Every finding on record at Moments Hospice of Eau Claire, LLC

Based on observation, interview, record review, and agency policy review, the hospice agency failed to provide one of three patients (Patient (P) 1) a copy of the signed admission consents, including the "Election of Hospice Benefits." This may have resulted in the patient and/or representative not receiving information regarding the items agreed to on the hospice admission consents. Findings include: --- Review of P1's "Patient Information Report," provided by the facility, revealed P1 was admitted to hospice services on 03/29/26 with the terminal illness of Alzheimer's disease. During a home visit on 04/29/26 at 9:00 AM, the observation revealed there were no copies of the signed consents, including the Election of Hospice Benefits, in the folder kept in the home by P1’s caregiver. During an interview on 04/29/26 at 9:30 AM, Caregiver (CG) 1 was asked if there were copies of the signed Election of Hospice Benefits in the home. CG1 stated that if they were not in the folder, then he/she would not know where they were. During an interview on 04/30/26 at 4:45 PM, the Registered Nurse Case Manager (RNCM) 1 confirmed that a copy of the signed Election of Hospice Benefits should have been left in the patient's home. The RNCM1 stated, "The copy of the consents are in the educational materials that we give to the patient and/or caregiver on admission to hospice." Review of the undated agency's policy titled, "Admission Criteria and Process" indicated, ". . .  Review appropriate forms and subsequently sign forms by patient and family/caregiver once agreement for the hospice program has been decided . . . If eligibility criteria is met the patient and/or family/caregiver will be provided with a hospice brochure and various educational materials . . . The patient or his/her representative will sign the required forms indicating election of hospice care and receipt of patient rights and privacy information . . ."

Based on record review, interview, and agency policy review, the agency failed to ensure the Social Worker's comprehensive assessment, for one of 10 patients reviewed (Patient (P) 3), was completed within five calendar days of the election of hospice benefits. This failure had the potential for P3 to have care needs unmet. Findings included: --- Review of P3's "Patient Information Report," provided by the agency, indicated P3 was admitted on 02/18/26 to the hospice agency with the terminal illness of alcohol induced persistent dementia. Review of P3's "Election of Benefits," provided by the agency, indicated it was signed by the patient's caregiver on 02/18/26. Review of P3's "Client Coordination Note Report," provided by the agency and dated 02/24/26, indicated, "Writer completed a Social Work evaluation visit . . ." During an interview on 04/29/26 at 4:30 PM, Team Director (TD) 1 stated the social worker was out on medical leave and confirmed the social work comprehensive assessment was not completed within five calendar days after the election of hospice benefits was signed by P3's caregiver. Review of the agency's undated policy titled, "Admission Criteria and Process" indicated, ". . . a comprehensive assessment of the patient will be performed no later than 5 calendar days after the election of hospice care . . ."

Based on observation, record review, and interviews, the hospice agency failed to ensure a current medication list for one of three patients observed on home visits (Patient (P) 1) was available in the home folder. This failure had the potential to result in P1 not receiving prescribed medications and/or receiving medications administered incorrectly by the caregiver. Findings include: --- Review of P1's "Patient Information Report," provided by the facility, revealed P1 was admitted to hospice services on 03/29/26 with the terminal illness of Alzheimer's disease. During a home visit on 04/29/26 at 9:00 AM, the hospice home folder was reviewed and did not contain a current medication list for P1. During an interview on 04/29/26 at 9:30 AM, Caregiver (CG) 1 was asked whether hospice staff had provided a current medication list for the home folder. CG1 stated, "What do I need that for? I know how to give the medications." CG1 also stated that if it was not in the folder, he/she did not know where it would be. During an interview on 04/30/26 at 4:45 PM, the Team Director (TD) 1 stated the medication list for P1 was on the inside of a cabinet drawer in the home. TD1 also stated he/she would make sure that P1's caregiver had an updated medication list that he/she would provide at the next scheduled nurse visit.

