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

Hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG in collaboration with the attending physician (if any), the patient or patient representative if any of them so desire, and the primary caregiver in accordance with the patient’s needs if any of them so desire. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed of patients with documented wounds, the agency did not ensure that the hospice care provided followed the individualized plan of care established by the hospice IDG in collaboration with the attending physician. Clinical Record 7: The patient elected the hospice benefit on 10/11/2024. The Registered Nurse (RN) visit note dated 10/11/2024 documented that the patient had a stage 2 pressure ulcer to the buttocks. An order for wound care documented, "Cleanse with soap and water, cover with border foam, using sterile technique. Dressing to be changed 3x per week by caregiver or RN. Hospice RN to measure weekly." The initial comprehensive assessment dated 10/11/2024 did not document a wound assessment and measurements. The RN documented "wound care not provided due to caregiver completed care." The RN assessment dated 10/12/2024 did not document a wound assessment and measurements. The RN documented "no wound care provided due to caregiver completed." On 10/14/2024, the RN documented "provided decubitus care per orders. Dressing removed and large adhesive bandage placed due to bordered foam not being the right size." No measurements were documented. The RN assessment dated 10/23/2024 did not document wound measurements or wound care provided. During an interview on 01/22/2025, the Clinical Director stated that the RN did not follow the order for wound care that was written by the physician. Clinical Record 8: The patient elected the hospice benefit on 12/23/2024. The initial assessment completed by the RN dated 12/23/2024 documented that the patient had a "left heel diabetic ulcer (L)2x(W)2.5x(D)0.5, surface area 5, depth description full thick, shape round, edges rolled." On 12/23/2024, the physician ordered wound care for the patient's left heel: "irrigate with normal saline, pat dry, apply mupirocin ointment, cover with abd pad, and wrap with ace wrap. Hospice nurse to assess and take measurements weekly." The RN visit notes dated 01/02/2025 and 01/07/2025 did not document a wound assessment and measurements. The RN documented that the wound was healed on 01/14/2025. During an interview on 01/22/2025, the Clinical Director agreed that the RN did not follow orders written by the physician or the plan of care developed by the IDG team. State regulation: "Subchapter III — Patient Care" DHS 131.21 Plan of care. (1) General requirements. A written plan of care shall be established and maintained for each patient admitted to the hospice program and the patient’s family. The hospice plan of care is a document that describes both the palliative and supportive care to be provided by the hospice to the patient and the patient’s family, as well as the manner by which the hospice will provide that care. The care provided to the patient and the patient’s family shall be in accordance with the plan of care."

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 clinical record review and interview. In 2 of 2 (100%) clinical records reviewed of patients with wounds, the agency did not ensure that the patient's plan of care included measurable outcomes anticipated from implementing and coordinating the plan of care. Clinical Record 7: The patient elected the hospice benefit on 10/11/2024. The RN visit note dated 10/11/2024 documented that the patient had a stage 2 pressure ulcer to the buttocks. The physician ordered wound care, "cleanse with soap and water, cover with border foam, using sterile technique. Dressing to be changed 3x per week by caregiver or RN. Hospice RN to measure weekly." The plan of care dated 10/11/2024 did not include documented measurable outcomes or goals for wound care. During an interview on 01/22/2025, the Area Executive Clinical Director agreed that the plan of care did not document goals with measurable outcomes. Clinical Record 8: The patient elected the hospice benefit on 12/23/2024. The Registered Nurse (RN) initial assessment dated 12/23/2024 documented that the patient had a "left heel diabetic ulcer (L)2x(W)2.5x(D)0.5, surface area 5, depth description full thick, shape round, edges rolled." On 12/23/2024, the physician ordered wound care for the patient's left heel: "irrigate with normal saline, pat dry, apply mupirocin ointment, cover with abd pad, and wrap with ace wrap. Hospice nurse to assess and take measurements weekly." The plan of care dated 12/23/2024 did not include documented measurable outcomes or goals for wound care. During an interview on 01/22/2025, the Area Executive Clinical Director agreed that the plan of care did not document goals with measurable outcomes. State regulation: "Subchapter III — Patient Care" DHS 131.21(3)(b)(3) Plan of care (b) Content of the plan of care. The hospice shall develop an individualized written plan of care for each patient. The plan of care shall reflect patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care shall include all services necessary for the palliation and management of the terminal illness and related conditions, including all of the following: Measurable outcomes anticipated from implementing and coordinating the plan of care.

