Compassus Milwaukee

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current: prescription and over-the-counter (OTC) drugs: supplements; herbal remedies;[and] other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: the effectiveness of drug therapy; drug side effects; actual or potential drug interactions; duplicate drug therapy; drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review, observation, and interview. Agency policy and procedure C_15C “Medication Reconciliation” (Revision date 01/20/2019) read in part, “Regardless of setting, it is the responsibility of the registered nurse completing the admission to complete a comprehensive medication review and reconciliation. It s the responsibility of the nurse to perform a medication review at each nursing visit. If the medications lists do NOT match, the nurse ensures the incorrect list is promptly updated to reflects the correct orders. In 4 of 14 (29%) clinical records reviewed and home visit observations, the agency did not ensure that the comprehensive assessment included a review of the patient’s current medications. Clinical Record 1/Home Visit 1: The patient elected hospice care on 02/01/2024 and resided in a skilled nursing facility (SNF). The initial assessment completed by the Registered Nurse (RN) on 02/01/2024 documented that the patient was using 10 liters per minute (LPM) of oxygen with difficulty titrating below 7 LPM. During the home visit on 02/28/2024, a review of the SNF medication record revealed “oxygen 1-10L/min per NC continuous.” Oxygen was not documented on the hospice medication profile. Clinical Record 2/ Home Visit 2: The patient elected hospice care on 06/26/2023. A medication reconciliation was completed during the home visit on 02/28/2024. The patient’s son filled the Mediset pillbox during the home visit. The plan of care dated 12/23/2024 - 02/20/2024, updated and signed effective 02/20/2024, ordered: “Bisacodyl 10 mg rectal suppository daily.” The patient stated that he does not take a suppository. The Registered Nurse (RN) [Personnel Record 1] present during the home visit stated the order should read “PRN” (as needed) and stated they would update the order. The hospice medication profile documented two entries for Omeprazole: “Omeprazole 40 mg capsule, delayed release one capsule twice a day” and “Omeprazole 40 mg capsule, delayed release one tablet at bedtime.” The son reported that the patient takes Omeprazole once a day at bedtime. The RN [Personnel Record 1] stated the order was changed from twice a day to once daily at bedtime on 09/26/2024 but did not get changed on the medication profile. The medication profile was not updated to include documentation of the patient’s current medication regimen. Clinical Record 3/Home Visit 3: The patient elected hospice care on 02/20/2024 and resided in an assisted living facility (ALF). The ALF staff manages the patient’s medications. The hospice medication profile and the ALF medication records documented orders for prednisone. The orders for tapering the medication were different between the hospice medication profile and the ALF medication record. Both medication records included tapering prednisone from 40mg to 30 mg to 20 mg to 10 mg with a taper every three days. However, the hospice medication profile documented prednisone 6 mg to start on 03/03/2024, and the ALF medication record documented prednisone 6 mg to start on 03/01/2024. The RN [Personnel Record 1] confirmed the finding and stated they would get clarification. Clinical Record 9: The patient elected hospice care on 12/19/2023 with the diagnoses of Pulmonary Fibrosis and Pulmonary Hypertension. The initial assessment completed by the Registered Nurse (RN) on 12/19/2023 documented that the patient was cyanotic with and without oxygen and was using oxygen at 5 LPM continuously. Oxygen was not documented on the hospice medication profile. During an interview on 02/27/2024, the Area Director confirmed that oxygen was not on the medication profile for clinical record #1 or #9.”

“It is required that the hospice designates a registered nurse member of the IDG to provide coordination of care and ensure continuous assessment of each patient’s and family’s needs and the implementation of the interdisciplinary plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure the Registered Nurse (RN) member of the IDG provided coordination of care, ensured continuous assessment of the patient’s and family’s needs and the implementation of the interdisciplinary care plan. Clinical Record 11: The Registered Nurse (RN) completed the start of care assessment on 01/05/2024 which included documentation of a psychosocial and spiritual assessment. The coordination note dated 01/10/2024 documented “SW (Social Worker) completed assess...SW completed an assessment with information from the patient chart on this day D/T (do to) no return call from the family. The patient is a full-code, and there is no funeral home on file. SW to follow pt 1x/mo to assess other psychosocial needs.” The coordination note completed by the Chaplain (SCC) on 01/10/2024 documented, “SCC called POA (Power of Attorney) to schedule a visit. No answer. Left a message and did an office assessment.” A clinical record review revealed that SW and SCC assessment forms were completed during the phone call and patient record review. The record did not include documentation of attempts by the SW or the SCC to reach the patient or caregiver prior to 01/10/2024 and prior to the patient’s discharge. On 01/10/2024, visit notes were documented by the Skilled Nurse (SN) and Hospice Aide. During an interview on 02/28/2024, the Area Director confirmed that the SW and SCC assessments for clinical record 11 were not completed appropriately in the home. The Area Director stated in part, “I have spoken to all parties involved and have clarified the expectations post-COVID. I have begun a PIP and a monitoring process.””

