Transitions Home Health of Central Wisconsin

This agency failed to ensure there is a comprehensive Emergency Preparedness Program, in 1 of 1 Emergency Programs reviewed.

This agency failed to develop, implement, evaluate, and maintain an effective ongoing home health agency wide data driven QAPI (Quality Assessment and Performance Improvement) program in 1 of 1 QAPI programs reviewed.

This agency failed to document the Emergency Plan risk assessment is reviewed and updated every two years in 1 of 1 Emergency Preparedness Programs reviewed.

This agency failed to ensure the Emergency Preparedness Policy and Procedures were reviewed and updated every two years in 1 of 1 Emergency Preparedness Plan reviewed.

This agency failed to ensure the Emergency Preparedness communication plan is reviewed and updated every two years in 1 of 1 Emergency Preparedness Plan reviewed.

This agency failed to ensure the Emergency Preparedness training and testing is reviewed and documented every two years in 1 of 1 Emergency Preparedness Plan reviewed.

This agency failed to conduct one full-scale community-based exercise every two years in 1 of 1 Emergency Preparedness Plan reviewed.

This agency failed to ensure a QAPI (Quality Assessment Performance Improvement) program that showed measurable improvements in quality indicators in 1 of 1 QAPI programs reviewed.

This agency failed to ensure a QAPI (Quality Assessment Performance Improvement) program that utilized quality indicator data, such as OASIS (Outcome and Assessment Information Set) in the design of its program in 1 of 1 QAPI programs reviewed.

This agency failed to ensure the QAPI (Quality Assessment Performance Improvement) program included performance improvement activities in 1 of 1 QAPI programs reviewed.

This agency failed to ensure the QAPI (Quality Assessment Performance Improvement) program conducted performance improvement projects in 1 of 1 QAPI programs reviewed.

This agency failed to ensure the QAPI (Quality Assessment Performance Improvement) program that had continued oversight by the Governing Body in 1 of 1 QAPI programs reviewed.

Agency staff failed to ensure patient medication orders were accurately recorded on the agency medication list as compared to what patients are taking in 2 of 3 home visits observed (Patients #3 and #6) in a total of 11 patient records reviewed.

Agency staff failed to develop Plans of Care (POC) that were individualized to meet the specific needs of the patients and/or develop goals that were measurable within a specified timeframe and/or individualized in 7 of 11 patients (Patients #1, #2, #5, #6, #8, #9, and #11) records reviewed.

This agency failed to ensure the QAPI (Quality Assessment Performance Improvement) program focused on high risk, high volume, or problem-prone areas in 1 of 1 QAPI programs reviewed.

This agency failed to ensure a QAPI (Quality Assessment Performance Improvement) program included incidence, prevalence, and severity of problems in 1 of 1 QAPI programs reviewed.

This agency failed to ensure a QAPI (Quality Assessment Performance Improvement) program measured success and tracked performance to ensure sustainability in 1 of 1 QAPI programs reviewed.

The agency failed to ascertain that the secondary location as different from the parent location in which patient care was provided out of, was identified as a branch, subunit or drop-site location in 1 of 1 Home Health agency's reviewed.