Interim Healthcare of NE WI Inc.

“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 failed to develop plan of care (POC) goals that were measurable, time specific and/or individualized to meet the needs of the patient in 7 of 7 patients reviewed (Patient #1, #2, #3, #4, #5, #6, and #7). Record review of Patient #4’s “Home Health Certification and POC certification period 12/04/2025 - 12/01/2026” revealed “Goals: Patient will demonstrate compliance with medication regimen as evidenced by verbalization of taking correct medications at the correct time, and medications taken correctly from medication box set up throughout episode of care. Patient will be free of falls/injury during this episode of care as evidence by patient verbalization of no falls or injury. Patient will demonstrate measures to prevent skin breakdown as evidenced by verablization of need to change position every 2 hours assess skin daily for any redness or open areas, to report any areas of concern of skin to nurse and skilled nurse assessment of skin will yield no noted open areas during this episode of care. Patient will remain free of infection during this episode of care as evidenced by patient afebrile and no other signs of potential infection.” The POC goals were not time specific in which to measure anticipated outcomes by. Record review of Patient #5’s “Home Health Certification and POC certification period 01/06/2026 - 03/06/2026” revealed “Goals: Patient will be free of falls/injury throughout the episode of care. Patient will be free of skin lesions on the lower extremities throughout the episode of care. Patient will demonstrate measures to prevent skin breakdown as evidenced by verablization of need to change position every 2 hours assess skin daily for any redness or open areas, to report any areas of concernt of skin to nurse and skilled nurse assessment of skin will yield no noted open areas during this episode of care. Patient will have no acute care hospitalizations, emergency room visits nor readmissions during this episode of care.” The POC goals were not measurable and/or time specific in which to measure anticipated outcomes by. Record review of Patient #6’s “Home Health Certification and POC certification period 10/23/2025 - 12/21/2025” revealed “Goals: Patient will be free of falls/injury throughout the episode of care. Patient will remain free of infection during episode of care as evidenced by patient afebrile and no other signs of potential infection.” The POC goals were not time specific in which to measure anticipated outcomes by. Record review of Patient #7’s “Home Health Certification and POC certification period 10/09/2025 - 12/07/2025” revealed “Goals: Will be able to verbalize signs and symptoms of cardiac complications, when to call physician, nurse or 911 throughout the entirety of care. Will demonstrate compliance with prescribed treatment regimen regarding Hypertension and Hyperlipidemia including adherence to cardiac regimen/program throughout the entirety of care. Patient will demonstrate improvement from current functional level to prior functional level of independence before hospitalization, as evidenced by safe use of energy conservation techniques and adherence to cardiac regimen to increase functional activity throughout the entirety of care. Demonstrate ability to effectively manage medication regimen throughout the entirety of care. Patient will demonstrate measures to prevent skin breakdown as evidenced by verablization of need to change position every 2 hours assess skin daily for any redness or open areas, to report any areas of concern of skin to nurse and skilled nurse assessment of skin will yield no noted open areas during this episode of care. Patient will demonstrate return to stable genitourinary status regarding Benign Prostatic Hyperplasia and Overactive Bladder and verbalize improvement to symptoms throughout the entirety of care.” The POC goals were not time specific in which to measure anticipated outcomes by. Findings were reviewed during an interview with Director of Healthcare Services A and Administrator B on 01/13/2026 at 11:10 AM. When asked about the POC and if they are editable and can be individualized, Director of Healthcare Services A replied, “Yes, they should be. There’s some work to be done.” Findings include: Review of agency policy titled “Developing a Plan to Meet Patient/Client Needs” dated 04/02/2021 revealed in part, “Procedure: 7. The designated employee collaborates with the patient/client, representative, and caregivers as well as the patient’s physician to define a POC. The designated employee identifies the following: b) Realistic patient-specific goals and the anticipated outcomes of care/services that are measurable, time specific, and relate to identified patient/client needs.” Review of Patient #1’s record “Home Health Certification and POC (Recertification of Continuing Need for Care) certification period 12/17/2025 - 2/14/2026 revealed in part, “Goals: Patient will be free of falls/injury during this episode of care as evidenced by patient verbalization of no falls or injury. Patient will have no acute care hospitalizations, ER visits or readmissions during this episode of care as evidenced by no transfer to inpatient facility and patient’s verbalization of no ER visits. Patient will verbalize understanding and demonstrate compliance