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

It is required that each patient’s individualized written plan of care reflects patient and family goals; 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 and interview. In 2 of 19 (11%) clinical records reviewed, the agency did not ensure that the patient's plan of care included patient and family goals based on interventions and problems identified in the comprehensive assessments. CLINICAL RECORD 3: The patient elected hospice care on 12/23/2025 with a diagnosis of neoplasm of the right and left lungs. The patient’s plan of care was updated on 04/16/2026 to include interventions for the patient’s identified problem with “Comfort”: "SN-Administer analgesics as prescribed, monitoring for efficacy and side effects. SN-Educate family about proper pain management at home, including dosing schedules and signs that indicate a need to re-evaluate medication plans. SN-Monitor for non-verbal pain indicators like grimacing or restlessness." The POC documented the goal "Potential for pain related to neoplasm and interventions." The plan of care did not reflect a patient or family goal for the identified problem of “comfort.” Additionally, the patient’s plan of care was updated 05/01/2026 to include interventions for the patient’s identified problem with "Quality of Life:" "SN-Involve family members in visits as available so they can remind pt of what instructions were given. Write all important information discussed at visits down for pt to look back at." The POC documented the goal as "Memory Assistance." The POC interventions for "Quality of Life" documented "SN-Involve family members in visits as available so they can remind pt of what instructions were given. Write all important information discussed at visits down for pt to look back at." The goal for "Quality of Life" was documented as "Memory Assistance." The plan of care did not reflect a patient or family goal for the identified quality-of-life problem. CLINICAL RECORD 6: The patient elected hospice care on 03/27/2026 with a diagnosis of senile degeneration of the brain. The skilled nursing assessment dated 04/19/2026 documented that the patient had a fall resulting in a skin tear: "Skin tear to rt elbow. Site cleansed, skin approximated, 3 steri strips applied, covered with dressing as pt is picking at elbow." The plans of care effective 03/27/2026 through 06/24/2026 did not include documentation of the patient or family goal for the identified problem and interventions to address the patient's skin tear/skin integrity. During a joint record review and an interview on 05/20/2026, the Area Executive of Clinical Operations/Administrator (Personnel Record 5) confirmed that the individualized plan of care for clinical records 3 and 6 did not include patient and family goals based on identified problems and planned interventions.

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 and procedure #HOS-C_12A "Supervision of Hospice Aides and LP/VN Colleagues" (reviewed 12/31/2024) stated in part, "The RN is responsible to perform a supervisory visit of the LPN/LVN at least every 30 days." In 2 of 13 (15%) clinical records reviewed for patients who received Licensed Practical Nurse (LPN) visits, the agency did not ensure that a Registered Nurse (RN) supervised the LPN services, as per agency policy. CLINICAL RECORD 1: The patient elected hospice care on 03/11/2025 with a diagnosis of senile degeneration of the brain. The hospice recertification plans of care dated 01/15/2026 through 03/15/2026, 03/16/2026 through 05/04/2025, and 05/05/2026 through 07/03/2026 ordered skilled nursing (SN) services once (1) weekly. The LPN visits began on 01/22/2026 and continued through the benefit periods reviewed (most recent LPN visit 05/07/2026). A Licensed Practical Nurse (LPN) supervisory visit was completed by the RN on 02/12/2026. A clinical record review revealed no evidence that LPN supervisory visits were completed every 30 days per agency policy between 02/12/2025 and the date of the last documented LPN visit (84 days outstanding). CLINICAL RECORD 18: The patient elected hospice care on 06/06/2025 with a diagnosis of heart failure. The hospice certification and plan of care dated 06/06/2025 through 09/03/2025 and the hospice recertification plan of care dated 09/04/2025 through 12/02/2025 ordered skilled nursing (SN) services once (1) weekly beginning 06/06/2025. The LPN visits began on 06/23/2025 and continued through benefit periods 1 and 2. The RN completed the LPN supervisory visits on 07/16/2025, 08/14/2025, and 10/16/2025. A clinical record review revealed no evidence that LPN supervisory visits were completed every 30 days per agency policy between 08/14/2025 and 10/16/2025 (63 days outstanding). During a joint record review and interview on 05/20/2026, the Area Executive of Clinical Operations/Administrator confirmed that LPN supervisory visits were not completed at least every 30 days, per agency policy. DHS_131.25(4)(a)2 Nursing services shall be provided by or under the supervision of a registered nurse and shall consist of all of the following: Supervising and teaching other nursing personnel, including licensed practical nurses, nurse aides.

