Every finding on record at Horizon Home Care and Hospice Inc.

An unannounced, onsite Recertification survey was conducted on 06/24/2024 - 06/25/2025 at Horizon Home Care in Milwaukee, WI. Horizon Home Care is in compliance with Emergency Preparedness Regulations 42 CFR 484.102 for Home Health Agencies.

An unannounced, onsite Recertification survey was conducted on 06/24/2024 - 06/25/2025 at Horizon Home Care in Milwaukee, WI. Horizon Home Care is in compliance with the Medicare Conditions of Participation 42 CFR 484 for Home Health Agencies. Citations are issued at a standard level or below. For a total of 5,970 unduplicated skilled admissions for twelve months, 6 home visits were conducted and 17 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 failed to develop individualized and/or measurable Plan of Care (POC) goals to meet the needs of the patient in 7 of 17 patient records reviewed (Patient #2, #3, #5, #6, #7, #10 and #11). Findings include: Record review of Patient #2's "Home Health Certification and Plan of Care" dated 06/16/2025 to 08/14/2025 revealed Patient #2 had a primary diagnosis of "Encounter for Orthopedic Aftercare" with a secondary diagnosis of "Cutaneous Abscess of Right Foot." Patient #2 receives skilled nursing care 3 times per week for wound care. Patient #2's POC goals revealed "Patient will demonstrate improved wound status as evidence by a decrease in size/drainage of wound, absence of infection, and decreased pain." The goals are not measurable with time specific dates and/or individualized to meet the patient needs. Record review of Patient #6's "Home Health Certification and Plan of Care" dated 05/04/2025 to 07/02/2025 revealed Patient #6 had a primary diagnosis of "Encounter for Attention to Colostomy". Patient #6 receives skilled nursing care 3 times per week for colostomy care and wound care for a buttock wound. Patient #6's POC goals revealed "Patient will demonstrate improved wound status as evidence by a decrease in size/drainage of wound, absence of infection, and decreased pain." The goals are not measurable with time specific dates and/or individualized to meet the patient needs. Record review of Patient #11's "Home Health Certification and Plan of Care" dated 06/15/2025 to 08/13/2025 revealed Patient #11 had a primary diagnosis of "Gastrointestinal Hemorrhage" and has additional diagnosis of "Other Specified Chronic Obstructive Pulmonary Disease." Patient #11 receives skilled nursing care 1 time per week. The POC orders revealed in part, "Skilled Nurse to observe and assess cardiovascular system to identify changes and intervene to minimize complications...May perform oxygen saturation levels PRN (as needed) for signs and symptoms of possible respiratory complications. Goals: Abnormal oxygen saturation levels will be reported to physician." The goals are not measurable with time specific dates and/or individualized goal parameters to meet the patient needs. During an interview on 06/25/2025 at 10:15 AM with Substitute Administrator B, findings for Patient #2, #6, and #11 were reviewed. Substitute Administrator B agreed that the goals were either not measurable or not individualized for Patients #2, #6, and #11. Findings include: Review of agency policy titled, “Care Planning Process- Home care” dated 02/04/2025 revealed in part, “The initial Plan of Care will include: Patient-specific interventions and education; measurable outcomes and goals identified by the Agency and the patient.” Record review of Patient #3's "Home Health Certification and Plan of Care" for certification period 05/28/2025 to 07/26/2025 revealed primary diagnosis of “Displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing” receiving SN care 3 times per week for wound care. POC goals revealed “Wound status will improve as evidence by a decrease in size/drainage of wound, absence of infection, and decreased pain." The goals are not measurable with time specific dates and/or individualized to meet the patient needs. Record review of Patient #5's "Home Health Certification and Plan of Care" for certification period 06/10/2025 to 08/08/2025 revealed primary diagnosis of “Type 2 Diabetes Mellitus with other skin ulcer” receiving SN care 3 times per week for wound care. POC goals revealed “Wound status will improve as evidence by a decrease in size/drainage of wound, absence of infection, and decreased pain." The goals are not measurable with time specific dates and/or individualized to meet the patient needs. Record review of Patient #7's "Home Health Certification and Plan of Care" for certification period 05/16/2025 to 07/12/2025 revealed primary diagnosis of “Postural Orthostatic Tachycardia Syndrome (POTS) receiving SN care 1 time per week for intravenous (IV) infusion. POC goals revealed “IV fluids/meds will be administered per orders. Patient will verbalize/demonstrate tolerance." The goals are not measurable with time specific dates and/or individualized to meet the patient needs. Record review of Patient #10's "Home Health Certification and Plan of Care" for certification period 05/16/2025 to 07/14/2025 revealed primary diagnosis of “Pressure ulcer of right buttock, stage 2” receiving SN care 1 time per week for wound care. POC goals revealed “Wound status will improve as evidence by a decrease in size/drainage of wound, absence of infection, and decreased pain." The goals are not measurable with time specific dates and/or individualized to meet the patient needs.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency Registered Nurse (RN) failed to supervise the Home Health Aide (HHA) no less than every 14 days in 1 of 2 patients (Patient #10) receiving HHA services in a total of 17 patient records reviewed. Findings include: Review of agency policy titled, "Clinical Supervision / Joint Visits" dated 02/20/2025 revealed in part, "4. The case manager for patients receiving home health aide with skilled services or hospice services will complete a direct or indirect supervisory visit for paraprofessional staff to evaluate staff competency and patient experience at least every 14 days…5. Direct or indirect supervisory visits for both skilled and non-skilled services with home health aide will be completed in the medical record on the appropriate supervisory visit form…” Record review of Patient #10's medical record with start of care date of 11/17/2024 revealed "Skilled Nurse (SN) 1 time per week. HHA 2 times per week." SN visit note documentation revealed HHA supervision was documented to be occurring every 60 days on 01/15/2025, 03/14/2025 and 05/13/2025. During an interview on 06/25/2025 at 8:20 AM, Substitute Administrator B stated, “I could not find that supervisory visits were completed at least every 14 days for this patient.”