with prescribed care to improve health status and minimize long-term debilitating diabetes complications within episode of care. Patient will remain free of infection during this episode of care.” The POC goals were not time specific in which to measure outcomes by nor were they individualized for Patient #1’s specific needs. Review of Patient #2’s record “Home Health Certification and POC certification period 1/9/2026 - 3/9/20206” revealed in part, “Goals: Patient will be free of falls/injury during this episode of care as evidenced by patient verbalization of no falls or injury. Patient will have no acute care hospitalizations, ER visit nor readmissions during this episode of care.” The POC goals were not time specific in which to measure outcomes by nor were they individualized for Patient #2’s specific needs. Review of Patient #3’s record “Home Health Certification and POC certification period 12/29/2025 - 2/26/2026” revealed in part, “Goals: Patient will be free of infection during this episode of care. Patient will have no acute care hospitalizations, ER visit nor readmissions during this episode of care. Patient will be free of falls/injury during this episode of care as evidenced by patient verbalization of no falls or injury. Patient will have promotion of healing and restoration of skin integrity without complications by 2/26/2026.” The POC goals were not time specific and/or measureable nor were they individualized for Patient #3’s specific needs.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure that Occupational Therapy (OT) evaluations and treatment orders were followed per physician signed orders in 4 of 5 eligible patients that had OT evaluation and treatment orders (Patients #1, #3, #4, and #7) in a total of 7 records reviewed. Record review of Patient #4’s referral orders revealed “Encounter Date: 11/25/2025. Order Date: 12/02/2025: Disciplines Requested: Home Health OT.” Review of Patient #4’s “Home Health Certification and Plan of Care” dated 12/04/2025 - 02/01/2025 revealed “Orders for Discipline and Treatment: Frequency: OT frequency 1 week 1: Evaluate and treat week of effective date: 12/06/2025.” Record review revealed no OT evaluation visit completed per physician signed orders and no documentation for reason or orders for why OT did not evaluate. Record review of Patient #7’s “Home Health Certification and Plan of Care” dated 10/09/2025 - 12/07/2025 revealed “Orders for Discipline and Treatment: Frequency: OT frequency 1 week 1: Evaluate and treat week of effective date: 10/09/2025.” Record review revealed no OT evaluation visit was completed per physician signed orders and no documentation for reasoning or orders for why OT did not evaluate. During an interview, findings were confirmed with Director of Healthcare Services (DHCS) A and Administrator B on 01/13/2026 at 11:10AM. When asked regarding the process for patients who require an OT evaluation, DHCS A replied, “They should be putting in a note and an order to the Medical Doctor (MD) if not needed.” DCHS A stated there is a process issue for OT orders and referrals and stated after the nurse’s initial assessment, they (the nurses) will click on what services are needed from the initial referral. Physical Therapy does an evaluation if still a need for OT. Findings include: Review of agency policy titled “Referral Intake/Acceptance to Service” dated 12/20/2024 revealed “Policy: Information is obtained from the referral source during the intake process to identify the referred individual’s needs. Procedure: 4. A designated employee reviews the information provided at intake and accepts the referral only if the agency’s scope of services provided can adequately meet the anticipated full needs of the prospective patient.” Review of agency policy titled “Developing a Plan to Meet Patient/Client Needs” dated 04/02/2021 revealed “Policy: The Plan of Care/Service Plan directs the delivery of care/service. Care/Services are furnished in accordance with standards of practice, law and regulation. Procedure: 4. The Director of Healthcare Services (DHCS)/Clinical Manager ensures that processes are in place to deliver only care/service that correlates to the plan of care/service plan...When Orders for Care/Service Required: Policy: Drugs, services, and treatments are administered only as ordered by the physician or allowed practioner. 8. The DHCS or designee documents any orders added or changed at the time the orders are received. a) Orders for skilled services added or changed are documented in a format defined by law and regulation.” Review of Patient #1’s record revealed a start of care date of 10/18/2025. The referral/order for admission to home care included an OT evaluation. There was no documented evidence that an OT evaluation was completed. Patient #1 then had resumption of care on 11/13/2025 following a hospitalization and resumption of care order included an OT evaluation. There was no documented evidence that an OT evaluation was completed. There was no documentation as to why these OT evaluations had not taken place. Review of Patient #3’s record revealed a start of care date of 12/29/2025. The referral/order for admission to home care included an OT evaluation. There was no documented evidence that an OT evaluation was completed. There was no documentation as to why the OT evaluation had not taken place.”

