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

It is required that the written Patient Bill of Rights includes the right to receive effective pain management and symptom control for conditions related to the terminal illness. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) clinical records reviewed for patients that resided at skilled facilities, the agency did not ensure that the patient was provided with timely, effective pain management. Clinical Record 1: The Hospice Benefit of Election was signed on 03/18/2024. During the admission comprehensive assessment by the Registered Nurse at 1:30 pm, the pain level was 10/10. The physician was notified of the need for pain control. The physician documented and faxed a script for morphine at 2:38 pm to the facility and the facility pharmacy. This facility required that their pharmacy dispense all medications to patients. The nurse texted the family that the script had been written and sent to the pharmacy. (the family had requested that hospice communication be preferred by text). The family had asked the facility staff for the pain medication numerous times and had not received it. A chaplain visit was made at 5:00 pm, and the family communicated to the chaplain about the pain medication not being given yet. The chaplain notified the Director of Nursing at the facility and the hospice nurse. The Director of Nursing from the facility and the pharmacy were able to access the morphine at 7:18 pm. The pain medication was provided by 7:30 pm. The pharmacy had trouble with its access code and consequently could not retrieve the script and medication when it was sent. The family communicated with the facility staff during the afternoon once they found out the medication had been ordered. The hospice had not been notified that the patient had not received the ordered morphine. The pharmacy had not notified the Director of Nursing, the hospice, or the physician of the difficulty accessing their system. The facility contract did not contain language that the facility would provide all medication, as was the facility's practice. The facility contract did contain the language that they would notify the hospice of any change in the patient's condition. The pain medication was not supplied timely to a patient with a pain level of 10/10. The assessment after the morphine was administered was a pain level of 4/10. Morphine was administered during the night, with pain control achieved. The patient died at 2:00 am the next day. During an interview with the Director of Clinical Services, the hospice was unaware of the facility's dispensing problems, as neither the facility nor the family had communicated with the hospice.

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. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) clinical records reviewed, the agency did not ensure all interventions identified in the initial comprehensive assessment were documented in the plan of care. Clinical Record 4: The Registered Nurse documented the initial comprehensive assessment on 02/10/2024 that identified the patient had a Foley catheter that included large bag drainage. An initial plan of care was documented on 02/10/2024 and updated every two weeks as of the review date 05/30/2024. None of the plans of care documented any interventions for the Foley catheter. During an interview with the Director of Clinical Services on 05/30/2024 stated that the interventions were missed on the plans 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: medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, interview and observation. In 1 of 5 (20%) clinical records reviewed, the agency did not ensure that all medical supplies required to manage patient care were documented on the care plan. Clinical Record 4: The hospice benefit of the election was signed on 02/10/2024. The initial plan of care, dated 02/12/2024 and updated every two weeks, did not include documentation of the DME (durable medical equipment) for the Foley catheter and supplies. During an interview with the Director of Clinical Services on 05/30/2024, the Director of Clinical Services stated that the supplies were missing from the plan of care.

It is required that the hospice assumes responsibility for the professional management of the SNF/NF or ICF/IDF resident's hospice services in accordance with the hospice plan of care (POC) and the hospice conditions of participation. This standard was not met as evidenced by a review of clinical records and interview. In 1 of 5 (20%) clinical records reviewed of patients residing in a skilled facility, the agency did not ensure timely, effective pain management. Clinical Record 1: The Hospice Benefit of Election was signed on 03/18/2024. During the admission comprehensive assessment by the Registered Nurse at 1:30 pm, the pain level was 10/10. The physician was notified of the need for pain control. The physician documented and faxed a script for morphine at 2:38 pm to the facility and the facility pharmacy. The facility required that their pharmacy dispense all medications to patients. The nurse texted the family that the script had been written and sent to the pharmacy. The family had requested that hospice communication be preferred by text. The family had asked the facility staff for the pain medication numerous times and had not received it. A chaplain visit was made at 5:00 pm, and the family communicated to the chaplain about the pain medication not being given yet. The chaplain notified the Director of Nursing at the facility and the hospice nurse. There was no documentation that the Hospice RN communicated with the facility regarding the medication delay or provided subsequent direction for other pain relief measures. The Director of Nursing from the facility and the pharmacy accessed the morphine at 7:18 pm. The pain medication was provided by 7:30 pm. The pharmacy had trouble with its access code and could not retrieve the script and medication when it was sent. The family communicated with the facility staff during the afternoon once they found out that the medication had been ordered. The hospice had not been notified that the patient had not received the ordered morphine. The pharmacy had not notified the Director of Nursing, the hospice, or the physician of the difficulty accessing their system. The facility contract did not contain language that the facility would provide all medication, as was the facility's practice. The facility contract did contain the language that they would notify the hospice of any change in the patient's condition. The pain medication was not supplied timely to a patient with a pain level of 10/10. The assessment after the morphine was administered was a pain level of 4/10. Morphine was administered during the night, with pain control achieved. The patient died at 2:00 am the next day. During an interview with the Director of Clinical Services, the hospice was unaware of the facility's dispensing problems, as neither the facility nor the family had communicated with the hospice.

