Every finding on record at Bristol Hospice - Green Bay, LLC

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current: prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; [and] other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: the effectiveness of drug therapy; drug side effects; actual or potential drug interactions; duplicate drug therapy; [and] drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and as appropriate, preventive measures are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met, as evidenced by clinical record review, document review, and interview. Agency policy #1-014 "Comprehensive Assessment" (reviewed 05/2020) stated in part, "During the comprehensive patient assessment... Review of current and related past medications, including prescription over-the-counter medications, supplements, herbal remedies, alternative treatments, allergy history, and other medication information." Agency policy #2-004 "Medication Profile" (reviewed 09/2024) stated in part, "The medication profiles will be updated for each change to reflect current medications, and new and/or discontinued medications. A drug regimen review will be performed at the time of initial and comprehensive assessment, when updates to the comprehensive assessments are performed, when care is resumed after a patient has been placed on hold, and with the addition of new medication." In 2 of 19 (11%) clinical records reviewed, the agency did not ensure that the comprehensive assessment included a drug profile that contained the patient's current prescription and OTC drugs. Clinical Record 16: The patient elected hospice care on 09/26/2024 with a diagnosis of chronic obstructive pulmonary disease (COPD). The comprehensive nursing assessment completed by the skilled nurse (SN) on 09/26/2024 documented, "She is requiring use of supplemental oxygen at 2l/min." The interdisciplinary group (IDG) meeting log dated 09/27/2024 documented "supplemental oxygen at 2l/m." The hospice medication profile did not document the oxygen noted in the clinical note or the IDG meeting log. Clinical Record 18: The patient elected hospice care on 04/27/2024 with a diagnosis of hypertensive heart disease with heart failure. The SN visit note dated 07/31/2024 documented, "O2 Flow Rate-2LPM via NC, discussed using oxygen when he's up and moving around." The IDG meeting log dated 08/02/2024 documented, "Looking very SOB. I asked if he'd put his oxygen on so I could maybe get an oxygen saturation reading on him." The hospice medication profile did not document the oxygen noted in the clinical note or the IDG meeting log. During a joint record review and interview on 02/27/2025, the Executive Director/Administrator confirmed that oxygen was not documented on the medication profiles for clinical records 16 and 18.

It is required that each patient’s individualized written plan of care reflects patient, and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #9-017, "The Plan of Care" (reviewed 09/2024), stated in part, "A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. This plan will focus on identified problems, goals, and interventions." In 5 of 19 (26%) clinical records reviewed, the agency did not ensure that the patient’s plan of care reflected patient and family goals and identified planned interventions based on problems identified in the initial and comprehensive assessments. Clinical Record 5: The patient elected hospice care on 05/17/2024 with the diagnoses of hypertensive heart and chronic kidney disease with heart failure. The comprehensive assessment completed by the skilled nurse (SN) on 05/17/2024 documented, "She has had 2 falls since March r/t her wanting to keep her independence, MAHC 10 score of 6." The plan of care dated 05/17/2024 through 08/14/2024 and the IDT (Interdisciplinary Team) meeting logs dated 05/24/2024 through the review date did not include planned interventions and patient and family goals for the patient's identified fall risk. Clinical Record 9: The patient elected hospice care on 10/26/2024 with a diagnosis of Alzheimer's disease with late-onset. The on-call/as-needed SN visit dated 01/30/2025, due to a change in the patient's respiratory status, documented, "Lung sounds revealed slight inspiratory wheezes in the left upper lobe and right lower lobe. Continuing patient education on coughing and deep breathing exercises to promote lung expansion and prevent respiratory infections." The plan of care dated 01/24/2025 through 04/23/2025 and the IDT meeting logs dated 01/31/2025 and 02/14/2025 did not include planned interventions and patient and family goals for the patient's identified respiratory change in condition. Clinical Record 11: The patient elected hospice care on 11/15/2024 with a diagnosis of malignant neoplasm of the ascending colon. The on-call/as-needed SN visits dated 12/08/2024, 01/08/2025, and 02/06/2025 documented follow-up to patient falls. The plan of care dated 11/15/2024 through 02/12/2025 and the IDT meeting logs dated 12/31/2024 through 02/18/2025 (last IDT meeting) did not include planned interventions and patient and family goals for the patient's identified problem with falls. Clinical Record 13: The patient elected hospice care on 01/12/2025 with a diagnosis of emphysema. The comprehensive assessment completed by the SN on 01/12/2025 documented, "Patient struggles with pain in her neck, back, and legs, stating it is continuous and sharp. She experiences pain with fevers and SOB, rated 9/10." The plan of care dated 01/12/2025 through 03/12/2025 and the IDT meeting logs dated 01/21/2025 and 02/18/2025 did not document patient and family goals for the identified pain problem. Clinical Record 15: The patient elected hospice care on 05/10/2024 with a diagnosis of hypertensive heart and chronic kidney disease with heart failure. The comprehensive assessment completed by the SN on 05/10/2024 documented, "Patient c/o dull, right-sided, abdominal pain r/t tumor rated 6/10." The plan of care dated 05/10/2024 through 08/07/2024 and the IDT meeting logs dated 05/24/2024 and 07/05/2024 did not document patient and family goals for the identified pain problem. During a joint record review and an interview on 02/27/2025, the Executive Director/Administrator confirmed that clinical record 5 did not include patient and family goals and planned interventions for fall risk, clinical record 9 did not document patient and family goals and planned interventions for respiratory problems, clinical record 11 did not document patient and family goals and planned interventions for fall risk, clinical record 13 did not document patient and family goals for pain, and clinical record 15 did not document patient and family goals for pain.

