Every finding on record at Moments Hospice of Appleton, LLC

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, document review, and interview. Agency policy #1-014 "Comprehensive Assessment" stated in part, "An assessment of the patients and family /caregivers spiritual orientation, including as appropriate, any involvement in a religious group such as a church or synagogue or a support group such as alcoholics anonymous and spiritual concerns or needs such as despair suffering guilt, etc..." In 1 of 19 (5%) clinical records reviewed, the agency did not ensure the chaplain completed an initial comprehensive spiritual assessment no later than five (5) calendar days after the election of hospice care. Clinical Record 7: The patient elected hospice care on 08/24/2023. The plan of care dated 08/24/2022 through 11/21/2022 ordered Chaplain services "1 m1." The Chaplain documented in the coordination note dated 08/25/2023, "will visit when COVID restrictions lifted." A clinical record review revealed all disciplines: Medical Social Worker (MSW), music therapist, and massage therapist saw the patient that week. The Interdisciplinary Group (IDG) note dated 08/29/2023 documented Chaplain services as "not seen." The IDG note dated 09/12/2023 documented Chaplain services as a monthly frequency. There was no evidence the Chaplain communicated with the family prior to 09/23/2023. The Chaplain completed the initial spiritual assessment on 09/23/2023, with 30 days outstanding. During an interview, the Vice President of Clinical Operations and the Chaplain stated that a phone call was made on 08/25/2023 to learn that COVID precautions were in place and the assessment would be delayed. They agreed the spiritual assessment was conducted on 09/23/2023, a month late, and confirmed no documentation was in place regarding the COVID status. They confirmed that the complimentary disciplines of music and massage, and the MSW made their assessments within the five-day window.

It is required that the Interdisciplinary Group, in collaboration with the individual's attending physician (if any), reviews, revises, and documents the individualized care plan as frequently as the patient's condition requires; but no less frequently than every 15 calendar days. A revised plan of care includes: information from the patient’s updated comprehensive assessment; [and] record of the patient’s progress toward the outcomes and goals specified in the plan of care. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #1-036 "Interdisciplinary Group Meeting" stated in part, "An interdisciplinary group meeting plan of care update form will be used for update of the patient and family/caregiver and the attending physician. It will note changes, response to treatment and progress toward targeted outcomes." In 2 of 19 (11%) clinical records reviewed, the agency did not ensure progress toward goals was documented during the interdisciplinary (IDG) meeting. Clinical Record 9: The patient elected hospice care on 07/27/2023 with the diagnosis of Alzheimer's Disease. The skilled nursing assessment dated 08/30/2023 documented a new skin opening on left buttock that required a Mediplex dressing to be changed 2 times a week. The IDG meeting notes dated 09/11/2023 documented for nursing "decline symptom management needs since last IDG...1 fall...Goals well managed." The order for wound care did move to the plan of care. The IDG meeting notes dated 09/26/2023 documented for nursing "declines symptom managed needs since last IDG... Goals well managed." The IDG meeting notes did not document an update to the wound's progress. The wound was healed as of 10/04/2023. Clinical Record 10: The patient elected hospice care on 05/05/2023 with the diagnoses of Pancreatic Cancer and Diabetes. The skilled nursing assessment dated 10/05/2023 documented the patient had "three (3) liters of fluid removed the previous day and feeling better." The IDG meeting notes dated 10/6/2023 did not include documentation of the three (3) liters of fluids removed and a status update. During an interview on 10/17/2023, the Vice President of Operations and Clinical Manager stated that the interdisciplinary conferencing was a work in progress and will continue. with recommendations related to update of progress.

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. This standard was not met as evidenced by document review, interview, and observation. Agency policy #7-009 "Hand Hygiene" (reviewed 09/07/2022) stated in part, "Hand decontamination using an alcohol-based hand rub should be performed: After contact with patients intact skin." Agency policy #7-016 "Bag Technique" (reviewed 09/07/2022) stated in part, "Hands will be decontaminated prior to returning clean equipment to bag." In 2 of 4 (50%) home visits observed, the agency did not ensure personnel performed hand hygiene, as indicated by agency policy, to prevent transmitting infections and communicable diseases. Home Visit 1: During the home visit with the Registered Nurse (RN) [Personnel Record 8] on 10/16/2023, the RN removed the equipment: stethoscope, pulse ox, and blood pressure cuff from the bag, assessed the patient and placed the equipment on top of the bag. The equipment was cleaned with an anti-bacterial wipe and left to dry on top of the bag. The RN returned the clean medical equipment to the bag without decontaminating hands per the policy. Home Visit 3: During the home visit with the Chaplain [Personnel Record 5] on 10/16/2023, the Chaplain held the patient's hand, said a prayer, and returned their prayer book to their bag. The Chaplain did not perform hand decontamination after direct contact with the patient's hand and before entering the bag. During an interview on 10/17/2023, the staff and the Vice President of Clinical Operations agreed that hand hygiene did not follow policy.

