Every finding on record at Compassus Aah of Wisconsin I, LLC

It is required that the hospice provides nursing care under the supervision of a registered nurse. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #C_12A "Supervision of Hospice Aides and LP/VN Colleagues" (dated 08/18/2022) read in part, "The registered nurse is responsible to perform a supervisory visit of the LPN/LVN at least every 30 days." In 2 of 19 (11%) clinical records reviewed, the agency did not ensure that Licensed Practical Nurses (LPN) were supervised by a Registered Nurse (RN) at least every 30 days per the agency policy. Clinical Record 3: The patient elected the hospice benefit on 06/30/2023. The plans of care dated 06/30/2023-09/27/2023 and 09/28/2023-12/25/2023 ordered skilled nursing (SN) "SN 1x/week." A clinical record review revealed skilled nursing visits performed by a LPN dated 07/21/2023, 11/01/2023, and 11/15/2023. The first LPN supervisory visit was dated 11/22/2023, with 64 days outstanding. Clinical Record 10: The patient elected the hospice benefit on 12/30/2023. The plans of care dated 03/29/2024-06/26/2024, 06/27/2024-08/25/2024, and 08/26/2024-10/24/2024 ordered "SN 1x/week." A clinical record review revealed skilled nursing visits performed by a LPN dated 04/09/2024, 04/25/2024, 07/19/2024, 08/07/2024, 09/10/2024, and 09/25/2024. The first LPN supervisory visit was dated 10/02/2024, with 146 days outstanding. During a joint record review on 01/07/2025, the Director of Clinical Services confirmed that the LPN supervisory visits were completed less frequently than every 30 days.

It is required that a hospice aide provides services: ordered by the Interdisciplinary Group; included in the plan of care; permitted to be performed under state law and regulation; [and] consistent with the hospice aide training. This standard was not met as evidenced by clinical record review and interview. In 4 of 14 (29%) clinical records reviewed of patients with Hospice Aide services, the agency did not ensure that aide services were provided as written in the plan of care. Clinical Record 4: The patient elected the hospice benefit on 12/23/2024. The plan of care dated 12/23/2024-03/21/2025 ordered "Aide 2x per week." The Hospice Aide (HA) care plan dated 12/23/2024 assigned the Hospice Aide the relevant task: "Weigh patient at first visit of the month." The first HA visit for January 2025 was dated 01/03/2025. The HA visit note dated 01/03/2025 did not include documentation of the patient being weighed. Clinical Record 8: The patient elected the hospice benefit on 11/01/2024. The plan of care dated 11/01/2024-01/29/2025 ordered "Aide 2x per week." The HA care plan dated 11/01/2024 assigned the HA the relevant task: "Weigh patient at first visit of the month." A clinical record review revealed no evidence of the patient being weighed during HA visits. Clinical Record 12: The patient elected the hospice benefit on 06/26/2024. The plans of care dated 06/26/2024-09/23/2024 and 09/24/2024-12/22/2024 ordered "Aide 2x per week." The HA care plan dated 06/26/2024 assigned the HA the relevant task: "Weigh patient at first visit of the month." The first HA visit for September 2024 was dated 09/03/2024. The HA visit note dated 09/03/2024 did not include documentation of the patient being weighed. The first HA visit for October 2024 was dated 10/02/2024. The HA visit note dated 10/02/2024 did not include documentation of the patient being weighed. The first HA visit for December 2024 was dated 12/02/2024. The HA visit note dated 12/02/2024 did not include documentation of the patient being weighed. Clinical Record 13: The patient elected the hospice benefit on 11/09/2024. The plan of care dated 11/09/2024-02/06/2025 ordered "Aide 1x per week." The HA care plan dated 11/14/2024 assigned the HA the relevant task: "Weigh patient at first visit of the month." The first HA visit for December 2024 was dated 12/05/2024. The HA visit note dated 12/05/2024 did not include documentation of the patient being weighed. During a joint record review on 01/07/2025, the Director of Clinical Services confirmed that the HA did not document the patients' weight as written in the HA care plan. State regulations: "DHS 131.26, Nurse aide services. The hospice may provide nurse aide services as follows: (a) Assignment. Nurse aides are assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group. Written patient care instructions for a nurse aide shall be prepared by a registered nurse who is responsible for the supervision of a nurse aide as specified under par. (c)."