It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure the comprehensive assessment included an initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. CLINICAL RECORD 17: The patient elected the hospice benefit on 02/26/2025. The Registered Nurse (RN) documented on the start of care assessment dated 02/26/2025, "Bereavement: Was the bereavement risk assessed? Yes. Please complete the bereavement risk assessment within demographics>contacts>edit>hold on contact>add bereavement risk assessment." However, the clinical record did not include documentation of a bereavement risk assessment at the time of admission. During a joint clinical record review and interview on 12/12/2025, the Vice President of Clinical Operations/Administrator/Registered Nurse/Volunteer Coordinator confirmed that the record lacked a completed initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review and interview. In 1 of 18 (6%) clinical records reviewed with hospice aide services provided, the agency did not ensure the hospice aide notified the registered nurse of the changes in the patient’s condition and plan of care. CLINICAL RECORD 5: The patient elected the hospice benefit on 11/03/2025. The Hospice Aide Care Plan dated 11/04/2025 assigned the aide the tasks of ambulation, assist to toilet, assist with feeding, bathing - shower weekly, dressing, hair care, nail care (do not clip toenails), oral care, perineal care, shampoo weekly, shaving weekly, skin care, transfers, wipe down surfaces, change linens weekly, empty trash, offer fluids, adjust lighting (per principles of namaste care), use music, communication with RN (Registered Nurse) case manager, document in binder, socialization, and provide supply audit. The hospice aide visit dated 11/13/2025 at 1220 included the documentation, "bathing - shower completed: N [no], pt [patient] declined, stated (patient) washed up last night, prefers to wash up in evening; shampoo completed: N, pt (patient) stated washed up last night, stated (patient) hair didn’t need to be washed. Pt appears clean; hair care completed: N, task already completed; perineal care completed: N, pt stated didn’t need to use the toilet; shaving completed: N, task already completed; oral care completed: N, task already completed; dressing completed: N, task already completed; change linens completed: N, pt stated bedding was fine. Has a housekeeper that will change them tomorrow; and communication with RN case manager completed: N, no new concerns." The hospice aide visit dated 11/21/2025 at 1216 included the documentation, "bathing - shower completed: N, offered pt declined, offered again later in visit, pt stated would wash up later tonight as that what prefers and is routine; shampoo completed: N, pt declined, wasted to it with a wash up this evening; hair care complete: N, not enough hair to style at this time; perineal care completed: N, brief checked. Pt clean, no incontinence; shaving completed: N, not needed; nail care (do not clip toenails) completed: N, pt declined, wanted to rest; dressing completed: N, task already completed; change linens completed: N, pt wanted to remain in bed. Linens appear clean; communication with RN case manager completed: N, no new concerns." The hospice aide visit dated 11/25/2025 at 1214 included the documentation, "assist to toilet completed N: offered pt stated was fine and wanted to remain in bed to rest; bathing - shower completed: N, pt declined, stated likes to shower closer to evening; shampoo completed: N, declined shower; hair care completed: N, pt in bed, Pt stated hair was fine; shaving completed: N, not needed; dressing completed: N, task already completed, empty trash completed: N, task already completed; change linens completed: N, linens clean. Pt wanted to remain in bed; communication with RN case manager completed: N, no new concerns." The hospice aide visit dated 12/02/2025 at 1201 included the documentation, "ambulation completed: N, pt declined, not feeling up for it; assist to toilet completed N: offered pt stated was okay and didn’t need to use the toilet; bathing - shower completed: N, pt declined full shower, requested sponge bath wash-up; shampoo completed: N, declined shower; hair care completed: N, not enough hair to style; perineal care completed: N, no incontinence, pt declined and declined toileting; shaving completed: N, not needed; empty trash completed: N, task already completed by staff; communication with RN case manager completed: N, no new concerns." The hospice aide visit dated 12/04/2025 at 1134 included the documentation, "ambulation completed: N, pt declined feels weaker and unsteady; assist to toilet completed N: pt declined needing to toilet. Pt brief dry; bathing - shower completed: N, pt wanted to eat lunch and shower later in evening; shampoo completed: N, declined shower; perineal care completed: N, not needed. No incontinence or use of toilet; shaving completed: N, not needed; empty trash completed: N, not needed; communication with RN case manager completed: N, no new concerns." There was no documented evidence in the clinical record that the Hospice Aide notified the Registered Nurse of changes in the patient’s condition and the patient’s refusal for care that could lead to changes in the patient’s plan of care. During a joint clinical record review and interview on 12/12/2025, the Vice President of Clinical Operations/Administrator/Registered Nurse/Volunteer Coordinator confirmed that the hospice aide documentation lacked notification to the registered nurse of changes to the patient's condition that could lead to changes in the patient's plan of care.

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 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 1 of 18 (6%) clinical records reviewed with aide services provided, the agency did not ensure the Registered Nurse made an on-site supervisory 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 ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s needs. CLINICAL RECORD 10: The patient elected the hospice benefit on 12/13/2023. The RN documented an aide supervisory visit on 10/14/2025 and the next aide supervisory visit was dated 11/06/2025. There was no documented evidence in the clinical record of an on-site aide supervisory visit to the patient’s home from 10/14/2025 to 11/06/2025, totaling 23 days, with 9 days outstanding. The RN documented an aide supervisory visit on 11/19/2025 and no further aide supervisory visits were documented, as of the date of record review on 12/12/2025, a total of 23 days and 9 days outstanding. During a joint clinical record review and interview on 12/12/2025, the Vice President of Clinical Operations/Administrator/Registered Nurse/Volunteer Coordinator confirmed that the organization did not ensure the Registered Nurse made an on-site supervisory 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 ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s needs.