“Goals in the patient’s plans of care CFR(s): 484.110(a)(3) Goals in the patient’s plans of care and the patient’s progress toward achieving them; This Element is not met as evidenced by: Based on record review and interview, the agency failed to document patient progression toward agency established goals in the patient plan of care and/or clinical record in 3 of 5 eligible active patient records reviewed (Patients #1, #3, and #4) in a total of 7 patient records reviewed. Record review of Patient #4 (start of care 12/03/2025) skilled nursing visit notes 12/03/2025 to 01/12/2026 revealed no documented evidence of Patient #4’s progress towards goals. Under the “Goals/Progress Toward Goals/Plan for Next Visit”, the goals from the Plan of care dated 12/03/2025 were documented in this section with no documentation of progress towards Patient #4’s goals. During an interview on 01/13/2026 at 10:05AM, Director of Healthcare Services A stated, “At recertification, goals should be reviewed. Goals that should be met should be eliminated and continuing goals should be revised. The plan of care gets pulled into the visit. I agree when reviewing the notes, it’s hard to follow where they are going.” Findings include: Review of agency policy titled “Developing a Plan to Meet Patient/Client Needs” dated 04/02/2021 revealed “Procedure: The Director Healthcare Services/Clinical Manager ensures that processes are in place so that the designated employee has access to and is aware of current orders for the care/service provided to a patient/client and any subsequent revisions or additions to the plan of care/service plan.” Review of agency policy titled “Implementing the Plan of Care/Service” dated 04/02/2021 revealed “Documentation of Care/Service: 1. The employee completes documentation of care/service delivered in a approved standardized format by the end of visit.” Review of Patient #1’s record (recertification date of 12/17/2025 - 2/14/2026) skilled nursing visit notes from 12/17/20205 - 1/12/2026 revealed no documented evidence of Patient #1’s progress towards goals. Under the “Goals/Progress Toward Goals/Plan for Next Visit”, the goals from the Plan of care dated 12/17/2025 were documented in this section with no documentation of progress towards Patient #1’s goals. Review of Patient #3’s record (start of care date of 12/29/2025 - 2/26/2026) skilled nursing visit notes from 12/29/20205 - 1/12/2026 revealed no documented evidence of Patient #3’s progress towards goals. Under the “Goals/Progress Toward Goals/Plan for Next Visit”, the goals from the Plan of care dated 12/29/2025 were documented in this section with no documentation of progress towards Patient #3’s goals.”

“Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This Condition is not met as evidenced by: Based on record review and interview, the agency nurse failed to remain with the patient requiring medical intervention or EMS (Emergency Medical Services) in 1 of 6 patients reviewed (Patient #1). Findings include: Agency nurse failed to remain with the patient requiring medical intervention or EMS with a change in condition. See G 706. The cumulative effect of these systematic problems resulted in the home health agency’s inability to ensure the provision of quality health care in a safe environment having a potential effect on all 54 active home health patients.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on record review and interview, the agency nurse failed to notify the physician in changes in the patient condition in 1 of 6 patient records reviewed (Patient #1). Findings include: Review of agency policy titled “Medical Emergency” (dated 12/21/2021) revealed in part “Procedure: 2. If a clinician is present in the event of a medical emergency or they find the patient/client in a medical emergency in the location where the patient/client receives care/service, the following steps are taken: a) The clinician assesses the situation and the patient/client to determine the nature of the emergency. i) If the clinician judges the patient/client does not require immediate medical intervention (e.g., CPR-Cardiopulmonary Resuscitation), the clinician notifies the patient’s/client’s physician or allowed practitioner of the medical emergency.” Review of Patient #1’s home health record revealed Patient #1 was admitted to this home health agency on 02/27/2025 with primary diagnosis of Type 2 Diabetes Mellitus and other diagnoses of Acute osteomyelitis right ankle and foot and Type 2 Diabetes Mellitus with foot ulcers. Patient #1 had home health nursing 3 times per week for bilateral foot ulcers wound care. Patient #1 was transferred to an inpatient facility on 03/10/2025. Record review of Patient #1’s “Skilled Nurse Visit” note dated 03/10/2025 revealed “Poor balance, muscle weakness, unsteady gait, ambulates with device. Visit Narrative: Upon entering the home, patient was sleeping in recliner. Had a table next to the chair that was tipped over. Picked up the table and things on the floor. After finishing dressing change, patient wanted to get up. Used the lift chair to help him up, but he could not bear weight and was sliding out of the chair. Put the patient back in the chair with the footrest up. Family had called over a camera in the home. Advised them that patient was going to slide out of the chair and needed more assistance They stated to call 911. EMS (Emergency Medical Service) was called. Family stated they would try and get a hold of a neighbor to come over. EMS brought patient to the hospital.” There was no evidence that the physician was notified of the change in condition or that the home health agency office was notified, and no evidence EMS or the receiving hospital were given a report on Patient #1’s condition. Record review of Patient #1’s “Patient/Client Complaint Form” dated 03/10/2025 revealed under “Investigation: Communication Note 03/10/2025. Conclusion: Home Health RN (Registered Nurse) B felt patient was not in danger or displaying significant change in condition, but contacted family, neighbor, and EMS to help reposition patient in his chair.” During an interview with Director C on 04/14/2025 at 3:30 PM, when asked what the agency expectations are for staff providing care to a patient with a potential patient change in condition, Director C replied, “Staff are expected to call the office, or call the physician or nurse practitioner. There was no notification to the physician, supervisor or office or next receiving facility (referring to Patient #1).” During an interview with Assistant Director K on 04/15/2025 at 8:02 AM, when asked what the agency expectations are for staff providing care to a patient with a potential patient change in condition, Assistant Director K replied, “Notify the primary care provider and POA if one is activated.” During an interview with RN B on 04/15/2025 at 3:39 PM, when asked if there was notification to the physician regarding condition of Patient #1, RN B replied, “No. I didn’t realize it was a change in condition, just that the vitals were stable, but just couldn’t help get him up.””

“Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This Element is not met as evidenced by: Based on record review and interview, the agency nurse failed to meet patient needs by remaining with and assessing the patient with a potential change in condition in 1 of 6 patient records reviewed (Patient #1). Findings include: Review of agency policy titled “Medical Emergency” (dated 12/21/2021) revealed in part “Procedure: 2. If a clinician is present in the event of a medical emergency or they find the patient/client in a medical emergency in the location where the patient/client receives care/service, the following steps are taken: a) The clinician assesses the situation and the patient/client to determine the nature of the emergency. i) If the clinician judges the patient/client does not require immediate medical intervention (e.g., CPR-Cardiopulmonary Resuscitation), the clinician notifies the patient’s/client’s physician or allowed practitioner of the medical emergency. ii) If the clinician judges the patient/client does require immediate medical intervention (e.g., CPR), the clinician calls the EMS (Emergency Medical Services) and the employee remains with the patient/client until the emergency response team arrives.” Review of Patient #1’s home health record revealed Patient #1 was admitted to this home