Every finding on record at Holy Family Memorial Inc.

An unannounced, on-site recertification survey was conducted on 02/17/25 through 02/18/25 at Froedtert Holy Family Memorial Home Care in Manitowoc, WI. Froedtert Holy Family Memorial Home Care is in compliance with Medicare Conditions of Emergency Preparedness for Home Health Agencies, 42 CFR 484.102.

An unannounced, on-site recertification survey was conducted on 02/17/25 through 02/18/25 at Froedtert Holy Family Memorial Home Care in Manitowoc, WI. Froedtert Holy Family Memorial Home Care is in compliance with the Medicare Conditions of Participation for Home Health Agencies, 42 CFR 484. For an unduplicated admission number of 401 in the last 12 months a total of 10 medical records (7 current and 3 discharged), and 9 employee files were reviewed and 4 home visits were completed. Citations are issued at a standard level or below.

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to transmit OASIS (Outcome and Assessment Information Set) assessments within 30 days. In 1 of 1 Home Health Agency Error Summary Reports reviewed. Review of policy titled, “FHFMH Home Health OASIS Completion Review Correction and Submission Policy” (dated 02/07/2025) revealed, "that after completion of the review process, OASIS data on all applicable patients are electronically sent at least monthly by the QA reviewer/designee, OASIS data files are uploaded to the CMS iQIES system at minimum monthly and OASIS file submission validation reports are uploaded to the home health EHR at minimum monthly." Review of Home Health Agency Error Report from 1/01/2024 to 01/01/2025 revealed under error #3330 (Record Submitted Late), the number of assessments with errors was 188 with a 17.49% rating. During an interview conducted with Administrator A on 2/18/2025 at 10:03 AM, Administrator A reviewed the error summary report dated 1/01/2024 to 01/01/2025 revealing this Home Health Care Agency had 188 assessments submitted beyond 30 days of completing the assessment. Administrator A stated it may be an issue with a payor source.

Property and person treated with respect CFR(s): 484.50(c)(1) Have his or her property and person treated with respect; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to inform patient and/or patient's legal representatives, in writing, of the right to have his or her property and person treated with respect in 1 of 1 home health admission booklets reviewed. Findings include: Record review of this agency's "Patient and Caregiver Handbook" under "Admission and Rights" section revealed no evidence that the agency informs the patient and/or patient's legal representative of the right to have his or her property and person treated with respect. The above findings were reviewed on 02/17/2025 at 2:30 PM with Administrator A. During an interview with Administrator A on 02/18/2025 at 9:55 AM, Administrator A stated, "I did not find a place that identified this language specifically."

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to inform patient and/or patient's legal representatives of the right to participate in, be informed of and consent or refuse care regarding completion of assessments, care to be furnished based on assessments, and establishing and revising of the plan of care in 1 of 1 home health admission booklets reviewed. Findings include: Record review of this agency's "Patient and Caregiver Handbook" under "Admission and Rights" section revealed no evidence that the agency informs the patient and/or patient's legal representative of the right to participate in, be informed of, and consent or refuse care regarding completion of assessments, care to be furnished based on assessments and establishing and revising of the plan of care. The above findings were reviewed on 02/17/2025 at 2:30 PM with Administrator A. During an interview with Administrator A on 02/18/2025 at 9:55 AM, Administrator A confirmed the above information is not included in the part of the patient rights section when informing the patient of their rights.

Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to inform patient and/or patient's legal representatives of the right to receive all services as outlined in the plan of care in 1 of 1 home health admission booklets reviewed. Findings include: Record review of this agency's "Patient and Caregiver Handbook" under "Admission and Rights" section revealed no evidence that the agency informs the patient and/or patient's legal representative of the right to receive all services as outlined in the plan of care. The above findings were reviewed on 02/17/2025 at 2:30 PM with Administrator A. During an interview with Administrator A on 02/18/2025 at 9:55 AM, Administrator A confirmed the patient rights section did not include this content specifically.

Investigate complaints made by patient CFR(s): 484.50(e)(1)(i) The HHA must— (i) Investigate complaints made by a patient, the patient's representative (if any), and the patient's caregivers and family, including, but not limited to, the following topics: (A) Treatment or care that is (or fails to be) furnished, is furnished inconsistently, or is furnished inappropriately; (B) Mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and/or misappropriation of patient property by anyone furnishing services on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to inform patient and/or patient's legal representatives of the complaint procedures for the agency’s responsibility to investigate complaints made including treatment or care that is or fails to be furnished, and regarding mistreatment, neglect, or verbal, mental, sexual and physical abuse, and misappropriation of property by anyone furnishing services 1 of 1 home health admission booklets reviewed. Findings include: Record review of this agency's "Patient and Caregiver Handbook" under "Complaints" section revealed no evidence that the agency informs the patient and/or patient's legal representative of the complaint procedures to investigate complaints made including treatment or care that is or fails to be furnished, and regarding mistreatment, neglect, or verbal, mental, sexual and physical abuse, and misappropriation of property by anyone furnishing services. The above findings were reviewed on 02/17/2025 at 2:30 PM with Administrator A. During an interview with Administrator A on 02/18/2025 at 9:55 AM, Administrator A confirmed the complaint section does not have this content. Administrator A stated, “I know we could use some work and revisions on this.”