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] ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed of patients who received Hospice Aide (HA) services, the agency did not ensure that HA supervisory visits were completed no less frequently than every 14 days. Clinical Record 3: The patient elected the hospice benefit on 06/30/2023. The plan of care dated 06/24/2024-08/22/2024 and 08/23/2024-10/21/2024 ordered "Aide 2x/week." A clinical record review revealed a HA supervisory visit dated 08/06/2024. The next HA supervisory visit was dated 09/10/2024, with 35 days outstanding. Clinical Record 10: The patient elected the hospice benefit on 12/30/2023. The plans of care dated 03/29/2024-06/26/2024 and 08/26/2024-10/24/2024 ordered "Aide 2x/week." A Hospice Aide supervisory visit was documented on 04/02/2024. The next HA supervisory visit was documented on 04/17/2024, with 15 days outstanding. A Hospice Aide supervisory visit was documented on 10/02/2024. The next HA supervisory visit was documented on 10/17/2024, with 15 days outstanding. During a joint record on 01/07/2025, the Director of Clinical Services confirmed that HA supervisory visits were not completed less frequently than every 14 days. State Regulations: "DHS 131.26 Non-core services. (2) Nurse Aide Services. The hospice may provide nurse aide services as follows:(c) Supervision of nurse aides.1. A registered nurse shall make 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 nurse aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient’s needs. The nurse aide does not have to be present during this visit."

Based on record review and interview, the agency failed to ensure core nursing needs of patients and/or caregivers were met in 1 of 4 patients (Patient #1) requiring on-call services in a total of 10 patient records reviewed. --- Findings include: 1. The agency failed to ensure nursing staff addressed the needs of the patient and/or caregiver on an as-needed basis (on-call). See L591.

