Every finding on record at Bay at Woodlands Home Health LLC

An unannounced on-site recertification survey was conducted at Woodlands Home Health in Suring, WI from 02/26/2024-02/27/2024. Woodlands Home Health was found to be out of compliance with Medicare Conditions of Participation for Emergency Preparedness for Home Health Agencies, 484.102. 42 CFR 484.102 Conditions of Participation for Emergency Preparedness for Home Health Agencies is NOT MET.

Establishment of the Emergency Program (EP) CFR(s): 484.102 §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.542, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: * (Unless otherwise indicated, the general use of the terms "facility" or "facilities" in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This CONDITION is not met as evidenced by: Based on record review and interview, this agency failed to ensure there is a comprehensive Emergency Preparedness Program, in 1 of 1 Emergency Programs reviewed. Findings include: This agency failed to establish an Emergency Preparedness program that is reviewed and updated every two years. See tag E-0004. This agency failed to ensure the Emergency Preparedness policy and procedures are reviewed and updated every two years. See tag E-0013. This agency failed to ensure the communication plan is reviewed every two years. See tag E-0029. This agency failed to ensure training and testing of the emergency preparedness program is documented and reviewed every two years. See tag E-0036. This agency failed to conduct One full-scale community-based exercise every two years. See tag E-0039. The cumulative effect of these systemic problems resulted in the clinic's inability to effectively develop or implement an emergency preparedness policy and procedures utilizing an all-hazards risk assessment, emergency preparedness communication plan, emergency preparedness training and testing program that includes one full-scale community-based exercise and is reviewed and updated every 2 years.

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on interview and record review this agency failed to document the Emergency Plan risk assessment is reviewed and updated every two years in 1 of 1 Emergency Preparedness Programs reviewed. Findings Include: A review of policy and procedure titled “Emergency Preparedness” dated 04/24/2019, revealed in part “Responsibilities: Home Health Administrator – reviewing the Woodland Village Home Health HVA (Hazard Vulnerability Analysis) tool and Emergency Preparedness policy annually and updating as appropriate.” Interview with Administrator A on 2/27/2024 at 9:08AM. Administrator A was asked if the emergency preparedness program and policy and procedures are reviewed and updated every two years. Administrator A stated, “I will look in the back for that I am sure I have that." Follow up with Administrator A on 2/27/2024 at 10:20 AM Administrator A stated, “I don’t have that.”

Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility's geographic area. This STANDARD is not met as evidenced by: Based on interview and record review this agency failed to ensure Emergency Preparedness Policy and Procedures were reviewed and updated every two years in 1 of 1 Emergency Preparedness Plan reviewed. A review of policy and procedure titled “Emergency Preparedness” dated 04/24/2019, revealed in part “Responsibilities: Home Health Administrator – reviewing the Woodland Village Home Health HVA tool and Emergency Preparedness policy annually and updating as appropriate.” Interview with Administrator A on 2/27/2024 at 9:08AM. Administrator A was asked if the emergency preparedness program and policy and procedures are reviewed and updated every two years. Administrator A stated, “I will look in the back for that I am sure I have that." Follow up with Administrator A on 2/27/2024 at 10:20 AM Administrator A stated, “I don’t have that.”

Development of Communication Plan CFR(s): 484.102(c) §403.748(c), §416.54(c), §418.113(c), §441.184(c), §460.84(c), §482.15(c), §483.73(c), §483.475(c), §484.102(c), §485.68(c), §485.542(c), §485.625(c), §485.727(c), §485.920(c), §486.360(c), §491.12(c), §494.62(c). (c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. This STANDARD is not met as evidenced by: Based on interview and record review this agency failed to ensure the Emergency Preparedness communication plan is reviewed and updated every two years in 1 of 1 Emergency Preparedness Plan reviewed. A review of policy and procedure titled “Emergency Preparedness” dated 04/24/2019, revealed in part “Responsibilities: Home Health Administrator – reviewing the Woodland Village Home Health HVA tool and Emergency Preparedness policy annually and updating as appropriate.” Interview with Administrator A on 2/27/2024 at 9:08AM. Administrator A was asked if the emergency preparedness program and policy and procedures are reviewed and updated every two years. Administrator A stated, “I will look in the back for that I am sure I have that." Follow up with Administrator A on 2/27/2024 at 10:20 AM Administrator A stated, “I don’t have that.”

EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This STANDARD is not met as evidenced by: Based on interview and record review this agency failed to ensure the Emergency Preparedness training and testing is reviewed and documented every two years in 1 of 1 Emergency Preparedness Plan reviewed. A review of policy and procedure titled “Emergency Preparedness” dated 04/24/2019, revealed in part “Responsibilities: Home Health Administrator – reviewing the Woodland Village Home Health HVA tool and Emergency Preparedness policy annually and updating as appropriate.” Interview with Administrator A on 2/27/2024 at 9:08AM. Administrator A was asked if the emergency preparedness program and policy and procedures are reviewed and updated every two years. Administrator A stated, “I will look in the back for that I am sure I have that." Follow up with Administrator A on 2/27/2024 at 10:20 AM Administrator A stated, “I don’t have that.”

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on interview and record review this agency failed to conduct one full-scale community-based exercise every two years in 1 of 1 Emergency Preparedness Plan reviewed. A review of policy and procedure titled “Emergency Preparedness” dated 04/24/2019, revealed in part “Responsibilities: Home Health Administrator – reviewing the Woodland Village Home Health HVA tool and Emergency Preparedness policy annually and updating as appropriate.” Interview with Administrator A on 02/27/2024 at 9:08 AM. Administrator A was asked to provide information that a full-scale testing with community has been done in 2 years. Administrator A stated, “I basically attend the HERC (Northeast Wisconsin Healthcare Emergency Readiness Coalition) and chime in, but we have not had any drills. To be very honest, I haven’t heard anything at HERC on a full community drill.”

An unannounced on-site recertification survey was conducted 02/26/2024 to 02/27/2024 at Woodland Home Health in Suring, WI. Woodland Home Health in Suring was found to be in compliance with Medicare Conditions of Participation for Home Health Agencies, 42 CFR 484. Citations are issued at a standard level or below. A total of 8 patient records and 2 home visits were conducted for an unduplicated skilled admission census of 165 in the past year.