health agency on 02/27/2025 with primary diagnosis of Type 2 Diabetes Mellitus and other diagnoses of Acute osteomyelitis right ankle and foot and Type 2 Diabetes Mellitus with foot ulcers. Patient #1 had home health nursing 3 times per week for bilateral foot ulcers wound care. Per the home health record, “Patient #1 lived alone as well as had neighbors who check in on him. Patient spends most of day in recliner in the living room. He does his own ADLS (Activities of Daily Living) but should probably have help with it.” On 03/10/2025, it was reported by a receiving facility (hospital) that the patient was transferred to hospital with concern that the home health nurse left the patient alone during a home health visit with no report to the EMS or receiving facility. Record review of Patient #1’s “Skilled Nurse Visit” note documentation dated 03/10/2025 (date of transfer to inpatient facility) revealed bilateral foot ulcer wounds care completed with no complications, blood sugars and vital signs assessed as stable, and ambulatory status documented “Poor balance, muscle weakness, unsteady gait, ambulates with device. Visit Narrative: Upon entering the home, patient was sleeping in recliner. Had a table next to the chair that was tipped over. Picked up the table and things on the floor. After finishing dressing change, patient wanted to get up. Used the lift chair to help him up, but he could not bear weight and was sliding out of the chair. Put the patient back in the chair with the footrest up. Family had called over a camera in the home. Advised them that patient was going to slide out of the chair and needed more assistance They stated to call 911. EMS was called. Family stated they would try and get a hold of a neighbor to come over. EMS brought patient to the hospital.” The RN did not wait until EMS arrived and did not remain with Patient #1. Record review of Patient #1’s “Communication Note” on 03/10/2025 revealed in part, “Writer received a call from (hospital)…reported had some concerns about nurse that visited Patient #1 earlier in the day that had called EMS…Reported EMS reported that when EMS picked up Patient #1, he was alone and no one was with him to give patient update and they were also concerned he was left alone due to poor patient status.” Review of agency “Patient/Client Complaint Form” dated 03/10/2025 revealed “Conclusion: Home Health RN B felt patient was not in danger or displaying significant change in condition, but contacted family, neighbor, and EMS to help reposition patient in his chair.” During an interview with Director C on 04/14/2025 at 3:30 PM, when asked about Patient #1 and what the agency expectations are for staff when providing care for a patient with a potential change in condition, Director C replied, “The nurse should have stayed with the patient.” During an interview with Assistant Director K on 04/15/2025 at 8:02 AM, when asked about Patient #1 and what the agency expectations are for staff when providing care for a patient with a potential change in condition, Assistant Director K replied in part, “The nurse should be staying with the patient until EMS arrives, should do hand off to report off to EMS...RN B should have stayed with the patient.” During an interview with RN B on 04/15/2025 at 3:39 PM, when asked about Patient #1, RN B stated, “I didn’t notice a change in condition... When done (with wound care), the patient asked to help get up. Patient #1 started sliding and it wasn’t safe. I helped slide him back up in the chair. I wasn’t sure if he was a little weaker. While there, the family called. I answered as they have a video phone and told them the situation and needed help to get him up. Family said they would call a neighbor or they suggested to call 911. I called non-emergency EMS and family said if the nurse had to go to go and a neighbor would come. I called and talked to the EMS and they told me they didn’t know when they could get there. In hindsight I should have stayed but couldn’t wait there forever.””

“Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure staff were oriented and trained to medical emergency procedures in 1 of 5 personnel records reviewed (Registered Nurse B). Findings include: Review of agency policy titled “Medical Emergency” (dated 12/21/2021) revealed in part “Responsibility: The DHCS (Director Home Care Services) educates employees in the procedures for emergency intervention in the home. “ Review of personnel record for RN (Registered Nurse) B with date of hire 04/15/2024 revealed a document titled “Employee Caregiver Orientation Checklist” dated 09/03/2024 that included check boxes for each item completed. Under “Section: Patient Policies and Procedures: Care Delivery-Medical Emergency Procedures” the checkbox for completion was blank. During an interview with Assistant Director K on 04/15/2025 at 8:02 AM, when asked about staff training regarding medical changes in condition and involving calling EMS (Emergency Medical Services), Assistant Director K replied, “RN B admitted to having poor training. We went over what should have been done and was made aware that RN B should not have left.” When was asked if any additional training or follow up had been done formally for RN B since the incident on 03/10/2025, Assistant Director K replied, “No, not with me.” During an interview with RN B on 04/15/2025 at 3:39 PM, when asked about staff training regarding medical changes in condition of a patient and involving calling EMS, RN B replied in part, “Coming into home health was new to me. I got a week or two of shadowing then that’s pretty much it. Didn’t have much sit-down time. No, no training. Hence the reason why I didn’t know the situation and what to do.””