Based on record review and interview, the agency failed to ensure nursing staff addressed the needs of the patients and/or caregivers on an as needed basis (on-call) in 1 of 4 patients requiring on-call services (Patient #1) in a total of 10 patient records reviewed. --- Findings include: Review of agency policy titled ";On-Call Services" dated 07/21/2022 revealed in part, ";Purpose: To ensure timely and appropriate intervention is provided by trained professional staff as needed by patients, families and facility-based caregivers during non-business hours and ensure compliance with 42 CFR 418.100 regarding availability of services on a 24-hour/day, 7-day/week basis. On-Call Requirements: 1. Availability: a. The on-call RN (Registered Nurse) is available to respond to all calls received from the beginning to the end of the on-call shift. Available means ready to perform an admission, make a visit, and/or assume the response to afterhours needs. c. All calls are addressed and the response documented in the clinical record via the EMR (Electronic Medical Record). 2. Response: a. The expectation from our patients is a compassionate, professional response to a perceived concern or need, regardless of when the concern or need is expressed. The Compassus on-call nurse is expected to respond as quickly as possible to requests for after-hours support, including visits when indicated. 4. Care Delivery: Calls received during non-business hours indicate a need for patient/family/caregiver reassurance in some fashion...When a call is routed to the on-call nurse, the first duty is to determine whether the nurse should provide on-site nursing assessment or care for the hospice patient. In the following situations, a visit is necessary to establish a baseline for care plan management: ii. The patient has a change in condition including escalation of pain or other symptoms associated with their disease process or the terminal trajectory of dying. v. The patients caregiver requests a visit for support. vi. If the patient or caregiver calls more than 1 times in an after-hours shift, a visit is made to provide in-person support, assessment, and reassurance. 5. Documentation: a. All interactions with the patient/family/facility caregivers are documented according to standard clinical record requirements. Coordination notes are completed for phone calls and visit notes are completed at the time of any visit." Review of Patient #1s hospice record revealed Patient #1 was admitted to Compassus Hospice on 07/24/2023 with primary diagnosis of Malignant Neoplasm of colon, unspecified. Patient #1 passed away 04/25/2024 at home on hospice services. Review of this agencys ";On-Call Log" and associated documentation from 02/25/2024 to 04/25/2024 for Patient #1 revealed, in part: 03/02/2024 On-Call Log: ";8:07 PM: Call from Complainant A. Stated she needs to know how to get stoma swelling to go down. Please call." There was no documented evidence of a phone call or visit made by the SN (Skilled Nurse) on 03/02/2024 that addressed the patient needs related to the stoma. A SN visit was not made until 03/05/2024 at 12:42 PM. 04/19/2024 On-Call Log: ";7:41 PM: Call from Complainant A. Have not been updated on who is supposed to be visiting patient today or who is coming to change patients colostomy bag as the site is currently bleeding. Please call as soon as possible." There was no documented evidence of a phone call or visit made by the SN on 04/19/2024 that addressed the patient needs related to issues with colostomy bag. A SN visit was not made until 04/23/2024 at 9:46 AM. 04/22/2024 On-Call Log: ";8:58 PM: Call from Complainant A. Patient is very aggressive and agitated. Morphine and Lorazepam is not working. Patient needs a medication change. Per caller, patients regular nurse Nurse D is a constant no show and no call." 04/22/2024: Medication order entered for Seroquel for mood/sleep. There was no documented evidence of a phone call or visit made by the SN on 04/22/2024 to assess Patient #1's change in condition and assess effectiveness with change in medication. A SN visit was not made until 4/23/2024 at 9:46 AM. 04/24/2024 On-Call Log: ";8:10 PM: Call from Complainant A. Patient has the death rattle and caller is requesting a nurse...to come out" 04/24/2024: Medication order entered for Atropine eye drops for excessive secretions. There was no documented evidence of a phone call or visit made by the SN on 04/24/2024 to assess the needs of the patient/caregiver. A SN visit was not made until 4/25/2024 at 9:28 AM. During an interview with DCS (Director of Clinical Services) B on 06/10/2024 at 2:35 PM, when asked for the Case Coordination notes for the dates of 04/19/2024 and 04/22/2024, DCS B replied, ";Those last dates noted with the death rattle and medication issues, I couldnt find a case coordination note for those." During an interview with DCS B and ACO (Area Executive Clinical Operations) C on 06/10/2024 at 3:20 PM, when asked what the agencys process and expectations are for nurse on-call visit or patient calls taken after hours with concerns or requesting a visit, ACO C replied, ";We triage the best we can and may remedy or teach over the phone before going and making a visit. With terminal congestion or pain then we may make a visit." When asked about on-call log SN documentation for Patient #1 on 03/02/2024 not addressing concerns about the stoma, DCS B replied, ";The only thing is that it might not have been brought up when the nurse took the call." When asked about on-call log SN documentation for Patient #1 on 04/19/2024 not addressing concerns about who was coming to see the patient and to change Patient #1s colostomy bag, DCS B replied, ";Theres no coordination note. The on-call nurse called me (DCS B) to discuss the call. It was the nurses first time on-call but did not document and no, a visit was not made." When asked about on-call log SN documentation for Patient #1 on 04/22/2024 not addressing concerns about patient change in condition, ACO C replied, ";With the change in condition, I would have expected a visit or at least a follow-up phone call to see if the medication changes were effective." When asked about on-call log SN documentation for Patient #1 on 04/24/2024 not addressing concerns about death rattle and request for a nurse, ACO C replied, ";The scheduled daily visit was made the next morning. My assumption is the nurse would have seen a visit was scheduled the next day and discussed with Complainant A if a visit was needed." DCS B added, ";There is no documentation of case coordination for this call. No, a visit was not made until the next day."

