Every finding on record at Bridges Healthcare, LLC

An unannounced onsite recertification survey was conducted on 10/24/2023 – 10/25/2023 at Bridges Home Healthcare in Waukesha, WI. The agency was found to be out in compliance with the Emergency Preparedness regulations for Home Health Agencies, 42 CFR 484.22. Citations are issued at a standard level or below.

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 record review and interview the agency failed to conduct one testing exercise on an annual basis, which may be either one community-based full-scale exercise, if available, or an individual facility-based functional exercise for 1 of 1 emergency programs reviewed. Findings include: Review of agency's Emergency Preparedness Program revealed, the last documented testing exercise conducted by agency was on 08/2021. In an interview with Chief Operating Officer A on 10/23/2023 at 11:45 AM, he/she stated, "We have to do a table top or drill soon."

An unannounced onsite recertification survey was conducted on 10/24/2023 – 10/25/2023 at Bridges Home Healthcare in Waukesha, WI. The agency was found to be in compliance with the Medicare Conditions of Participation for Home Health Agencies, 42 CFR 484. Citations issued at standard level for a total of 220 unduplicated skilled admissions for the past twelve months, 3 home visits were conducted and a total of 7 records reviewed.

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 the agency staff failed to document patient specific and measurable goals in 7 of 7 patient's (#1-7) medical records reviewed. Findings include: Review of agency policy titled "Care Planning Process Policy #4-001.1” not dated revealed under heading "Procedure 3. c. Reasonable, measurable, and individualized goals…" Review of patient #1's plan of care (POC) dated 10/05/23-12/03/2023 revealed under "SN Goals", "The patient will be free from injury during the certification period." Goal is not specific to the patient or measurable. “Patient will be without signs or symptoms of UTI (pain, foul odor, cloudy or blood-tinged urine and fever) during this episode.” Goal is not specific to the patient. Review of Patient #2's POC dated 10/09/2023-12/07/2023 revealed under "SN Goals", "The patient will be free from injury during the certification period." Goal is not specific to the patient or measurable. “Patient will be without signs or symptoms of UTI (pain, foul odor, cloudy or blood-tinged urine and fever) during this episode.” Goal is not specific to the patient. Review of Patient #3's POC dated 09/25/2023-11/23/2023 revealed under "SN Goals", "Patient will be free from signs and symptoms of respiratory distress during episode." Goal is not specific to the patient or measurable. Review of Patient #4's POC dated 10/02/2023-11/30/2023 revealed under "SN Goals", “Patient will be without signs or symptoms of UTI (pain, foul odor, cloudy or blood-tinged urine and fever) during this episode.” Goal is not specific to the patient. Review of Patient #5's POC dated 09/29/2023-11/27/2023 revealed under "SN Goals", “Patient will be without signs or symptoms of UTI (pain, foul odor, cloudy or blood-tinged urine and fever) during this episode.” Goal is not specific to the patient. “Patient will be independent with medication management by end of episode.” Goal is not specific to the patient or measurable. Review of Patient #6's POC dated 08/15/2023-10/13/2023 revealed under "SN Goals", "The patient will be free from injury during the certification period." Goal is not specific to the patient or measurable. “Patient will be without signs or symptoms of UTI (pain, foul odor, cloudy or blood-tinged urine and fever) during this episode.” Goal is not specific to the patient. Review of Patient #7's POC dated 06/06/2023-08/04/2023 revealed under "SN Goals", "Patient will be free from signs and symptoms of respiratory distress during episode." “Patient skin integrity will remain intact during this episode.” Goals are not specific to the patient or measurable. During an interview on 10/25/2023 at 12:20 PM, the medical record review findings were discussed with Chief Operating Officer A and Registered Nurse (RN) Administrator B. When asked about the possibility for staff to free text in the electronic medical record, RN Administrator B stated, “I’m still learning.”

