Interim Hospice and Palliative Care

“Based on record review and interview, the agency failed to complete a full-scale exercise to test the emergency plan for the full agency program in 1 of 1 Emergency Preparedness Programs reviewed. Findings include:Record review of State of Wisconsin issued letter and licensure dated 02/16/2024 revealed a branch location in Green Bay, WI was approved on 02/08/2024.Record review of agency patient census list effective 04/28/2025 revealed the Green Bay branch location has a total of 4 patients. The oldest start of care date listed for this branch admitting a patient was 06/06/2024.Record review of this agency’s “After Action Report” (dated 03/04/2025 - 03/05/2025) revealed this agency did not include the Green Bay branch location in the testing of the full-scale exercise for Emergency Preparedness. The last evidence of a testing for a full-scale exercise for the Green Bay branch was 06/15/2022, when this location was not a hospice branch at the time.During an interview with Director A on 04/29/2025 at 1:30PM, when asked if the Green Bay branch was included in the emergency preparedness program testing exercise, Director A replied, “I don’t think they found anything.””

“Based on record review and interview, the agency failed to develop a POC (Plan of Care) with goals and/or interventions individualized to meet the needs of the patient in 7 of 19 records reviewed (Patients #4, #5, #8, #10, #11, #12, and #18). Findings include: Review of agency policy “IDG (Interdisciplinary Group) Plan of Care” dated 12/02/2008 revealed “Policy: An individualized plan of care is established for each patient/family by the Hospice IDG in collaboration with the patient/family and the attending physician, if any. The IDG plan of care reflects patient/family goals and interventions based on the findings of the initial and updated comprehensive assessments. 4. The plan of care includes, but is not limited to the following: a) Interventions to manage pain and symptoms; e) Measurable outcomes anticipated as a result of implementing and coordinating the care plan.”Record review of Patient #4’s “Comprehensive Plan of Care” dated 02/04/2025 to 05/04/2025 with primary diagnoses of Leukemia. The POC revealed under Pain “Teach Pain Management: Patient/caregiver will describe pharmacological and non-pharmacological interventions that can be used to achieve self-identified pain goal and when to notify hospice team.” Patient #4’s POC lacked individualized interventions and goals related to pain.Record review of Patient #5’s “Comprehensive Plan of Care” dated 03/06/2025 to 06/03/2025 with primary diagnoses Chronic Congestive Heart Failure and record revealed Patient #5 had issues with back pain. The POC revealed under Pain “Teach Pain Management: Patient/caregiver will describe pharmacological and non-pharmacological interventions that can be used to achieve self-identified pain goal and when to notify hospice team. Patient will report pain using standardized pain scale, establish a self-identified pain goal and report/demonstrate that pain is managed at or below this level.” Patient #5’s POC lacked individualized interventions and goals related to pain.Record review of Patient #8’s “Comprehensive Plan of Care” dated 04/08/2025 to 07/06/2025 with primary diagnoses of Chronic Obstructive Pulmonary. The POC revealed under Pain “Teach Pain Management: Patient/caregiver will describe pharmacological and non-pharmacological interventions that can be used to achieve self-identified pain goal and when to notify hospice team. Patient will report pain using standardized pain scale, establish a self-identified pain goal and report/demonstrate that pain is managed at or below this level.” Patient #8’s POC lacked individualized interventions and goals related to pain.Record review of Patient #10’s “Comprehensive Plan of Care” dated 04/17/2025 to 07/15/2025 with primary diagnoses of Chronic Congestive Heart Failure. The POC revealed under Pain “Teach Pain Management: Patient/caregiver will describe pharmacological and non-pharmacological interventions that can be used to achieve self-identified pain goal and when to notify hospice team.” Patient #10’s POC lacked individualized interventions and goals related to pain.Record review of Patient #11’s “Comprehensive Plan of Care” dated 02/20/2025 to 05/20/2025 with primary diagnoses of Emphysema. The POC revealed under Pain “Teach Pain Management: Patient/caregiver will describe pharmacological and non-pharmacological interventions that can be used to achieve self-identified pain goal and when to notify hospice team.” Patient #11’s POC lacked individualized interventions and goals related to pain.Record review of Patient #12’s “Comprehensive Plan of Care” dated 03/05/2025 to 06/02/2025 with primary diagnoses Parkinson’s Disease and record revealed Patient #12 had issues with chronic back pain. The POC revealed under Pain “Teach Pain Management: Patient/caregiver will describe pharmacological and non-pharmacological interventions that can be used to achieve self-identified pain goal and when to notify hospice team.” Patient #12’s POC lacked individualized interventions related to pain.Record review of Patient #18’s “Comprehensive Plan of Care” dated 02/03/2025 to 02/09/2025 with primary diagnoses Atherosclerotic Heart Disease revealed under Pain “Teach Pain Management: Patient/caregiver will describe pharmacological and non-pharmacological interventions that can be used to achieve self-identified pain goal and when to notify hospice team. Patient will report pain using standardized pain scale, establish a self-identified pain goal and report/demonstrate that pain is managed at or below this level.” Patient #18’s POC lacked individualized interventions and goals related to pain.During an interview with Director A on 04/29/2025 at 2:25 PM, when asked about the agency’s expectations for POC related to goals and interventions, Director A replied, “They should be individualized. I’ve done audits and know this has been an issue.””

