Every finding on record at Visiting Nurse Association of Wisconsin, Inc.

Observed in Record Review. In 1 of 3 patient records reviewed with live discharge, During HOSRRDC# 3's patient record review it was noted the organization had not ensured it complied with law and regulation. For example: review of HOSRRDC# 3's patient record revealed HOSRRDC# 3's was discharged due to extended prognosis. Further review of HOSRRDC# 3's patient record revealed no documentation of a Notice of Medicare Non-Coverage. This was reviewed, discussed, and validated with the Director of Education and Clinical Practice.

Observed in Patient Home. In 2 of 4 Home visits conducted with medication reconciliation, During HOSRRHV# 1 and HOSRRHV# 4's home observation and patient record review it was noted the organization had not ensured it assessed and reassessed its patients. For example: during HOSRRHV# 1's home observation's medication reconciliation it was noted the biscodyl supposities had expired in May 2025. During HOSRRHV# 6's home observation the RN completed a medication reconciliation with the Skilled Nursing Facility (SNF) that revealed Oxycodone immediate release 100mg/ml 30ml was not present on the current month's medication administration record and not present in the narcotic drawer. The organization Leadership was notified and it was determined the Oxycodone had been delivered to the SNF on July 30th and the SNF was investigating why the medication did not make it to the medication cart narcotic box. Review of four Skilled Nurse visits completed after the mediation was ordered revealed documentation that the medications were reviewed and no issues noted. This was observed, discussed, and validated with the RN and the Clinical Manager and reviewed, discussed, and validated with the Director of Education and Clinical Practice.

Observed in Record Review. In 1 of 26 patient records reviewed, During HOSRRHV# 1's patient record review it was noted the organization had not ensured it maintained complete and accurate patient records. For example: review of HOSRRHV# 1's patient record revealed and IDG (Interdisciplinary Group)/update to plan of care dated 19 days apart. Discussion and review of the IDG agenda revealed the IDG had an inaccurate date and the IDG meeting was actually 14 days apart. This was reviewed, discussed, and validated with the KAYLA AND LEADERSHIP...WILL GET TITLES

Observed in Record Review. In 23 of 26 patient records reviewed, During 23/26 patient records reviewed it was noted the organization had not ensured the written plan of care was based on the patient's goals. For example: review of the 23/26 patient records revealed the pain goal Patient will remain at or below the patient's identified pain goal with no documentation of what the identified pain goal was. Review of 23/26 patient records revealed documentation of patient identified pain goals from 0/10 to 4/10 or with no documented pain goal due to the patient being unable to verbalize a pain goal. This was reviewed, discussed and validated with the Director of Education and Clinical Practice.

Observed in Record Review. In 23 of 26 patient records reviewed, During 23/26 patient records reviewed it was noted the organization used standing orders that were not consistent with assessed clinical needs. For example: review of 23/26 patient records revealed the same as needed interventions to include a Macy catheter for rectal administration of medication, an indwelling urinary catheter with a size range of 14-18 Fr., and oxygen 1-5 lpm as needed for patient comfort. Review of HOSRRHV# 1's start of care plan of care dated approximately 7 months prior to the surveyor review of the record and recertification plans of care included the intervention of a Macy Catheter as needed for rectal administration of medications when the patient was no longer able to swallow. Review of HOSRRHV# 1's patient record revealed no documentation HOSRRHV# 1 was unable to take medications orally. Further review of the start of are plan of care and recertification plans of care revealed the intervention for an indwelling urinary catheter prn with a size range of 14-18 Fr, and oxygen 1-5 lpm as needed and with documentation of oxygen 1-5 lpm as needed on the medication profile. Review of HOSRRHV# 2's start of care plan of care dated approximately 17 months prior to the surveyor review of the record and subsequent recertification plans of care revealed the intervention of a Macy Catheter as needed for rectal administration of medications and indwelling urinary catheter prn with a size range of 14-18 Fr., and oxygen 1-5 lpm as needed for patient comfort with no oxygen in the home. This was reviewed, and discussed and validated with the Director of Education and Clinical Practice.

