Every finding on record at St. Croix Valley Shared Services Inc.

An unannounced onsite recertification survey was conducted on 09/12/2023 – 09/13/2023 at Adoray Home Health and Hospice HHA in Baldwin, WI. The agency was found to be in compliance with the Emergency Preparedness regulations for home health, 42 CFR 484.22.

An unannounced onsite recertification survey was conducted on 09/12/2023 – 09/13/2023 at Adoray Home Health and Hospice HHA in Baldwin, WI. The agency was found to be in substantial compliance with the Medicare Conditions of Participation for Home Health, 42 CFR 484. Citation issued at standard level. For a total of 778 unduplicated skilled admissions for the past twelve months, 5 home visits (2 RN, 1 LPN, 1 PTA, & 1 OT) were conducted and a total of 13 records reviewed.

Patient's or legal representative's signature CFR(s): 484.50(a)(2) Obtain the patient's or legal representative's signature confirming that he or she has received a copy of the notice of rights and responsibilities. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to provide written documentation that patient's received their rights in 13 of 13 patient's (1-13) medical records reviewed. Findings includes: Review of medical records 1-13 revealed that no documentation was present within the records showing written confirmation of having received the patient bill of rights. In an interview with Home Health Director G on 09/12/2023 at 2:30 PM, Home Health Director G stated that written confirmation of patient rights should be on the service agreement. After Home Health Director G reviewed the service agreement, it was determined that it was not present within the service agreement. When asked if it might be located on another patient signed document Home Health Director G stated that, the two pieces of information they (patients) sign are the service agreement and the individualized plan of care, they do not sign anything else. Home Health Director G, confirmed that the records did not contain written documentation of patient's receiving the bill of rights statement.

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 in 13 of 13 patient's (1-13) medical records reviewed. Findings include: Review of agency policy titled "Plan of Care" #CL.63 last revised on 10/18/2021 revealed under heading "Procedure" "4. n. patient-specific interventions and education: measurable outcomes and goals identified by the HHA and the patient..." Review of patient #1's plan of care (POC) revealed under "Goals", "Patient / caregiver will verbalize measure to reduce the risk of infection and preventing the spread of infection by the end of home care episode. "Patient / caregiver will verbalize understanding of falls/injury prevention and home safety measures." Goals are not specific to the patient or measurable. Review of Patient #2's POC revealed under "Goals", "Patient / caregiver will verbalize measure to reduce the risk of infection and preventing the spread of infection by the end of home care episode. "Patient / caregiver will verbalize understanding of falls/injury prevention and home safety measures." Goals are not specific to the patient or measurable. Review of Patient #3's POC revealed under "Goals", "Patient / caregiver will verbalize measure to reduce the risk of infection and preventing the spread of infection by the end of home care episode. "Patient / caregiver will verbalize understanding of falls/injury prevention and home safety measures." Goals are not specific to the patient or measurable. Review of Patient #4's POC revealed under "Goals", "Patient / caregiver will verbalize understanding of falls/injury prevention and home safety measures." Goals are not specific to the patient or measurable. "Patient / caregiver will verbalize understanding of pain management regimen." Review of Patient #5's POC revealed under "Goals", "Patient / caregiver will verbalize measure to reduce the risk of infection and preventing the spread of infection by the end of home care episode. "Patient / caregiver will verbalize understanding of falls/injury prevention and home safety measures." Goals are not specific to the patient or measurable. Review of Patient #6's POC revealed under "Goals", "Patient / caregiver will verbalize measure to reduce the risk of infection and preventing the spread of infection by the end of home care episode. "Patient / caregiver will verbalize understanding of falls/injury prevention and home safety measures." Goals are not specific to the patient or measurable. Review of Patient #7's POC revealed under "Goals", "Patient / caregiver will verbalize measure to reduce the risk of infection and preventing the spread of infection by the end of home care episode. "Patient / caregiver will verbalize understanding of falls/injury prevention and home safety measures." Goals are not specific to the patient or measurable. Review of Patient #8's POC revealed under "Goals", "Patient / caregiver will verbalize understanding of falls/injury prevention and home safety measures." "Patient will be pain free or verbalize an acceptable pain level with current pain management regimen." Goals are not specific to the patient or measurable. Review of Patient #9's POC revealed under "Goals", "Patient / caregiver will verbalize understanding of falls/injury prevention and home safety measures." "Patient / caregiver understand signs/symptoms of complications related to diabetes and when to report." Goals are not specific to the patient or measurable. Review of Patient #10's POC revealed under "Goals", "Patient / caregiver will verbalize understanding of falls/injury prevention and home safety measures." "Patient / caregiver understand signs/symptoms of complications related to diabetes and when to report." Goals are not specific to the patient or measurable. Review of Patient #11's POC revealed under "Goals", "Patient / caregiver will verbalize understanding of falls/injury prevention and home safety measures." "Patient / caregiver understand signs/symptoms of complications related to diabetes and when to report." Goals are not specific to the patient or measurable. Review of Patient #12's POC revealed under "Goals", "Patient / caregiver will verbalize understanding of falls/injury prevention and home safety measures." "Patient will be pain free or verbalize an acceptable pain level with current pain management regimen." Goals are not specific to the patient or measurable. Review of Patient #13's POC revealed under "Goals", "Patient / caregiver will verbalize understanding of falls/injury prevention and home safety measures." "Patient / caregiver understand signs/symptoms of complications related to diabetes and when to report." Goals are not specific to the patient or measurable. During the exit interview on 09/13/2023 at 1:30 PM, when discussing the concerns about patient goals, Nursing Director A, Chief Operating Officer I and Home Health Director G nodded in agreement, confirming above findings. No comments were made in regards to the goals not being specific or measurable.