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 interview. In 3 of 5 (60%) clinical records reviewed who resided in a skilled facility, the agency did not ensure documentation of which care provider was responsible for performing the functions that were included in the patient's plan of care. Clinical Record 3: The hospice benefit of the election was signed on 03/08/2024 with a primary diagnosis of CV (cardiovascular) disease and dysphagia. During the time care was provided, complications included aspiration of food and fall with changes in the equipment of a Broda chair and a Hoyer lift, as well as feeding changes that included facility staff feeding the patient to control quantity and speed of eating. The facility plan of care in the patient folder at the facility was documented and was dated 2/10/2024. This plan of care and the updated plans of care in the patient's clinical record did not include the detail that the patient was to use the Broda chair, not a wheelchair, and did not include that the facility was to feed the patient each meal. Clinical Record 4: The hospice benefit of the election was signed on 02/10/2024 with a primary diagnosis of protein deficiency malnutrition. The initial comprehensive assessment documented by the nurse identified a Foley catheter, which the patient continued to have and was cared for by both the hospice team and the facility staff. The initial plan of care and the Facility plan of care (dated 03/08//2024) documented at the facility did not include any interventions for the Foley catheter or who specifically would provide the care as of review 05/302024. Clinical Record 5: The hospice benefit of the election was signed on 03/13/2024 with a primary diagnosis of senile dementia. During care provided, the patient had several falls and changes made to using the Hoyer lift and Broda chair, medications changes, and on 04/03/2024, skin changes required barrier cream twice a day. The plan of care was documented in the clinical record and updated every two weeks, and the facility plan of care documented at the facility did not include any documentation of who would provide the wound intervention twice a day or that the facility would be using the Broda chair and Hoyer Lift. During an interview with the Director of Clinical Services, the facility's plans of care would need to be updated, and education was provided.

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, document review, and interview. Agency Policy #HH - C13, "Home Health Aide Services" (Dated:10/19/22), stated in part, "The agency provides home health aide services according to the patient's plan of care (POC) as assigned by the Registered Nurse or other qualified professional." In 1 of 16 (6%) clinical records reviewed for patients receiving hospice aide services, the agency did not ensure that the hospice aide care plan prepared by the registered nurse (RN) included specific written patient care instructions. Clinical Record 1: The patient elected the hospice benefit on 3/3/23. The RN visit note dated 6/14/23 stated the patient had an unstageable wound on the right trochanter that required wound care with a dressing being applied. The aide care plan dated 6/27/23 did not include documentation of specific information as to how the aide should address the wound dressing on the right trochanter while performing the patient bed bath. Additionally, the aide care plan dated 5/23/23 assigned the aide the tasks: routine catheter care every visit and emptying the urinary drainage bag every visit. There was a physician's order dated 5/8/23 to discontinue the urinary catheter. The urinary catheter was inadvertently pulled prior to the RN visit on 5/8/23. The aide care plan was not updated to remove the aide tasks: routine catheter care and emptying the urinary drainage bag. Upon interview on 6/28/23, the Area Executive of Clinical Operations and the Director of Clinical Services for the main branch and ADS reviewed and agreed the agency did not ensure the aide care plan included how to care for the wound dressing while performing a bath and to ensure that the aide POC was updated based on changes in patient status - removal of the urinary catheter.