An unannounced, onsite complaint survey was conducted from 4/25/23 to 5/12/23 at Horizon Home Care and Hospice in response to complaint #WI00096811. Horizon Home Care and Hospice was found to be in compliance with Medicare Conditions of Participation 42 CFR 484 for Home Health Agencies. Complaint #WI00096811 is substantiated, with citations.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency staff failed to notify the primary care provider with a change in condition in 1 of 3 patients (patient #1) with wound care in a sample of 10 records reviewed. Findings include: Per facility policy "Physician Communication," (last updated 3/3/21). "Staff of Horizon Home Care and Hospice, Inc. will maintain communication with all physicians or allowed practitioners involved in the patient's care, in order to ensure the continuity of safe, appropriate, quality care." "Professional staff will contact the physician or allowed practitioner at the following times.... Whenever there are significant changes in the patient's condition." Record review of patient #1's medical record indicating start of care on 5/8/22. Patient #1 was admitted to this agency with a primary diagnosis of dehiscence of amputation stump, type 2 diabetes mellitus with foot ulcer. Secondary diagnoses include non-pressure chronic ulcer of other part of right foot with unspecified severity, non-pressure chronic ulcer of right calf with unspecified severity, pressure ulcer of right heel with unspecified stage, and end stage renal disease including hemodialysis. Changes to right calf per patient #1 medical record: Nurse progress note dated 9/1/2022 -"6.6 x 5.1 x 0.1 cm small amount of serosanguineous drainage, pink wound bed." Nurse progress note dated 9/10/2022 - "Right lower extremity dressing changed serosanguinous drainage with pink/red granulation." Nurse progress note dated 9/15/2022 - "Right Calf/lateral wound: 6.6 x 5.1 x 0.1, small amount of serosanguineous drainage. This wound has a u-shaped opening with pink wound bed and some white/yellow tissue. Wound and surrounding tissue is very painful to touch." Changes to right heel per patient #1 medical record: Nurse progress note dated 8/1/22 - "Right lateral heel: 2.5 x 5.5 x 0.1cm." Nurse progress note dated 9/1/22- "Right heel pressure ulcer 6.0 x 6.3 x 0.1 cm." Nurse progress note dated 9/15/22-"Right heel pressure ulcer 6.1 x 6.3 x 0.1cm scant amount of serosanguineous drainage, pink wound bed, partially scabbed, surrounding skin is dry, peeling. Wound is very painful to touch/pressure." No primary care provider notification given regarding changes in wounds on 9/15/22. Notation on 9/15/22, per patient #1 medical record, "Skilled Nurse will call MD and return tomorrow as there is an increased drainage and pain on R heel/foot wound." No documentation of MD call or change in orders noted. During an interview conducted on 5/12/23 at 9:30 AM with Administrator B, "Nurse D states she did communicate, but there is no documentation. States in documentation she "will call," but did not document the conversation."

