Every finding on record at Compassionate Care Hospice of Wisconsin, LLC

It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient's attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and associated conditions. This standard was not met as evidenced by a review of clinical records and interview. 3 of 6 (50%) clinical records reviewed revealed the agency did not ensure the plans of care included the specific care needs for each patient which were identified in the comprehensive assessments. Clinical Record 1: The patient elected the hospice benefit on 11/18/22 with a terminal diagnosis of End-Stage Renal Disease (ESRD). The initial comprehensive assessment, completed by the RN on 11/18/22, documented the patient had a "hemodialysis catheter to right upper chest CDI (clean, dry, intact)." The plan of care effective from 11/18/22 to the patient's death on 11/24/22 did not include any problems, goals or interventions related to the hemodialysis catheter. During the record review the DOO agreed that the plan of care should have stated something to related to the catheter "even if to say there was no dressing and not to touch it." Clinical Record 5: The patient elected the hospice benefit on 9/2/22 with a terminal diagnosis of malignant neoplasm of the colon. The initial comprehensive nursing assessment, completed on 9/2/22, documented the patient had a colostomy with ostomy bag present. The plan of care effective from 9/2/22 to present (11/29/22, the date of review) listed a nursing diagnosis problem (NDP) of "altered GI (gastrointestinal) status" without any goals or interventions to address the colostomy. The DOO was present during the record review and confirmed that the plan of care did not address the patient's needs related to the colostomy. Clinical Record 6: The patient elected the hospice benefit on 4/8/22 with a terminal diagnosis of Chronic Obstructive Pulmonary Disease (COPD): the diagnosis list also included "repeated falls." The initial comprehensive assessment completed by the RN on 4/8/22 documented a fall risk assessment that reported "3 or more falls in past 3 months," "balance problem while standing," "requires assistive device," and a total score of 11 which based on that score is "high risk" for falls. On 5/24/22 an occurrence report documented the patient fell out of bed. On 11/14/22 a nursing note documented patient was "unsteady and holding onto walls." The initial plan of care from 4/8/22 to the plan of care effective for the current benefit period (10/5/22-12/3/22) documented the patient was ambulatory and listed a rollator walker as an assistive device, however there were no problems, goals, or interventions related to safety or fall prevention. The DOO was present during the record review and agreed that the safety problem "should have been opened" along with specifics related to fall prevention strategies.

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 a review of clinical records and interviews. 1 of 5 (20%) clinical records reviewed, in which aide services were accepted, revealed that the agency did not ensure the registered nurse (RN) developed and updated the hospice aide care plan to include specific, individualized, patient care instructions. Clinical Record 4: The patient elected the hospice benefit on 4/5/22 with listed diagnoses of cerebral vascular disease and Alzheimer's disease. The hospice aide plan of care effective for the benefit period, 10/2/22 to 11/30/22, documented the aide visit frequency ordered for three (3) visits per week. The relevant assigned tasks included: "assist with sponge bath", "assist with shower", and "assist with bed bath", all to be performed "every visit"; these included a note that stated, "depending on patient request- if she wants bed bath or shower." The clinical record contained evidence that the patient was unable to make the decision: on 10/30/22 the RN narrative note reported "non-sensical speech", and the RN narrative note on 11/29/22 stated "confused and disoriented." The Director of Operations (DOO/Administrator) was present during the clinical record review and agreed that the patient was unable to direct the aide regarding what type of bath/shower to provide and stated, "We have been educating the nurses on making these more specific."

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. This standard was not met as evidenced by a review of clinical records and interview. 1 of 5 (20%) clinical records reviewed, in which the aide services were accepted, revealed the agency did not sure the hospice aides informed the registered nurse (RN) when changes in following the plan of care occurred. Clinical Record 4: The patient elected the hospice benefit on 4/5/22 with listed diagnoses of cerebral vascular disease and Alzheimer's disease; the patient resided in a skilled nursing facility. The hospice aide care plan orders, effective 10/2/22 to 11/30/22, listed several assigned tasks to be performed "every visit" with the aide visit frequency three (3) times per week. On the visit notes from 11/23/22 and 11/28/22 the aide documented multiple tasks (bed bath, shower, oral hygiene, feeding, and apply barrier cream) as not completed due to "patient/caregiver declined". The visit notes did contain a field "Any observations to report to RN" with a completed answer "Y" for yes. However, there is no documentation that specifically stated what observations were reported or if that included the care plan items that were not completed. The Director of Operations (DOO/Administrator) was present for the clinical record review and agreed that the record did not contain any documentation the RN was informed that the assigned tasks were not completed and stated, "I have been trying to get the aides to write a note about the communication to the RN" and agreed without any other documentation there was no way to determine what was reported to the RN. DOO confirmed that the expectation was for the aide to communicate tasks that were not completed to the RN. THIS IS A CONTINUING PRIOR REQUIRED ACTION at a significantly lower non-compliance threshold than previously cited (75%). CONTINUING PRIOR REQUIRED ACTION