It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. This standard was not met, as evidenced by clinical record review, document review, and interview. Agency policy #1-037 “Hospice Aide Supervisory Visits” (reviewed 11/ 2021 stated in part, “The frequency of supervisory visits will be based upon the needs of the patient after the plan of care is established. They must be conducted no less frequently than every 14 days.” In 2 of 18 (11%) clinical records reviewed of patients who received Hospice Aide (HA) services, the agency did not ensure that a Registered Nurse (RN) made an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the HA. Clinical Record 11: The patient elected hospice care on 11/15/2024 with a diagnosis of malignant neoplasm of the ascending colon. The plan of care dated 11/15/2024 through 02/12/2025 ordered HA services twice (2) weekly beginning 11/19/2024. The HA visits were provided as ordered, beginning 11/19/2024. The HA supervisory visit was provided on 12/18/2024, with 15 days outstanding. Clinical Record 15: The patient elected hospice care on 05/10/2024 with the diagnoses of hypertensive heart and chronic kidney disease with heart failure. The plan of care dated 05/10/2024 through 08/07/2024 ordered HA services twice (2) weekly beginning 05/13/2024. The HA visits were provided as ordered, beginning 05/15/2024. The HA supervisory visit was provided on 06/21/2024, with 23 days outstanding. In a joint record review and interview on 02/22/2025, the Executive Director/Administrator confirmed that, per agency policy, HA supervisory visits were not completed every 14 days.

It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services are: noted in the plan of care. This standard was not met, as evidenced by clinical record review, document review, and interview. Agency policy #9-024 "Volunteer Services" (review 01/2023) stated in part, "To ensure that qualified volunteers provide appropriate services in accordance with the plan of care and hospice program needs. The Volunteer Coordinator will arrange for volunteers to provide volunteer support to patient and family/caregiver in accordance with the plan of care." In 1 of 2 (50%) clinical records reviewed of patients with identified volunteer needs who accepted volunteer services, the agency did not ensure that volunteer services were provided and noted in the plan of care based on the patient's needs as identified in the comprehensive assessment. Clinical Record 6: The patient elected hospice care on 11/05/2024 with a diagnosis of senile degeneration of the brain. The comprehensive assessment completed by the skilled nurse on 11/05/2024 documented, "HCA Accepted Hospice Clergy, Accepted MSW, Accepted Volunteer Accepted for companionship." A clinical record review revealed no evidence that the volunteer services were provided, a follow-up assessment was completed, or a care plan was initiated to address volunteer needs. During the joint record review and interview on 02/27/2025, the Executive Director/Administrator confirmed that the clinical record did not include evidence that volunteer services were implemented based on needs identified in the comprehensive assessment.

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. Agency policy #9-024 Volunteer Services review date: January 2023 read in part "The Volunteer Coordinator will track the use of volunteers, the cost savings achieved, and that the hours of volunteer services will meet or exceed 5% of the total patient care hours of paid and contracted hospice personnel." The hospice agency did not ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The "Volunteer Coordinator" report for 02/25/2024 through 02/25/2025 was reviewed with the Executive Director on 02/28/2025. The Executive Director confirmed that 3% of volunteers provided day-to-day administrative and/or direct patient care services from 02/25/2024 through 02/25/2025, less than the required 5%. During an interview on 02/27/2025, the Executive Director/Administrator confirmed that volunteer utilization was below the 5% requirement for 02/25/2024-02/25/2025 and stated, in part, "Our volunteer coordinator is focusing on recruitment." During an interview on 02/28/2025, the Volunteer Coordinator confirmed that volunteer utilization was below the requirement of 5% for 02/25/2024-02/25/2025 and stated in part, "The focus is recruitment. I have two (2) active volunteers, and I'm in the process of onboarding four (4) additional volunteers." The hospice agency did not ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff.

