Every finding on record at Grace Hospice of Wisconsin, LLC

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs. The medication review process includes the identification of the following: the effectiveness of drug therapy. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed, the hospice did not ensure a complete medication review was conducted with each comprehensive assessment and/or when a new medication is added or changes are made to existing medication. Clinical Record 1/Home Visit 1: The patient’s date of election of Hospice services was 7/9/2021. During an observed home visit to this patient residing at a SNF (skilled nursing facility) with the Registered Nurse (RN) (Staff 4) on 3/28/2023, the unit Nursing Manager at the SNF confirmed the facilities medication profile documented Morphine Sulfate 100mg/5ml with a start date of 3/23/2023, give 0.5ml by mouth every 1 hour as needed for pain/end of life restlessness. During the visit, the Registered Nurse (Staff 4) asked the SNF if she had had a dose of Morphine yet today. RN visits were completed on 3/23/2023, 3/24/2023, 3/25/2023, 3/26/2023, 3/27/2023 and 3/28/2023. Morphine was not listed on the hospice medication profile as of the review date, 3/30/2023. Clinical Record 2/Home Visit 3: The patient’s date of election of Hospice services was 10/3/2022. During an observed home visit to this patient with the hospice aide (Staff 7) on 3/30/2023, the daughter was interviewed about medications. The hospice medication profile was reviewed on 3/29/2023 and listed Atorvastatin, Glipizide, and Carvedilol as an active scheduled medications. The daughter reported the patient hasn’t taken: Atorvastatin for at least 2 months, Glipizide for at least 4 months, and Carvedilol for at least 1 ½ months. The daughter reported she had been given “many” doses from the bottle labeled 12/8/2022 Haloperidol 2mg/ml, 0.5ml every 4 hours as needed for severe agitation/anxiety/hallucinations, and Lorazepam 0.5mg tablet, 1 or 2 every 2 hours as needed for anxiety/restlessness. The daughter reported each medication above was discussed with the hospice nurse, “they are aware,” and “the nurse said it's ok to stop taking the carvedilol when it ran out.” A Nurse Practitioner's documentation on 11/15/2022 revealed: “lorazepam ordered PRN.” A Registered Nurse telephone documentation on 12/11/2023 told, “daughter called asking if Haldol (haloperidol) was given around 1400, could she give at the time of the phone call, RN provided medication education, informed daughter those two medications can be given at the same time.” Haloperidol and Lorazepam were not listed on the hospice medication profile as of the review date, 3/29/2023. Additionally, the medication profile was not updated with the discontinued medications, Atorvastatin, Glipizide, and Carvedilol. The Regional Quality Manager was interviewed on 3/30/2023 and agreed there was no documented evidence the medication review was completed and updated to the hospice medication profile. Additionally, during the interview on 3/30/2023, the Regional Quality Manager stated that the medication profiles were not updated. Record 1: The patient’s date of election was 7/9/2021. During an observed home visit to this patient residing at a SNF (skilled nursing facility) with the Registered Nurse (RN) (Staff 4) on 3/28/2023, the unit nursing manager at the SNF confirmed the facilities medication profile documented Morphine Sulfate 100mg/5ml with a start date of 3/23/2023, give 0.5ml by mouth every 1 hour as needed for pain/end of life restlessness. During the visit, the Registered Nurse (Staff 4) asked the SNF if she had a dose of Morphine yet today. RN visits were completed on 3/23/2023, 3/24/2023, 3/25/2023, 3/26/2023, 3/27/2023 and 3/28/2023. Morphine was not listed on the hospice medication profile as of the date of review, 3/30/2023. Record 2: The patient’s date of election was 10/3/2022. During an observed home visit to this patient with the hospice aide (Staff 7) on 3/30/2023, the daughter was interviewed about medications. The hospice medication profile was reviewed on 3/29/2023 and listed Atorvastatin, Glipizide, Carvedilol as an active scheduled medication. The daughter reported the patient hasn’t taken: Atorvastatin for at least 2 months, Glipizide for at least 4 months, and Carvedilol for at least 1 ½ months. The daughter reported she has given “many” doses from the bottle labeled 12/8/2022 Haloperidol 2mg/ml, 0.5ml every 4 hours as needed for severe agitation/anxiety/hallucinations and Lorazepam 0.5mg tablet, 1 or 2 every 2 hours as needed for anxiety/restlessness. The daughter reported each medication above was discussed with the hospice nurse, “they are aware,” “the nurse said its ok to stop taking the carvedilol when it ran out.” A Nurse Practitioner documentation on 11/15/2022 revealed “lorazepam ordered PRN.” A Registered Nurse telephone documentation on 12/11/2023 revealed “daughter called asking if Haldol (haloperidol) was given around 1400, could she give at time of the phone call, RN provided medication education, informed daughter those two medications can be given at the same time.” Haloperidol and Lorazepam was not listed on the hospice medication profile as of the date of review, 3/29/2023. Additionally, the medication profile was not updated with the discontinued medications, Atorvastatin, Glipizide, and Carvedilol. The Regional Quality Manager was interviewed on 3/30/2023 and agreed, there was no documented evidence the medication review was completed and updated to the hospice medication profile. Additionally, during interview on 3/30/2023, the Regional Quality Manager stated, the medication profiles were not updated.

