Heartland Hospice Green Bay

“Upon observation, there was no evidence the hospice is in compliance with accepted professional standards and principles for all non-core services which includes physical therapy, occupational therapy and speech-language pathology. During survey home visit, aide was noted not to follow acceptable standards of practice as noted on Patient #12: the aide was preparing to transfer the patient from the patients bed to the shower chair via the Hoyer lift. After fully extending the hospital bed to the highest level the aide noted the patients shower chair and Hoyer sling was not present in the patients room. The aide left the room prior to lowering the patients bed back into a safe position which does not align with acceptable standards of practice.”

“Upon patient record review, 4 of 19 (Patient #6, #10, #12, #13) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient# 6: The facility MAR contains an order for Hydrocortisone cream, ondansetron and morphine. The hospice medication profile does not have this order. The hospice medication profiles has a order for Ativan PRN and Warfarin. The Facility MAR does not have this order. Oxygen orders noted on the hospice medication profile as 3 Liters continuous and facility MAR had oxygen @ 2 liters as dc’d. Patient #10: Duplicate medication entries noted in the hospice medication profile for Cetirizine with different doses noted. 1 order dated 4/24/26 states to take 1 tablet daily PRN and 2nd order dated 5/15/26 states to take 1-2 tablets daily PRN. Facility MAR has an order for Haldol 4 times a day, the hospice medication profile has an order for Haldol 3 times a day. Facility MAR has order for Haldol PRN. The hospice medication profile does not have this order. Patient #12: The hospice Medication profile has a order for ClearLax and is lacking reconstituting instructions. Facility MAR order to administer Morphine every 1 hour PRN. Hospice medication profile order states to administer Morphine every 2 hours PRN. Facility MAR order for oxygen therapy 2.5-3 liters. Hospice medication profile order states to administer Oxygen @ 2 liters. The Hospice medication profile contains orders for Senna scheduled, Levothyroxine scheduled and Clearlax. The facility MAR does not have these orders. The Facility MAR has orders for Nystatin BID and Hyoscyamine PRN. The hospice medication profile does not have these orders. Patient#13: The facility MAR order states Bupropion 150mg once daily and the hospice medication profile order states Bupropion 75 mg take 2 tablets BID (300mg daily). The facility MAR order states to take Quetiapine 37.5 mg, 1 tablet BID. The hospice medication profile order states to take Quetiapine 25 mg, 1 tablet BID.”

“Upon patient record review, 1 of 19 (Patient #4) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient’s family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #4: The patient was admitted on 2-19-26. The record indicated that initial Bereavement Risk assessment was completed on 3-2-26 which is greater than the 5 day requirement.”

“Upon patient record review, 1 of 19 (Patient #13) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family’s needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient #13: SW documentation noted on 5-8-26 that RN case manager informed of identifying via assisted living report of alleged sexual abuse. No evidence of follow up documentation by the RN.”

“Upon patient record review, 2 of 19 (Patient #6, #8) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #6: A history of seizures noted within the record but lacking seizure precautions care planned with goals and interventions in place. Patient #8: Care planning was initiated for oxygen safety and use. No evidence oxygen was ordered for this patient.”

“Upon patient record review, 4 of 19 (Patient #6, #10, #12, #13) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient# 6: The facility MAR contains an order for Hydrocortisone cream, ondansetron and morphine. The hospice medication profile does not have this order. The hospice medication profiles has a order for Ativan PRN and Warfarin. The Facility MAR does not have this order. Oxygen orders noted on the hospice medication profile as 3 Liters continuous and facility MAR had oxygen @ 2 liters as dc’d. Patient #10: Facility MAR has an order for Haldol 4 time a day, the hospice medication profile has an order for Haldol 3 times a day. Facility MAR has order for Haldol PRN. The hospice medication profile does not have this order. Patient #12: The hospice Medication profile has a order for Clear Lax and is lacking reconstituting instructions. Facility MAR order to administer Morphine every 1 hour PRN. Hospice medication profile order states to administer Morphine every 2 hours PRN. Facility MAR order for oxygen therapy 2.5-3 liters. Hospice medication profile order states to administer Oxygen @ 2 liters. The Hospice medication profile contains orders for Senna scheduled, Levothyroxine scheduled and Clear lax. The facility MAR does not have these orders. The Facility MAR has orders for Nystatin BID and Hyoscyamine PRN. The hospice medication profile does not have these orders. Patient#13: The facility MAR order states Bupropion 150mg once daily and the hospice medication profile order states Bupropion 75 mg take 2 tablets BID (300mg daily). The facility MAR order states to take Quetiapine 37.5 mg, 1 tablet BID. The hospice medication profile order states to take Quetiapine 25 mg, 1 tablet BID.”

