Moments Hospice of 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; [and] 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 measures 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, interview, and observation. In 2 of 14 (14%) clinical records reviewed and home visits observed, 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 12/26/2025 with a diagnosis of Alzheimer’s Disease. During the home visit observation on 06/23/2026 with the Medical Social Worker [Personnel Record 1], the patient’s medications were reviewed with the patient’s niece (caregiver). The hospice medication profile did not match the medications the patient’s niece verbalized the patient was taking. The hospice medication profile did not document Donepezil 10 mg every evening (prescription fill date 05/26/2026), Memantine 10 mg twice daily (prescription fill date 05/26/2026), Lovastatin 20 mg daily (prescription fill date 05/26/2026), Metoprolol 10 mg daily (prescription fill date 05/26/2026), Iron 325 mg daily (per niece taking two years or so), and Calcium 600 mg (per niece taking two years or so). Skilled nursing visits were provided weekly as ordered. The clinical record review and home visit observation revealed no evidence that the medication profile was updated, and the medications were reviewed with the patient’s medication regimen. CLINICAL RECORD 3/HOME VISIT 3: The patient elected hospice care on 05/19/2065 with a diagnosis of chronic systolic heart failure. The patient resided in a skilled nursing facility (SNF). During the home visit observation on 06/23/2026 with the Registered Nurse (RN)/Team Director [Personnel Record 3], the patient’s hospice medication profile and SNF medication administration record (MAR) were reviewed. The SNF MAR documented ipratropium-albuterol inhalation solution 0.5-2.5mg/3ml every six hours as needed (order date 04/11/2026) or Miralax Oral Packet 17 gm, one (1) packet every 24 hours as needed (order date 04/10/2026). The hospice medication profile and the initial and updated comprehensive assessments did not include documentation of ipratropium-albuterol inhalation solution and Miralax, or the use of these medications with the patient’s medication regimen. Skilled nursing visits were provided every week as ordered. During the joint record review and interview on 06/24/2026, the Alternate Administrator/Vice President of Clinical Operations confirmed that the medication profiles did not accurately represent the medications the patients received. DHS_131.20(3)(f)Drug profile. A review of the patient’s prescription and over-the-counter drugs, herbal remedies and other alternative treatments that could affect drug therapy. This includes, but is not limited to, identification of the following:”

“It is required that the hospice designates a registered nurse member of the IDG to: ensure the implementation of the interdisciplinary plan of care. 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). This standard was not met as evidenced by clinical record review, document review and interview. Agency policy “Wound Process” (revision date 11/30/2023) read in part, “Hospice Nurses should be providing wound care during their visit. For patients in facilities, we should be partnering with the facilities and providing this care. (Please make arrangements with facility to be present during wound care at least once per week). Documentation: Wound assessment at least weekly or with each wound care provided. Measurement at least weekly.” In 1 of 6 (17%) clinical records reviewed of patients with wounds, the agency did not ensure that hospice care followed the plan of care established by the hospice IDG. CLINICAL RECORD 9: The patient elected care on 07/28/2023 with diagnosis of Alzheimer’s Disease. A physician order was received on 05/29/2026 for wound care. The physician order read in part, “Order to cleanse area to left anterior upper thigh with wound cleanser, pat dry, apply border foam dressing for comfort and prevent re-opening. SNF staff nurses assess and complete Q M-W-F and prn if soiled or dislodged. Hospice RN assesses and measures at least weekly and provides wound care prn if dressing is soiled or dislodged.” Skilled Nursing (SN) visits were provided on 06/04/2026 and 06/08/2026. The RN visit notes dated 06/04/2026 and 06/08/2026 documented “Wound Assessed: No, caregiver completed care.” The wound was measured on 06/15/2026 during the skilled nursing assessment. The clinical record review did not evidence that the wound was assessed and measured per the plan of care or agency process. During the joint record review and interview on 06/24/2026, the Alternate Administrator/Vice President of Clinical Operations (Personnel Record 4) confirmed that the wound was not assessed and measured per the agency’s wound process.”