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 and Procedure #HOS-C_12A "Supervision of Hospice Aides and LP/VN Colleagues" (reviewed 12/31/2024) read in part, " At every scheduled visit, the RN is responsible to evaluate the care provided by the hospice aide (if one is assigned); it is required that the supervision be completed not less than every 14 days but it can be completed more frequently." In 1 of 14 (7%) 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 18: The patient elected hospice care on 06/06/2025 with a diagnosis of heart failure. The plan of care dated 06/05/2025 through 09/03/2026 ordered HA services two (2) times weekly beginning the week of 03/08/2026. The HA visits were provided as ordered. The HA supervisory visits were documented as completed on 07/21/2025 and 08/14/2025 (24 days outstanding). In a joint record review and interview on 05/20/2026, the Area Executive of Clinical Operations/Administrator confirmed that HA supervisory visits were not completed every 14 days per agency policy. DHS_131.26(2)(c)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."

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. This standard was not met as evidenced by document review, interview, and personnel record review. Agency policy #HOS-C20 "Volunteer Services" (reviewed 03/19/2026) read in part, "Maintain a personnel file for volunteers which contains, at minimum, .... evidence of competency evaluation at start of role and annually...." In 1 of 12 (8%) personnel records reviewed, the agency did not ensure that the hospice assessed the skills and competencies of all individuals providing care, including volunteers. PERSONNEL RECORD 11: The Volunteer was hired on 08/06/2025. A personnel record review with the Volunteer Coordinator (Personnel Record 9) on 05/18/2026 revealed no evidence of a competency evaluation at the start of the role, per agency policy. During an interview and joint personnel record review on 05/18/2026, the Area Executive of Clinical Operations/Administrator (Personnel Record 5) confirmed that the volunteer's personnel record (Personnel Record 11) did not include a competency at the start of the role, per agency policy. During the joint personnel record review on 05/18/2026, the Volunteer Coordinator (Personnel Record 9) confirmed the findings and stated in part, "This was identified with our internal mock survey. I have it completed on the ones just brought on (onboarded May 2026)." DHS_131.31(5) "Continuous training. A program of continuing training directed at maintenance of appropriate skill levels shall be provided for all hospice employees providing services to patients and their families."

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: physician orders. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy and procedure #C_15B "Wound and Impaired Skin Integrity Management" (review date: 04/16/2026) read in part, "If a new skin impairment is identified, obtain orders for care from the patient's physician." In 1 of 19 (5%) clinical records reviewed, the agency did not ensure the patient's clinical record contained physician orders for the care and services provided. CLINICAL RECORD 6: The patient elected hospice care on 03/27/2026 with a diagnosis of senile degeneration of the brain. The skilled nursing assessment dated 04/19/2026 documented that the patient had a fall resulting in a skin tear: "Skin tear to rt elbow. Site cleansed, skin approximated, 3 steri strips applied, covered with dressing as pt is picking at elbow." A clinical record review revealed no evidence that a physician order was obtained for the wound care provided. In a joint record review and interview on 05/20/2026, the Area Executive of Clinical Operations/Administrator (Personnel Record 5) confirmed that clinical record 6 did not include a physician order for the wound care provided. DHS_131.33(3)(j) "Content. A patient's clinical record shall contain all of the following: Physician orders."