An unannounced onsite complaint survey was conducted 11/29/2021 at Horizon Home Care & Hospice in Milwaukee WI for complaint # 61078. The complaint was unsubstantiated and one standard level citation was issued. The agency was found to be in substantial compliance with the Medicare Conditions of Participation for Home Health, 42 CFR 484.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and interview, the staff failed to ensure that the physician orders on the patient Plan of Care were followed in 5 of 10 patient records reviewed. (Patients #1, #6, #7, #8, #9.) Findings include: Review of policy "Assessment/Reassessment of Patients" last revised 3/17/21 revealed "Attachment 1: Guide to Data Collection Frequency. Wound measurement: Weekly. *Frequencies listed are minimums, increased frequencies can be done based on patient conditions/changes/requests/physician orders." Review of Patient #1's two "Home Health Certification and Plan of Care" with dates of 7/26/2020 - 9/3/2020 and 9/24/2020 - 11/22/20 revealed physician order of "Measure wounds weekly and monitor for signs/symptoms of infection." Review of Patient #1's medical record "SN Visit Notes" showed wounds on left foot and ankle were measured during visit on 8/19/2020 and then not until visit on 8/31/2020. This was greater than one week. Further review of Patient #1's medical record "SN Visit Notes" showed wounds were measured during visit on 9/7/2020 and then not until visit of 10/5/2020. This was greater than one week. Review of Patient #6's "Home Health Certification and Plan of Care" with dates of 11/3/2021 – 1/1/2022 and revealed physician order of "Measure wounds upon admission and weekly thereafter." Review of Patient #6's medical record "SN Visit Notes" showed a wound on buttocks was measured during visit on 10/19/2021 of initial certification and then not until visit on 11/16/2020 in the most recent certification. This was greater than one week. Review of Patient #7's "Home Health Certification and Plan of Care" with dates of 8/26/2021 - 10/24/2021 revealed physician order of "Measure wounds upon admission and weekly thereafter." Review of Patient #7's medical record "SN Visit Notes" showed wounds on right lateral leg and left lateral leg were measured during visit on 8/26/2021 and then not until visit on 9/8/2021. This was greater than one week. Review of Patient #8's "Home Health Certification and Plan of Care" with dates of 10/9/2021 – 12/14/2021 revealed physician order of "Measure wounds upon admission and weekly thereafter." Review of Patient #8's medical record "SN Visit Notes" showed a wound on right lateral foot was measured during visit on 10/9/2021 and then not until visit on 11/5/2021. This was greater than one week. Review of Patient #9's "Home Health Certification and Plan of Care" with dates of 9/13/2021 - 11/11/2021 revealed physician order of "Measure wound weekly." Review of Patient #9's medical record "SN Visit Notes" showed a wound on coccyx was measured during visit on 9/13/2021 and then not until visit on 10/4/2021. This was greater than one week. Further review of Patient #9's medical record "SN Visit Notes" showed wound was measured during visit on 10/18/2021 and then not until visit of 11/26/2021. This was greater than one week. An interview was conducted with Administrator E, Chief Operating Officer C, and Director of Home Care D on 11/29/2021 at 2:45 p.m. When asked what the expectation for documenting wound measurements are, Chief Operating Officer C stated "weekly."

An unannounced onsite Complaint survey was conducted on 05/26/2021 at Horizon Home Care and Hospice, Milwaukee Wisconsin in response to complaint # WI00040492 Horizon Home Care and Hospice was found to be in substantial compliance with Medicare Conditions of Participation 42 CFR 484 for Home Health Agencies. Complaint #WI00040492 was unsubstantiated. No citations related to the complaint were issued.

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 failed to include all medications on the patients plan of care in 1 of 10 (#1) patient records reviewed. Findings include: Review of patient #1 record revealed #1 was admitted to the hospital on 01/11/2021. Hospital course included repair of incarcerated left inguinal hernia. Post surgical procedure #1 was noted to have bleeding at the surgical site. #1 was taken back to the operating room for wound exploration, evacuation of a hematoma and control of subcutaneous bleeding. Intraoperative cultures were completed and #1 was placed on intravenous antibiotics. #1 was then transitioned to oral Augmentin and Flagyl on 01/19/2021 recommended through 01/24/2021. Patient #1 was discharged home from hospital on 01/20/2021 and admitted to home care on 01/22/2021. Review of patient #1's plan of care (POC) revealed, that the Augmentin and Flagyl were not included in the list of medications. In an interview with Director of Home Care A on 05/26/2021 at 12:45 PM, when asked what the expectation of staff was related to medication reconciliation A stated that the staff are expected to reconcile the patients medications on admission, at recertification periods, new medications, and weekly throughout admission. When asked if A could verify patient #1's medication list was missing the two medications, A stated, "I'm not seeing them, it (medication list) should have been reconciled." Home Care Staff placed a phone call to Registered Nurse (RN) B while onsite in an attempt to interview B. At time of survey exit, B had not returned the phone call. In an email correspondence on 05/26/2021 at 2:53 PM with Administrator C, C provided this information. "We just finished speaking with .......(RN B), the nurse for the patient (#1)...... The patient (#1) was on the oral antibiotics upon discharge and was taking them. The nurse (RN B) believes she (#1) had two days' worth of medication to complete. The nurse (RN B) failed to enter on the med profile or the POC......