Compassus Northern Wisconsin

“It is required that each patient’s individualized written plan of care reflects patient and family goals; 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 2 of 19 (11%) clinical records reviewed, the agency did not ensure that the patient’s plan of care included patient and family goals based on interventions and problems identified in the comprehensive assessments. CLINICAL RECORD 3: The patient elected hospice care on 12/23/2025 with a diagnosis of neoplasm of the right and left lungs. The patient’s plan of care was updated on 04/16/2026 to include interventions for the patient’s identified problem with “Comfort”: “SN-Administer analgesics as prescribed, monitoring for efficacy and side effects. SN-Educate family about proper pain management at home, including dosing schedules and signs that indicate a need to re-evaluate medication plans. SN-Monitor for non-verbal pain indicators like grimacing or restlessness.” The POC documented the goal “Potential for pain related to neoplasm and interventions.” The plan of care did not reflect a patient or family goal for the identified problem of “comfort.” Additionally, the patient’s plan of care was updated 05/01/2026 to include interventions for the patient’s identified problem with “Quality of Life:” “SN-Involve family members in visits as available so they can remind pt of what instructions were given. Write all important information discussed at visits down for pt to look back at.” The POC documented the goal as “Memory Assistance.” The POC interventions for “Quality of Life” documented “SN-Involve family members in visits as available so they can remind pt of what instructions were given. Write all important information discussed at visits down for pt to look back at.” The goal for “Quality of Life” was documented as “Memory Assistance.” The plan of care did not reflect a patient or family goal for the identified quality-of-life problem. CLINICAL RECORD 6: The patient elected hospice care on 03/27/2026 with a diagnosis of senile degeneration of the brain. The skilled nursing assessment dated 04/19/2026 documented that the patient had a fall resulting in a skin tear: “Skin tear to rt elbow. Site cleansed, skin approximated, 3 steri strips applied, covered with dressing as pt is picking at elbow.” The plans of care effective 03/27/2026 through 06/24/2026 did not include documentation of the patient or family goal for the identified problem and interventions to address the patient’s skin tear/skin integrity. During a joint record review and an interview on 05/20/2026, the Area Executive of Clinical Operations/Administrator (Personnel Record 5) confirmed that the individualized plan of care for clinical records 3 and 6 did not include patient and family goals based on identified problems and planned interventions.”

“It is required that the hospice provides nursing care under the supervision of a registered nurse. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy and procedure #HOS-C_12A “Supervision of Hospice Aides and LP/VN Colleagues” (reviewed 12/31/2024) stated in part, “The RN is responsible to perform a supervisory visit of the LPN/LVN at least every 30 days.” In 2 of 13 (15%) clinical records reviewed for patients who received Licensed Practical Nurse (LPN) visits, the agency did not ensure that a Registered Nurse (RN) supervised the LPN services, as per agency policy. CLINICAL RECORD 1: The patient elected hospice care on 03/11/2025 with a diagnosis of senile degeneration of the brain. The hospice recertification plans of care dated 01/15/2026 through 03/15/2026, 03/16/2026 through 05/04/2025, and 05/05/2026 through 07/03/2026 ordered skilled nursing (SN) services once (1) weekly. The LPN visits began on 01/22/2026 and continued through the benefit periods reviewed (most recent LPN visit 05/07/2026). A Licensed Practical Nurse (LPN) supervisory visit was completed by the RN on 02/12/2026. A clinical record review revealed no evidence that LPN supervisory visits were completed every 30 days per agency policy between 02/12/2025 and the date of the last documented LPN visit (84 days outstanding). CLINICAL RECORD 18: The patient elected hospice care on 06/06/2025 with a diagnosis of heart failure. The hospice certification and plan of care dated 06/06/2025 through 09/03/2025 and the hospice recertification plan of care dated 09/04/2025 through 12/02/2025 ordered skilled nursing (SN) services once (1) weekly beginning 06/06/2025. The LPN visits began on 06/23/2025 and continued through benefit periods 1 and 2. The RN completed the LPN supervisory visits on 07/16/2025, 08/14/2025, and 10/16/2025. A clinical record review revealed no evidence that LPN supervisory visits were completed every 30 days per agency policy between 08/14/2025 and 10/16/2025 (63 days outstanding). During a joint record review and interview on 05/20/2026, the Area Executive of Clinical Operations/Administrator confirmed that LPN supervisory visits were not completed at least every 30 days, per agency policy. DHS_131.25(4)(a)2 Nursing services shall be provided by or under the supervision of a registered nurse and shall consist of all of the following: Supervising and teaching other nursing personnel, including licensed practical nurses, nurse aides.”

