Every finding on record at Bristol Hospice Madison

Based on record review and interview, the agency staff failed to ensure that the volunteer level of activity equaled at least 5 percent of the total patient care hours of paid hospice staff for the past year in 1 of 1 volunteer program reviewed. --- Findings include:Review of the hospice's volunteer program revealed an average level of volunteer activity at 2.6 percent in the last 12 months.During an interview conducted on 09/15/2025 at 1:42 PM with Volunteer Coordinator C, C stated that their volunteer numbers dip down drastically in the summer due to there not being as many college students during that time of the year.

It is required that each patient’s individualized written plan of care: identifies planned interventions based on problems identified in the initial and updated comprehensive assessments; includes all services necessary for the palliation and management of the terminal illness, including the following: intervention to manage pain and symptoms; measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by a review of clinical records, document review and interviews. In 7 of 11 (64%) records reviewed it was revealed that there was no evidence of individualized planned interventions or measurable outcomes documented. There was no evidence that the interventions for, specifically, the nutrition and hydration needs had been individualized for patient needs. In the electronic medical record system used by agency it states in the nutrition section of the comprehensive assessment "If the patient's nutritional status and total risk score is 6 or above, Nutrition care plan is needed." It also states, "What nutritional interventions are indicated for this patient?" All of the following clinical records identified a high risk score for nutritional need: Clinical Record 10: This patient's start of care (SOC) was 7/22/22 with a diagnosis of Malignant Neoplasm of urinary organ. This patient had a nutritional risk assessment score of 8. It was documented on on the initial comprehensive assessment that a social work assessment was made for nutritional concerns. There was no documented evidence that the social worker followed up for this specific concern. There was no evidence of any measurable outcomes related to nutrition in the patient's care plan. Clinical Record 9: This patient's SOC was 7/26/22 with a diagnosis of Senile Degeneration of Brain. This patient had a nutritional risk assessment score of 8. A nutrition/hydration care plan was documented in the plan of care, however there was no evidence of individualized interventions or measurable outcomes. A social work referral was documented; no evidence was found that the social worker followed up specifically for this need. Clinical Record 7: This patient's SOC was 8/22/22 with a diagnosis of Other Noninflammatory disorders of ovary and fallopian tube. This patient had a nutritional risk assessment score of 10. There was no evidence that a nutrition/hydration care plan was added to the initial plan of care on 8/22/22 or on the updated plan of care dated 9/1/22. There was documentation present on the initial assessment that a social work referral was made for nutrition risk; there was no documented evidence that the social worker followed up for this specific need. Clinical Record 6: The patient's SOC was 9/9/22 with a diagnosis of Senile Degeneration of Brain. This patient had a nutritional risk assessment score of 13. There was a nutrition/hydration care plan added to plan of care, but no interventions attached. A universal statement "Skilled Observation & Assessment of nutrition/hydration" was listed. There was no evidence of individualized interventions or measurable outcomes. The question that was asked, what nutritional interventions are indicated for this patient, the answer was social work referral and weight monitoring. No specific documentation was found of what social work referral was for. There was no evidence documented that the referral was made or that the social worker followed up. Clinical Record 5: The patient's SOC was 8/23/22 with a diagnosis of COPD. This patient had a nutritional risk assessment score of 10. There was no evidence of a nutrition/hydration care plan being added to plan of care. Clinical Record 1: This patient's SOC was 7/26/22 with a diagnosis of Senile Degeneration of Brain. This patient had a nutritional risk assessment score of 6. The needed intervention documented was a social work referral. There was no evidence of other planned interventions documented. No measurable outcomes were documented. There was no evidence that a social work referral had been made or that social worker had followed up on the specific identified need. Clinical Record 4: This patient's SOC was 7/15/22 with a diagnosis of COPD. This patient had a nutritional risk assessment score of 13. No documented evidence was found to support that the patient had any individualized interventions or measurable outcomes on the plan of care. A social work referral was made for nutrition, however no documented evidence was found that social work followed up on this specific need. It is required by standards that each patient have an individualized plan of care. In review of clinical records there was no evidence that the interventions for specifically the nutrition and hydration needs had been individualized for patient needs. In the electronic medical record system used by agency it states in the nutrition section of the comprehensive assessment "if the patient's nutritional status and total risk score is 6 or above, Nutrition care plan is needed." It also states, "What nutritional interventions are indicated for this patient?" All of the following clinical records identified a high risk score for nutritional need,

It is required that the hospice’s policies and procedures define a system of communication and integration that sustains coordination of services and provides documentation of exchange of information. The policies and procedures ensure that: sharing of information occurs and is ongoing with other non-hospice healthcare providers providing services unrelated to the terminal illness and related conditions. This standard was not met as evidenced by a review of clinical records, and observation on home visits. 3 of 3 (100%) visits to patients residing in Assisted Living Facilities (ALF) revealed that there were no updated plans of care for hospice patient residents. There was no evidence the the IDG (interdisciplinary group) team had placed updated plans of care or verbally updated the facility staff on changes to the plans of care made at IDG meetings. Home Visit 3/Clinical Record 2: This patient was admitted on 8/12/22. There was no evidence of an initial or updated plan of care in the patient's communication binder in the facility. There were copies of the RN's initial assessment and hospice aide visits only in the binder. Home Visit 1/Clinical Record 4: The facility's patient communication binder did not evidence an updated plan of care. The initial plan of care, established on 7/15/22, was present in the binder, however there were changes made to the plan of care on 8/18/22 and 9/1/22; these changes were not updated in patient's facility binder. Home Visit 2/Clinical Record 9: In the patient information and update binder there was no evidence of an updated plan of care. The patient's Start of Care was 7/26/22; the initial plan of care was present in the binder. There were changes made to plan of care on 8/18/22; there was not an updated plan of care placed in facility binder at the time of the update or to the date of review. Upon visits to Assisted Living Facility there was no evidence the the IDG team had placed an updated plan of care or verbally updated the facility staff on changes to the Plan of Care made at interdisciplinary group meetings.