Every finding on record at Stch De Pere Wi Opco LLC

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. A joint review of the agency report titled "Hospice Volunteer Requirement Report" with the Regional Director of Clinical Operations and the Volunteer Coordinator on 01/28/2026 revealed that the volunteer utilization was 0.51% for the year 2025, which did not meet the requirement of five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. During an interview on 01/28/2026, the Volunteer Coordinator and the Regional Director of Clinical Operations stated that it had been challenging to recruit volunteers since COVID and the agency had initiated a performance improvement (PIP) to re-build the volunteer program. A joint review of the agency report titled "Hospice Volunteer Requirement Report" with the Regional Director of Clinical Operations and the Volunteer Coordinator on 01/28/2026 revealed that the volunteer utilization was 0.51% for the year of 2025, which did not meet the requirement of five percent (5%) of the total patient care hours of all paid hospice employees and contract staff.

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/IID 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, interview and observation. In 2 of 2 (100%) clinical records reviewed where patients resided in a skilled nursing facility, the agency did not ensure that the care and services that were needed were identified and did not specify which provider was responsible for performing the functions that were agreed upon were included in the plan of care. HOME VISIT 4/CLINICAL RECORD 4: An observed home visit was conducted on 01/29/2026 to observe the Licensed Medical Social Worker (Personnel Record #4). This patient elected the hospice benefit on 01/05/2026 with a terminal diagnosis of atherosclerotic heart disease, and resided in a skilled nursing facility. The initial RN comprehensive assessment dated 01/05/2026 documented the following pressure ulcers: #1-buttock med-UP, stage 3, 2-1.2-0; and #2 MED lower buttocks, Stage III, 1X0.2X0. A new wound was documented on 01/12/2026, which was on the right elbow which measured 1X0.5X0 and a new wound was documented on 01/15/2026 #4 Patellar Right, Stage II, 1X1.5X0. The plan of care was reviewed for the dates of 01/05/2026-01/30/2026. The hospice plan of care did not identify which provider was responsible for the care of the pressure ulcers. CLINICAL RECORD 19: This patient, residing in a nursing facility, elected the hospice benefit on 01/25/2025 with a terminal diagnosis of congestive heart failure, and died on 02/08/2025. The clinical record wound care form documented two open areas on 01/30/2025: #1 Posterior-Sacral Stage II wound, and #2 left 3rd toe diabetic ulcer. A physician's order was written on 01/25/2026 which stated that the hospice nurse was to perform wound care utilizing clean technique. The hospice plan of care was reviewed for the dates of 01/25/2025-02/08/2025. The hospice plan of care did not identify which provider was responsible for the care of the pressure ulcers. An interview was conducted with the Regional Director of Clinical Operations on 01/29/2026. It was acknowledged that the plans of care did not state who was responsible for the care of the pressure ulcers. She stated the hospice nurses knew that the facilities had wound care nurses that were responsible for wound care, and they knew it must be identified in the plan of care.