Protect patient during investigation CFR(s): 484.50(e)(1)(iii) (iii) Take action to prevent further potential violations, including retaliation, while the complaint is being investigated. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to inform patient and/or patient's legal representatives of the complaint procedures that the agency must take action to prevent further potential violations, including retaliation while a complaint is being investigated in 1 of 1 home health admission booklets reviewed. Findings include: Record review of this agency's "Patient and Caregiver Handbook" under "Complaints" section revealed no evidence that the agency informs the patient and/or patient's legal representative of the complaint procedures that the agency must take action to prevent further potential violations, including retaliation while a complaint is being investigated. The above findings were reviewed on 02/17/2025 at 2:30 PM with Administrator A. During an interview with Administrator A on 02/18/2025 at 9:55 AM, Administrator A confirmed the complaint section does not have this content. Administrator A stated, “I know we could use some work and revisions on this.”

Immediate reporting of abuse by all staff CFR(s): 484.50(e)(2) Any HHA staff (whether employed directly or under arrangements) in the normal course of providing services to patients, who identifies, notices, or recognizes incidences or circumstances of mistreatment, neglect, verbal, mental, sexual, and/or physical abuse, including injuries of unknown source, or misappropriation of patient property, must report these findings immediately to the HHA and other appropriate authorities in accordance with state law. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to inform patient and/or patient's legal representatives of the agency’s staff responsibility to report incidences of mistreatment, neglect, or verbal, mental, sexual and physical abuse, and misappropriation of property by anyone furnishing services immediateley to the home health agency and other appropriate authorities in accordance with state law in 1 of 1 home health admission booklets reviewed. Findings include: Record review of this agency's "Patient and Caregiver Handbook" under "Complaints" section revealed no evidence that the agency informs the patient and/or patient's legal representative of the agency’s staff responsibility to report incidences of mistreatment, neglect, or verbal, mental, sexual and physical abuse, and misappropriation of property by anyone furnishing services immediateley to the home health agency and other appropriate authorities in accordance with state law The above findings were reviewed on 02/17/2025 at 2:30 PM with Administrator A. During an interview with Administrator A on 02/18/2025 at 9:55 AM, Administrator A confirmed the complaint section does not have this content. Administrator A stated, “I know we could use some work and revisions on this.”

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on record review and interview, agency staff failed to document wound measurements in 3 out of 4 medical records with wounds out of a total of 10 patient records reviewed (Patients # 6,7,8). Record review of Patient #7's "Home Health Care Certification and Plan of Care" for certification period 11/26/24-01/24/2025 revealed in part, "Primary Diagnosis: Hypertensive heart disease with heart failure and also a right axilla wound. Physician orders within the medical record reviewed for skilled nursing (SN) visits 2 times weekly to assess and treat Right Axilla wound unless seen by wound clinic." Record review for Patient #7 revealed no documentation of wound measurements for the weeks of 12/22/2024, 12/29/2024 and 01/05/2025. During interview with Administrator A on 02/18/2025 at 10:30 AM, Administrator A confirmed that for weeks 12/22/2024, 12/29/2024 and 1/5/2025, no measurements were completed. When asked what the expectation was for frequency of wound measurements Administrator A replied, “weekly.” Findings include: Review of agency document titled "Standard Work: Wound Measurement and Assessment" (dated 11/21/2018) revealed in part "Wound Measurements: Length in cm (centimeter), Width in cm, Depth in cm, Tunneling and undermining are assessed when measuring wound. Reassessment of Wound: Weekly or bi-weekly in the wound clinic or as ordered by the provider." Record review of Patient #6's "Home Health Care Certification and Plan of Care" for certification period 01/10/2025 to 03/10/2025 revealed in part, "Primary Diagnosis: Pressure ulcer of right buttock unstageable. Other pertinent diagnosis: Encounter for change or removal of nonsurgical wound dressing. Orders/Treatments: SN (Skilled Nurse) wound care: Right buttock change Monday, Wednesday, and Friday until seen in the Wound Clinic 01/15/2025." Record review for Patient #6 revealed no documented wound measurements the week of 01/10/2025 (start of care visit) and week of 02/02/2025. During an interview with Administrator A on 02/18/2025 at 10:30 AM, Administrator A confirmed for the week of 01/10/2025 and 02/02/2025, there were no wound measurements for Patient #6. Administrator A stated the agency realized there is an issue in evaluating and missing wound assessment standards for staff. Record review of Patient #8's "Home Health Care Certification and Plan of Care" for certification period 09/11/2024 to 11/09/2024 revealed in part, "Primary Diagnosis: Venous insufficiency (chronic peripheral). Other pertinent diagnosis: Non-pressure chronic ulcer other part of right foot with unspecified severity. Orders/Treatments: SN: Assess wound status including signs and symptoms of healing and complications. SN wound care: Right foot- Therabond and dry dressing to be changed three times weekly." Record review for Patient #8 revealed no documented wound measurements the week of 09/22/2024, 10/06/2024, 10/13/2024, and 10/20/2024. During an interview with Administrator A on 02/17/2025 at 3:35 PM, Administrator A confirmed for the weeks of 09/22/2024, 10/06/2024, 10/13/2024, and 10/20/2024, no measurements were completed for Patient #8.