It is required that each patient’s individualized written plan of care: 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 and interview. In 1 of 3 (33%) clinical records reviewed with wounds, the hospice did not ensure the plan of care was updated with patient and family goals and planned interventions for the wounds. Record 2: The patient’s date of election of Hospice services was 10/3/2022. The plan of care was reviewed for 10/3/2022-3/1/2023. A Registered Nurse assessment on 10/3/2022 documented wound #1, 2nd right toe unstageable Deep Tissue Injury, and wound #2, left heel pressure ulcer stage III. There was no documented evidence the individualized written plan of care reflected patient and family goals with planned interventions for the wounds. The Regional Quality Manager was interviewed on 3/30/2023 and agreed there was no documented evidence the plan of care included planned interventions or patient and family goals for the wounds identified. Record 2: The patient’s date of election was 10/3/2022. A Registered Nurse assessment on 10/3/2022 documented wound #1 2nd right toe unstageable DTI and wound #2 left heel pressure ulcer stage III. The plan of care was reviewed for 10/3/2022-3/1/2023. There was no documented evidence the individualized written plan of care reflected patient and family goals with planned interventions for the wounds. The Regional Quality Manager was interviewed on 3/30/2023 and agreed, there was no documented evidence the plan of care included planned interventions or patient and family goals for the wounds identified.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene, safe handling of equipment in the patient’s care environment if it is likely to have been contaminated with body fluids, safe handling of soiled items in the patient’s care environment. This standard was not met as evidenced by document review, interview, and observation. In 2 of 3 (67%) visit observations, the hospice did not ensure adherence to agency infection control policies and procedures for hand hygiene. Agency Policy, titled Hand Hygiene, stated in part, “Hand hygiene should be performed frequently and especially at the following times: before and after handling dressings or touching open wounds, after having contact with body fluids, excretions, non-intact skin, dressings or contaminated services, after having contact with inanimate objects in the patient’s environment.’ During observation of Home Visit #1 (Record 1) on 3/28/2023 with the Registered Nurse (RN) (Staff 4), the hospice RN was observed donning gloves, removing the patient’s socks, completing a foot skin assessment, then putting on the socks back on, touching the bed remote to position, turned the patient to her side and removed the colostomy wound dressing on the buttocks and touched the skin with the gloved hand. The RN was not observed performing hand hygiene before touching the colostomy wound dressing and the skin around the wound. During observation of Home Visit #3 (Record 2) on 3/30/2023 with hospice aide 1 (Staff 7) and hospice aide 2, hospice aide 2 assisted hospice aide 1 (primary). Hospice aide 1 (Staff 7) was observed donning gloves and washing the patient from chest to feet (minus peri area). The hospice aide 1 removed gloves, washed hands, donned clean gloves, then provided peri care with bathing wipes dipped in the basin with the same water. Hospice aide 1 and hospice aide 2 turned the patient, hospice aide 1 used a bathing wipe, dipped it in the same basin with dirty water (from peri care), and washed the patient’s upper back. The hospice aide 1 dipped a washcloth in the same basin with dirty water and rinsed the patient’s back. The hospice aide 1 then used a bathing wipe, dipped in the dirty water basin, and washed the patient’s upper buttocks, including over and around the open wound on the right upper buttock. The hospice aide then used the same washcloth, dipped it in the same dirty water basin, and rinsed the upper back again and upper buttocks, including over and around the open wound. Hospice aide 1 (Staff 7) was not observed performing hand hygiene before or after touching the open wound on the buttocks. The water in the water basin was initially changed after the shampoo, but the same water was used from the upper chest to feet, peri care, upper back, and buttocks area. The Regional Quality Manager was interviewed on 3/30/2023 and agreed the hospice aide did not follow the infection control policy on hand hygiene. Agency Policy, titled Hand Hygiene, stated in part, “Hand hygiene should be performed frequently and especially at the following times: Before and after handling dressings or touching open wounds, after having contract with body fluids, excretions, non-intact skin, dressings or contaminated services, after having contact with inanimate objects in the patient’s environment.’ During observation of Home Visit #1 (Record 1) on 3/28/2023 with the Registered Nurse (RN) (Staff 4), the hospice RN was observed donning gloves, removing the patient’s socks, completing a foot skin assessment then putting the socks back on, touching the bed remote to position, turned the patient to her side and removed the colostomy wound dressing on the buttocks and touched the skin with the gloved hand. The RN was not observed performing hand hygiene before touching the colostomy wound dressing and skin around the wound. During observation of Home Visit #3 (Record 2) on 3/30/2023 with the hospice aide 1 (Staff 7) and hospice aide 2, the hospice aide 2 assisted the hospice aide 1 (primary). The hospice aide 1 (Staff 7) was observed donning gloves and washing the patient from chest to feet (minus peri area). The hospice aide 1 removed gloves, washed hands, donned clean gloves, then provided peri care with bathing wipes dipped in the basin with the same water. The hospice aide 1 and hospice aide 2 turned the patient, hospice aide 1 used a bathing wipe, dipped it in the same basin with dirty water (from peri care) and washed the patient’s upper back. The hospice aide 1 dipped a washcloth in the same basin with dirty water and rinsed the patient’s back. The hospice aide 1 then used a bathing wipe, dipped in the dirty water basin, and washed the patient’s upper buttocks, including over and around the open wound on the right upper buttock. The hospice aide then used the same washcloth, dipped it in the same dirty water basin and rinsed the upper back again and upper buttocks, including over and around the open wound. The hospice aide 1 (Staff 7) was not observed performing hand hygiene before or after touching the open wound on the buttocks. The water in the water basin was initially changed after the shampoo, but the same water was used from the upper chest to feet, peri care, upper back, and buttocks area. The Regional Quality Manager was interviewed on 3/30/2023 and agreed, the hospice aide did not follow the infection control policy on hand hygiene.

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 12 (8%) clinical records reviewed with a hospice aide ordered, the hospice did not ensure hospice aide services were provided in accordance with the plan of care. Record 2: The patient’s date of election of Hospice services was 10/3/2022. The hospice aide care plan dated 10/4/2022 assigned instructions for the aide to complete every visit: shampoo, bathing, bed bath. The hospice aide visit documentation on 2/14/2023 revealed bed bath was not completed with the note, “bath is completed Thursday.” The hospice aide visit documentation on 2/21/2023 revealed shampoo not completed with the note, “Thursdays or PRN,” and bed bath not completed with the note, “Thursdays or PRN.” The Regional Quality Manager was interviewed on 3/30/2023 and agreed the hospice aide did not follow the plan of care as ordered. Record 2: The patient’s date of election was 10/3/2022. The hospice aide care plan dated 10/4/2022 assigned instructions for the aide to complete every visit: shampoo, bathing bed bath. The hospice aide visit documentation on 2/14/2023 revealed bed bath not completed with the note, “bath is completed Thursday.” The hospice aide visit documentation on 2/21/2023 revealed shampoo not completed with the note, “Thursdays or PRN” and bed bath not completed with the note, “Thursdays or PRN.” The Regional Quality Manager was interviewed on 3/30/2023 and agreed, the hospice aide did not follow the plan of care as ordered.

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary described in HCDT 40.I and the patient’s record, if requested. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record review of a patient transferred to another hospice, the hospice did not ensure the discharge summary was forwarded to the receiving hospice agency. Record 12: The patient’s date of election of hospice services was 3/9/2022. The patient was transferred due to the patient/family's request for transfer to another hospice effective 5/26/2022. There was no documented evidence the discharge summary was sent to receiving hospice agency. The Regional Quality Manager was interviewed on 3/30/2023 and agreed there was no documented evidence the discharge summary was sent to the receiving hospice. Record 12: The patient’s date of election was 3/9/2022. The patient was transferred due to the patient/family request for transfer to another hospice effective 5/26/2022. There was no documented evidence the discharge summary was sent to receiving hospice agency. The Regional Quality Manager was interviewed on 3/30/2023 and agreed, there was no documented evidence the discharge summary was send to the receiving hospice.