Observed in Record Review. In 2 of 26 patient records reviewed, During HOSRRHV# 2 and HOSRRHV# 3's patient records review it was noted the organization had not ensured the registered nurse prepared complete patient care instructions for the hospice aide. For example: review of HOSRRHV# 2's plan of care revealed the hospice aide patient written care instructions with the task of indwelling catheter care beginning at the start of care approximately 15 months prior to the surveyor review of the record. Further review of HOSRRHV# 2's patient record revealed HOSRRHV# 2 did not have an indwelling catheter at start of care and an indwelling catheter had not been implemented. In addition, the plan of care has the interventions for the SN or Hospice aide to apply zinc to the peri-area and tubi-grips to the bilateral lower extremities, however, the hospice aide written instructions did not have this tasks and the hospice aide was observed providing those tasks during the home observation. Review of HOSRRHV# 3's hospice aide patient written care instructions revealed the task of applying a condom catheter at night and PRN as needed and the task of caring for the condom catheter. However, there were not specific directions as to determine PRN by the hospice aide. This was reviewed, discussed, and validated with the Director of Education and Clinical Practice.

Observed in Patient Home. In 3 of 4 Home visits conducted with medication reconciliation, During HOSRRHV# 4, HOSRRHV# 5, AND HOSRRHV# 6's home observation it was noted the organization had not ensured the patient record contained information that reflected the patient's care, treatment, or services. For example: during HOSRRHV# 4's medication reconciliation it was noted on the Skilled Nursing Facility (SNF) medication administration record (MAR) the HOSRRHV# 4 was taking Lasix 40mg tablet, one tablet three times a week. However, the organization medication profile had Lasix 20mg tablet, take one tablet three times a week. During HOSRRHV# 5's home observation review of the SNF MAR revealed acetaminophen 500mg tablet take 1,000 mg three times a day. However, the organization's medication profile revealed acetaminophen 500mg take 1,000mg every 6 hours for pain. During HOSRRHV# 6's home observation it was noted HOSRRHV# 6 was taking Rosuvastatin 40 mg daily for approximately the last nine months per HOSRRHV# 6. However, review of HOSRRHV# 6's medication profile revealed no documentation of Rosuvastatin. This was observed, discussed, and validated with the Clinical Manager.

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 a review of clinical records and interviews. In 1 of 5 (20%) records did not identify interventions and goals for all problems identified in the initial comprehensive assessment. Clinical Record 3 - Admission assessment completed 04/17/2022 identified two stage 2 coccyx pressure ulcers. No interventions or goals to address the ulcers were documented on the care plan. The patient died the following day, on 04/18/2022, on GIP [general in patient] care. Interview with the director of the home team stated that the pressure areas should have been documented on the plan of care.

Observed in Record Review. In 2 of 20 patient records reviewed, the hospice surveyor found that the organization had not assessed the patient as required by organization policy. For example, in review of the medical record for HosRR10, the surveyor found that the organization had not conducted a gastrointestinal assessment, other than last BM, since admission. In review of the medical record for HosRR12, wound measurements were not completed weekly as required. This was discussed with the clinical informatics educator assisting with review of the clinical record. Observed in Individual Tracer. The hospice surveyor observed in HOS visit 2 that the wound on patients chin had not measured weekly as required by HCO policy. The last wound care measurement had been on 7/26/22 and as of 8/10/22 no further wound care measurements had been documented and no documentation for exception had been found by hospice representative assisting in record review. This was discussed and confirmed with hospice. Observed in Tracer Visit. In 2 of 3 home visits conducted, The hospice surveyor observed in HOS home visit 1 and 2 that the hospice nurse had not assessed patient according to organization policy as evidenced by in visit one and two the nurse had not assessed all pressure points to include coccyx in patients at risk for skin breakdown.

Observed in Record Review. In 1 of 20 patient records reviewed, the hospice surveyor found that an initial bereavement assessment was not completed. This assessment was not completed for HosRR6. This was discussed with the clinical informatics educator assisting with review of the clinical record.