“Based on record review and interview the agency staff failed to include all ordered medications on the plan of care (POC) to meet the patients needs in 1 of 19 (#1) patient records reviewed. Findings include:Review of agency policy titled, “Comprehensive Assessment of Patient/Family Need” dated 12/02/2008 revealed, under heading, “Procedure 1. f) A review of all of the patients prescriptions and over-the-counter drugs, herbal remedies and any alternative treatment.”Review of Patient #1’s medical record revealed Patient #1 was admitted to hospice on 05/14/2024 with a diagnosis Huntington’s disease and resides at an assisted living facility (ALF). Frequencies include skilled nursing 1x/week and hospice aide 2x/week.Review of Patient #1’’s facility medication profile dated 04/28/2025 revealed, “Ensure three times a day start date of 01/21/2025, Hyoscyamine Sulfate oral tablet 0.125 MG one tablet every 4 hours as needed with a start date of 07/12/2024, Melatonin oral liquid 5 MG/ML (milliliter) give 5 MG one time a day for sleep with a start date of 03/07/2025, Preparation H Rapid Relief External Cream four times daily as needed with a start date of 04/16/2025, Prochlorperazine Maleate 10 MG one tablet every 12 hours as needed with a start date of 07/12/2024, Tylenol extra strength 500 MG two tablets four times a day with a start date of 03/12/2025, Senna 8.6 MG one tablet two times a day with a start date of 04/16/2025, and Senna 8.6 MG one tablet every 24 hours as needed with a start date of 04/04/2025.”Review of Patient #1’s hospice medication profile dated 03/10/2025 - 05/08/2025 on 04/28/2025 revealed, none of the medications listed above were included on the hospice medication profile.During an interview with Hospice Registered Nurse (RN) E on 04/28/2025 at 1:30 PM, RN H stated that medications are reviewed/reconciled every comprehensive assessment and that she verbally checks with facility staff and healthcare power of attorney of Patient #1 at each visit.During an interview with Director A on 04/29/2025 at 2:25 PM, Director A stated that the expectation is for medications to be updated every comprehensive assessment and each Interdisciplinary group (IDG) meeting.”

