Every finding on record at HHA of Wisconsin, LLC

An unannounced onsite recertification survey was conducted on 05/07/2024 - 05/08/2024 at Almost Family in Onalaska, WI. The agency was found to be in compliance with the Emergency Preparedness regulations for Home Health Agencies, 42 CFR 484.102.

An unannounced onsite recertification survey was conducted on 05/07/2024 - 05/08/2024 at Almost Family in Onalaska, WI. The agency was found to be in compliance with the Medicare Conditions of Participation for Home Health Agencies, 42 CFR 484. Citations were issued at the standard level for a total of 233 unduplicated skilled admissions for the past twelve months, 3 home visits were conducted and a total of 7 records 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, record review and interview, agency staff failed to follow standard precautions regarding sharps (needle) safety in 1 of 1 home visit observation where a needle was used, out of a total of 3 home visit observations (Registered Nurse A). During an interview with Clinical Leader B and Administrator C 05/08/2024 at 12:40 PM, the above findings were reviewed. When asked what the expectation would be regarding sharps use and disposal, Clinical Leader B replied, "Bring the sharps container to the area providing care." Administrator C replied, "If it didn't have a guard, she shouldn't have recapped it. It is standard practice. I don't know why she would have done that." Findings include: Review of policy number 8.002 "Standard Precautions" last revised 10/01/2022 revealed in part, "Staff will follow guidelines for protection from infectious disease based on Occupational Safety and Health Administration (OSHA) and Centers for Disease Control (CDC) guidelines for Standard Precautions." Further review revealed "e. Sharps Safety. ii. Never recap used needles, or otherwise manipulate them using both hands, or use any other technique that involves directing the point of the needle toward any part of the body." A visit was conducted at the home of Patient #3 on 5/8/2024 at 7:55 a.m. to observe Registered Nurse (RN) A provide care. After administering an insulin injection subcutaneously, RN A then attempted to recap the needle by sliding it into the cap which was on Patient #3's chair-side table. When this was unsuccessful, RN A then placed the end of his/her finger on the top of the cap and slid the needle inside until the cap snapped into place. During an interview with Clinical Leader B on 05/08/2024 at 12:40 PM, Clinical Leader B stated, RN A, "was nervous." During an interview with Administrator C on 05/08/2024 at 12:45 PM, Administrator C stated, that the expectation of staff was to not recap needles and to use a designated sharps container.

An unannounced on-site Recertification survey was conducted at Almost Family in La Crosse, WI from 05/17/2021 to 05/19/2021. Almost Family was in compliance with Medicare Conditions of Participation for Emergency Preparedness for Home Health Agencies, 42 CFR 484.102.

