Every finding on record at Agnesian Healthcare Inc.

An unannounced onsite recertification survey was conducted 12/8/2025 - 12/9/2025 at SSM Health at Home Home Health in Fond du lac, WI. The agency is in compliance with the Emergency Preparedness Regulations, 42 CFR 484.102 for Home Health.

An unannounced onsite recertification survey was conducted 12/8/2025 - 12/9/2025 at SSM at Home Home Health located in Fond du lac, WI. The agency is in compliance with the Medicare Conditions of Participation, 42 CFR 484 for Home Health. Based on the number of unduplicated admissions of 873 within the last twelve months, 17 record reviews were completed (7 with home visits, 5 discharged, 5 current) and 9 employee files were reviewed.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, interview and record review, the agency staff failed to perform hand hygiene/glove changes per policy and failed to ensure distinct separation of clean and dirty equipment and supplies for 1 of 2 patients (Patient #6) observed in a total of 7 patient home visits. Findings include: Review of agency policy titled “Infection Control, Prevention…” last reviewed 07/2025 revealed in part, “VI. Hand Hygiene. Indications for hand hygiene: Before and after each patient contact or after handling patient equipment. Before and after removing gloves. Before and after contact with wounds…” During an observation on 12/09/2025 starting at 9:25 AM, observed Registered Nurse (RN) C perform the following while assessing Patient #6: RN C was observed placing dirty equipment on/in a clean container prior to disinfecting them. RN C then used a disinfecting wipe to clean the stethoscope, thermometer, pulse oximeter, and blood pressure cuff. RN C proceeded to perform wound care on Patient #6’s bilateral lower extremities. After removing gloves RN C did not perform hand hygiene. RN C then placed previously cleaned equipment in the same container that the dirty equipment was placed on/in without disinfecting the container and placed in nursing bag. RN C continued to discard barriers and handle nursing bag without completing hand hygiene between tasks. During the exit interview on 12/09/2025 at 12:50 PM, with Clinical Education Manager D the above findings were reviewed and confirmed.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on record review, observation, and interview, the agency Home Health Aide (HHA) failed to provide services accordingly to plan of care orders in 1 of 1 HHA visits observed (Patient #1) in a total of 7 patient visits conducted. Findings include: Review of agency policy titled "HHA Services, Supervision, and Duties in Home Health" dated 03/2022 revealed "Process: II. HHA Assignments and Duties. C. The HHA provides services that: 1. Are ordered by a physician. 2. Are included in the patient's plan of care." Review of agency policy titled "Gait Belt" dated 07/2025 revealed "Definitions: II. All patients whose feet will be on the floor must have a gait belt on. This includes patients who are transferring from one surface to another, standing, walking, or showering. Process: E. Use during transfers and ambulation: Use the gait belt whenever the patient is moving, whether it's transferring from bed to chair, standing up, showering, or walking." Record review of Patient #1's "Home Health Plan of Care: Certification Period 11/22/2025 to 01/20/2026" revealed "Care Plan: Problem/Intervention: HHA Personal Care: Ambulation/Transfers: Using walker for ambulation. Gait belt required: YES, gait belt required with all transfers, per policy. Precautions: fall risk." During a home visit observation for Patient #1 conducted by Aide B on 12/08/2025 at 11:40 AM, observed Patient #1 sitting in a wheelchair in the kitchen and walker located in front of Patient #1. Aide B had Patient #1 go from sit to standing, ambulate to patient's bedroom with walker, and lie down on the bed. Aide B had Patient #1 get back to a sitting position, stand with assist of walker, and ambulate to the bathroom where Aide B assisted Patient #1 in and out of the shower. Aide B had Patient #1 ambulate back to the bedroom with assist of walker. At no time during the visit did Aide B address use of the gait belt or utilize gait belt per plan of care orders during transfers or ambulation. The above findings were reviewed during an interview with Registered Nurse Supervisor A on 12/08/2025 at 8:50 AM.

