Compassus Neenah

“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 #C_12A “Supervision of Hospice Aides and LP/VN Colleagues” (dated 08/18/2022) read in part, “The registered nurse is responsible to perform a supervisory visit of the LPN/LVN at least every 30 days.” In 2 of 19 (11%) clinical records reviewed, the agency did not ensure that Licensed Practical Nurses (LPN) were supervised by a Registered Nurse (RN) at least every 30 days per the agency policy. Clinical Record 3: The patient elected the hospice benefit on 06/30/2023. The plans of care dated 06/30/2023-09/27/2023 and 09/28/2023-12/25/2023 ordered skilled nursing (SN) “SN 1x/week.” A clinical record review revealed skilled nursing visits performed by a LPN dated 07/21/2023, 11/01/2023, and 11/15/2023. The first LPN supervisory visit was dated 11/22/2023, with 64 days outstanding. Clinical Record 10: The patient elected the hospice benefit on 12/30/2023. The plans of care dated 03/29/2024-06/26/2024, 06/27/2024-08/25/2024, and 08/26/2024-10/24/2024 ordered “SN 1x/week.” A clinical record review revealed skilled nursing visits performed by a LPN dated 04/09/2024, 04/25/2024, 07/19/2024, 08/07/2024, 09/10/2024, and 09/25/2024. The first LPN supervisory visit was dated 10/02/2024, with 146 days outstanding. During a joint record review on 01/07/2025, the Director of Clinical Services confirmed that the LPN supervisory visits were completed less frequently than every 30 days.”

“It is required that a hospice aide provides services: ordered by the Interdisciplinary Group; included in the plan of care; permitted to be performed under state law and regulation; [and] consistent with the hospice aide training. This standard was not met as evidenced by clinical record review and interview. In 4 of 14 (29%) clinical records reviewed of patients with Hospice Aide services, the agency did not ensure that aide services were provided as written in the plan of care. Clinical Record 4: The patient elected the hospice benefit on 12/23/2024. The plan of care dated 12/23/2024-03/21/2025 ordered “Aide 2x per week.” The Hospice Aide (HA) care plan dated 12/23/2024 assigned the Hospice Aide the relevant task: “Weigh patient at first visit of the month.” The first HA visit for January 2025 was dated 01/03/2025. The HA visit note dated 01/03/2025 did not include documentation of the patient being weighed. Clinical Record 8: The patient elected the hospice benefit on 11/01/2024. The plan of care dated 11/01/2024-01/29/2025 ordered “Aide 2x per week.” The HA care plan dated 11/01/2024 assigned the HA the relevant task: “Weigh patient at first visit of the month.” A clinical record review revealed no evidence of the patient being weighed during HA visits. Clinical Record 12: The patient elected the hospice benefit on 06/26/2024. The plans of care dated 06/26/2024-09/23/2024 and 09/24/2024-12/22/2024 ordered “Aide 2x per week.” The HA care plan dated 06/26/2024 assigned the HA the relevant task: “Weigh patient at first visit of the month.” The first HA visit for September 2024 was dated 09/03/2024. The HA visit note dated 09/03/2024 did not include documentation of the patient being weighed. The first HA visit for October 2024 was dated 10/02/2024. The HA visit note dated 10/02/2024 did not include documentation of the patient being weighed. The first HA visit for December 2024 was dated 12/02/2024. The HA visit note dated 12/02/2024 did not include documentation of the patient being weighed. Clinical Record 13: The patient elected the hospice benefit on 11/09/2024. The plan of care dated 11/09/2024-02/06/2025 ordered “Aide 1x per week.” The HA care plan dated 11/14/2024 assigned the HA the relevant task: “Weigh patient at first visit of the month.” The first HA visit for December 2024 was dated 12/05/2024. The HA visit note dated 12/05/2024 did not include documentation of the patient being weighed. During a joint record review on 01/07/2025, the Director of Clinical Services confirmed that the HA did not document the patients’ weight as written in the HA care plan. State regulations: “DHS 131.26, Nurse aide services. The hospice may provide nurse aide services as follows: (a) Assignment. Nurse aides are assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group. Written patient care instructions for a nurse aide shall be prepared by a registered nurse who is responsible for the supervision of a nurse aide as specified under par. (c).””

“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 need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed of patients who received Hospice Aide (HA) services, the agency did not ensure that HA supervisory visits were completed no less frequently than every 14 days. Clinical Record 3: The patient elected the hospice benefit on 06/30/2023. The plan of care dated 06/24/2024-08/22/2024 and 08/23/2024-10/21/2024 ordered “Aide 2x/week.” A clinical record review revealed a HA supervisory visit dated 08/06/2024. The next HA supervisory visit was dated 09/10/2024, with 35 days outstanding. Clinical Record 10: The patient elected the hospice benefit on 12/30/2023. The plans of care dated 03/29/2024-06/26/2024 and 08/26/2024-10/24/2024 ordered “Aide 2x/week.” A Hospice Aide supervisory visit was documented on 04/02/2024. The next HA supervisory visit was documented on 04/17/2024, with 15 days outstanding. A Hospice Aide supervisory visit was documented on 10/02/2024. The next HA supervisory visit was documented on 10/17/2024, with 15 days outstanding. During a joint record on 01/07/2025, the Director of Clinical Services confirmed that HA supervisory visits were not completed less frequently than every 14 days. State Regulations: “DHS 131.26 Non-core services. (2) Nurse Aide Services. The hospice may provide nurse aide services as follows:(c) Supervision of nurse aides.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.””