“It is required that each patient’s individualized written plan of care reflects patient and family goals and 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. In 2 of 14 (14%) clinical records reviewed, the agency did not ensure that the patient’s plan of care reflected the patient’s and family’s goals and interventions based on problems identified in the initial and comprehensive assessments CLINICAL RECORD 8: The patient elected hospice care on 01/16/2026 with a diagnosis of Cerebral Infarction. A physician order dated 05/22/2026 ordered, “Change level of care to respite from 05/22/2026 to 05/25/2026.” The patient’s individualized written plans of care (Plan of Care Update Reports), dated 05/27/2026 and 06/10/2026, did not document patient and family goals and interventions related to the respite care being provided. CLINICAL RECORD 9: The patient elected hospice care on 07/28/2023 with a diagnosis of Alzheimer’s Disease. The patient resided in a facility. A physician’s order dated 05/29/2026 ordered wound care: “Order to cleanse area to left anterior upper thigh with wound cleanser, pat dry, apply border foam dressing for comfort and prevent reopening. Skilled Nursing Facility (SNF) staff nurses assess and complete every (Q) M-W-F and as needed (prn) if soiled or dislodged. Hospice Registered Nurse (RN) assesses and measures at least weekly and provides wound care prn if dressing is soiled or dislodged.” The patient’s individualized written plan of care (Plan of Care Update Report), dated 06/10/2026, did not document patient and family goals related to the wound care being provided. During the joint record review and interview on 06/24/2026, the Alternate Administrator/Vice President of Clinical Operations (Personnel Record 4) confirmed that the plan of care for clinical record 8 did not document patient and family goals and interventions for the respite care being provided, and the plan of care for clinical record 9 did not document patient and family goals for the wound care being provided. DHS_131.21(3)(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:”

“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, interview, and observation. In 2 of 14(14%) clinical records reviewed and home visits observed, the agency did not ensure the patient’s individualized plan of care included the drugs and treatments necessary to meet the patient’s needs. CLINICAL RECORD 1/HOME VISIT 1: The patient elected hospice care on 12/26/2025 with a diagnosis of Alzheimer’s Disease. During the home visit observation on 06/23/2026 with the Medical Social Worker [Personnel Record 1], the patient’s medications were reviewed with the patient’s niece (caregiver). The patient’s individualized written plan of care (Plan of Care Update Report), dated 06/10/2026 did not document Donepezil 10 mg every evening (prescription fill date 05/26/2026), Memantine 10 mg twice daily (prescription fill date 05/26/2026), Lovastatin 20 mg daily (prescription fill date 05/26/2026), Metoprolol 10 mg daily (prescription fill date 05/26/2026), Iron 325 mg daily (per niece taking two years or so), and Calcium 600 mg (per niece taking two years or so). Skilled nursing visits were provided weekly as ordered. CLINICAL RECORD 3/HOME VISIT 3: The patient elected hospice care on 05/19/2065 with a diagnosis of chronic systolic heart failure. The patient resided in a skilled nursing facility (SNF). During the home visit observation on 06/23/2026 with the Registered Nurse (RN)/Team Director [Personnel Record 3], the SNF MAR documented ipratropium-albuterol inhalation solution 0.5-2.5mg/3ml every six hours as needed (order date 04/11/2026) and Miralax Oral Packet 17 gm, one (1) packet every 24 hours as needed (order date 04/10/2026). The patient’s individualized written plans of care (Plan of Care Update Reports), dated 06/02/2026 and 06/10/2026, did not document Albuterol Inhalation Solution 0.5-2.5mg/3ml every six hours as needed (order date 04/11/2026) or Miralax Oral Packet 17 gm, one packet every 24 hours as needed (order date 04/10/2026). Skilled nursing visits were provided every week as ordered. During the joint record review and interview on 06/24/2026, the Alternate Administrator/Vice President of Clinical Operations confirmed that the plan of care did not document all the patient’s current medications. DHS_131.21(3)(b)(4)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: Drugs and treatment necessary to meet the needs of the patient.”

“It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene, This standard was not met as evidenced by document review, interview, and observation. Agency policy #7-009 “Hand Hygiene” (revised: 1/6/25) read in part, “Hand Washing with Soap and Water 1. Wet hands and apply the soap, and rub hands together vigorously; avoid use of hot water because repeated exposure to hot water may increase risk of dermatitis. 2. Wash hands for at least fifteen (15) seconds, covering all surfaces of the hands and fingers. 3. Rinse with warm water and dry the hands with a disposable towel from the fingers toward the forearm. 4. Use a dry disposable towel to turn off faucet.” In 1 of 3 (33%) home visits observed, the agency did not ensure that hand hygiene was performed per the agency’s policy. HOME VISIT 2/ CLINICAL RECORD 2: The patient elected hospice care on 05/27/2026 with a diagnosis of hypertensive heart disease and chronic kidney disease. During the home visit observation on 06/23/2026, the Hospice Aide (HA) [Personnel Record 2], turned on the faucet, applied soap and scrubbed their hands, rinsed their hands, and dried their hands with the patient’s hand towel (fabric), and turned the faucet off with a dry washcloth. This process was repeated three times throughout the home visit observation. The Hospice Aide did not use a disposable towel to dry their hands or turn off the faucet. During an interview on 06/24/2026, the Alternate Administrator/Vice President of Clinical Operations (Personnel Record 4) confirmed that the Hospice Aide did not follow the agency policy of using a disposable towel to dry hands and turn off the faucet.”

