care.” RN A stated: “that will pop up every single visit until somebody checks it off and says that this is either not applicable to the patient or this is completed as a goal.” RN A stated: “usually when the LVN sees the patient (for the subsequent visit) the LVN picks the interventions that they’re teaching on that visit and say whether it’s completed or needs more teaching.” RN A stated: “I was told with this company there were a lot of interventions … (because) nobody’s checking them off right and it’s because the LVN’s were unable to complete interventions.” RN A stated: “only the RN for some reason was able to complete them (the interventions) and I wasn’t seeing a lot of the patients for sequential visits… so I think that that particular intervention for diabetic foot care could have stayed on for the whole episode.” The surveyor asked who was responsible for the interventions and goals on the plans of care. RN A stated the RN who does the recertification. RN A stated she thought the diabetic foot care was “linked to safety for some reason even if they’re not diabetic.” RN A stated the electronic medical record puts that intervention on the plan of care when you add safety interventions and goals. An interview was conducted with LVN A on 09.30.2024 at 12:34 PM. The surveyor if the patients listed above had a diagnosis of diabetes. LVN A looked up each patients record and reviewed the medications and diagnoses and stated they did not have diabetes. The surveyor asked who was responsible for the interventions and goals on the plans of care. LVN A stated the RN completed those during assessments. An interview was conducted with the Administrator / DON on 09/30/2024 1:33 PM. The surveyor reviewed the record review, home visit, and nurse interview findings with the Administrator / DON. The Surveyor asked why the patients had interventions and goals for teaching diabetic foot care to patients who were not diabetic. The Administrator / DON reviewed the patients in the electronic medical record and stated this was an issue with the electronic medical record. The Administrator / DON stated the agency had transitioned to this system about a year ago and really struggled with the transition. The Administrator / DON stated she had been hired approximately 2 months ago and was familiar with the new electronic medical record software. The Administrator / DON stated there were issues with the nursing staff understanding how to build and modify the plans of care. The surveyor asked whose responsibility was it to develop the plans of care. The Administrator / DON stated it was the RN who completed the comprehensive assessments. The Administrator / DON stated the Quality Assurance staff should have picked this up as each comprehensive assessment and plan of care was reviewed after the RN finished them and changes were recommended and sent back to the RN for review and approval of the changes recommended. Agency policy titled: Plan of Care PC.35 dated 050224 read in part: “Each patient/client must receive an individualized written Plan of Care, including any revisions or additions. 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, including identification of the responsible discipline(s), and the measurable outcomes that the Agency anticipates will occur as a result of implementing and coordinating the Plan of Care. The individualized Plan of Care will indicate if the patient/client has an advance directive(s) and if so, what type(s) of advance directive(s) exists. If the patient does not have an advance directive, this should also be listed on the individualized Plan of Care. The individualized Plan of Care must also specify the patient/client and caregiver education and training. A. The individualized Plan of Care must include the following: 1. All pertinent diagnoses … All medication and treatments … Patient/client-specific interventions and education … Measurable outcomes and goals identified by the Agency and the patient/client…””