Every finding on record at Laabs Home Health Care Inc

An unannounced, onsite Recertification survey was conducted on 12/09/2024-12/10/2024 at Laabs Home Health Care, a Home Health Agency located in Milwaukee, WI. Laabs Home Health Care is in compliance with the Medicare Conditions of Participation for Emergency Preparedness for Home Health Agencies 42 CFR 484.22.

An unannounced, onsite Recertification survey was conducted on 12/09/2024-12/10/2024 at Laabs Home Health Care, a Home Health Agency located in Milwaukee, WI. Laabs Home Health 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. A total of seven clinical records were reviewed including 5 open records and two closed records. Three home visits were attempted with two being completed for an unduplicated admission census of 10 in the last 12 months.

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, agency staff (Registered Nurse) RN E failed to comply with standard medication administration procedures in 1 of 2 (Patient #1) home visits observed. Review of policy titled, “Medication Management Visit” (not dated) revealed in part “Each visit will consist of filling medication boxes, checking new and discontinued medications, and communication with each client about their usage and side effects, if any, of their medications.” During a home visit with Patient #1 on 12/10/24 at 9:58 AM, RN E was observed removing a medication box from RN E’s front sweatshirt pocket. RN E then administered the medications contained in the medication box to Patient #1. RN E then proceeded to return the medication box back to RN E’s front sweatshirt pocket. At the conclusion of the home visit RN E was observed leaving Patient #1’s home with the medication box. During an interview with RN E on 12/10/24 at 10:06 AM, when asked about Patient #1’s medications being taken out of the home, RN E stated, “The staff take the pill box with them.” RN E went on to state that there have been medication compliance concerns with Patient #1 in the past. During interview with (Director of Nursing) DON C on 12/10/24 at 11:50 AM when asked if patients’ medications are to be removed from patients’ homes, DON C stated, “No, not typical. “It is not the standard of care for staff to remove medications from the residence.” “If there are questions about compliance a lock box is placed at the location.” Findings Include:

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 (Registered Nurse) RN E failed to follow accepted standards of practice related to the use of standard precautions, to prevent the transmission of infections and communicable diseases, during 1 of 2 (Patients # 1) home visits observed. Review of policy titled, “Laabs Home Health Care Standard Procedures” (not dated) revealed in part, “This agency follows all standard safety procedures as follows but not limited to: properly handle, clean disinfect client care equipment, instruments and devices.” An observation during a home visit with Patient # 1 with RN E was conducted on 12/10/24 at 9:58 AM. RN E was observed entering Patient #1’s home with a blood pressure cuff on her wrist. RN E proceeded to remove blood pressure cuff from RN E’s wrist and then placed on Patient #1’s wrist. After obtaining Patient #1’s blood pressure RN E was observed placing the blood pressure cuff back on RN E’s own wrist. No cleaning or disinfection of the blood pressure cuff was observed prior to placement on Patient #1’s wrist or after completion of taking Patient #1’s blood pressure. During an interview with (Director of Nursing) DON C on 12/10/24 at 11:50 AM, when asked what the agency’s expectations are regarding disinfecting reusable medical equipment, DON C stated, “The cleaning of reusable equipment is the expectation standard with alcohol between patients.” When asked if the agency provides staff with disinfecting supplies for reusable medical equipment, DON C stated, “Yes.” Findings Include:

An unannounced onsite recertification survey was conducted on 1/11/2022 at Laabs Home Health Care in Milwaukee, WI. The agency was found to be in substantial compliance with the Emergency Preparedness regulations 42 CFR 484.22 for Home Health. Standard level citations issued.

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), §485.625(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 record review and interview, the agency staff failed to ensure their Emergency Plan was updated every 2 years in 1 of 1 Emergency Plan reviewed. Findings include: Review of the agency's Emergency Program Plan revealed a review date of 2/2019. An interview was conducted with Office Manager A on 1/11/2021 at 12:30 p.m. When asked if there was an updated review date, A stated "2/2019 is the latest."

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(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 the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[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. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on record review and interview, agency staff failed to complete an all-hazards risk assessment for their agency in 1 of 1 Emergency Preparedness program reviewed. Findings include: Review of the agency's Emergency Preparedness Plan revealed no documentation of an all-hazards risk assessment. An interview was conducted with Office Manager A on 1/11/2022 at 12:30 p.m. When asked if there was a risk assessment for their agency, A replied "I'm not sure what that is."