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, agency staff failed to develop Plans of Care (POC) that were individualized to meet the specific needs of the patients and/or develop goals that were measurable within a specified timeframe and/or individualized in 8 of 8 patients (Patients #1, #2, #3, #4, #5, #6, #7, and #8) records reviewed. Record review of Patient #4’s “Home Health Certification and Plan of Care” dated 02/06/2024 - 04/05/2024 revealed in part, “Patient #4 start of care date: 02/06/2024 with a Primary Diagnosis of Fracture of Right Femur. Summary of SN orders: SN: Educate patient on importance of stool softeners, fluid intake, ambulation to help decrease risk of constipation. Teach on high-risk medications, educate on increased iron diet, educate patient on smoking cessation, teach home safety/fall prevention, notify physician vital signs out of parameter, educate patient on sign/symptoms of infection, patient has nonremovable dressing in place. PT (physical therapy) orders: Gait training, PT may Include ex-activities, gait, mobility skills, balance, stair climbing skills, transfer training. PT Goals: Independent bed mobility. Target date: 03/07/2024. Independent gait 150 ft with devices. Target date: 02/29/2024. Independent with HEP (home exercise program). Target date: 02/29/2024. Independent wit transfers. Target date: 02/29/2024. Patient to complete TUG (timed up and go) in 12 seconds. Target date: 03/08/2024. Patient to improve LE strength to 4/5 to facilitate improved functional mobility skills. Target date: 03/08/2024. Up/down 2 steps with devices without assistance. Target date: 03/08/2024.” The PT POC goals not measurable or individualized to the patient's specific needs. SN Goals: There were no SN Goals on Patient #4's Plan of Care Record review of Patient #5’s “Home Health Certification and Plan of Care” dated 01/20/2024 - 03/19/2024 revealed in part, “Patient #5 start of care date: 01/20/2024 with a Primary Diagnosis of Non-pressure ulcer of other part of right foot with fat layer exposed. HHA (Home Health Aide) Orders: Assist with ambulation, transfers, dressing, shampoo hair, sponge bath, empty drainage bag, external Cath care, perineal care, walker, clean nails, file nails. HHA Goals: Provide assistance for optimal well-being r/t activity. Target date: 03/19/2024. Provide assistance for optimal well-being r/t bathing needs. Target date: 03/19/2024. Provide assistance for optimal well-being r/t elimination/toileting, monitoring. Target date: 03/19/2024. Provide assistance for optimal well-being r/t skin care. Target date: 03/19/2024. Provide assistance for optimal well-being r/t vital signs. Target date: 03/19/2024." HHA POC goals not measurable or individualized to the patient's specific needs. Record review of Patient #6’s “Home Health Certification and Plan of Care” dated 11/21/2023 - 01/19/2024 revealed in part, “Patient #6 start of care date: 09/22/2023 with a Primary Diagnoses of Hypertension, Type 2 Diabetes. PT orders: Gait training, PT may Include their ex-activities, gait, mobility skills, balance, stair climbing skills, transfer training. PT Goals: Independent bed mobility. Target date: 11/17/2023. Independent with HEP. Target date: 11/10/2023. Patient to complete TUG in 12 seconds. Target date: 11/17/2023. Patient to improve LE strength to 4/5 to facilitate improved functional mobility skills. Target date: 11/10/2023. Up/down 26 steps with devices with partial rails in/out of home with supervision. Target date: 12/31/2023. Patient to complete 4 reps STS. Target date: 11/10/2023. SN Orders: Educate patient on importance of elevation legs while in recliner. Educate on sign/symptom of hypo/hyperglycemia. Teach/educate on following diabetic diet. Educate on new or changed medications. Educate on fall prevention. Report vital signs outside of agency parameters to Physician. Patient will have wound vac changed Monday at the wound clinic and Wednesday and Friday by home health. Educate patient on wet to dry dressing in case wound vac is not working. Education on sign and symptoms of infection.” PT POC goals not measurable or individualized to the patient's specific needs, SN POC Goals: There were no SN Goals on Patient #6's Plan of Care. Record review of Patient #7’s “Home Health Certification and Plan of Care” dated 12/11/2023 - 02/08/2024 revealed in part, “Patient #7 start of care date: 12/11/2023 with a Primary Diagnoses of Weakness, Spinal Stenosis. PT orders: Gait training, PT may Include their ex-activities, gait, mobility skills, balance, stair climbing skills, transfer training. PT Goals: Independent bed mobility. Target date: 01/12/2024. Patient to do HEP with caregiver assistance as needed. Target date: 12/29/2023. Patient to improve LE strength to 4/5 to facilitate improved functional mobility skills. Target date: 01/12/2024. Gait in home with upright stand by assistance. Target