“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 clinical record review and interview. 1 of 14 (7%) clinical records reviewed, the agency did not ensure that the individualized written plan of care identified planned interventions based on problems identified in the comprehensive assessment. Clinical Record 9: The patient elected hospice care on 12/19/2023 with the diagnoses of Pulmonary Fibrosis and Pulmonary Hypertension. The initial assessment completed by the Registered Nurse (RN) on 12/19/2023 documented the patient was cyanotic with and without oxygen, and the patient was using oxygen at 5 liters per minute (LPM) continuously. The plan of care dated 12/19/2023 did not include interventions for oxygen administration. In an interview on 02/27/2024, the Director of Clinical Services (DCS) confirmed that oxygen administration interventions were not included in 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: drugs and treatment necessary to meet the needs of the patient. This standard was not met, as evidenced by clinical record review, observation, and interview. In 2 of 14 (14%) clinical records reviewed, the agency did not ensure that the patient’s written plan of care included medications necessary to meet the patient’s needs. Clinical Record 1/Home Visit 1: The patient elected hospice care on 02/01/2024 and resided in a skilled nursing facility (SNF). The initial assessment completed by the Registered Nurse (RN) on 02/01/2024 documented that the patient was using 10 liters per minute (LPM) of oxygen with difficulty titrating below 7 LPM. During the home visit on 02/28/2024, a review of the SNF medication record revealed “oxygen 1-10L/min per NC continuous.” The plan of care did not document oxygen. Clinical Record 9: The patient elected hospice care on 12/19/2023 with the diagnoses of Pulmonary Fibrosis and Pulmonary Hypertension. The initial assessment completed by the Registered Nurse (RN) on 12/19/2023 documented that the patient was cyanotic with and without oxygen and was using oxygen at 5 LPM continuously. Oxygen was not documented on the plan of care dated 12/19/2024. In an interview on 02/27/2024, the Director of Clinical Services (DCS) confirmed that oxygen and administration, including the dose, route, and frequency, were not included in the plan of care.”

“It is required that consistent with current professional standards of practice, licensed professionals actively participate in the coordination of all aspects of patient care including conducting ongoing interdisciplinary comprehensive assessments, developing and evaluating the plan of care, contributing to patient and family counseling and education. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed, the agency did not ensure that the Social Worker (SW) and Chaplain (SCC) actively participated in the comprehensive assessment and made adequate attempts to contribute to the patient’s assessment and plan of care development. Clinical Record 5: The patient elected hospice care, and the initial comprehensive assessment was completed by the RN on 02/16/2024 and included documentation of a spiritual and psychosocial assessment. A review of the assessment form completed by the SCC on 2/20/2024 revealed no patient contact. The SCC assessment form documented that the SCC spoke to the wife on the phone and would see the patient one time per month. A clinical record review revealed no documented evidence of further attempts to complete an in-home SCC assessment. Clinical Record 11: The Registered Nurse (RN) completed the start of care assessment on 01/05/2024 which included documentation of a spiritual and psychosocial assessment. The coordination note dated 01/10/2024 documented “SW (Social Worker) completed assess...SW completed an assessment with information from the patient chart on this day D/T (do to) no return call from the family. The patient is a full-code, and there is no funeral home on file. SW to follow pt 1x/mo to assess other psychosocial needs.” The coordination note completed by the Chaplain (SCC) on 01/10/2024 documented, “SCC called POA (Power of Attorney) to schedule a visit. No answer. Left a message and did an office assessment.” A clinical record review revealed that SW and SCC documented assessment forms during the phone call and patient record review. The record did not include documentation of attempts by the SW or the SCC to reach the patient or caregiver prior to 01/10/2024 and prior to the patient’s discharge. On 01/10/2024, visit notes were documented by the Skilled Nurse (SN) and Hospice Aide. The skilled nursing (SN) note dated 01/22/2024 documented that the patient’s out-of-town daughter wanted the patient to come live with her. The custodial daughter had concerns about moving the patient related to drug diversion and comments the other sister had made related to narcotics. A review of the clinical record revealed no documented evidence of SW involvement or coordination. The patient was discharged from hospice care on 01/29/2023 due to moving out of the area. There was no evidence that an in-home visit from the SW or SCC was completed. During an interview on 02/28/2024, the Area Director confirmed that the SCC and SW did not adequately assess and provide interdisciplinary collaboration in records 5 and 11.”