“Based on record review and interview the agency staff failed to review/revise Patients plan of care per agency policy in 1 of 19 (Patient #4) medical records reviewed. Findings include:Review of agency policy titled, “Coordination of Care and Services” dated 12/02/2008 revealed, “The IDG (Interdisciplinary Group) is responsible for ongoing, effective sharing of information among all disciplines providing care and services to patients/family in all settings...”Review of Patient #4’s medical record revealed Patient #4 was admitted to hospice on 02/04/25 with a diagnosis of Leukemia. Frequencies included, skilled nursing 1x/week. Patient #4 elected to have hospice physician be her attending physician.Review of Patient #4’s active medication profile dated 02/04/2025 - 05/04/2025 revealed, Furosemide (Lasix) 20 milligrams (MG) daily with a start date of 03/18/2025. (Furosemide is a medication used as a water pill or diuretic that helps your body get rid of extra water and salt through your unne.)Review of Patient #4’s medical record nurse narrative note dated 04/01/2025 revealed registered nurse (RN) and Patient #4 discussed and decided holding Lasix for one week due to Patient #4 disliking urinary frequency. RN narrative note dated 04/09/2025 revealed “+1 pitting edema to her BLE (bilateral lower extremities). Discussed restarting Lasix, Patient would prefer to manage the leg swelling without Lasix at this time...” RN narrative note dated 04/15/2025 revealed, “Patient elects to stop taking Lasix due to side effects.” There was no care communication note informing hospice physician or a hospice physician order to hold or discontinue Lasix. Review of hospice agency IDG meetings dated 04/08/2025 and 04/22/2025 revealed no new physician orders/updates related to the holding or discontinued use of Lasix was documented.During an interview with Director A on 04/29/2025 at 11:30 AM, Director A stated that the hospice physician update documentation would be found in care communication notes or with a physician order.”

“Based on record review and interview, the agency QAPI (Quality Assessment and Performance Improvement) program failed to monitor and track data and document progress for the PIP (Performance Improvement Projects) identified as priority for this agency in 1 of 1 QAPI programs reviewed. Findings Include:Review of agency policy and procedure manual dated 03/30/2020 revealed “Chapter 8: QAPI Procedure: 4. The PIP conducted annually are: a) Documented; e) The measurable progress made.”Record review for agency PIP Form dated 04/09/2023 revealed “Low percentage of volunteer hours.” The PIP form does not indicate a starting data point or identify a goal for this agency to progress to.Review of QAPI meeting minutes dated 10/19/2023, 02/01/2024, 05/02/2024, 07/30/2024, 10/29/2024, and 02/04/2025 revealed for each meeting “New/Ongoing PIPs: Low percentage of Volunteer Hours: We are still not meeting required 5% of hours.” There was no documented evidence that the agency tracks data to measure progress.Record review for agency PIP Form (not dated) revealed “Quarter 3 data shows decreased scores on ‘Did the Hospice team give you training you needed about what side effects to watch for from pain medications.” The PIP form does not indicate what data was decreased, what the starting data point was, or identify a goal for this agency to progress to.Review of QAPI meeting minutes dated 07/30/2024 and 10/29/2024 revealed for each meeting “New/Ongoing PIPs: CAHPS scores for training on side effects of medications. We will need to continue to monitor over time as CAHPS scores come in.” There was no documented evidence that the agency tracks data to measure progress.During an interview with Director A on 04/29/2025 at 8:35AM, when discussed the above findings related to the 2 PIPs lacking goals for the agency and lacking documented evidence of data driven analysis to evaluate the PIP progress, Director A replied, “I get what you are saying. It’s not in there. We talk about it; I just don’t know why we don’t put it in the minutes.””

