Every finding on record at Personalized Plus Home Health Care, LLC

An unannounced, on-site Recertification survey was conducted on 01/02/2024-01/04/2024 at Personalized Plus Home Health Care in Milwaukee, Wisconsin. Personalized Plus Home Health Care was found to be in compliance with Medicare Conditions of Participation for Emergency Preparedness for Home Health Agencies 42 CFR 484.22.

An unannounced, onsite Recertification survey was conducted on 01/02/2024-01/04/2024 at Personalized Plus Home Health Care in Milwaukee, WI. Personalized Plus Home Health Care was found to be 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 9 patient records were reviewed, including 7 active and 2 discharged records for an unduplicated admission census of 37 for the past 12 months. One home visit was completed during this survey and two additional record reviews were completed due to no other home visit availability. A total of 5 personnel records were reviewed during this survey.

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's Plans of Care failed to include the frequency and duration of visits to be made in 4 of 9 (Patients #1, #4, #5, and #7) clinical records reviewed. Findings Include: Review of agency's policy titled, "Plan of Care" (not dated) revealed in part, "2. The Plan of Care shall be completed in full to include: e.Type, frequency, and duration of all visits/services." Record review of Patient #1's clinical record revealed a SOC (Start of Care) date of 04/25/2023. According to the document titled, "Home Health Plan of Care and Certification" with certification period of 12/21/2023 to 02/18/2024 under the "Orders and Goals" section of the document was "SN (Skilled Nursing) 4 times a day." The duration of visits was not indicated. Record review of Patient #4's clinical record revealed a SOC (Start of Care) date of 12/28/2022. According to the document titled, "Home Health Plan of Care and Certification" with certification period of 12/23/2023-02/20/2024 under "Order and Goals" section on the document was "SN (Skilled Nursing) every other day." The duration of the visits was not indicated. Record review of Patient #5's clinical record revealed a SOC (Start of Care) date of 10/16/2023. According to the document titled, "Home Health Plan of Care and Certification" with certification period of 12/15/2023-02/12/2024 under "Order and Goals" section on the document was "SN (Skilled Nursing) 1X/DX7D/WK." The duration of the visits was not indicated. Record review of discharged Patient #7's clinical record revealed a SOC (Start of Care) date of 10/31/2023 and discharge date of 11/20/2023. According to the document titled, "Home Health Plan of Care and Certification" with certification period of 10/31/2023-12/29/2023 under "Order and Goals" section on the document was "SN (Skilled Nursing) 1x/day x7day/wk." The duration of the visits was not indicated. During an interview with Administrator/Director of Nursing (DON) A on 01/03/2024 at 2:36 PM, when asked about the duration of the services to be completed, Administrator/DON A stated, "We had it with the old paper 485's we used but I am not sure how to get that on with this new software we switched to with EVV (Electronic Verification Visits). I am still trying to make sure all of the right information is on the Plans of Care."