It is required that each patient’s individualized written plan of care (POC) 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. 4 of 13 (31%) records revealed the hospice did not ensure that individualized Plans of Care, which included interventions and goals, were written for each patient. Record #51119: On the Certification of Terminal Illness document(CTI) dated 1/11/22 for the certification period 1/22/22 --> 3/22/22, the physician narrative stated the patient had a foley catheter. The Plan of Care dated 1/11/22 for the same certification period lacked a goal and interventions for the foley catheter. Record #45630: On the CTI dated 1/4/22 for the certification period 1/4/22 --> 4/2/22, the physician narrative stated the patient had a foley catheter. The POC dated 1/4/22 for the same certification period lacked a goal and interventions for the foley catheter. Record #86212: The Chaplain completed the initial evaluation on 1/17/22. The POC dated 1/19/22 for the certification period 1/14/22 --> 4/13/22 lacked evidence of goals and interventions for the Chaplain. Record #59346: On the CTI dated 1/19/22 for the certification period 1/20/22 --> 3/20/22, the physician narrative stated the patient is newly contracted, lays in bed in the fetal position, now using a Hoyer lift, and incontinent of bowel and bladder. The POC dated 1/19/22 for the same certification period lacked goals and interventions for skin integrity, Hoyer lift, and bowel and bladder incontinence. The Procedure C09A (Revised 1/20/20), "Individualized Plan of Care" states, "PLAN OF CARE - the plan of care is the complete treatment plan that provides the pathway for the hospice IDG to follow in providing care that is based on the initial and comprehensive assessments of the patient by all of the members of the IDG team." During an interview at the exit conference on Friday 2/25/22, the Director of Clinical Services reviewed and agreed with the above findings.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care (POC). This standard was not met as evidenced by clinical record review, document review, and interview. 2 of 9 (22%) records reviewed that had hospice aide services revealed the hospice aide lacked providing services as ordered on the hospice aide Plan of Care (POC). Record #86421: The RN ordered a weekly weight on the hospice aide POC dated 1/10/22. On the hospice aide visit notes dated 2/24/22, 2/22/22, 2/17/22, 2/15/22, the hospice aide documented, "Weight not required this visit". Record #74716: The RN ordered a monthly weight on the hospice aide POC dated 8/10/21. On the hospice aide visit notes, over one month, dated: 1/24/22, 1/31/22, 2/3/22, 2/7/22, 2/10/22, 2/14/22, 2/22/22, and 2/24/22, the hospice aide documented, "Weight not required this visit". Policy C21 (Revised 9/10/21), "Hospice Aide and Homemaker Services" states, "The specific activities of the hospice aide are written by the RN for each patient and the hospice aide follows the assigned activities in the delivery of care and services to the patient." During an interview at the exit conference on Friday 2/25/22, the Director of Clinical Services reviewed and agreed with the above findings.

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid/MediCal-certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary described in HCDT 41. I, and the patient’s record, if requested. This standard was not met as evidenced by clinical record review, document review and interview. 2 of 2 (100%) records reviewed of patients that either transferred to another hospice or transferred/discharged to the hospital and revoked the hospice benefit to pursue aggressive treatment, revealed the agency failed to forward a discharge summary to the receiving facility. Record #30236: The patient request to change the designated hospice provider form was completed and signed on 12/15/21. The record lacked evidence of the discharge summary being sent to the receiving hospice. Record #81875: The patient was transferred to the hospital on 12/10/21 via ambulance per a communication note, and the patient revoked the hospice benefit to pursue aggressive treatment. The record lacked evidence of the discharge summary being sent to the hospital. Policy #C04 (Revised on 8/19/19), "Discharge/Transfer/Revocation" states, "Transfer - Agency will provide a discharge summary to the receiving hospice containing: 1) Treatments, symptoms and pain management information; 2) Current plan of care; 3) Latest physician orders, and 4) Other documentation facilitating continuity of care and/or requested by the attending physician or receiving facility. Revocation - Agency will provide a discharge summary to the attending physician or receiving facility containing: 1) Treatments, symptoms, and pain management information; 2) Current plan of care; 3) Latest physician orders, and 4) Other documentation facilitating continuity of care and/or requested by the attending physician or receiving facility." During an interview at the exit conference on Friday 2/25/22, the Director of Clinical Services reviewed and agreed with the above findings.

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 as evidenced by clinical record review and document review. 1 of 1 (100%) record reviewed for a patient receiving routine hospice care in a Skilled Nursing Facility (SNF) revealed the hospice failed to delineate which provider is responsible for care and services included in the plan of care. Record #86421: The patient observation visit was completed on 2/24/22. The hospice binder and the SNF binder for this patient lacked documentation of delineation of care and services in the plan of care. Policy #C25 (Revised 5/14/18), "Professional Management" states, "B - Coordination of Care and Services - patients who reside in a SNF/NF or ICF/IID facility: A delineation of agency responsibilities which include (but are not limited to): providing medical direction and management of the patient; nursing; counseling; social work; provisions of medical supplies, DME, and medications according to the plan of care which are necessary for the palliation of pain and other symptoms; and all other services necessary for the patient's care; provision of bereavement support/services to staff of the facility." During an interview on Thursday 2/24/22, while doing a joint clinical record review, the Director of Clinical Services reviewed and agreed the patient record lacked evidence of a copy of the delineation of service form or documentation of delineation of services. This finding was also confirmed by the Director of Clinical Services during an interview at the exit conference on Friday 2/25/22.