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. 2 of 9 (22%) records failed to document all elements of the comprehensive assessment within 5 calendar days; specifically the spiritual assessment. Record #37043: The election of the hospice benefit was 04/13/2022. The spiritual assessment was completed 04/20/2022. No reason was documented for the delayed assessment (7 days from the election of the benefit). Record #30561: The election of the hospice benefit was 01/25/2022. The spiritual assessment was not completed as of the patient's death on 02/04/2022. There was no reason documented for the assessment not being completed or a declination of the chaplain. The social worker did document contact with the patient's pastor who visited the patient while on service. The administrator, on interview, stated that the one patient did refuse the chaplain but agreed it was not documented.

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including the following: Measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by review of clinical records, document review and interview. 9 of 9 (100%) records failed to document individualized, measurable goals for all disciplines provided. Agency Policy 9-017 [revised May 2020] states in part, "The written plan of care will contain, but will not be limited to, the following: Measurable outcomes anticipated from implementing and coordinating the plan of care." The following goals are not measurable for the patients receiving care: Record #30515: Spiritual goal: "Spiritual healing will be met." Record #54285: Skilled Nursing goal: "Early detection and intervention for signs/symptoms of complication of disease process within certification. (the patient has dementia, hypertension and kidney disease); Spiritual goal: "Patient/Family spiritual needs will be met within certification."; Medical Social Worker goal: "Social/emotional problems will be resolved within certification." Record #37042: Social Work goal: "Decreased feeling of anxiety. Decrease family conflict/strengthen family support."; Spiritual goal: "Patient/family spiritual needs will be met."; Skilled Nursing goal: "Early detection and intervention for signs/symptoms of disease process." (the patient is chair-bound, with Huntington's disease, frequent wounds and falls). Record #94785: Social Work goal: "Client wishes will be followed." Record #74417: Social Work goal: "Increase Coping. Social/Emotional problem resolved. Decrease family conflict/strengthen family support."; Spiritual goal: "Patient/family spiritual needs will be met."; Skilled Nursing goal: "Patient will establish regular elimination pattern. Early detection and intervention for signs/symptoms of disease process." (the patient has Down's Syndrome, heart failure, senile dementia). Record #30561: Social Work goal: "Client wishes will be followed." Record #89169: Spiritual goal: "Patient family spiritual goals will be met." Social Work goal: "Expression of grief by end of certification." Record #39709: Skilled Nursing goal: "Early detection and intervention for signs/symptoms complications of disease process." (the patient has Parkinson's, constipation, incontinence and choking).; Social Work goal: "Decreased feelings of anxiety." (the patient has a great deal of difficulty communicating verbally). Record #76963: Skilled Nursing goal: "Early detection and intervention for signs/symptoms complication of disease process.: (the patient has senile dementia, kidney disease and heart disease); Spiritual goal: "Patient/family spiritual needs will be met."; Social Work goal: "Social/emotional problem will be resolved. Will be engaged in a therapeutic relationship." The Director of Clinical Services, on interview, stated that goals and care plans were recently identified as a "need area".