It is required that the hospice assesses the skills and competencies of all individuals providing care. This standard was not met as evidenced by interview and review of personnel records. In 2 of 4 (50%) personnel records reviewed for individuals providing patient care, and hired after 2/16/22, revealed that the agency did not ensure that the skills and competencies were assessed.. Staff 3 - RN case manager, date of hire 6/13/22: The personnel record did not contain evidence of a skills and competency assessment. Staff 2 - RN case manager, date of hire 6/27/22: The personnel record did not contain evidence of a skills and competency assessment. During the 11/29/22 interview the director of operations (DOO) stated, "I had recently realized they didn't have them (competency checklist), so I had their manager go out with them on visits." The DOO further reported that the skills/competency checklists were not yet completed and thus were not available at the time of the site visit. THIS IS A CONTINUING PRIOR REQUIRED ACTION at a higher non-compliance rate than previously cited (29%) CONTINUING PRIOR REQUIRED ACTION

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 review of clinical records and interview. 1 of 6 (17%) applicable records for patients who accepted social work services revealed that the hospice social worker did not complete a comprehensive assessment related to the terminal illness in order to promote the patient's well-being within five calendar days after the patient elected the hospice benefit. Record #75012: Admitted on 04/06/2021, the patient accepted a social worker. There was no documented evidence on the Nurse Progress Initial Assessment dated 04/06/2021 that the RN discussed the psychosocial needs related to the terminal illness. The clinical record lacked evidence of follow-up telephone calls by the social worker. This finding was reviewed during an interview with the Director of Operations on 02/16/2022, who had the opportunity to review the clinical record and stated that the Social Worker did not complete an initial assessment and did not make any follow-up phone calls because the patient was readmitted.

It is required that a hospice aide provides services: ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by a review of clinical records, document review, and interview. 6 of 10 (60%) applicable records of patients that received hospice aide services, documentation on clinical notes revealed that an aide did not complete tasks as ordered by the interdisciplinary group. Record #51727: Patient admitted on 11/27/2021 diagnosis: Malignant Neoplasm of the Prostate. On 11/27/2021, the aide plan of care assigned shampoo patient's hair and shower on the first and last visit of the week. The aide visited on 12/06/2021, 12/07/2021, and 12/09/2021 there was no documentation of shampoo completed. Record #43246: Patient admitted on 11/12/2021 diagnosis: Malignant Neoplasm of the Prostate. On 11/12/2021, the aide plan of care assigned nail care and oral care every visit. The aide visited on 11/15/2021 did not document oral care, and nail care was performed. Record #78445: Patient admitted on 01/10/2022 diagnosis: Malignant Neoplasm of the Prostate. On 01/10/2022, the aide plan of care assigned bed bath, shampoo, and shave every visit. The aide visited on 01/18/2022, and no shampoo was performed. Record #78989: Patient admitted on 10/15/2021 diagnosis: CVA. On 10/15/2021, the aide plan of care assigned the aide to provide oral care and nail care every visit. The aide visited on 10/18/2021 and did not document that nail and oral care were completed. Record #75012: Patient admitted on 04/06/2021 diagnosis: ALS. On 04/06/2021, the aide plan of care assigned the aide to weekly nail care, shampoo, and denture care. The aide visited on 04/07/2021, did not document nail care, and completed oral care. Record #52250: Patient admitted on 10/18/2021 diagnosis: CVA. On 10/25/2021, the aide plan of care assigned the aide to provide nail care, shampoo, and oral care every visit. The aide visited on 10/25/2021 and did not document that nail care, shampoo, or oral care was completed. These findings were reviewed during an interview with the Director of Operations on 02/15/2022. She had an opportunity to review the records and stated that the aide did not follow the plans of care.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by a review of clinical records, document review, and interview. 6 of 8 (75%) applicable records of patients receiving hospice aide services revealed no documented evidence that the hospice aide reported changes to the RN that may impact the plan of care. Record #51727: Patient admitted on 11/27/2021 diagnosis: Malignant Neoplasm of the Prostate. On 11/27/2021, the aide plan of care assigned shampoo patient's hair and shower on the first and last visit of the week. The aide visited on 12/06/2021, 12/07/2021, and 12/09/2021, there was no documentation of shampoo completed or that she informed the RN about task not performed. Record #43246: Patient admitted on 11/12/2021 diagnosis: Malignant Neoplasm of the Prostate. On 11/12/2021, the aide plan of care assigned nail care and oral care every visit. The aide visited on 11/15/2021, did not perform oral care and nail care, and did not inform the RN about tasks not performed. Record #78445: Patient admitted on 01/10/2022 diagnosis: Malignant Neoplasm of the Prostate. On 01/10/2022, the aide plan of care assigned bed bath, shampoo, and shave every visit. The aide visited on 01/18/2022, no shampoo was performed, and she did not inform the RN about the task not performed. Record #78989: Patient admitted on 10/15/2021 diagnosis: CVA. On 10/15/2021, the aide plan of care assigned the aide to provide oral care and nail care every visit. The aide visited on 10/18/2021 and did not document that nail and oral care were completed or that she informed the RN about tasks not performed. . Record #75012: Patient admitted on 04/06/2021 diagnosis: ALS. On 04/06/2021, the aide plan of care assigned the aide to weekly nail care, shampoo, and denture care. The aide visited on 04/07/2021 and did not perform nail or oral care. She did not inform the RN about tasks not performed. Record #52250: Patient admitted on 10/18/2021 diagnosis: CVA. On 10/25/2021, the aide plan of care assigned the aide to provide nail care, shampoo, and oral care every visit. The aide visited on 10/25/2021 and did not perform nail care, shampoo, or oral care. She did not inform the RN about tasks not performed. These findings were reviewed during an interview with the Director of Operations on 02/15/2022. She had an opportunity to review the records. She indicated that the aide did not inform the RN of tasks not performed.