“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 to ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy and Procedure #HOS-C_12A “Supervision of Hospice Aides and LP/VN Colleagues” (reviewed 12/31/2024) read in part, “ At every scheduled visit, the RN is responsible to evaluate the care provided by the hospice aide (if one is assigned); it is required that the supervision be completed not less than every 14 days but it can be completed more frequently.” In 1 of 14 (7%) clinical records reviewed of patients who received Hospice Aide (HA) services, the agency did not ensure that a Registered Nurse (RN) made 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 HA. CLINICAL RECORD 18: The patient elected hospice care on 06/06/2025 with a diagnosis of heart failure. The plan of care dated 06/05/2025 through 09/03/2026 ordered HA services two (2) times weekly beginning the week of 03/08/2026. The HA visits were provided as ordered. The HA supervisory visits were documented as completed on 07/21/2025 and 08/14/2025 (24 days outstanding). In a joint record review and interview on 05/20/2026, the Area Executive of Clinical Operations/Administrator confirmed that HA supervisory visits were not completed every 14 days per agency policy. DHS_131.26(2)(c)1 “A registered nurse shall make 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 nurse aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient’s needs. The nurse aide does not have to be present during this visit.””

“It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. This standard was not met as evidenced by document review, interview, and personnel record review. Agency policy #HOS-C20 “Volunteer Services” (reviewed 03/19/2026) read in part, “Maintain a personnel file for volunteers which contains, at minimum, .... evidence of competency evaluation at start of role and annually....” In 1 of 12 (8%) personnel records reviewed, the agency did not ensure that the hospice assessed the skills and competencies of all individuals providing care, including volunteers. PERSONNEL RECORD 11: The Volunteer was hired on 08/06/2025. A personnel record review with the Volunteer Coordinator (Personnel Record 9) on 05/18/2026 revealed no evidence of a competency evaluation at the start of the role, per agency policy. During an interview and joint personnel record review on 05/18/2026, the Area Executive of Clinical Operations/Administrator (Personnel Record 5) confirmed that the volunteer’s personnel record (Personnel Record 11) did not include a competency at the start of the role, per agency policy. During the joint personnel record review on 05/18/2026, the Volunteer Coordinator (Personnel Record 9) confirmed the findings and stated in part, “This was identified with our internal mock survey. I have it completed on the ones just brought on (onboarded May 2026).” DHS_131.31(5) “Continuous training. A program of continuing training directed at maintenance of appropriate skill levels shall be provided for all hospice employees providing services to patients and their families.””

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: physician orders. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy and procedure #C_15B “Wound and Impaired Skin Integrity Management” (review date: 04/16/2026) read in part, “If a new skin impairment is identified, obtain orders for care from the patient’s physician.” In 1 of 19 (5%) clinical records reviewed, the agency did not ensure the patient’s clinical record contained physician orders for the care and services provided. CLINICAL RECORD 6: The patient elected hospice care on 03/27/2026 with a diagnosis of senile degeneration of the brain. The skilled nursing assessment dated 04/19/2026 documented that the patient had a fall resulting in a skin tear: “Skin tear to rt elbow. Site cleansed, skin approximated, 3 steri strips applied, covered with dressing as pt is picking at elbow.” A clinical record review revealed no evidence that a physician order was obtained for the wound care provided. In a joint record review and interview on 05/20/2026, the Area Executive of Clinical Operations/Administrator (Personnel Record 5) confirmed that clinical record 6 did not include a physician order for the wound care provided. DHS_131.33(3)(j) “Content. A patient’s clinical record shall contain all of the following: Physician orders.””