Every finding on record at Transitions at Home Inc.

An unannounced recertification survey was conducted 07/11/2022 - 07/14/2022 at Transitions Home Health, located in Elkhorn, Wisconsin. The agency was found to be in compliance with the Emergency Preparedness regulations for home health, 42 CFR 484.22.

An unannounced on-site recertification survey was conducted 07/11/2022 - 07/14/2022 at Transitions Home Health, located in Elkhorn, Wisconsin. The agency was found to be in compliance with the Medicare Conditions of Participations for Home Health 42 CFR 484. Citations issued at the standard level. Unduplicated admissions for the past 12 months reported as 596; A total of 5 home visits and 13 record reviews were completed.

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, agency staff failed to ensure each patient's Plan of Care included individualized, measurable goals in 13 of 13 patient records reviewed (Patients #1--#13). Based on record review and interview, agency staff failed to ensure each patient's Plan of Care included individualized, measurable goals in 13 of 13 patient records reviewed (Patients #1--#13). FINDINGS INCLUDE: Review of policy "Plan of Care-CMS 485 and Physician Orders" not dated, revealed in part "Procedure. 2) The individualized plan of care, must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible disciplines and measurable outcomes that the agency anticipates will occur as a result of implementing the Plan of Care. 3) Each patient must receive home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals...." Further review of the policy revealed, "Patient-specific goals must be individualized to the patient based on the patient's medical diagnosis, Physician's orders, comprehensive assessment and patient input." Review of Patient #1's "Home Health Care Certification and Plan of Care" dated 7/7/2022 revealed the following unmeasurable nursing goals: "Patient will understand pain management regimen and patient will verbalize understanding of falls/injury prevention." Skilled nursing visits ordered: 1day1 end 7/7/2022 to admit. No additional nursing visits planned to meet goals. Review of Patient #2's "Home Health Care Certification and Plan of Care" dated 5/27/2022 revealed the following unmeasurable nursing goal: "Patient to remain in own residence with the assistance of a caregiver." Review of Patient #3's "Home Health Care Certification and Plan of Care" dated 6/16/2022 revealed the following unmeasurable nursing goals: "Patient will demonstrate medication compliance and patient/caregiver will install all adaptive equipment to prevent falls." Review of Patient #4's "Home Health Care Certification and Plan of Care" dated 5/17/2022 revealed the following unmeasurable nursing goals: "patient/caregiver will install all adaptive equipment to prevent falls and patient will understand anticoagulation precautions." Skilled nursing completed the admission visit for a Physical Therapy only case. Review of Patient #5's "Home Health Care Certification Plan of Care" dated 6/15/2022 revealed the following unmeasurable nursing goals: "Peripheral edema will be reduced and Complete healing of stasis ulcer." Target date 6/13/2022. Goals were carried over from the previous certification period and not evaluated during the recertification assessment. Review of Patient #6's "Home Health Care Certification Plan of Care" dated 6/30/2022 revealed the following unmeasurable nursing goals: "patient/caregiver will install all adaptive equipment to prevent falls and patient will be pain free." No skilled nursing visits ordered for certification period 6/30/2022--8/28/2022. Goals were carried over from previous certification period. Review of Patient #7's "Home Health Care Certification Plan of Care" dated 6/11/2022 revealed the following unmeasurable nursing goals: "Patient's incision will be free from infection and patient will be knowledgeable regarding use of medications and side effects. Target date: 8/9/2022." No skilled nursing visits were ordered for certification period 6/11/2022--8/9/2022. Goals were carried over from previous certification period. Review of Patient #8's "Home Health Care Certification Plan of Care" dated 6/11/2022 revealed the following unmeasurable therapy goal: "Patient will complete HEP (home exercise plan) 7/7 days to improve ROM (range of motion). Target date: 6/10/2022." The Occupational Therapy goal was carried over from previous certification period and not evaluated during the recertification assessment. Review of Patient #9's "Home Health Care Certification and Plan of Care" dated 6/13/2022 revealed the following unmeasurable nursing goals: "Urinary elimination pattern within baseline and Free from signs and symptoms of infection." Review of Patient #10's "Home Health Care Certification Plan of Care" dated 3/18/2022 revealed the following unmeasurable nursing goals: "patient/caregiver will install all adaptive equipment to prevent falls and patient will be pain free." Skilled nursing visits ordered: 1day1 end 3/18/2022 to admit. No additional nursing visits were planned. Review of Patient #11's "Home Health Care Certification Plan of Care" dated 3/24/2022 revealed the following unmeasurable nursing goals: "patient/caregiver will install all adaptive equipment to prevent falls; patient will be free from side effects of anticoagulation therapy and patient will be pain free." Skilled nursing visits ordered: 1day1 end 3/24/2022 to admit. Skilled nursing 1 day 1 on 3/29/2022 to check INR (bleeding time). No additional nursing visits were planned. Review of Patient #12's "Home Health Care Certification Plan of Care" dated 3/26/2022 revealed the following unmeasurable therapy goal: "Patient will complete HEP (home exercise plan) 7/7 days to improve ROM (range of motion). Target date: 02/22/2022." The following unmeasurable nursing goals: "Patient will be pain free and Patient will demonstrate necessary behaviors to maintain safety. Target date: 3/25/2022." The Therapy and nursing goals were carried over from the previous certification period 01/25/2022—03/25/2022 and not evaluated during the recertification assessment. Review of Patient #13's "Home Health Care Certification and Plan of Care" dated 04/05/2022 revealed the following unmeasurable nursing goals: "Urinary elimination pattern within baseline and Free from signs and symptoms of infection." An interview was conducted 07/14/2022 at 1:00 PM with Administrator A and Clinical Director B to review the above findings. When asked if the staff could individualize goals within the electronic medical record, Administrator A stated "yes." Clinical Director B reported, the agency changed clinical documentation programs in December 2021. The goals download based on the skilled nursing and therapy interventions chosen. Administrator A stated the staff is aware of the need to individualize and update interventions and goals throughout the patient's service.