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 4 of 19 (21%) clinical records reviewed of patients receiving hospice aide services, the agency did not ensure that the hospice aide received specific written patient care instructions. Clinical Record 4: The patient elected hospice care on 06/062023. The hospice aide care plan documented 06/07/2023 assigned the hospice aide the tasks: sponge bath every visit and shower two times a week. The hospice aide care plan did not specify the type of bath, leaving the hospice aide to make decisions outside their scope of practice. Clinical Record 9: The patient elected hospice care on 07/27/2023 with the diagnosis of Alzheimer's Disease. The patient had a Mepilex dressing on the left buttock from 08/30/2023 through 10/04/2023 when the area was healed. The hospice aide care plans documented on 07/27/2023 and updated on 08/23/2023, and 10/04/2023 did not include documentation of instructions for the hospice aide for care of the Mepilex dressing during the weekly shower. The hospice aide care plan did not provide the hospice aide with instructions regarding the Mepilex dressing during the shower. Clinical Record 11: The patient elected hospice care on 05/24/2023 with the diagnosis of Alzheimer's Disease. The hospice aide plan of care dated 05/25/2023 documented the hospice aide assigned tasks: bed bath weekly and shower weekly. The hospice aide care plan did not specify the type of bath, leaving the hospice aide to make decisions outside their scope of practice. Clinical Record 13: The patient elected hospice care on 06/10/2023 with the diagnosis of Alzheimer's Disease. The hospice aide care plan documented 06/12/2023 assigned the hospice aide the tasks: bed bath two times a week, shower weekly, and shampoo weekly. There was no identified decision-maker for these tasks. The hospice aide care plan did not specify the type of bath, leaving the hospice aide to make decisions outside their scope of practice. During an interview on 10/17/2023, the Vice President of Clinical Services and Clinical Manager confirmed the finding. They stated that the hospice aide care plan needed more attention and education.