Based on record review and interview, the agency failed to meet the nursing needs individualized to patient and/or family caregiver in 1 of 8 patients requiring on-call nursing service needs (Patient #5) in a total of 10 patient records reviewed. Findings include: Review of agency admission booklet titled "Care for Who I Am: Patient and Family Admission Guide for Hospice Care" revealed information provided to patients and family and included topics such as: Call Us First brochure with toll free number, Compassus magnet with toll free numbers, after hours services expectation. Review of admission booklet revealed "A nurse is available for all patients 24 hours a day, 365 days a year. Calls received after office hours, on weekends and on holidays may be received by our answering services. The after hours hospice nurse will return your call within 15 minutes. Our nurse will return your call and determine your need and how best to handle this need. If your need cannot be addressed over the phone, a visit will be arranged." Review of agency policy and procedure titled "On Call Services" dated 05/31/2019 revealed "Procedure: 1. Each program location maintains an answering service available to field phone calls for the location and provide a written record of all calls received into the service. 2. Each program location designates a primary on-call nurse and a back up nurse to ensure redundancy for potential overlap of care needs. 4. Each program location designates an administrative leader who is on call to provide leadership or operational support for the on-call nurse. On-Call Requirements: 1. Availability: a. The on-call RN (Registered Nurse) is available to respond to all calls received from the beginning to the end of the on-call shift. In the event the RN cannot be available due to a patient care need, the RN notifies the back up nurse and/or administrator on call for support. b. The answering service will utilize the primary cell phone number of the on-call nurse as a first notification. 2. Response: a The on-call nurse is expected to respond as quickly as possible to requests for after hour support, including visits when indicated. The nurse must use professional judgment and triage philosophies to determine the type of response needed. b. If the nurse will be delayed in responding to a call or request for a visit, the nurse communicates to the back up nurse or the administrator on-call to revise the response plan and then communicates with the patient/family caregiver the new plan. 4. Care Delivery (On My Way): a. Calls received during non-business hours indicate a need for patient/family/caregiver reassurance in some fashion. Compassus delivers hospice care 24 hours/day, 7 days/week. In the following situations, a visit is necessary to establish baseline for care plan management: ii. The patient has a change in condition including escalation of pain or other symptoms associated with their disease process or the terminal trajectory of dying; iv. The patient is reported as not breathing or suspected to have died by the caregiver, regardless of the location of death; v. The patient's caregiver requests a visit for support; vi. If the patient or caregiver calls more than one time in an after hours shift, a visit is made to provide in-person support, assessment and reassurance." During an interview on 10/18/2021 at 1:45 PM with Area Executive Clinical Operations C, when asked about expectation of staff on-call and the response time to talk with patient/family and make a visit if needed, B replied in part "Call for patient passing, try to get to the patient within an hour, but different factors can be, based on location or if nurse with another patient. The call can be patched right to the nurse on-call depending on need or message can be taken by the call service to get to the nurse on-call." Record review for Patient #5 revealed patient admitted to hospice agency 10/07/2021 with Severe Protein-Calorie Malnutrition with terminal diagnosis and comfort measures. Review of Patient #5's "Hospice Certification and Plan of Care" with start of care date 10/07/2021 revealed plan of care orders for 3x (times) per week for 1 week. Review of nurse visit notes for week of 10/07/2021 revealed nurse visits were made on 10/07/2021 and 10/09/2021. No nurse visit was made on 10/08/2021. Review of agency call log for Patient #5 dated 10/08/2021 revealed "8:45 PM Call from the answering service requesting to call patient daughter about increased secretions." Education regarding medications use and symptom management with verbalization of patient daughter understanding. Patient daughter was instructed to call back if further concerns. On 10/09/2021 at 11:53 AM, patient daughter called back for symptoms of patient passing with timely nurse response and "Hospice Death at Home" nurse visit. During an interview on 10/19/2021 at 1:25 PM with Director of Clinical Services B, when asked about the missing scheduled nurse visit on 10/08/2021 for Patient #5, B replied "No visit was made on 10/08/2021 as it was scheduled incorrectly and was not caught until Monday." During an interview on 10/19/2021 at 1:30 PM with Director of Quality Outcomes D, when asked about the expectations regarding the on-call phone call on 10/08/2021 for Patient #5, D replied "The House of Dove triage nurse took the call. While did notify the nurse the next day of the call, did not triage out and send a nurse. House of Dove is our inpatient unit helping with on-call calls and helping us due to staffing issues. Unfortunately this was missed, a visit should have been warranted as our Compassus motto is 'I am on my way.'"