Observed in Record Review. In 16 of 20 patient records reviewed, the hospice surveyor noted that the organization had not specified the unique medications and treatments necessary to meet the patient's needs. For example, in review of the medical record for HosRR1, the plan of care had ibuprofen, hydrocodone 5/325 and acetaminophen ordered as needed for pain without further defining when each one should be taken. In review of the medical record for HosRR2 and HosRR4, the plan of care had acetaminophen and morphine sulfate ordered as needed for pain and haloperidol and prochlorperazine as needed for nausea, without further defining when each one should be taken. In review of the medical record for HosRR3, the plan of care had acetaminophen and tramadol ordered as needed for pain and haloperidol and prochlorperazine as needed for nausea, without further defining when each one should be taken. The order for as needed lidocaine did not include an indication or a site of application. In review of the medical record for HosRR5, the plan of care had acetaminophen and Norco 10/325 ordered as needed for pain and Bisacodyl and docusate as needed for constipation, without further defining when each one should be taken. In review of the medical record for HosHV5, the patient had an order for Lorazepam 0.5 mg oral tablet, 1-2 tab(s) as needed and Lidocaine patch, 1-2 patches as needed. It was not specified under what circumstances each dosage should be administered. There were similar examples found in HosRR6, HosRR7, HosRR8, HosRR9, HosRR10, HosRR11, HosRR12, HosRR13, HosRR14, and HosRR15. In HosRR7, the nurse documented the performance of a dressing change for a new skin tear but there were no orders for this treatment. In HosRR11, the plan of care order was not complete for the site of the wound dressing. This was discussed with the clinical informatics educator assisting with review of the clinical record.

Observed in Record Review. In 3 of 20 patient records reviewed, the hospice surveyor noted that the organization had not specified the unique medical supplies and appliances necessary to meet the patient’s needs. For example, in review of the medical record for HosRR3 and HosRR12, the hospice surveyor noted that the patient was admitted with and continued with a foley catheter but the plan of care order for this was not specific for the catheter size or balloon size. In review of the medical record for HosHV5, the patient had a foley catheter in place but the plan of care was not specific for the catheter size or balloon size to be inserted. This was discussed with the clinical informatics educator assisting with review of the clinical record.

Observed in Record Review. In 2 of 13 patient records reviewed, where hospice aide services were ordered, the hospice surveyor found that the registered nurse had not provided the aide with information on safety precautions to implement or when to notify the nurse. For example, in review of the medical record for HosRR1, the patient was assessed to be at risk for falls (MACH 9/10), and had Eliquis, Keppra and oxygen ordered. The plan of care for the hospice aide did not specify the unique safety precautions or notification requirements related to these findings. In review of the medical record for HosRR12, the patient was bedbound and had a sacral wound with a dressing in place. The plan of care for the hospice aide did not specify the unique safety precautions or notification requirements related to this finding. This was discussed with the clinical informatics educator assisting with review of the clinical record.

Observed in Record Review. In 2 of 20 patient records reviewed, the hospice surveyor found that the physician had not incorporated required clinical information (Related diagnoses, if any - Current subjective and objective medical findings - Current medication and treatment orders - Information about the medical management of the patient’s conditions unrelated to the terminal condition) into the narrative on the certificate of terminal illness (CTI). For example, in review of the medical record for HosRR2, the narrative information for the initial CTI and the recertification CTI was the patient's gender, age and terminal diagnosis. In review of the medical record for HosRR8, the CTI completed for recertification contained essentially the same information as was present on the initial CTI without demonstrating the patient's declining condition and need for continuing hospice care. This was discussed with the clinical informatics educator assisting with review of the clinical record.

Observed in Record Review. The hospice surveyor observed in visit 2 that the patient on oxygen had a gas stove and in review of record found no evidence of education related to gas stove. This patient was also still cooking in kitchen as during home visit patient discussed items she liked to cook. The surveyor also observed that staff had not provided education on the safe storage of oxygen cylinders in the home and the surveyor observed in HOS visit 1&2 oxygen being stored standing without being secured. This issue was discussed and observed by hospice nurse on visit with hospice surveyor. Observed in Record Review. In 11 of 20 patient records reviewed, the hospice surveyor found that the organization had not provided education based on the patients needs and abilities. For example, in review of the medical record for HosRR1, HosRR3, HosRR5, HosRR6, HosRR7, HosRR8, HosRR9, HosRR13, HosRR14, and HosRR15, the patient had oxygen ordered but there was no education related to the causes of fire, ways to prevent fire related injury, risks to neighboring residence and buildings and no specific recommendations to address any identified risks. In HosRR10, the patient had finasteride ordered and paid female caregivers that assisted with medication administration. There was no education found related to the safety precautions required for handling this medication. This was discussed with the clinical informatics educator assisting with review of the clinical record.