“It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services provided to patients/families are in a defined role and under the supervision of a designated hospice employee. Volunteer services are noted in the plan of care and are documented in the patient record, including the time spent. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed in which a volunteer was accepted, the agency did not ensure that the volunteer services were provided. CLINICAL RECORD 5: The patient elected hospice services on 02/25/2026 with a diagnosis of hypertensive heart disease and chronic kidney disease. The comprehensive assessment completed by the Registered Nurse (RN) on 02/25/2026 documented, “Were volunteer services offered? Yes. Does client want volunteer services? Yes. A clinical record review revealed no documented evidence that volunteer services were added to the plan of care or provided to address the patient’s volunteer needs. CLINICAL RECORD 11: The patient elected hospice services on 12/12/2025 with a diagnosis of Alzheimer’s disease. The comprehensive assessment completed by the RN on 12/12/2025 documented, “Were volunteer services offered? Yes. Does client want volunteer services? Yes. The Medical Social Worker (MSW) hospice add-on evaluation completed by the Social Worker on 12/15/2025 documented, “Evaluated level of support needed by volunteers for companionship, supportive listening, and emotional support and activities. Patient would be great for the volunteer program.” A clinical record review revealed no documented evidence that volunteer services were added to the plan of care or provided to address the patient’s volunteer needs. During the joint record review and interview on 06/24/2026, the Alternate Administrator/Vice President of Clinical Operations (Personnel Record 4) confirmed that the clinical records did not include evidence that volunteer services were implemented based on needs identified in the comprehensive assessments.”

“It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. The hospice agency did not ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. During an interview and a joint review of the agency’s “Hospice Volunteer Requirement Report” on 06/24/2026, the Alternate Administrator/Vice President of Clinical Operations (Personnel Record 4) confirmed that volunteer utilization was below 5% for 01/01/2025 through 12/31/2025 (1.42%) and 01/01/2024 through 12/31/2024 (3.78%), stating, “Recruitment has been challenging in this area. We have also increased our discipline frequencies for Hospice Aides and the psychosocial staff to meet the companionship needs of the patient when unable to match a volunteer.” During an interview on 06/24/2026, the Volunteer Coordinator (VC-Personnel Record 7) confirmed volunteer utilization was below 5%. The agency has one administrative volunteer, one volunteer in the onboarding process, and two volunteers in the interview process. The VC reported in part, “The recruitment plan includes: online events, local community, job postings, and rolling out new programs.” The hospice agency did not ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff.”

“It is required that the designated IDG member provide the SNF/NF or ICF/IID with the following information for each patient/resident: the most recent hospice plan of care and the physician certification and recertification of the terminal illness. This standard was not met as evidenced by clinical record review, document review, interview, and observation. In 1 of 1 (100%) home visit observed and clinical record reviewed for a patient residing in a skilled nursing facility (SNF), the agency did not ensure that the designated IDG member provided the SNF with the patient’s most recent hospice plan of care and the physician certification of terminal illness. HOME VISIT 3/CLINICAL RECORD 3: The patient elected hospice care on 05/19/2065 with a diagnosis of chronic systolic heart failure. During the home visit observation on 06/23/2026 with the Registered Nurse (RN)/Team Director (TD) [Personnel Record 3], a review of the patient’s SNF medical record revealed no plan of care or certification of terminal illness for the election period dated 05/19/2026 through 08/16/2026. During an interview, the RN/TD [Personnel Record 3] stated, “We usually bring these out after our first Interdisciplinary Group (IDG) meeting after admission.” The IDG meeting dates after admission were 05/27/2026 and 06/10/2026. During an interview on 06/24/2026, the Alternate Administrator/Vice President of Clinical Operations (Personnel Record 4) confirmed that the facility should have been provided with the patient’s plan of care and certification of terminal illness.”

“It is required that the designated IDG member provide the SNF/NF or ICF/IID with the following information for each patient/resident: the most recent hospice plan of care and the physician certification and recertification of the terminal illness. This standard was not met as evidenced by clinical record review, document review, interview, and observation. In 1 of 1 (100%) home visit observed and clinical record reviewed for a patient residing in a skilled nursing facility (SNF), the agency did not ensure that the designated IDG member provided the SNF with the patient’s most recent hospice plan of care and the physician certification of terminal illness. HOME VISIT 3/CLINICAL RECORD 3: The patient elected hospice care on 05/19/2065 with a diagnosis of chronic systolic heart failure. During the home visit observation on 06/23/2026 with the Registered Nurse (RN)/Team Director (TD) [Personnel Record 3], a review of the patient’s SNF medical record revealed no plan of care or certification of terminal illness for the election period dated 05/19/2026 through 08/16/2026. During an interview, the RN/TD [Personnel Record 3] stated, “We usually bring these out after our first Interdisciplinary Group (IDG) meeting after admission.” The IDG meeting dates after admission were 05/27/2026 and 06/10/2026. During an interview on 06/24/2026, the Alternate Administrator/Vice President of Clinical Operations (Personnel Record 4) confirmed that the facility should have been provided with the patient’s plan of care and certification of terminal illness.”