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. In 1 of 19 (5%) clinical records reviewed it was revealed that the agency did not ensure that all members of the Interdisciplinary Group completed their initial comprehensive assessment within 5 calendar days after the patient elected their hospice benefit. Clinical Record 16: The patient elected the hospice benefit on 5/15/2023 and the first documented Social Work visit was dated as completed on 5/22/2023, which was seven days after the date the patient elected their benefit. There was no documentation present that described the reason for the delay in making the first visit. In an interview with the Area Director of Quality Outcomes on 7/11/2023, it was confirmed that there was no initial Social Work assessment documented as completed within the 5-day timeframe, nor could any documentation be located to address the reason for the delay in the initial assessment. It was also reported that a new QAPI Performance Improvement project for "Timely Initial Psychosocial Assessments" was identified and initiated by the hospice on 5/29/2023.

Each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness. This standard was not met as evidenced by clinical record review and interview. 5 of 19 (26%) clinical records reviewed, the hospice did not ensure that the patients' plans of care included orders for all services necessary to meet the patients' needs. Clinical Record 5: The patient elected the hospice benefit on 8/23/2022. The LPN visit note dated 11/2/2023 documented the placement of a 16 French suprapubic catheter. There was no documentation of specific orders for suprapubic catheter insertion on the initial plan of care dated 8/23/2022 and the recertification plan of care dated 11/8/2022. Clinical Record 17: The patient elected the hospice benefit on 5/15/2023. The Registered Nurse (RN) visit note dated 5/28/2023 documented the administration of an enema. The plans of care for the period of 5/15/23 - 8/12/23 did not include documentation of orders for administration of an enema, and there was no documented evidence of interim orders obtained. Clinical Record 19: The patient elected the hospice benefit on 7/3/2021. The RN visit notes dated 4/28/2023 and 6/10/2023 and the Licensed Practical Nurse (LPN) visit notes dated 5/12/2023 and 6/16/2023 documented that the patient/family reported the patient's issues with constipation and requested an enema. The visit notes for the RN and the LPN documented the administration of an enema during each visit. There was no documented evidence of orders obtained for the administration of an enema. Clinical Record 9: The patient elected the hospice benefit on 3/28/2023. The RN visit note dated 4/6/2023 documented that the patient fell and hit their head on the floor with a resulting skin tear to the left forehead. The RN visit note dated 4/24/2023 documented a MAHC 10 Fall Risk Assessment score of 7, which put the patient at risk for further falls, and the 5/13/2023 nursing visit note documented that the patient was assessed as unsteady on their feet. There was no evidence that the patient's plan of care and/or IDG notes dated 4/11/23, 4/25/23, 5/9/23, 5/23/23, 6/6/23, 6/20/23, and 7/3/23 were updated to include documentation of problems, goals, and interventions to address the patient's safety and fall prevention. Clinical Record 14: The patient elected the hospice benefit on 1/11/2023. The PRN RN visit note dated 5/19/2023 documented that the patient experienced an episode during the shower in the morning and felt like she was going to fall, reporting intermittent dizziness and moments "where it feels as if the floor is moving." The RN visit note dated 6/1/2023 documented the patient was experiencing increased weakness in bilateral lower extremities and the nurse assessed the patient's MAHC 10 score at 6, which put the patient at risk of falling. There was no evidence that the patient's plan of care and/or IDG notes dated 5/23/23, 6/6/23, 6/20/23, and 7/3/23 were updated to include documentation of problems, goals, and interventions to address the patient's safety and fall prevention. During ongoing interviews and record reviews with the Area Director of Quality Outcomes on 7/10/2023, 7/11/2023, and 7/12/2023, it was confirmed that the patients' Plans of Care and IDG notes were not consistently revised to include documentation to address newly identified patient problems.

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. In 1 of 18 (5%) clinical records reviewed in which Hospice Aide services were provided, the hospice did not ensure that the Registered Nurse provided specific written instructions for the aide to follow. Clinical Record 13: The patient elected the hospice benefit on 12/9/2022 and resided in a long-term care facility. The patient had an Aspire drain placed, and the drain dressing was changed during nursing visits. The Aide Plan of Care dated 4/14/2023 did not include documentation of instructions or precautions for the aide to follow regarding the Aspire drain and dressing. During an interview and clinical record review on 7/12/2023, the Director of Quality Outcomes/Interim Director of Clinical Services confirmed that no direct instruction was provided to the Aide by the RN regarding the patient's Aspire drain.