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 clinical record review and interview. 1 of 11 (9%) records reviewed failed to provide documentation that the patient's needs identified in the assessment were addressed in the Plan of Care (POC). Record #98284: A PRN RN visit was made on 1/18/2022 for a patient complaint of anuria. The nurse documented that patient was catheterized and there was blood in the urine. The plan of care did not specify the care and services needed to meet the problem of anuria. Morphine 0.25 ml 5 mg every hour as needed was started on 1/6/2022. On 3/14/2022, the RN documented that the patient's pain score was 1 and was using the opioid. The plan of care did not specify the care and services needed to meet the problem of pain. The Regional Director of Quality was interviewed on 3/18/2022 and stated the plan of care did not include problems as identified in the assessments and there was no additional information to provide.

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 and documented in the patient record, including the time spent. This standard was not met as evidenced by clinical record review and interview. 1 of 11 (9%) records reviewed failed to provide documentation that volunteer services were offered to the patient. In a review of Record #74289, which included the initial RN assessment dated 9/18/2021, the initial MSW assessment dated 9/21/2021, the Chaplain assessment dated 9/21/2021, and IDG notes dated 9/29/2021 and 10/13/2021, no documentation was present that volunteer services were offered to the patient and family. The Regional Director of Quality was interviewed on 3/17/2022 and stated there was no documentation that the volunteer services were offered nor was there any additional information to provide.

It is required that the hospice medical director or physician designee reviews the clinical information for each patient being evaluated for admission and provides written certification that it is anticipated that the patient's life expectancy is six months or less if the illness runs its normal course. The physician considers the following when making this determination: information about the medical management of any of the patient's conditions unrelated to the terminal illness. This standard was not met as evidenced by clinical record review and interview. 1 of 11 (9%) records reviewed, the hospice failed to include the information about medical management of the patient's conditions unrelated to the terminal illness in the written certification. Record #16987: The medication profile included Digoxin, Carvedilol, Furosemide, and Nitroglycerine for heart disease. The written certification did not include heart disease, which was being medically managed by the hospice and not related to the hospice diagnosis of breast cancer. The Regional Director of Quality was interviewed on 3/17/2022 and stated there was no documentation of the heart disease in the CTI nor was there any additional information to provide.

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 and interview. 1 of 11 (9%) of records reviewed failed to provide documentation of physician orders. Record #98284: There was no physician order for a urinary catheterization which was performed by the RN during a PRN visit on 1/18/2022 for oliguria. The RN documented that patient was "straight cath'd". An interview with the Regional Director of Quality on 3/17/2022 confirmed there was no physician order in the clinical record.

It is required that hospice inpatient facilities store medications and biologicals in secure areas. All controlled drugs listed in Schedules II, III, IV, and V of the Comprehensive Drug Abuse Prevention and Control Act of 1976 are stored in locked compartments within secure storage areas. This standard was not met as evidenced by observation and interview. During the observation of site location on 3/17/2022 at approximately 10:20 am, the West Wing medication cart was found unlocked. This was observed by the Regional Director of Quality. Staff Member #45057 indicated that a patient needed care and verified that the Staff Member forgot to lock the medication cart before assisting the patient. The Regional Director of Quality was interviewed on 3/16/2022 and confirmed the medication was unlocked and unattended and there was no additional information provided.

It is required that each patient room in the hospice facility always has an adequate supply of hot water and has plumbing fixtures with control valves that automatically regulate the temperature of the hot water used by patients. This standard was not met as evidenced by observation and interview. During the tour of the site location with the facility engineer on 3/16/2022 at 9:20 am, it was observed through testing of the water temperature from the sink in patient room #9 that the water temperature was 122 Fahrenheit, which exceeded the recommended water temperature not to exceed 120 degrees Fahrenheit. In an interview with the facility engineer, it was stated that the site location did not routinely check water temperatures in patients' rooms and therefore did not keep a log of the water temperatures for the patient rooms.