Compassus Central Wisconsin

“Hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG in collaboration with the attending physician (if any), the patient or patient representative if any of them so desire, and the primary caregiver in accordance with the patient’s needs if any of them so desire. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed of patients with documented wounds, the agency did not ensure that the hospice care provided followed the individualized plan of care established by the hospice IDG in collaboration with the attending physician. Clinical Record 7: The patient elected the hospice benefit on 10/11/2024. The Registered Nurse (RN) visit note dated 10/11/2024 documented that the patient had a stage 2 pressure ulcer to the buttocks. An order for wound care documented, “Cleanse with soap and water, cover with border foam, using sterile technique. Dressing to be changed 3x per week by caregiver or RN. Hospice RN to measure weekly.” The initial comprehensive assessment dated 10/11/2024 did not document a wound assessment and measurements. The RN documented “wound care not provided due to caregiver completed care.” The RN assessment dated 10/12/2024 did not document a wound assessment and measurements. The RN documented “no wound care provided due to caregiver completed.” On 10/14/2024, the RN documented “provided decubitus care per orders. Dressing removed and large adhesive bandage placed due to bordered foam not being the right size.” No measurements were documented. The RN assessment dated 10/23/2024 did not document wound measurements or wound care provided. During an interview on 01/22/2025, the Clinical Director stated that the RN did not follow the order for wound care that was written by the physician. Clinical Record 8: The patient elected the hospice benefit on 12/23/2024. The initial assessment completed by the RN dated 12/23/2024 documented that the patient had a “left heel diabetic ulcer (L)2x(W)2.5x(D)0.5, surface area 5, depth description full thick, shape round, edges rolled.” On 12/23/2024, the physician ordered wound care for the patient’s left heel: “irrigate with normal saline, pat dry, apply mupirocin ointment, cover with abd pad, and wrap with ace wrap. Hospice nurse to assess and take measurements weekly.” The RN visit notes dated 01/02/2025 and 01/07/2025 did not document a wound assessment and measurements. The RN documented that the wound was healed on 01/14/2025. During an interview on 01/22/2025, the Clinical Director agreed that the RN did not follow orders written by the physician or the plan of care developed by the IDG team. State regulation: “Subchapter III — Patient Care” DHS 131.21 Plan of care. (1) General requirements. A written plan of care shall be established and maintained for each patient admitted to the hospice program and the patient’s family. The hospice plan of care is a document that describes both the palliative and supportive care to be provided by the hospice to the patient and the patient’s family, as well as the manner by which the hospice will provide that care. The care provided to the patient and the patient’s family shall be in accordance with the plan of care.””

“It is required that each patient’s individualized written plan of care: includes all services necessary for the palliation and management of the terminal illness, including the following: measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed of patients with wounds, the agency did not ensure that the patient’s plan of care included measurable outcomes anticipated from implementing and coordinating the plan of care. Clinical Record 7: The patient elected the hospice benefit on 10/11/2024. The RN visit note dated 10/11/2024 documented that the patient had a stage 2 pressure ulcer to the buttocks. The physician ordered wound care, “cleanse with soap and water, cover with border foam, using sterile technique. Dressing to be changed 3x per week by caregiver or RN. Hospice RN to measure weekly.” The plan of care dated 10/11/2024 did not include documented measurable outcomes or goals for wound care. During an interview on 01/22/2025, the Area Executive Clinical Director agreed that the plan of care did not document goals with measurable outcomes. Clinical Record 8: The patient elected the hospice benefit on 12/23/2024. The Registered Nurse (RN) initial assessment dated 12/23/2024 documented that the patient had a “left heel diabetic ulcer (L)2x(W)2.5x(D)0.5, surface area 5, depth description full thick, shape round, edges rolled.” On 12/23/2024, the physician ordered wound care for the patient’s left heel: “irrigate with normal saline, pat dry, apply mupirocin ointment, cover with abd pad, and wrap with ace wrap. Hospice nurse to assess and take measurements weekly.” The plan of care dated 12/23/2024 did not include documented measurable outcomes or goals for wound care. During an interview on 01/22/2025, the Area Executive Clinical Director agreed that the plan of care did not document goals with measurable outcomes. State regulation: “Subchapter III — Patient Care” DHS 131.21(3)(b)(3) Plan of care (b) Content of the plan of care. The hospice shall develop an individualized written plan of care for each patient. The plan of care shall reflect patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care shall include all services necessary for the palliation and management of the terminal illness and related conditions, including all of the following: Measurable outcomes anticipated from implementing and coordinating the plan of care.”