“It is required that counseling services include spiritual counseling. The hospice provides an assessment of the patient’s and family’s spiritual needs. Spiritual counseling to meet spiritual needs is provided in accordance with the patient’s and family’s acceptance of the services and in a manner consistent with the patient and family beliefs and desires. The hospice advises the patient and family of spiritual counseling services and documents the acceptance or refusal of services. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed with a spiritual counseling need identified, the agency did not ensure that the spiritual needs were assessed and addressed by a spiritual counselor. Clinical Record 6: The patient elected hospice care on 02/08/2024. The initial comprehensive assessment completed by the Registered Nurse (RN) dated 02/08/2024 documented that fear and punishment were psychosocial/spiritual factors that influence pain and that a referral was made to chaplain/pastoral counselor related to spiritual existential concerns. As of 02/29/2024, the patient has not been seen by the Chaplain. The Chaplain assessment dated 02/13/2024 documented only that a phone message was left with no return call. A review of the clinical record revealed no further attempts documented to meet with the patient. The Area Director confirmed in an interview on 02/28/2024 that the Chaplain did not appropriately complete an assessment.”

“It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. This standard was not met as evidenced by clinical record review and interview. In 1 of 13 (15%) clinical records reviewed of patients receiving Hospice Aide services, the agency did not ensure that the Hospice Aide (HA) reported changes in the patient’s medical, nursing, and social needs as the changes related to the plan of care, to a Registered Nurse (RN). Clinical Record 6: The patient elected hospice care on 02/08/2024. The initial comprehensive assessment completed by the Registered Nurse (RN) dated 02/08/2024 documented the patient’s weakness and risk for falls. The HA care updated on 02/12/2024 assigned the HA the relevant tasks: aide to dress, hair care, standby assist with ambulation, transfer to /from bed/chair, standby assist and 2 wheeled walker (WW) with activity. The HA visit note dated 02/14/2023 documented stand by assistance with ambulation and assist with transfers to/from bed/chair, were “not required this visit.” The HA documented that the patient walked to the door to let the HA in. A clinical record review revealed no evidence that the HA reported the changes in the patient’s needs related to the care plan to the RN. The Director of Clinical Services (DCS) and the Area Director of Operations (ACO) confirmed the findings in an interview on 02/27/2024. The DCS stated, in part, that we just talked about this with staff.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. Each patient’s record includes, at a minimum: physician orders. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed, the agency did not ensure the patient’s clinical record included physician orders for care and services. Clinical Record 1: The patient elected hospice care on 02/01/2024 and resided in a skilled nursing facility (SNF). The initial assessment completed by the Registered Nurse (RN) on 02/01/2024 documented that the patient was using 10 liters per minute (LPM) of oxygen with difficulty titrating below 7 LPM. The plan of care dated 02/01/2024 documented interventions and goals to address respiratory discomfort. The plan of care did not document an order for oxygen. The medical director documented in the IDG notes on 2/20/2024 that the medication list had been reviewed and approved, but there was no mention of oxygen. A clinical record review revealed no evidence of a physician order documenting the use of oxygen. Clinical Record 9: The patient elected hospice care on 12/19/2023. The initial assessment completed by the Registered Nurse (RN) on 12/19/2023 documented the patient was using oxygen 5 LPM continuously and the need for continued oxygen. Oxygen was not documented on the plan of care dated 12/19/2024. A clinical record review revealed no evidence of a physician order documenting the use of oxygen. In an interview on 02/27/2024, the Director of Clinical Services confirmed that no oxygen orders were in the clinical records.”