Every finding on record at Southport Healthcare, LLC

An unannounced onsite recertification survey was conducted on 09/24/2024 – 09/25/2024 at Kenosha Visiting Nurse Association in Kenosha, 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 09/24/2024 – 09/25/2024 at Kenosha Visiting Nurse Association in Kenosha, 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 513 unduplicated skilled admissions for the past twelve months, 4 home visits were conducted and a total of 13 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 staff failed to document patient specific and measurable goals on the plan of care in 13 of 13 patient's (#1-13) medical records reviewed. Findings include: Review of agency policy titled "Care Planning Procedure #4-001.1" not dated revealed, "Individualized Plan Of Care: The patient-specific clinical plan of care includes: G. Measurable outcomes and goals..." Review of patient #1's plan of care (POC) dated 08/23/2024 – 10/21/2024 revealed under "Goals"…will verbalize understanding of infection control/prevention…” “…will verbalize/demonstrate ability to manage hypertension…” Goals are not specific to the patient or measurable. Review of Patient #2's POC dated 07/29/2024 – 09/26/2024 revealed under "Goals"…will verbalize understanding of infection control/prevention…” “…will verbalize/demonstrate ability to manage diabetes…” Goals are not specific to the patient or measurable. Review of Patient #3's POC dated 09/17/2024 – 11/15/2024 revealed under "Goals"…will verbalize understanding of infection control/prevention…” “…will effectively manage depression…” Goals are not specific to the patient or measurable. Review of Patient #4's POC dated 08/05/2024 – 10/03/2024 revealed under "Goals"…will verbalize understanding of infection control/prevention…” “…will demonstrate safe bathing…” Goals are not specific to the patient or measurable. Review of Patient #5's POC dated 08/12/2024 – 10/10/2024 revealed under "Goals"…will verbalize understanding of infection control/prevention…” “…will receive medications as prescribed…” Goals are not specific to the patient or measurable. Review of Patient #6's POC dated 08/19/2024 – 10/17/2024 revealed under "Goals"…will verbalize understanding of infection control/prevention…” “…will verbalize/demonstrate to care for altered respiratory status…” Goals are not specific to the patient or measurable. Review of Patient #7's POC dated 09/13/2024 – 11/11/2024 revealed under "Goals"…will verbalize understanding of infection control/prevention…” “…will verbalize/demonstrate ability to manage diabetes…” Goals are not specific to the patient or measurable. Review of Patient #8's POC dated 05/22/2024 – 07/20/2024 revealed under "Goals"…will verbalize understanding of infection control/prevention…” “…will verbalize/demonstrate ability to manage hypertension…” Goals are not specific to the patient or measurable. Review of Patient #9's POC dated 07/16/2024 – 09/13/2024 revealed under "Goals"…will verbalize understanding of infection control/prevention…” “…will verbalize/demonstrate ability to manage diabetes…” Goals are not specific to the patient or measurable. Review of Patient #10's POC dated 05/21/2024 – 07/19/2024 revealed under "Goals"…will verbalize understanding of infection control/prevention…” “…incision will demonstrate progress with healing…” Goals are not specific to the patient or measurable. Review of Patient #11's POC dated 05/03/2024 – 07/01/2024 revealed under "Goals"…will verbalize understanding of infection control/prevention…” “…will demonstrate effective use of pain control methods…” Goals are not specific to the patient or measurable. Review of Patient #12's POC dated 02/21/2024 – 04/20/2024 revealed under "Goals"…will verbalize understanding of infection control/prevention…” “…will effectively manage depression…” Goals are not specific to the patient or measurable. Review of Patient #13's POC dated 08/09/2024 – 10/07/2024 revealed under "Goals"…will verbalize understanding of infection control/prevention…” “…will verbalize/demonstrate ability to manage hypertension…” Goals are not specific to the patient or measurable. During an interview on 09/25/2024 at 2:00 PM, the medical record review findings were discussed with Director of Clinical Services A. S/he stated that all patients are assigned the same five “standard goals” along with additional individual goals. S/he verbalized understanding about using parameters to make goals measurable.