An unannounced on-site Recertification and Complaint survey (Complaint #WI00040657) was conducted at Almost Family in La Crosse, WI from 05/17/2021 to 05/19/2021. Almost Family was in substantial compliance with Medicare Conditions of Participation for Home Health Agencies, 42 CFR 484. Complaint #WI00040657 was unsubstantiated. Citations are issued at a standard level or below, unrelated to the complaint. A total of 5 home visits conducted and 13 records reviewed for an unduplicated admissions amount in the last 12 months of 528. The CMS COVID-19 Infection Control Screening Tool was utilized during the survey with no issued related to infection control.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to follow physician visit frequency orders as indicated on the plan of care in 4 of 13 patient records reviewed (Patients #2, #3, #11, and #13). Findings include: Review of agency policy and procedure titled "Physician Orders" dated 02/01/2020 revealed "Procedure: 10. Services are provided according to the most recent orders updating the patient's plan of care." Record review of Patient #2's "Home Health Certification and Plan of Care" orders, dated 02/10/2021-04/10/2021 and 04/11/2021-06/09/2021, revealed "SN (Skilled Nursing) 4 visits weekly for 1 certification period starting 04/11/2021. RN (Registered Nurse) comprehensive visit every 56-60 days." Patient #2's record showed no evidence that 4 weekly SN visits were made during the week of 03/07/2021-03/13/2021. Patient #2's record showed evidence that two SN visits were made on 03/09/2021 and 03/13/2021. There was a "Missed Visit Note" for the missed SN visit on 03/11/2021 due to a medical appointment but no other documentation in regards to the other missed visit for that week. Patient # 2's record revealed no evidence that 4 weekly SN visits were made during the week of 04/04/2021-04/10/2021. Patient #2's record showed evidence of one SN being completed that week on 04/05/2021. Patient #2's record revealed evidence of a missed visit on 04/10/2021 due to the patient canceling the visit. No other documentation was found in regards to the two other ordered skilled nursing visits. During an interview with Nurse/Administrator B on 05/18/2021 at 1:10 PM when asked about missed visits for Patient #2, Nurse/Administrator B replied "The RN left abruptly due to a medical reason on April 4th (04/04/2021) so she was unable to do a visit." Nurse/Administrator B confirmed that there was no documentation of the the missed visit or reason for the missed visit in Patient #2's record. When asked about the other missed visit for that week, Nurse/Administrator B stated, "We note how many missed visits and the reasons on the next certification period's 485 (Home Health Certification and Plan of Care) in the 60 Day Summary section." On Patient #2's 485 for 04/11/2021-06/09/2021, there was no mention of any missed visits in the 60 Day Summary section. During an interview with Nurse/Administrator B on 05/18/2021 at 1:25 PM, when asked about the agency process for missed visits documentation, B replied "Missed visits are documented on the 60 day summary of care on the next 485. They document it within the plan of care or there's a missed visit report that runs the missed visits." Record review of Patient # 3's "Home Health Certification and Plan of Care" orders, dated 02/25/2021-04/27/2021 and 04/28/2021-06/26/2021, revealed "SN 1 visit daily for one certification period(s) starting 04/28/2021. RN comprehensive visit every 56-60 days." Patient #3's record showed no evidence that skilled nursing visits were made on the following dates: 04/20/21, 04/21/21, 04/22/21, and 04/26/2021. There was also no evidence of any "Missed Visit Notes" for any of those dates nor any documentation in the 60 Day Summary section of Patient # 3's Home Health Certification and Plan of Care dated 04/28/2021-06/26/2021 (the next certification period). During an interview with Nurse/Administrator B on 05/18/2021 at 5:00 PM, when asked about the missed visits for Patient #3, B replied, "We had an understanding with the patient's MCO (Managed Care Organization) RN Care Manager, that if she (the patient) had someone in her home then I, as her Registered Nurse, wouldn't have to go in there so that's why there are no visits for those days." Nurse/Administrator B then provided an email exchange between herself and a MCO Care Manager from My Choice Wisconsin. In this email, dated 05/18/2021 at 4:35 PM, Nurse/Administrator B wrote, "This is a follow up of our previous telephone conversation regarding Patient # 3. We had agreed that if her supportive care worker was in the home, the RN did not need to see the client as supportive care worker could assist with the stocking as client's status had improved." There was an email response from the MCO RN Care Manager stated 05/18/2021 at 4:37 PM which stated, "Nurse/Administrator B, this is correct and I recall the conversation." There was no physician order to establish daily visits were not needed if alternative caregiver present. Record review of closed record for Patient #11's "Home Health Certification and Plan of Care" orders, dated 03/10/2021-05/08/2021, revealed "SN Visit 1 visit monthly for 1 certification period(s) starting 03/10/2021." Per review of record, there was no documented evidence of SN visit in the month of April 2021. The Missed Visit/Canceled Visits report did not contain a missed/canceled visit for April, no evidence of documented "Missed Visit Notes," and no physician orders to cover the missed visits. During review on 05/18/2021 at 5:00 PM, the agency revealed that payroll confirmed a SN visit was made 04/10/2021. The agency was asked to provide proof of the SN visit and documentation by 05/19/2021. As of 05/19/2021, no additional proof of SN visit and documentation was provided. Per email correspondence with Nurse/Administrator B (regarding Patient #11) dated 05/19/2021 at 12:56 PM revealed "unable to find visit 04/10/2021." Record review of closed record for Patient #13's "Home Health Certification and Plan of Care" orders, dated 12/14/2020-02/11/2021, revealed "SN Visit 1 visit weekly for 1 certification period(s) starting 12/14/2020." Per review of record, there was no documented evidence of SN visits for week of 01/10/2021 and 01/17/2021. The Missed Visit/Canceled Visits report did not contain a missed/canceled visits for the week of 01/10/2021 and 01/17/2021, no evidence of documented "Missed Visit Notes," and no physician orders to cover the missed visits.." During review on 05/18/2021 at 5:00 PM, the agency revealed that payroll confirmed a SN visit was made 01/12/2021 and 01/19/2021. The agency was asked to provide proof of the SN visits and documentation by 05/19/2021. As of 05/19/2021, no additional proof of SN visits and documentation was provided. Per email correspondence with Nurse/Administrator B (regarding Patient #13) dated 05/19/2021 at 12:56 PM revealed "unable to find visits 01/12/2021 and 01/19/2021."