“Based on record review and interview, the agency failed to ensure nursing staff addressed the needs of the patients and/or caregivers on an as needed basis (on-call) in 1 of 4 patients requiring on-call services (Patient #1) in a total of 10 patient records reviewed. Findings include: Review of agency policy titled “;On-Call Services” dated 07/21/2022 revealed in part, “;Purpose: To ensure timely and appropriate intervention is provided by trained professional staff as needed by patients, families and facility-based caregivers during non-business hours and ensure compliance with 42 CFR 418.100 regarding availability of services on a 24-hour/day, 7-day/week basis. On-Call Requirements: 1. Availability: a. The on-call RN (Registered Nurse) is available to respond to all calls received from the beginning to the end of the on-call shift. Available means ready to perform an admission, make a visit, and/or assume the response to afterhours needs. c. All calls are addressed and the response documented in the clinical record via the EMR (Electronic Medical Record). 2. Response: a. The expectation from our patients is a compassionate, professional response to a perceived concern or need, regardless of when the concern or need is expressed. The Compassus on-call nurse is expected to respond as quickly as possible to requests for after-hours support, including visits when indicated. 4. Care Delivery: Calls received during non-business hours indicate a need for patient/family/caregiver reassurance in some fashion...When a call is routed to the on-call nurse, the first duty is to determine whether the nurse should provide on-site nursing assessment or care for the hospice patient. In the following situations, a visit is necessary to establish a baseline for care plan management: ii. The patient has a change in condition including escalation of pain or other symptoms associated with their disease process or the terminal trajectory of dying. v. The patients caregiver requests a visit for support. vi. If the patient or caregiver calls more than 1 times in an after-hours shift, a visit is made to provide in-person support, assessment, and reassurance. 5. Documentation: a. All interactions with the patient/family/facility caregivers are documented according to standard clinical record requirements. Coordination notes are completed for phone calls and visit notes are completed at the time of any visit.” Review of Patient #1s hospice record revealed Patient #1 was admitted to Compassus Hospice on 07/24/2023 with primary diagnosis of Malignant Neoplasm of colon, unspecified. Patient #1 passed away 04/25/2024 at home on hospice services. Review of this agencys “;On-Call Log” and associated documentation from 02/25/2024 to 04/25/2024 for Patient #1 revealed, in part: 03/02/2024 On-Call Log: “;8:07 PM: Call from Complainant A. Stated she needs to know how to get stoma swelling to go down. Please call.” There was no documented evidence of a phone call or visit made by the SN (Skilled Nurse) on 03/02/2024 that addressed the patient needs related to the stoma. A SN visit was not made until 03/05/2024 at 12:42 PM. 04/19/2024 On-Call Log: “;7:41 PM: Call from Complainant A. Have not been updated on who is supposed to be visiting patient today or who is coming to change patients colostomy bag as the site is currently bleeding. Please call as soon as possible.” There was no documented evidence of a phone call or visit made by the SN on 04/19/2024 that addressed the patient needs related to issues with colostomy bag. A SN visit was not made until 04/23/2024 at 9:46 AM. 04/22/2024 On-Call Log: “;8:58 PM: Call from Complainant A. Patient is very aggressive and agitated. Morphine and Lorazepam is not working. Patient needs a medication change. Per caller, patients regular nurse Nurse D is a constant no show and no call.” 04/22/2024: Medication order entered for Seroquel for mood/sleep. There was no documented evidence of a phone call or visit made by the SN on 04/22/2024 to assess Patient #1’s change in condition and assess effectiveness with change in medication. A SN visit was not made until 4/23/2024 at 9:46 AM. 04/24/2024 On-Call Log: “;8:10 PM: Call from Complainant A. Patient has the death rattle and caller is requesting a nurse...to come out” 04/24/2024: Medication order entered for Atropine eye drops for excessive secretions. There was no documented evidence of a phone call or visit made by the SN on 04/24/2024 to assess the needs of the patient/caregiver. A SN visit was not made until 4/25/2024 at 9:28 AM. During an interview with DCS (Director of Clinical Services) B on 06/10/2024 at 2:35 PM, when asked for the Case Coordination notes for the dates of 04/19/2024 and 04/22/2024, DCS B replied, “;Those last dates noted with the death rattle and medication issues, I couldnt find a case coordination note for those.” During an interview with DCS B and ACO (Area Executive Clinical Operations) C on 06/10/2024 at 3:20 PM, when asked what the agencys process and expectations are for nurse on-call visit or patient calls taken after hours with concerns or requesting a visit, ACO C replied, “;We triage the best we can and may remedy or teach over the phone before going and making a visit. With terminal congestion or pain then we may make a visit.” When asked about on-call log SN documentation for Patient #1 on 03/02/2024 not addressing concerns about the stoma, DCS B replied, “;The only thing is that it might not have been brought up when the nurse took the call.” When asked about on-call log SN documentation for Patient #1 on 04/19/2024 not addressing concerns about who was coming to see the patient and to change Patient #1s colostomy bag, DCS B replied, “;Theres no coordination note. The on-call nurse called me (DCS B) to discuss the call. It was the nurses first time on-call but did not document and no, a visit was not made.” When asked about on-call log SN documentation for Patient #1 on 04/22/2024 not addressing concerns about patient change in condition, ACO C replied, “;With the change in condition, I would have expected a visit or at least a follow-up phone call to see if the medication changes were effective.” When asked about on-call log SN documentation for Patient #1 on 04/24/2024 not addressing concerns about death rattle and request for a nurse, ACO C replied, “;The scheduled daily visit was made the next morning. My assumption is the nurse would have seen a visit was scheduled the next day and discussed with Complainant A if a visit was needed.” DCS B added, “;There is no documentation of case coordination for this call. No, a visit was not made until the next day.””