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 re cord review and interview. In 11 of 19 (58%) clinical records reviewed of patients receiving hospice aide services, the hospice did not ensure the hospice aide provided services included in the plan of care. Clinical Record 1: The patient elected hospice care on 06/01/2023 with the diagnosis of Neurocognitive with Lewy Body. The hospice aide plans of care dated 06/01/2023 and updated on 06/06/2023 and 07/17/2023, documented the hospice aide assigned task: weights the first visit of the month. For the first visit of July on 07/05/2023, August on 08/01/2023, September on 09/01/2023, and October on 10/04/2023, the hospice aide documented the patient's weights as "Not ordered this visit." The hospice aide did not document why the patient's weight was not documented. Clinical Record 3: The patient elected hospice care on 09/11/2023 with the diagnoses of end-stage kidney disease, congestive heart failure, and chronic obstructive pulmonary disease. The hospice aide plan of care dated 09/12/2023, documented the hospice aide's assigned task: monthly weight. The hospice aide visited the patient two times a week. The hospice aide documented the patient's weights as "Not ordered this visit " for the visits documented from 09/12/2023 through 10/17/2023. The hospice aide documented no patient weights. Clinical Record 4: The patient elected hospice care on 06/06/2023. The hospice aide plan of care dated 06/07/2023, documented the hospice aide's assigned tasks: weekly weight, sponge bath every visit, and shower two times a week. The hospice aide documented the patient's weights as "Not ordered this visit" for the visits documented 06/07/2023 through 07/15/2023. The hospice aide visited the patient two times a week, 06/07/2023 through 06/13/2023; no shower was provided until 06/14/2023 (week two). No further showers were provided through 07/14/2023, with five (5) weeks outstanding. Clinical Record 5: The patient elected hospice care on 08/16/2023. The hospice aide plan of care dated 08/17/2023, and updated on 08/25/2023, documented the hospice aide's assigned task: weight monthly. The hospice aide documented the patient's weight as "Y" for the hospice aide visits dated 08/17/2023, 08/22/2023, 08/24/2023 and 09/06/2023. No weights were documented for the patient. Clinical Record 6: The patient elected hospice care on 09/15/2023 with the diagnosis of chronic obstructive pulmonary disease end stage. The hospice aide plan of care dated 09/15/2023 and 09/20/2023, documented the hospice aide's assigned tasks: shower two times a week, shampoo two times a week, and weight the first visit of the month. The hospice aide visited the patient two times a week. The hospice aide visit note dated 09/19/2023 documented shower and shampoo as "not ordered this visit." Clinical Record 7: The patient elected hospice care on 08/24/2022 with Alzheimer's Disease. The hospice aide plan of care, dated 08/25/2022 and updated on 09/12/2022 and 09/23/2023, documented the hospice aide's assigned tasks: shower and shampoo two times a week and weight first visit of the month. For the first visit of September on 09/01/2022, October on 10/03/2022, and September on 09/01/2023, the hospice aide documented the patient's weight as "not ordered this visit." For the first visit of November on 11/1/2022 and October on 10/02/2023, the hospice aide documented the patient's weight as "Y." No weights were documented. Clinical Record 8: The patient elected hospice care on 02/07/2023. The hospice aide plan of care dated 02/08/2023, documented the hospice aide's assigned tasks: weight weekly, shower, and shampoo weekly. Week one of hospice aide visits dated 02/08/2023 and 02/09/2023, the hospice aide documented the patient's weight as "not ordered" and the shower and shampoo as "not ordered this visit." The following week of hospice aide visits dated 02/14/2023 and 02/15/2023, the hospice aide documented the patient's weight as "not ordered this visit." The hospice aide visits dated 03/07/2023 and 03/08/2023, the hospice aide documented the patient's weight as "not ordered this visit." The hospice aide did not weigh the patient and shower and shampoo the patient weekly as ordered. Clinical Record 9: The patient elected hospice care on 07/27/2023. The hospice aide plan of care, dated 07/27/2023 and updated on 08/23/2023 and 10/04/2023, documented the hospice aide's assigned tasks: shower and shampoo first visit of the week and weight first visit of the month. The hospice aide visit note dated 08/01/2023 (first visit of week and month) documented the tasks of shampoo, shower, and weight as "not ordered this visit." For the hospice aide visit notes dated 08/07/2023, 08/14/2023, and 08/21/2023 (first visit of the week), the hospice aide documented the tasks shower and shampoo as "not ordered this visit." On 09/01/2023 and 10/01/2023, the first visit of the month, the weight was documented as "not ordered this visit." Clinical Record 13: The patient elected hospice care on 06/10/2023 with the diagnosis of Alzheimer's Disease. The hospice aide plan of care documented the hospice aide's assigned tasks: bed bath two times a week and shower and shampoo weekly. The hospice aide visits were ordered daily. During week one, beginning 06/12/2023, the hospice aide documented a bed bath was provided on 06/13/2023, 06/14/2023, and 06/15/2023, three times a week. During week two, beginning 06/18/2023, the hospice aide documented a bed bath was provided on 06/18/2023, 06/19/2023, and 06/21/2023. The hospice aide did not provide a shower or shampoo as ordered during week one and week two of care. The patient died on 06/21/2023. Clinical Record 14: The patient elected hospice care on 04/06/2023 and was discharged on 07/06/2023. The hospice aide plan of care documented the hospice aide's assigned tasks: monthly weight and shower and shampoo two times a week. The ordered hospice aide frequency was one (1) time a week for one (1) week and then five (5) times a week. No weights were documented in the hospice aide visit notes completed from 04/06/2023 through 07/06/2023. The hospice aide documented the weights as "no ordered this visit." For the hospice aide visits conducted during week two (4/10/2023), the shower and shampoo were provided one time; week three (4/17/2023), no shower or shampoo were provided; week four (4/24/2023), one shower was provided; week five (5/1/2023) no shower or shampoo was provided; week six (5/8/2023), no shower or shampoo was provided; and week seven (5/15/2023), no shower or shampoo was provided. The hospice aide visit notes for each visit documented "not ordered this visit." The hospice aide did not weigh the patient monthly and provide the shower and shampoo as ordered. Clinical Record 15: The patient elected hospice care on 05/02/2023 and was discharged due to revocation on 06/29/2023. The hospice aide plan of care dated 05/03/2023, documented the hospice aide assigned tasks: monthly weight, and shower and shampoo weekly. The hospice aide visit notes completed 05/03/2023 through 06/29/2023 documented "Y" or "not ordered this visit." For the hospice aide visits conducted during week three (5/14/2023) and week four (5/21/2023), no shower was documented, and the shampoo was documented as "not ordered this visit." During an interview on 10/17/2023, the Vice President of Clinical Operations and Clinical Manager stated that education and audits will be started to ensure all tasks are followed. They confirmed that each aide note documented "Y" for communication with the case manager but did not document the communication.

Based on record review and interview the agency failed to include a process for tracking COVID vaccine status and a process for receiving and approving exemptions in 1 of 1 (1) COVID policies reviewed. Findings include: Centers for Medicare & Medicaid Services, "Guidance for the Interim Final rule - Medicare and Medicaid Programs, Omnibus COVID-19 Health Care Staff Vaccination #QSO-22-07-ALL" last updated 12/28/2021, states in part (3) The policies and procedures must include, at a minimum, the following components...(iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (d)(1) of this section...(vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the hospice has granted, an exemption from the staff COVID-19 vaccination requirements." Review of agency policy titled, "COVID-19 Vaccinations Policy No. 7-028" not dated, revealed the agency did not include a process for tracking employees who had the first dose of a multi dose vaccination series and how the agency would ensure the employee received the second dose. The policy did not include a process for how vaccine exemptions are tracked until approved or disapproved. In an interview with Administrator A on 03/08/2022 at 12:00 PM, administrator A stated that there is a tracking process in place, human resources are responsible for tracking vaccination dates and providing reminders to employee's when the second vaccination dose is due and vaccination exemptions submitted are tracked with the expectation that the agency approves or disapproves the request within 10 days. Administrator A confirmed that the tracking process is not outlined in the current agency COVID-19 vaccination policy.