It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services, and, as necessary, provides in-service training and education programs where required. The hospice has written policies and procedures describing the method(s) of assessing competency and maintains a written description of the in-service training provided during the previous 12 months. This standard was not met as evidenced by personnel record review, document review, and interview. 2 of 7 (29%) records reviewed revealed no documented evidence of any or a complete competency evaluation upon hire or annually. Record #45641: Spiritual Counselor hired on 08/16/2021. Record #55630: Social Worker hired on 04/19/2021. Agency policy # HR-001A stated in part, "Personnel Files may include but not limited to the following documents as appropriate to job function(s) On- hire skills competency checklist VS only, Annual skills competency checklist VS only. (VS=Visiting Staff.) These findings were reviewed during an interview with the Director of Operations on 02/14/2022, who had an opportunity to review the employee files and confirmed that they were missing competencies and would complete the competencies to ensure compliance.

It is required that Hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF or ICF/IDF representatives. The hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met by a review of clinical records and interview. 1 of 1 (100%) record reviewed revealed the agency had failed to provide a plan of care with delineation form to meet the standard for individualized interventions and responsibilities that the hospice and SNF have agreed upon to provide medical direction and management of the patient in the facility's binder. [Record #78989]. These findings were reviewed during an interview with the Director of Operations on 02/15/2022. She identified the delineation form in their admission packet and indicated that they deliver the plans of care to the facility every two weeks. The Social Worker was present at the facility, validated a delineation form, and the patient's plan of care was missing on 02/14/2022 in the facility's binder.

It is required that the hospice obtains a criminal background check on all hospice employees who have direct patient contact or access to patient records. Hospice contracts require that all contracted employees who have direct patient contact or access to patient records obtain criminal background checks. Criminal background checks are obtained in accordance with state requirements. In the absence of state requirements, criminal background checks are obtained within three (3) months of the date of employment for all states in which the individual has lived or worked during the past three (3) years. This standard was not met as evidenced by review of employee records and interview. 1 of 8 (13%) employee records reviewed there was no documented evidence that a background check was obtained. Record #41699: RN, Director of Clinical Operations there is no documented evidence that a background check was completed upon hire on 06/09/2020. This finding was reviewed during an interview with the Director of Operations on 02/14/2022. she stated that they would complete a background check to ensure compliance.

Based on record review, and interview the agency failed to provide all patient rights to patients in 10 of 10 (#1-10) records reviewed. Findings include: Review of patient records #1-10 on 11/02/2021 revealed that the patient's right, to be free from restraints and seclusion, was not included on the agency's patient rights form. During an interview with Director of Office Operations (DOO) C on 11/02/2021 at 11:45 AM, DOO C confirmed that the information was not included on the agency's patient rights form and stated that it would be added.