date: 01/05/2024. Patient to stand 5 minutes with devices/assist. Target date: 01/12/2024. Patient to transfer with stand by assistance. Target date: 01/19/2024. SN Orders: Educate patient on importance of elevation legs while in recliner. Monitor and mitigate pain. Educate on new or changed medications. Educate on fall prevention. Report vital signs outside of agency parameters to Physician. Education on fall prevention.” PT POC goals not measurable or individualized to the patient's specific needs, SN POC Goals: There were no SN Goals on Patient #7's Plan of Care. Record review of Patient #8’s “Home Health Certification and Plan of Care” dated 12/06/2023 - 02/03/2024 revealed in part, “Patient #8 start of care date: 12/06/2023 with a Primary Diagnoses of Poly osteoarthritis. PT orders: Gait training, PT may Include their ex-activities, gait, mobility skills, balance, stair climbing skills, transfer training. PT Goals: Independent bed mobility. Target date: 12/31/2023. Independent with HEP. Target date: 12/29/2023. Patient to improve LE strength to 4/5 to facilitate improved functional mobility skills. Target date: 12/23/2023. Up/down 2 steps with rails with stand by assistance. Target date: 12/31/2023. Gait front wheeled walker with supervision as needed. Target date: 12/27/2023. Independent with transfers. Target date: 12/22/2023. SN Orders: Monitor and mitigate pain. Educate on new, high risk, or changed medications. Educate on fall prevention. Report vital signs outside of agency parameters to Physician.” PT POC goals not measurable or individualized to the patient's specific needs, SN POC Goals: There were no SN Goals on Patient #8's Plan of Care. During an interview with Administrator A on 02/27/2024 at 8:56 AM, when the above findings for Patients #1, #2, #3, #4, #5, #6, #7, and #8 were reviewed, and when asked if the patient SN and PT POCs goals were measurable, Administrator A replied, "I think the SN goals print in another area, I will check, but the PT goals have been an issue the PT continues to not understand the goals and the need for them to be measurable or understanding the computer system, we continue to work with the PT." During an interview with Administrator A on 02/27/2024 at 10:00 AM, reviewed findings of the SN goals that Administrator A printed that were not on the patients 485 POC, it was reviewed that the goals continue to not be individualized or measurable, Administrator A replied, "I know, I get what you're saying." Findings Include: Review of agency policy and procedure titled “Patient Plan of Care and Medical Supervision" dated 05/20/2015 revealed “Procedure: 6. According to DHS 133.20 (2): Each plan of care must include: a. Measurable time-specific goals, with benchmark dates for review.” Review of document for Patient #1 titled “Home Health Certification and Plan of Care” dated 02/03/2024 - 04/02/2024 revealed in part “Patient #1’s start of care date: 02/18/2021 with a Primary Diagnosis of Fitting and Adjustment of Urinary Catheter. Secondary diagnoses included Hemiplegia on right (dominant) side from a stroke, Chronic Congestive Heart Failure and Chronic Kidney Disease- Stage 4." Further review revealed "SN (Skilled Nursing) Goals: Patient will remain free of UTI (urinary tract infection) throughout certification period. Target completion Date: 04/02/2024." There were no other goals on the Plan of Care. The Plan of Care Goal was not individualized to the patient's specific needs. Review of document for Patient #2 titled “Home Health Certification and Plan of Care” dated 02/06/2024 - 04/05/2024 revealed in part “Patient #2’s start of care date: 10/30/2019 with a Primary Diagnosis of Hemiplegia of left (nondominant) side following cerebral hemorrhage. Secondary diagnoses included Type 2 Diabetes with Diabetic Neuropathy and Acute Combined Systolic and Diastolic (Congestive) Heart Failure." Further review revealed goals including "Provide assistance for optimal well-being r/t (related to) bathing needs. Provide assistance for optimal well-being r/t elimination/toileting assistance/monitoring. Provide assistance for optimal well-being r/t skin care. Provide assistance for optimal well-being r/t pain." There was no target date for any goals. The Plan of Care goals were not measurable or individualized to meet the patient’s specific needs. Review of document for Patient #3 titled “Home Health Certification and Plan of Care” dated 01/12/2024 - 3/11/2024 revealed in part “Patient #9’s start of care date: 01/12/2024 with a Primary Diagnosis of Sepsis. Secondary diagnoses included Cellulitis of Right Lower Limb and Type 2 Diabetes with foot ulcer." Further review revealed "SN Goals: Wounds to heal throughout certification period. Target completion date: 3/11/2024." There were no other goals on the Plan of Care. The Plan of Care goal was not measurable or individualized to meet the patient’s specific needs.