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, record review and interview agency staff failed to follow accepted standards of practice for hand hygiene in 3 of 3 patient observation visits (Patients #1, #2, #3) and equipment disinfection in 2 of 3 patient observation visits (Patients #2 and #3) out of a total of 3 observation visits conducted. Findings include: Review of policy 6-027.1 titled “Infection Control Plan” last dated November 2013 revealed in part, “PURPOSE: To delineate an infection control program to meet the following goals…5. Comply with all applicable local, state, federal regulations, and accepted standards of practice including but not limited to: B. CDC (Centers for Disease Control) recommendations and guidelines.” Review of policy 6.004.1 titled “Standard Precautions” last dated November 2013 revealed in part, “PURPOSE: To reduce the risk of exposure to and transmission of infections when caring for patients.” Further review revealed “C. Gloves are to be changed between tasks and procedures on the same patient.” Review of policy 6-006.1 titled “Hand Hygiene” last dated November 2013 revealed in part, ”PURPOSE: To prevent cross-contamination and home care acquired infection. POLICY: Personnel providing care in the home setting will regularly wash their hands, per the most recently published CDC regulations and guidelines for hand hygiene in healthcare settings.” Further review revealed in part, “Procedure. Hand decontamination with an alcohol-based rub which conforms to CDC Guideline for Hand Hygiene…3. Hand decontamination using an alcohol-based hand rub should be performed: A. Before having direct contact with patients…C. After contact with a patient’s intact skin (when taking a pulse, blood pressure or lifting a patient)…F. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. G. After removing gloves.” Review of Sani-Cloth (germicidal disposable wipes) package information revealed disinfection of surfaces occurs when solution remains on surface/object for 2 minutes. An observation visit was conducted at Patient #1’s place of residence on 10/24/2023 at 1:17 p.m. with Registered Nurse (RN) C. Throughout the visit, while performing wound care, RN C had 6 glove changes with no hand hygiene prior to donning clean gloves. An observation visit was conducted at Patient #2’s place of residence on 10/25/2023 at 9:22 a.m. with RN D. Throughout the visit, while performing wound care, RN D had 4 instances of not performing hand hygiene prior to entering the nursing bag, 1 glove change with no hand hygiene prior to donning clean gloves, and 2 instances of donning gloves without performing hand hygiene prior. After cleaning equipment used during the visit with Sani-Cloth, the equipment was immediately returned to the nursing bag without proper dry-time. An observation visit was conducted at Patient #3’s place of residence on 10/25/2023 at 10:00 a.m. with Licensed Practical Nurse (LPN) E. Throughout the visit, while performing wound care, LPN E had 3 glove changes with no hand hygiene prior to donning clean gloves. After cleaning equipment used during the visit with Sani-Cloth, the equipment was immediately returned to the nursing bag without proper dry-time. An interview was conducted with Administrator B on 10/25/2023 at 12:31 p.m. When asked what the expectation of staff is regarding hand hygiene, Administrator B stated it was expected prior to entering the nursing bag, prior to donning gloves and after removing gloves. Administrator B also stated that Sani-Cloth wipes require a dry time for it to adequately disinfect surfaces/objects.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to screen employees for tuberculosis (TB) & communicable diseases per agency policy in 3 of 7 (Registered Nurse D, Licensed Practical Nurse E, & Physical Therapist F) personnel files reviewed. Findings include: Review of agency policy titled, "Management of Exposures in Personnel Policy #6-001.1" not dated revealed, "Medical surveillance 1. Where required by state and/or local regulations, all patient care personnel will be given a two step TB Mantoux skin test and baseline screening at the time of employment if no previously documented TB Mantoux skin test had been performed in the last 12 months." Review of Registered Nurse D's personnel file date of hire (DOH) 08/2022, revealed no documentation of TB and communicable disease screening being completed. Review of Licensed Practical Nurse E's personnel file DOH 08/2023, revealed no documentation of TB and communicable disease screening being completed. Review of Physical Therapist F's personnel file DOH 11/2021, revealed no documentation of TB and communicable disease screening being completed. During an interview on 10/25/2023 at 11:25 AM, the above findings were reviewed with Chief Operating Officer A who stated, “We lost a lot in the move from Hartford."

Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to conduct employee performance evaluations per agency policy in 5 of 7 (Registered Nurse's C, D, Physical Therapist's F, G, & I) personnel files reviewed. Findings include: Review of agency's policy titled, "Performance Evaluations Policy #1-021.1” not dated under heading, “Procedure 1. Performance evaluations will be completed (and dated) on all personnel as follow: A. During the probationary period. B. Annually, based on personnel’s evaluation date.” Review of Registered Nurse C's record, date of hire (DOH) 03/2022 revealed, no documentation of a completed performance evaluation. Review of Registered Nurse D's record DOH 08/2022 revealed, no documentation of a completed performance evaluation. Review of Physical Therapist F's record DOH 11/2021 revealed, no documentation of a completed performance evaluation. Review of Physical Therapist G's record DOH 03/2022 revealed, no documentation of a completed performance evaluation. Review of Physical Therapist I's record DOH 04/2022 revealed, no documentation of a completed performance evaluation. During an interview on 10/25/2023 at 11:25 AM, the above findings were reviewed with Chief Operating Officer A who stated, “We lost a lot in the move from Hartford. The previous administrator had not completed the paperwork prior to taking a new job.”