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as: Hand hygiene. This standard was not met as evidenced by observation during home visits on 05/09/2022, document review and interview. 3 of 3 (100%) visits revealed the agency's policy for hand hygiene was not followed. Agency Policy 7-016 "Bag Technique" [revised May 2020] states in part, "The bag will be placed on a surface protected by a clean moisture resistant protective barrier in the patient's residence. Reusable equipment will be cleaned using alcohol, soap and water, or other appropriate solution, hands will be washed, and equipment and supplies will be returned to the bag. Hands will be decontaminated prior to returning clean equipment to bag." Record #37043: During the observed nursing visit: on 5/9/2022 at 11:00am, the patient assessment was conducted, equipment was cleaned and returned to the nursing bag. Hand hygiene was not completed prior to returning the equipment to the bag. Additionally the bag was re-entered to obtain dressing supplies without hand sanitization. Record #39709: During the observed chaplain visit on 5/9/2022 at 10:30 am, the chaplain offered the patient music with phone, then a devotion for which a book was retrieved from the visit bag with no hand sanitization. During the visit, the chaplain's hand was placed on the patient's arm, the devotion book was returned to the visit bag and a phone retrieved from the visit bag with no hand sanitization. There was no barrier under the bag. Record #74417: During the observed nursing visit on 5/9/2022 at 11:30am, the patient assessment was conducted, equipment was cleaned and returned to the nursing bag. Hand hygiene was not completed prior to returning the equipment to the bag. The nurse, on interview, stated, "I did go back into my bag for the dressings; I realized it." The chaplain stated his/her hands were sanitized when exiting the patient's room.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review, and interview. 7 of 8 (88%) records of patients who accepted hospice aide services revealed a lack of clear and specific written instruction for the aide assignment, thus leaving the aide(s) to make decisions outside of the aide's scope of practice. Record #30515: The patient was admitted 04/05/2022 with a hospice aide plan assignment of tasks not limited to: perform catheter care, empty catheter bag, record bowel movement; these assigned tasks include no frequency for expected care. Record #54285: The patient was admitted 03/24/2022 with a hospice aide plan assignment of tasks not limited to: partial/complete bath and perineal care; these tasks include no frequency for expected care. Record #37043: The patient was admitted 04/13/2022 with a hospice aide plan assignment of tasks not limited to: change adult brief; this task included no frequency for expected care. Record #74417: The patient was admitted 01/22/2022 with a hospice aide plan assignment of tasks not limited to: bed bath (there was no frequency documented) and updated 02/07/2022 for a partial complete bath with no frequency of expected care. Record #89169: The patient was admitted 02/02/2022 with a hospice aide plan assignment of tasks not limited to, change adult brief; this task included no frequency of the task to be performed. Record #39709: The patient was admitted 02/01/2021 with a hospice aide plan assignment of tasks not limited to: shave, perineal care, bed bath, date of last bowel movement and transfer with 2 people; these tasks included no frequency to be performed. The nursing documentation on the record visit notes, stated that the patient transfer was with a "sit-to-stand with 2 people". The nurse did update the hospice aide plan of care to include a sit-to-stand transfer and a frequency to be performed on the date of review, 05/10/2022. Record #76063: The patient was admitted 04/01/2022 with a hospice aide plan assignment of tasks not limited to: bath of choice. The patient had senile dementia and was not able to make a safe choice. The case manager and hospice aide, on interviews, stated that the aide provided all tasks each visit. The hospice aide stated, "I provide all the care and I call the nurse or we do the care together often, if a bath is refused I document that and I tell the nurse." Review of the hospice aide notes did confirm tasks were completed each visit. There was no policy or documented process located to evidence that the intent for tasks to be performed was every visit; that was the care provided.

It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services provided to patients/families are in a defined role and under the supervision of a designated hospice employee. Volunteer services are: Noted in the plan of care. This standard was not met as evidenced by review of clinical records and interview. 2 of 4 (50%) records of patients who accepted volunteer services revealed the service was not documented as provided or the reason not provided. Record #54285: Volunteer need was documented 04/06/2022 on a nursing visit note in the clinical record, and that the volunteer coordinator was notified. There were no documented volunteer services provided as of the patient's death on 05/01/2022. Record #39709: Volunteer need was documented 04/28/2022 on social work visit note in the clinical record, and that the volunteer coordinator was notified. There were no documented volunteer services provided as of the date of review 05/09/2022. The volunteer coordinator, on interview, stated that the previous volunteer coordinator is no longer at the agency and the role began 04/30/2022 with a volunteer who had provided care to other patients but documentation of the volunteer need for these patients was not located. The current volunteer coordinator did call the patient's family to confirm the need for volunteer and determine needs during the site visit.

It is required that when controlled medications are first ordered, a copy of the hospice’s written policies and procedures for the management and disposal of controlled medications is provided to the patient or family or patient’s legal representative(s). The Interdisciplinary Group: Documents in the patient record that the policies and procedures for managing and disposing of controlled medications is provided and discussed. This standard was not met as evidenced by review of clinical records, document review and interview. 1 of 4 (25%) records of patients who died revealed no documented evidence that the disposal of controlled medications was discussed. Agency Policy 2-008 "Home Use and Disposal of Controlled Substances" [revised November 2021] states in part, "The hospice nurse, social worker, or chaplain attending the death of a hospice patient will inform the family/caregiver of their responsibility to dispose of all the patient's prescribed medications and will document this instruction in a clinical note. The disposal will be documented in the clinical record." Record #30561: The documented nursing visit note (death note dated 02/04/2022) addressed death and notification of the team but there was no documented instruction of medication disposal. The patient was a resident at an assisted living facility. The patient had medications not limited to lorazepam 0.5mg and morphine 20mg/ml. The administrator, on interview, stated the facility did dispose of the medications as they have a very strict policy at the facility.