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 clinical record review and interview. In 1 of 18 (6%) clinical records reviewed in which hospice aide services were accepted, the hospice did not ensure that the Hospice Aide provided all visits as ordered on the plan of care. Clinical Record 10: The patient elected the hospice benefit on 2/24/2023. On 4/12/2023, the physician ordered Hospice Aide visits once a week and the recertification plan of care dated 5/23/2023 ordered continued Hospice Aide visits once a week. A review of the clinical record revealed no Hospice Aide visits were completed for the weeks of 4/16/2023 and 4/30/2023. There was no evidence that orders for aide visit frequency were changed. During an interview and a joint record review on 7/12/2023 and 7/13/2023, the Director of Quality Outcomes/Interim Director of Clinical Services confirmed that there was an active order for this patient to receive Hospice Aide visits once a week and that during the weeks of 4/16/2023 and 4/30/2023, there were no aide visits documented as completed.

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, ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s needs. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 5 of 18 (27%) clinical records reviewed of patients who received hospice aide services, the hospice did not ensure that the Registered Nurse (RN) documented supervision of the Hospice Aide at least every 14 days. Clinical Record 7: The patient elected the hospice benefit on 2/8/2023 and the initial plan of care dated 2/8/2023 ordered Hospice Aide visits to be provided three (3) times a week. The Interdisciplinary Group (IDG) meetings notes dated 4/11/2023 through 6/20/2023 ordered continued Hospice Aide visits three (3) times a week. The Registered Nurse (RN) documented supervision of the Hospice Aide on 4/28/2023 and aide visits were documented as completed during the period of 5/1/2023 through 6/7/2023. The RN documented supervision of the Hospice Aide on 6/8/2023, which was 27 days, or 13 days past due, from the date of the end of the COVID-19 public health emergency on 5/11/2023, which ended the hospice aide supervisory visit waiver. Clinical Record 10: The patient elected the hospice benefit on 2/24/2023 and the Hospice Recertification Plan of Care Update on 5/23/2023 continued Hospice Aide visits once a week. The RN documented completion of aide supervisory visits on 5/24/2023 and 6/12/2023, which resulted in a time frame of 19 days between supervisory visits, or 5 days past due. Clinical Record 12: The patient elected the hospice benefit on 12/14/2022. The Hospice Recertification Plan of Care Update dated 2/28/2023 set the Hospice Aide visit frequency at twice a week and aide visits continued to be ordered through the Recertification Plan of Care Update dated 6/6/2023. Aide supervisory visits were documented as completed on 4/24/2023 and 5/11/2023, which was a span of 17 days between supervisory visits, or 3 days past due. Also, the RN documented aide supervisory visits completed on 5/30/2023 and 6/14/2023, which resulted in a 15-day timeframe between the visits, or 1 day past due. Clinical Record 15: The patient elected the hospice benefit on 2/15/2023. The Recertification Plans of Care dated 4/11/2023 and 6/6/2023 set the Hospice Aide visit frequency at once a week until a Physician Order dated 6/20/2023 increased the Aide visit frequency to twice weekly. Aide supervisory visits were documented as completed on 4/3/2023 and 4/19/2023, which was a 16-day time frame between supervisory visits, or 2 days past due. Clinical Record 18: The patient elected the hospice benefit on 4/7/2023. The initial Hospice Plan of Care dated 4/7/2023 set the Hospice Aide visit frequency at 3 times a week and the Recertification Plan of Care updated on 5/23/2023 continued the aide visits at the same frequency. Aide supervisory visits were documented as completed by the RN on 5/2/2023 and 5/19/2023, and on 5/30/2023 and 6/14/2023, which was a period of 17 days and 15 days, respectively, between supervisory visits, or 3 days and 1 day past due. During interviews with the Area Director of Clinical Outcomes on 7/12/2023 and 7/132023, it was confirmed that the records revealed aide supervisory visits were not completed at least every 14 days by the RN. It was reported that a new QAPI Performance Improvement Project for Hospice Aide Supervision was by the agency and the project was initiated on 6/14/2023. However, there has been insufficient time since the project's initiation to determine the effectiveness of the action and its sustainability.