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 the agency staff failed to adhere to standard precautions during 5 of 5 (#5,6,7,8,& 9) home visit observations. Findings include: Review of policy “Hand Washing, Hand Hygiene, and Gloving Guidelines” last revised 9/3/2021 revealed in part, “Hand washing/hand hygiene must be performed: b. Before and after caring for an individual. h. After removing gloves. j. Before and after using computer.” Review of policy “Equipment Cleaning” last revised 9/1/2021 revealed in part, “3. Upon entering the home, the clinician’s bag is placed in a clean, dry area away from children and pets. 7. Any equipment and/or supplies that are soiled during the visit will not be returned to the clinician’s bag unless cleaned using an antibacterial germicidal alcohol wipe.” The employees observed were using Clorox wipes in which the directions state “Disinfect: Use enough to keep wet for 4 min. Let air dry.” An observation of care provided to patient #5 by Licensed Practical Nurse (LPN) B was made on 9/12/2023 at 1:30 p.m. with Director A also in attendance. Upon entering the patient home, LPN B placed nursing bag on the floor. The patient’s small dog was sniffing inside the open nursing bag at times throughout the visit. Equipment used during the visit was wiped down with an antibacterial wipe and returned to directly to the nursing bag with no dry time. An observation of care provided to patient #6 by Registered Nurse (RN) C was made on 9/13/2023 at 8:00 a.m. with Director A also in attendance. RN C donned gloves at the start of the visit. RN C then picked up the patient’s urinary catheter bag to assess urine then went into nursing bag and removed the electronic tablet (used for patient documentation.) There was no hand hygiene performed between these tasks. RN C then proceeded to enter nursing bag and remove the necessary equipment to obtain vital signs. No hand hygiene was performed prior to entering the nursing bag. After vital signs were obtained, RN C then went back into the nursing bag to retrieve the INR meter (a hand-held device used to obtain a measure of blood clotting; much like a blood glucose machine.) No hand hygiene was performed prior to reentry into the nursing bag. RN C obtained a blood sample from the patient’s finger onto the test strip inserted into the machine. These tasks were completed wearing the same pair of gloves that were donned at the beginning of the visit. Later in the visit, RN C placed a protective dressing on the patient’s outer ankle. RN C then removed gloves and, without hand hygiene, applied the patient’s stockings to his/her legs, placed unused wound supplies back into the container they were stored and placed unused gloves back into the nursing bag. The equipment used to obtain vital signs were wiped with an antibacterial wipe and placed directly into the bag with no dry time. The INR meter was not wiped down prior to returning to the nursing bag. An observation of care to patient #7 provided by RN D was made on 9/13/2023 at 8:53 a.m. with Director A also in attendance. At the end of the care provided, RN D wiped down equipment used during the visit and placed it directly into the nursing bag with no dry time. An observation of care provided to patient #8 by Occupation Therapist (OT) E was made on 9/13/2023 at 10:36 a.m. with Quality Supervisor and Compliance H also in attendance. At the end of the care provided, OT E wiped down equipment used during the visit and placed it directly into the therapy bag with no dry time. An observation of care provided to patient #9 by Physical Therapy Aide (PTA) F was made on 9/13/2023 at 12:00 p.m. with Quality Supervisor and Compliance H also in attendance. At the end of the care provided PTA F wiped down equipment used during the visit and placed it directly into the therapy bag with no dry time. An interview was conducted with Director A on 9/13/2023 at 1:30 p.m. When asked if the same observations were made as the surveyor during the home visits, Director A stated “yes.”