“Upon patient record review, 3 of 19 (Patient #6, #9, #14) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient #6, #14: The record instructed the aide to utilize a hoyer lift with all transfers. Lacking evidence of a written order in the medical record for a hoyer lift. Patient #9: Documentation included that the patient had a raised toilet seat. There was not evidence that this equipment was part of the care plan or a written order for placement.”

“Upon observation, there was no evidence the hospice investigates all adverse events, incidents, accidents, variances or unusual occurrences that involve patient care and develops a plan of correction to prevent the same or similar event from occurring again. Patient 10: The medical record contained nursing documentation 4/19/26 identifying patient had a fall. There was no evidence of an investigation of the incident and plan to prevent similar events from occurring. Patient 13: The medical record contained social worker documentation 5/8/26 identifying the assisted living facility reported to hospice that the patient was sexually assaulted by another facility patient, and the facility reported the incident to the police and state authorities. There was no evidence the sexual abuse was reported to hospice leadership as required per Policy No. 2-035 and no evidence of an investigation into the incident.”

“Upon home visit observation in 1 of 4 visits, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient # 10. During the scheduled home observation visit the RN was observed placing her equipment bag on the seat of the patients wheelchair. No evidence of the area being sanitized by RN prior to setting her bag down. A paper towel was placed on the wheelchair seat as a barrier by the nurse. Despite placing this barrier the nursing bag remained in direct contact with the wheelchair. Agency policy requires bag to be placed on a barrier or a hard, clean surface.”

“Upon patient record review, 3 of 19 (Patient #2, #10, #12) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #2: The aide plan of care did not indicate the patient had an active wound. The aide plan of care was lacking additional details related to the location, instructions for care with an adhesive dressing and who to report findings to if dressing is soiled, becomes wet or dislodged during cares. Last home health plan of care updated was performed on 4/28/26 and did not include the patients active wound. Patient #10: The aide plan of care indicated both bed bath and shower to alternate between visit days. On 04/26/26 the aide frequency was changed from 2 times a week to 1 time a week. Aide care plan was not updated to reflect frequency change and bathing preference. Patient #12: The aide plan of care indicated oxygen precautions in place stating patient to utilize Oxygen @ 2.5L via nasal cannula. There is not evidence that the aide plan of care was updated to reflect the current Oxygen orders for 2L via nasal cannula.”

“Upon patient record review 4 of 19 (Patient #3, #5, #13,#14) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #3: Aide plan of care indicated shaving was to be completed 1 time a week. Aide was noted to complete this task on every visit. Patient #5 Aide plan of care indicated to alternate providing Showers and bed baths weekly. No evidence a shower was provided during the week of 5-10-26. Patient #13 The aide plan of care indicates to alternate providing a shower and bed bath each visit. No evidence a shower was provided during the week of 5-10-26. Patient #14 The aide plan of care indicates to alternate providing a sponge bath and shower weekly. No evidence a shower was performed since 4-14-26.”

“Upon patient record review, 1 of 19 (Patient #6) did not have evidence that the hospice provided the following information: • The most recent hospice plan of care specific to each patient • Physician certification and recertification of the terminal illness specific to each patient • Names and contact information for hospice personnel involved in hospice care of each patient • Hospice medication information specific to each patient • Hospice physician and attending physician (if any) orders specific to each patient Patient #6: During the Long Term Care facility onsite visit it was identified the hospice binder was not updated timely to include the most recent hospice plan of care, Hospice election form, the Physician certification and recertification of the terminal illness, current Hospice medication information, Hospice physician and attending physician (if any) orders and identification of the hospice team members. Evidence of updates occurred during survey.”