Gundersen Palmer Lutheran Hosp & Clin-Home Health

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient’s status, and must include, at a minimum, the following information: (1) The patient’s current health, psychosocial, functional, and cognitive status; This Element is not met as evidenced by: Based on staff interview, clinical record reviews and agency policy review, the agency failed to provide complete comprehensive assessments for patients with wounds for 3 of 4 sampled patients with wounds (Patient #1, #2 and #5). Failure to accurately and thoroughly complete wound assessments or provide a comprehensive assessment placed patients at an increased risk of unidentified condition changes. Findings include: 3. Patient #2 had a start of care date of 1/7/20. Clinical record review revealed: a. The POC, dated 8/3/26 to 10/1/26, included a primary diagnosis of unspecified convulsions and physician orders for skilled nursing services. b. The skilled nurse visit note, dated 8/28/26, completed by Staff C, RN, included documentation that the patient had a stage 3 pressure ulcer to the patient’s right foot with an 8/28/26 onset. The wound measured 2.5 cm by 2.5 cm. The assessment lacked documentation of measurement of wound depth. The nurse failed to document wound measurements, including depth, when the wound was initially identified. The above findings were shared with the Administrator, Clinical Manager, Risk Manager and Continuous Readiness Manager and Staff F, RN. 2. Patient #1 had a start of care date of 9/4/26. Clinical record review revealed: a. Plan of Care, dated 9/4/26 to 11/2/26, included primary diagnosis of encounter for surgical aftercare following surgery on digestive system [hernia repair of diaphragm (muscle between chest and abdomen)] and physician orders for skilled nursing services. b. Skilled nurse visit note, dated 9/14/26, completed by Staff H, RN, included documentation the left back thoracic area surgical incision, measured 18 cm by 0.2 cm by 0.1 cm with sanguinous drainage (bloody). Staff H called physician office and reported surgical incision on back had dehisced a little bit and there was some dried blood. The skilled nurse failed to measure the area of dehiscence. According to the agency policy titled Wound Care, dated 12/2025, all wounds should be assessed regularly and the outcomes of the assessment documented. It is an agency expectation that all aspects of care, including assessment, treatment and management plans, implementation and evaluation are documented clearly and comprehensively. During an interview on 9/15/26 at 11:45 AM, the Clinical Manager stated the nurse measures wounds weekly if providing wound care. Measurements include length, width and depth in centimeters (cm). The Clinical Manager identified nurses do not assess and/or measure wounds if the agency is not providing wound care. 1.Patient #5 had a start of care date of 8/15/13. Clinical record review revealed: a. The Plans of Care (POC), dated 6/8/26 to 8/6/26 and 8/7/26 to 10/5/26, identified the patient had a primary diagnosis of hypertension. The POC included physician orders for skilled nursing services to complete a physical assessment that includes a skin assessment. b. The skilled nurse comprehensive assessment completed at recertification, dated 8/6/26, completed by Staff D, Registered Nurse (RN), identified the patient had a wound to right foot, not assessed as wound clinic managing outpatient. The clinical record lacked a wound assessment and measurements for the identified wound. The RN failed to complete a wound assessment/measurements for the identified wound at the time of the comprehensive assessment.”

“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 clinical record reviews and agency policy reviews, the agency failed to ensure accurate completion of all components comprising the Plan of Care, including all medical supplies and all treatments for 1 of 4 sampled patients with a wound (Patient #5). Failure to maintain complete and accurate plans of care with current orders placed patients at risk to not receive services, supplies, medications and/or treatments according to assessed needs and physician orders. Findings include: According to the agency policy titled Plan of Care, dated 1/2026, home health staff members provide coordination of patient services to establish effective interchange, reporting and coordinated patient evaluation through the patient’s care coordination. The agency must integrate orders from all physicians or allowed practitioners involved in the plan of care to assure the coordination of all services and interventions provided to the patient. According to the agency policy titled Wound Care, dated 12/2025, it is an agency expectation that all aspects of care, including assessment, treatment and management plans, implementation and evaluation are documented clearly and comprehensively. Patient #5 had a start of care date of 8/15/13. Clinical record review revealed: a. The Plans of Care (POC), dated 6/8/26 to 8/6/26 and 8/7/26 to 10/5/26, identified the patient had a primary diagnosis of hypertension and included orders for interventions and treatments. b. The skilled nurse comprehensive assessment completed at recertification, dated 8/6/26, completed by Staff D, Registered Nurse (RN), identified the patient had a wound to right foot, not assessed as wound clinic managing outpatient. The clinical record lacked treatment orders for wound care on the POC. The agency failed to include physician orders for wound care on the POC. The above findings were reviewed with the Administrator, Clinical Manager, Risk Manager and Continuous Readiness Manager and Staff F, RN.”