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), §485.625(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 record review and interview, the agency staff failed to ensure Emergency Preparedness Policies and Procedures were based on an agency risk assessment and reviewed every two years in 1 of 1 Emergency Preparedness Plan. Findings include: Review of agency's Emergency Preparedness Program Policy revealed the date of the last policy update as 2/2019. There was no documentation of an all-hazards risk assessment on which to base their policies and procedures. An interview was conducted with Office Manager A on 1/11/2021 at 12:30 p.m. When asked if there was an updated review date, A stated "2/2019 is the latest." When A was asked if there was a risk assessment for their agency, A replied "I'm not sure what that is."

An unannounced, onsite Recertification survey was conducted on 1/11/2022 at Laabs Home Health Care in Milwaukee, WI. The agency was found to be out of compliance with the Medicare Conditions of Participation 42 CFR 484 for Home Health. 42 CFR 484.64: Quality assessment and performance improvement (QAPI) is NOT MET. Based on 5 unduplicated skilled admissions for the past 12 months current census of 11 patients receiving skilled care, a total of 7 record reviews were conducted. Two eligible patients available for home visits declined due to the increase in COVID-19 cases within the community and fear of exposure.

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, this agency staff failed to develop interventions and goals that were individualized with measurable outcomes to meet patient needs in 7 of 7 patients (Patient #1, #2, #3, #4, #5, #6, and #7) in a sample of 7 records reviewed. Findings include: During an interview with Office Manager A on 1/11/2022 at 2:09 PM, when asked for a policy on Plan of Care, Office Manager A replied "I can't find one." Review of Patient #1's "Home Health Certification and Plan of Care" dated 01/03/2022-03/03/2022 revealed Patient #1's start of care: 01/08/2021 with a Principal Diagnosis of "Type 2 Diabetes, Osteoarthritis, Hypertension. " Patient #1 had the following goals: 1. Client/Caregiver will verbalize understanding of disease process and current status. 2. Client/Caregiver will verbalize understanding of therapeutic diet. 3. Client/Caregiver will verbalize understanding of signs and symptoms to report to Registered Nurse (RN) or physician. 4. Client/Caregiver will verbalize understanding of medication regimen, actions, side effects, and adverse reactions. 5. Client will not have any signs/symptoms of hyper/hypoglycemia. These goals are not measurable or individualized to the patient's needs, and did not contain target dates for completion. Review of Patient #2's "Home Health Certification and Plan of Care" dated 11/4/2021-01/12/2022 revealed Patient #2's start of care: 05/18/2021 with a Principal Diagnosis of "Neuromuscular Dysfunction of Bladder, Pressure Ulcer of Sacral (stage 4), Quadriplegia." Patient #2 had the following goals: 1. Client/Caregiver will verbalize understanding of catheter care. 2. Patient to receive catheter changes as ordered by physician. 3. Client/Caregiver will be knowledgeable of Urinary Tract Infection (UTI). 4. Client/Caregiver will verbalize understanding of the healing process and ways to promote and prevent future complications. 5. Client/Caregiver will verbalize understanding of universal precautions and infection control measures. 6. Client's wound site will show signs of healing as evidenced by decreased size. These goals are not measurable or individualized to the patient's needs, and did not contain target dates for completion. Review of Patient #3's "Home Health Certification and Plan of Care" dated 01/06/2022-03/06/2022 revealed Patient #3's start of care: 03/12/2021 with a Principal Diagnosis of "Multiple Sclerosis, Urinary Track Infection, Pulmonary Embolism, Spinal Stenosis." Patient #3 had the following goals: 1. Client/Caregiver will verbalize understanding of catheter care, sign/symptoms of complications/infections and when to seek medical attention. 2. Client to receive catheter changes by physician. 3. Client/Caregiver will be knowledgeable of UTI and interventions to prevent its development. These goals are not measurable or individualized to the patient's needs, and did not contain target dates for completion. Review of Patient #4's "Home Health Certification and Plan of Care" dated 11/06/2021-01/14/2022 revealed Patient #4's start of care: 04/06/2018 with a Principal Diagnosis of "Lymphedema, Type 2 Diabetes, Major Depressive Disorder, Anxiety." Patient #4 had the following goals: 1. Client/Caregiver will decrease swelling. 2. Client/Caregiver will increase lymph drainage from the congested areas. 3. Client/Caregiver will improve skin thickening and improve skin condition. 4. Client/Caregiver will restore joint range of motion/flexibility. 5. Client/Caregiver will improve patient's functional status. 6. Client/Caregiver will relieve discomfort and improve quality of life. 7. Client/Caregiver will reduce the risk of infections. 8. Client/Caregiver will reduce the risk of wounds. 9. Client/Caregiver will verbalize understanding of disease process and current status. 10. Client/Caregiver will verbalize understanding of medication regiment. These goals are not measurable or individualized to the patient's needs, and did not contain target dates for completion. Review of Patient #5's "Home Health Certification and Plan of Care" dated 11/16/2021-01/14/2022 revealed Patient #5's start of care: 02/05/2018 with a Principal Diagnosis of "Malignant neoplasm of Bladder, Malignant neoplasm of left lung, Hypertension, Heart Disease, Chronic Obstructive Pulmonary disease." Patient #5 had the following goals: 1. Client/Caregiver will verbalize understanding of urostomy management, signs/symptoms of complications/infections and when to seek medical attention. 2. Client to receive urostomy changes as ordered by physician. These goals are not measurable or individualized to the patient's needs, and did not contain target dates for completion. Review of Patient #6's "Home Health Certification and Plan of Care" dated 12/14/2020-02/11/2021 revealed Patient #6's start of care: 12/14/2020 and Discharge date: 01/19/2021 with a Principal Diagnosis of "Type 2 Diabetes with foot Ulcer, Chronic Obstructive Pulmonary Disease, Hypertension." Patient #6 had the following goals: 1. Client's integumentary status will improve as evidence by no new breakdown. 2. Client will receive appropriate wound care as ordered by physician. 3. Client/Caregiver will verbalize understanding of the healing process and ways to promote healing and prevent future complications. 4. Client/Caregiver will verbalize understanding of signs/symptoms of wound complications/infections. 5. Client/Caregiver will verbalize understanding of universal precautions and infection control measures. 6. Client's wound site will show signs of healing as evidenced by decreased size. These goals are not measurable or individualized to the patient's needs, and did not contain target dates for completion. Review of Patient #7's "Home Health Certification and Plan of Care" dated 04/08/2021-06/06/2021 revealed Patient #7's start of care: 04/08/2021, and Discharge date: 04/29/2021 with a Principal Diagnosis of "Alcohol Dependence with Withdrawal, Hypertension, Major Depressive Disorder." Patient #7 had the following goals: 1. Client/Caregiver will verbalize understanding of disease process and current status. 2. Client/Caregiver will be compliant with medication regimen. 3. Client/Caregiver will verbalize understanding of medication regimen, actions, side effects and adverse reactions. 4. Client wants to return to stable affect. 5 Client wants to regain ability to return to work. These goals are not measurable or individualized to the patient's needs, and did not contain target dates for completion. The above findings were reviewed and confirmed during an interview with Office Manager A on 01/11/2022 at 2:20PM. Office Manager A replied "we will work on making the goals measurable and creating a plan of care policy."

Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA's governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA's performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This CONDITION is not met as evidenced by: Based on record review and interview, the agency staff failed to ensure that a Quality Assessment and Performance Improvement program (QAPI) was developed and implemented in 1 of 1 QAPI program reviewed. Findings include: 1. The agency failed to develop a QAPI program. See tag G640. 2. The agency failed to ensure that the Governing Body provided oversight of the QAPI program. See tag G660. The agency's QAPI binder was reviewed and revealed the definition of a QAPI program and how to select and write a performance improvement project. There was no documentation of any performance improvement projects; past or present. There was no documentation of tracking adverse events. There was not documentation of tracking and trending for infection control. An interview was conducted with Office Manager A on 1/11/2022 at 12:30 p.m. When asked what the current performance improvement project was, A stated "I'm not aware of one." When asked if there were any QAPI meeting minutes, A stated "Not that I can find."

Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA's governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This STANDARD is not met as evidenced by: Based on record review and interview, the agency's governing body failed to ensure that an ongoing program for performance improvement was implemented and maintained in 1 of 1 Quality Assurance and Performance Improvement (QAPI) plan. Findings include: Review of the agency's QAPI binder revealed no documentation of the governing body developing and implementing the QAPI program. Review of the agency's meeting minutes for the past two years revealed no governing body meeting minutes or agenda. An interview was conducted with Office Manager A on 1/11/2022 at 12:30 p.m. When asked if there were any other meeting minutes, to show that the governing body had met, A stated "Those are all the meeting minutes that I'm aware of."