Gundersen St. Elizabeth's Home Care

The facility failed to develop and implement emergency preparedness policies and procedures that included a system to inform state and local emergency preparedness officials of the need for patient evacuations from their residences, during an emergency.

The home health agency (HHA) failed to ensure their communication plan included; a method for sharing protected health information and medical documentation with other providers; and release patient information as permitted under 45 CFR 164.510(b)(1)(ii).

The facility failed to ensure their communication plan included a means of providing information about the facility's occupancy needs, and its ability to provide assistance, to the authority having jurisdiction, to the Incident Command Center, or designee.

The agency failed to ensure each patient had an initial assessment visit within 48 hours of their referral date for 4 of 9 (P1, P6, P7 & P8) patients who received nursing services.

The agency failed to complete a comprehensive drug regimen review to ensure all medications/dosages were accurate for 2 of 3 patients (P4 and P5) reviewed during a home visit.

The agency failed to ensure medications were administered only as ordered by a physician for 1 of 9 patients (P5) who had nursing services.

The agency failed to ensure review the plan of care (POC) was reviewed by the physician every 60 days for 1 of 9 (P3 ) patients who received nursing services.

The agency failed to ensure supervisory visits of home health aides (HHAs) were completed every 14 days for 2 of 3 patients (P4 and P5) reviewed who received home health aide and skilled nursing services.