“Based on record review and interview, the agency failed to utilize volunteer services for patients assessed to have volunteer needs and accepted volunteer services in 8 of 19 records reviewed (Patients #4, #5, #7, #8, #9, #11, #18, and #19). Findings include:Review of agency policy and procedures “Hospice Operations Manual: Chapter 6 Service Delivery” (dated 04/25/2018) revealed “I IV. Volunteer Services: Regulatory Requirements for Volunteer Services 418.78 Condition of Participation-Volunteers. ii. Standard: Role. Volunteers must be used in day-to-day administrative and/or direct patient care roles.”Review of agency policy “IDG (Interdisciplinary Group) Services” (dated 12/02/2008) revealed “Policy: The IDG also has access to and appropriately uses: d) Volunteer services to meet the needs of hospice patient/families.”Record review of Patient #4 (certification period 02/04/2025 to 05/04/2025) revealed Patient #4 was assessed for and accepted Volunteer services on 02/04/2025. There was no documented evidence that Patient #4 received volunteer services or that the agency did any follow up during IDG to address the status of volunteer services for this patient.Record review of Patient #5 (certification period 03/06/2025 to 06/03/2025) revealed Patient #5 was assessed for and accepted Volunteer services on 03/06/2025. There was no documented evidence that Patient #5 received volunteer services or that the agency did any follow up during IDG to address the status of volunteer services for this patient.Record review of Patient #7 (certification period 02/13/2025 to 05/13/2025) revealed Patient #7 was assessed for and accepted Volunteer services on 02/13/2025. There was no documented evidence that Patient #7 received volunteer services or that the agency did any follow up during IDG address the status of volunteer services for this patient.Record review of Patient #8 (certification period 04/08/2025 to 07/06/2025) revealed Patient #8 was assessed for and accepted Volunteer services on 01/08/2025. There was no documented evidence that Patient #8 received volunteer services or that the agency did any follow up during IDG to address the status of volunteer services for this patient.Record review of Patient #9 (certification period 02/17/2025 to 05/17/2025) revealed Patient #9 was assessed for and accepted Volunteer services on 02/17/2025. There was no documented evidence that Patient #9 received volunteer services or that the agency did any follow up during IDG to address the status of volunteer services for this patient.Record review of Patient #11 (certification period 02/20/2025 to 05/20/2025) revealed Patient #11 was assessed for and accepted Volunteer services on 12/9/2024. There was no documented evidence that Patient #11 received volunteer services or that the agency did any follow up during IDG to address the status of volunteer services for this patient.Record review of Patient #18 (hospice care dates 02/03/2025 to 02/09/2025) revealed Patient #18 was assessed for and accepted Volunteer services on 02/03/2025. There was no documented evidence that Patient #18 received volunteer services or that the agency did any follow up to address the status of volunteer services for this patient.Record review of Patient #19 (hospice care dates 12/02/2024 to 03/12/2025) revealed Patient #19 was assessed for and accepted Volunteer services on 12/02/2024. There was no documented evidence that Patient #19 received volunteer services or that the agency did any follow up during IDG to address the status of volunteer services for this patient.During an interview on 04/29/2025 at 11:50 AM, Director A stated, “It (volunteer services) would be in the record if it was provided. If there is no record, there was no volunteers available.” When asked if there is additional follow-up if volunteers were or were not available or any re-evaluation, Director A stated that patients are re-assessed on recertification, but it might not document if not available.”

“Based on record review and interview, the agency failed to provide the minimum 5% of the total patient care hours through volunteers for 1 of 1 volunteer programs reviewed. Findings include:Review of agency policy and procedure “Chapter 6: Service Delivery” (dated 04/25/2018) revealed “IV.Volunteer Services: Regulatory Requirement for Volunteer Services: v. Standard Level of Activity: Volunteers must provide day-to-day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract staff.”Review of the Hospice Survey Information form completed by the agency on 04/28/2025 revealed agency volunteer patient care hours at 0.91%. During an interview on 04/28/2025 at 11:40 AM, Volunteer Coordinator D confirmed the agency volunteer patient care hours at 0.91%. When asked if the program hours are meeting the requirement of 5%, Volunteer Coordinator D stated, “No it’s not.””

“Based on record review and interview, the agency failed to provide the employee orientation to hospice in 1 of 14 personnel records reviewed (Administrator B). Findings include:Review of agency policy and procedure manual “Chapter 2-Managing Employee Caregivers” dated 04/17/2025 revealed “Orientation of Employees Who Provide or Manage Patient/Family Care: Policy: Orientation is provided to all employees who provide or manage patient/family care. File Maintenance of Employees: Procedure: Employee Personnel File: 3. p) Evidence of completed Orientation including the scope of orientation content.”Record review of personnel record for Administrator B (date of hire 10/17/2022) revealed no evidence of completion of orientation to hospice.During review of Administrator B’s personnel record on 04/28/2025 at 2:10PM, People Operations Director C stated, “I newly took this over last year when Human Resources person left and am getting caught up.”The above findings of missing proof of orientation for Administrator B were reviewed with Director A on 04/29/2025 at 1:30PM. Director A stated, “No, it’s not in there.””