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on agency policy review, clinical record review and staff interview, the agency failed to ensure the clinical record included a complete clinical record for 1 of 7 sampled patients (Patient #2). Failure of the agency to ensure the clinical record included all of the physician or allowed practitioner orders placed agency patients at risk to receive care or not receive care meeting the needs of the patient. Findings include: According to agency policy titled Signatures on Charts, dated December 2025, the purpose of the policy is to identify specific documentation requirements and standards. Plan of care is a clinical record containing pertinent and current findings in accordance with accepted professional standards is maintained for every patient receiving home health services. Progress notes will include contacts with physicians and other health care providers and all documentation will be on the computer or in ink. During an interview on 9/15/26 at 11:23 AM, Staff F, Registered Nurse (RN), reported that when a patient reports a new medication during a skilled nurse visit, the nurse then verifies this with the provider and adds the medication to the patient’s medication list. During an interview on 9/15/26 at 1:00 PM, Staff C, RN, reported that the patient’s caregiver reported the patient took an antibiotic, but when Staff C looked at the patient’s pill planner, the pill planner did not contain an antibiotic. Staff C reported the patient must have completed the course of antibiotics. Patient #2 had a start of care date of 1/7/20. Clinical record review revealed: a. The plan of care (POC), dated 8/3/26 to 10/1/26, included primary diagnosis of unspecified convulsions and physician orders for skilled nursing services. b. The skilled nurse visit note, dated 8/28/26, completed by Staff C, included the patient was on an antibiotic 4 times per day, patient educated on dosage and frequency and put into pill planner. c. Review of the patient’s clinical record failed to identify a physician’s order for the antibiotic. The agency failed to ensure the clinical record included all of the physician or allowed practitioner orders. The above findings were reviewed with the Administrator, Clinical Manager, Risk Manager and Continuous Readiness Manager and Staff F, RN.”

“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 agency policy review, clinical record review, home visit observation and patient and staff interview, the agency failed to ensure the accurate completion of all components comprising the Plan of Care, including all supplies/equipment and medications used by the patient for 1 of 4 sampled patients with surveyor home visit observation and 1 of 10 current sampled patient records (Patients #1 and #2). Failure to maintain complete and accurate Plans of Care with current orders placed the patients at risk to not receive services, medications and/or treatments according to assessed needs and physician orders. Findings include: According to the agency policy titled Plan of Care, dated 11/2023, the client plan of care included client medication which includes all over the counter medications and any medications received on an outpatient basis such as chemotherapy or IM injections, client treatment, medical supplies/appliances and any other appropriate items necessary. 1. Patient #1 had a start of care date of 12/3/22. Clinical record review, home visit observation and accompanying interviews revealed the following: a. The Plan of Care, dated 10/26/23 to 12/24/23, included orders for the patient’s medications. b. The Client Medication Report, dated 11/13/23, included orders for the patient’s current medications. During a home visit observation on 11/13/23 at 8:00 AM, with Staff C, RN, the nurse set up the patient’s medications. The surveyor noted the patient had an almost empty tube of Triamcinolone Acetonide Cream 0.1% for psoriasis. An interview during the same home visit observation the patient stated he/she had long time usage and had psoriasis since the 6th grade. A bottle of the medication Ferrous Gluconate 324 milligrams (mg) daily also noted. The prescription bottle included a fill date of 7/25/23. The Plan of Care lacked the medications Triamcinolone Acetonide Cream and Ferrous Gluconate used by the patient. 2. Patient #2 had a start of care date of 11/7/23. Clinical record review, home visit observation and accompanying interviews revealed the following: The POC, dated 11/4/23 to 1/4/24, included order for a catheter. The POC identified the catheter managed by the Urologist home Staff. The order lacked identification of specific catheter size or balloon size. During an interview on 11/14/23 at 3:30 PM the Director stated if a problem occurred with the patient’s catheter, the agency would have him/her sent to the Emergency Room for care. The above stated findings were reviewed with the Director and Staff C, RN. The agency provided no additional information prior to the end of the survey.”

“Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This Element is not met as evidenced by: Based on agency policy review, clinical record review and staff interview, the agency failed to ensure home health aides provided care to agency patients only as ordered by the physician, permitted under state law and/or as directed by the skilled professional assigning the home health aide to the patient for 4 of 4 sampled patients receiving home health aide services (Patients #1, #7, #9 and #10). The agency reported 45 patients who received care provided by a home health aide. Failure to ensure that home health aide services are provided only as ordered by the physician, permitted under state law and/or as directed by the skilled professional assigning the home health aide to the patient and according to the home health aide care plan increased the risk that patients’ personal care needs were not adequately met. Findings including: According to the agency policy titled Home Care Aide Services, dated February 2023, the the home care aide will follow the plan of care, performing only those tasks that have been ordered by the physician. If the aide finds the client could benefit from a task that is not ordered on the plan of care, the aide may contact the primary nurse or any RN to obtain an order for the task. All concerns the aide has reported to the primary RN should be documented. During an interview on 11/13/23 at 1:25 PM the Quality Improvement Coordinator stated the home care aide and Registered Nurse review the care plan every 60 days and as needed. If the Aide had an unassigned task, they call the nurse and the nurse would give a verbal ok, then get a physician order to change the care plan for that day. If the task is required longer than one time, then would update the home care aide care plan. 1. Patient #1 had a start of care date of 12/30/22. The Plans of Care, dated 8/27/23 to 10/25/23 and 10/26/23 to 12/24/23, included physician orders for skilled nursing services for assessment 2 time a month and home health aide services 2 times per week to assist with personal care. Clinical record review revealed: a. The Aide Care Plan, dated 1/3/23, included direction to the aide to Aide to assist with personal care, use standard and fall precautions. COVID screening completed, proper personal protective equipment (PPE) Worn, report red or broken skin to Registered Nurse (RN), shower, shampoo, lotion to back and extremities, assist with dressing, tidy patient care area and remind patient/caregiver to call 800# for questions/concerns. b. The home health aide visit notes, dated 9/12, 9/15, 9/19, 9/22, 9/26, 9/29, 10/3, 10,6, 10/10, 10/13, 10/17, 10/20, 10/24, 10/27, 10/31, 11/3, 11/7 and 11/10/23, included documentation the home health aide assisted with personal care, use standard and fall precautions. COVID screening completed, proper PPE Worn, report red or broken skin to RN, shower, shampoo, lotion to back and extremities, assist with dressing, tidy patient care area and remind patient/caregiver to call 800# for questions/concerns. The home health aide failed to identify specific areas completed as listed on the care plan. 2. Patient #7 had a start of care date of 10/22/23. The Plans of Care, dated 10/22/23 to 12/20/23, included physician orders for skilled nursing services for assessment 3 times a month and home health aide services 1 times per week to assist with personal care. Clinical record review revealed: a. The Aide Care Plan, dated 10/25/23, included direction to the aide to Aide to assist with personal Care, use standard and fall precautions, report red or broken skin to Registered Nurse (RN), shower, shampoo, lotion to back and extremities, assist with dressing, assist with transfer and ambulation, stand by assist and walker, tidy patient care area and remind patient/caregiver to call 800# for questions/concerns. b. The home health aide visit notes, dated 10/25/23, included documentation the home health aide assisted with personal care, use standard and fall precautions. COVID screening completed, proper PPE worn, report red or broken skin to RN, shower, shampoo, lotion to back and extremities, assist with dressing, tidy patient care area and remind patient/caregiver to call 800# for questions/concerns. The note documented the tasks done. The narrative note included the aide did not assist in anyway and nurse notified. The home health aide failed to identify specific areas completed as listed on the care plan. 3. Patient #9 had a start of care date of 12/30/22. The Plans of Care, dated 8/27/23 to 10/25/23 and 10/26/23 to 12/24/23, included physician orders for skilled nursing services for assessment 1 time a week and home health aide services 2 times per week to assist with personal care. Clinical record review revealed: a. The Aide Care Plan, dated 3/20/23, included direction to the aide to assist with personal care, use standard and fall precautions, COVID screening completed/Proper PPE worn, report red or broken skin to RN, shower, shampoo, comb hair care, lotion to back and extremities, assist with dressing, assist with transfer into/out of shower, tidy patient care area, remind patient/caregiver to call 800# for questions/concerns. b. The home health aide visit notes, dated 3/10, 10/14 and 10/17/23, included documentation the home health aide assisted with personal care, use standard and fall precautions, COVID screening completed/Proper PPE worn, report red or broken skin to RN, shower, shampoo, comb hair care, lotion to back and extremities, assist with dressing, assist with transfer into/out of shower, tidy patient care area, remind patient/caregiver to call 800# for questions/concerns. The home health aide failed to identify specific areas completed as listed on the care plan. 4. Patient #10 had a start of care date of 3/12/23. The Plans of Care, dated 8/27/23 to 5/10/23 and 5/11/23 to 7/9/23, included physician orders for skilled nursing services for assessment 1 time a week and home health aide services 2 times per week to assist with personal care. Clinical record review revealed: a. The Aide Care Plan, dated 1/3/23, included direction to the aide to assist with personal care, use standard and fall precautions. COVID screening completed/proper PPE worn, report red or broken skin to RN, shower, shampoo, comb hair care, oral care, peri care, lotion to back and extremities, deodorant, assist with dressing, assist with transfer in and out of shower and ambulation, tidy patient care area and remind patient/caregiver to call 800# for questions/concerns. b. The home health aide visit notes, dated 3/20, 3/22, 3/23, 3/27, 3/30, 4/2, 4/3, 4/6, 4/10, 4/13, 4/17, 4/20, 4/24, 4/28, 5/1, 5/4, 5/11 and 5/15/23, included documentation the home health aide assist with personal care, use standard and fall precautions. COVID screening completed/proper PPE worn, report red or broken skin to RN, shower, shampoo, comb hair care, oral care, peri care, lotion to back and extremities, deodorant, assist with dressing, assist with transfer in and out of shower and ambulation, tidy patient care area and remind patient/caregiver to call 800# for questions/concerns. The home health aide failed to identify specific areas completed as listed on the care plan. The above concerns shared with the Clinical Manager and Staff C, RN. The agency provided no further information prior to the end of the survey.”