An unannounced, onsite, complaint survey was completed 9/28/2022 at SSM at Home Home Care in Fond du lac, WI for complaint # 71531. The complaint was substantiated and citations issued. The agency was found to be in compliance with the Medicare Conditions of Participation for Home Health, 42 CFR 484.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to involve patients/families with meeting the patient's Physical Therapy (PT) needs in 5 of 7 patients with therapy ordered at admission out of a total of 10 patient records reviewed (Patients #1, #3, #5, #8 and #9). Findings include: Review of policy "Admission Criteria-Home Care" last revised 7/12/2021 revealed in part, "1) Home Care Admission: Patients are accepted for treatment on the basis of a reasonable expectation that the patient's medical, nursing, and social needs can be met adequately by the agency in the patient's place of residence." Further review revealed in part, "5) Availability of agency personnel is established prior to admission to meet the level of care needed for a specific patient. If adequate employees are unavailable to meet patient's needs, patient will be referred to alternative resources." Review of policy "Prioritization and Scheduling of Therapy Patients in Home Care" last revised 10/1/2021 revealed in part, "1) Therapy referrals are listed according to date of referral received...2) When patient referrals exceed therapist availability, the patient/family/physician are advised of potential wait time at admission and are assisted to find alternate resources for services by Intake if requested." Further review revealed in part, "5) If referrals for therapy exceed therapist availability, the following procedure will be utilized to prioritize patients. a) Referrals are taken in chronological order by referral date. The only exceptions to this are based on geography and if a therapy cannot contact the patient that is next in line or they prefer a later date the therapist will document in a case communication in EMR (Electronic Medical Record.) b) Patients with diagnoses/needs that delay in obtaining therapy may result in negative outcomes or long term impairment. c) Patient considered higher priority for PT (Physicial Therapy): i. Total joint replacements ii. CVA (Cerebral Vascular Accident-Stroke) iii. New or recent falls. d) Patients considered higher priority for OT (Occupational Therapy): i. Shoulder replacement ii. Shoulder fracture iii. CVA....." Further review also revealed in part, "f) By location, to coincide with predetermined geographic location of the therapist." Review of Patient #1's medical record revealed Patient #1 was admitted to home care services on 8/4/2022 for the purpose of receiving therapy. Patient #1 had a primary diagnosis of Myasthenia Gravis (auto immune disease in which the communication between the nerves and skeletal muscles are destroyed resulting in weakness) and secondary diagnosis of Parkinson's Disease (brain disorder that causes unintended or uncontrollable movements such as trembling and stiffness.) Further review of Patient #1's "Home Health Certification and Plan of Care" dated 8/4/2022 - 10/2/2022 revealed in part, "Condition that results in an activity limitation or restriction that impairs the ability to leave home: Limited ambulation, Unsteady gait/poor balance, Fall risk." Further review revealed "Physical Therapy 1 time in 30 days for home exercise program and safety. One visit to evaluate patient and provide treatment with orders to follow." There was no documentation within the record that the patient/family was notified of PT wait time. Review of Patient #1's "PT Inital Eval (evaluation)" revealed that Patient #1 did not start PT services until 8/19/2022. Further review revealed in part "Patient was seen for PT evaluation to determine skilled need due to: impaired balance weakness, impaired standing tolerance, gait deficit due to myasthenia gravis, report of fall history x4...." Patient #1 waited 15 days for PT services to start despite risk factors that were identified on admit. Review of Patient #3's medical record revealed Patient #3 was admitted to home care service on 8/9/2022 with a primary diagnosis of encounter for surgical aftercare following surgery on the circulatory system with secondary diagnoses of hemiplegia and hemiparesis following cerebral infarction (stroke) affecting left non-dominate side and stage 5 chronic kidney disease (end stage.) Review of Patient #3's "Home Health Certification and Plan of Care" dated 8/9/2022 - 10/7/2022 revealed in part "Condition that results in activity limitation or restriction that impairs ability to leave home: unsteady gait/poor balance; gait deficit; fall risk; medical." Further review revealed "PT 1 every 30 days. PT one time in 30 days to evaluate and treat for in home safety, pain, ambulation and strengthening due to recent hospitalization for ESRD (end stage renal disease) CVA with left-sided weakness and CAD (coronary arterial disease). There was no documentation within the record that indicated the patient/family was informed of PT wait. Review of Patient #3's "PT Initial Eval" revealed that Patient #3 did not start PT services until 8/30/2022. Patient #3 waited 21 days for PT services to start despite the risk factors that were identified on admit. Review of Patient #5's medical record revealed Patient #5 was admitted to home care on 8/12/2022 with a primary diagnosis of unspecified fracture of right lower leg. Secondary diagnoses included unspecified fracture of left lower leg and unspecified fracture of of shaft of humerus, right arm. Review of initial verbal admit orders dated 8/10/2022 revealed OT and PT evaluations within 30 days. There was no documentation within the record to indicate that patient/family informed of PT wait time. Review of Patient #5's "Home Health Certification and Plan of Care" revealed in part "Activity limitation or restriction that impairs ability to leave home: weight bearing limitations; fall risk; chairfast." Review of Patient #5's "PT Initial Eval" revealed Patient #5 did not start PT services until 9/2/2022. Patient #5 waited 22 days for PT services to start despite the risks factors that were identified on admit. Review of Patient #8's medical record revealed Patient #8 was admitted to home care on 9/2/2022 with a primary diagnosis of infection and inflammatory reaction due to internal right hip prosthesis. Secondary diagnoses included primary generalized osteoarthritis, epilepsy. Review of Patient #8's "Home Health Certification and Plan of Care" dated 9/2/2022 - 10/31/2022 revealed "PT 1 every 30 days. One visit within 30 days to evaluate lower extremity strength, gait, balance, and use of DME (durable medical equipment) following right total hip arthroplasty." Further review revealed "Activity limitation or restriction that impairs the ability to leave home: limited ambulation, fall risk." There was no documentation within the record that patient/family was notified of PT wait. Review of Patient #8's "PT Inital Eval" revealed Patient #8 did not receive PT services until 9/13/2022. Patient #8 waited 11 days for PT services to start despite the risk factors that were identified on admit. Review of Patient #9's medical record revealed Patient #9 was admitted to home care on 8/8/2022 with a primary diagnosis of primary osteoarthritis, right ankle and foot. Review of Patient #9's "Home Health Certification and Plan of Care" dated 8/8/2022 - 10/6/2022 revealed PT orders "PT 1 every 30 days; one visit within 30 days in order to evaluate lower extremity strength, gait, balance, and use of DME..." Further review revealed "Condition that results in activity limitation or restriction that impairs the ability to leave home: limited ambulation; fall risk." There was no documentation in the record that indicated patient/family was informed of PT wait time. Review of Patient #9's "PT Initial Eval" revealed Patient #9 did not receive PT services until 8/23/2022. Patient #9 waited 15 days for PT services to start, despite the risk factors that were identified on admit. An interview was conducted with Clinical Manager A on 9/28/2022 at 11:40 a.m. When asked why therapy orders were written to give the therapist 30 days for initial evaluation, A stated that the order is written to get the patient on the therapy schedule. A also stated that therapy evaluations are prioritized by falls, strokes, hips and knees (joint replacements.) When asked how patient/families are informed of a delay in receiving therapy services A stated "Our intake informs referrals of our PT wait time." A also stated that it was difficult to recruit PT's in the area and agency staffing has been used.