An unannounced, onsite Complaint survey was conducted on 12/14/2022 at Adoray Home Health and Hospice in Baldwin, WI. in response to complaint WI000094257. Adoray Home Health and Hospice was found to be in substantial compliance with the Medicare Conditions of Participation 42 CFR 484 for Home Health agency's. Complaint WI000094257 was substantiated, citations were issued at the standard level.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on record review and interview the agency staffed failed to provided physician ordered services in 1 of 10 (Patient #1) medical records reviewed. Findings include: Review of agency policy tilted, "Visit Frequency - Missed visit Notification" dated, 09/29/2021 revealed, "When a patient's visit frequency does not match the physician ordered frequency... the clinician will attempt to reschedule that visit within the calendar week." Review of Patient #1's medical record revealed, Patient #1 was admit to the Home Health agency on 09/26/2022 with a diagnosis of type 2 diabetes with left foot ulcer. Services ordered included skilled nursing (SN) services 3 times per week for wound care of diabetic ulcer on outer lateral side of left foot. Prior to admission to Home Health agency, Patient #1 was hospitalized for the amputation of the 5th metatarsal on left foot and intra venous antibiotics related bone necrosis. Patient #1 was referred to the Home Health agency on 09/23/2022 and discharged from the hospital without oral antibiotics on 09/24/2022. Review of Patient #1's visit notes revealed Patient #1 was being seen every Monday by the podiatry clinic to perform wound care/debridement and wound evaluations. SN services were seeing Patient #1 Wednesdays and Fridays to perform wound care/assessment. During the week of 10/17/2022, Patient #1 was seen on 10/17/2022 at the podiatry clinic and had a wound debridement completed with an order to continue wound care and have x-rays of left foot on next podiatry visit (10/24/2022) to monitor healing of bone. Nurse visit note on 10/19/2022 revealed completion of wound care and wound assessment, no signs of wound infection or symptoms of infection were documented. Plan for next SN visit was to be conducted on 10/21/2022. Review of Patient #1's medical record revealed the SN visit was missed on 10/21/2022 due to a schedule conflict and rescheduled for 10/22/2022. Review of visit documentation revealed no visit was conducted on 10/22/2022. In an interview on 12/14/2022 at 1:00 PM with the Director of Home Health A, Director A stated that the missed visit on 10/21/2022 was rescheduled for Saturday, 10/22/22 and that the on call nurse missed the visit. Director A, stated that the on call nurse was new to the role and missed the email notification of visit. The visit was unable to be rescheduled for the week due to Patient #1's hospitalization on 10/24/2022.