North Shore at Home

“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, document review and interview. In 3 of 14 (21%) clinical records reviewed it was revealed that the agency did not ensure that the drug profile included all of the patient’s current medications. Document 1: Agency policy titled, Medication Profile-Hospice, effective 05/2024, read in part, “2. The patient’s medication profile is reviewed by the IDG whenever there is a significant change and, at a minimum, every fifteen days. 4. The patient’s medication profile review includes, but is not limited to: a. determining accuracy and completeness of the profile; b. monitoring medication effectiveness, actual or potential medication-related effects and untoward interactions; c. ensuring appropriateness of the medication, the dose, route of administration, and dosage schedule; d. ensuring that the prescribed medications are safe and appropriate and the most cost-effective solution for the patient’s symptom(s); e. determining if there are medications that have been or may be discontinued; f. identifying duplicate drug therapy associated with laboratory monitoring; g. reviewing lab values to ensure appropriate medication dosing; and h. assisting with the determination of which medications are and are not related to the patient’s terminal diagnosis.” Clinical Record 2: The patient elected hospice care on 02/22/2024 with a diagnosis of Acute on chronic combined systolic heart failure. The recertification plan of care effective 10/19/2024 read in part, “Oxygen per MD order; 2L NC PRN.” During the home visit with the chaplain (Personnel Record 2) on 11/26/2024, an oxygen concentrator was observed in the room. The hospice medication profile did not include the prescribed oxygen. Clinical Record 13: The patient elected hospice care on 01/04/2024 with a diagnosis of Unspecified Protein-Calorie Malnutrition. The initial nursing assessment completed on 01/04/2024 read in part “Oxygen Use, continuous: 3L/min.” The hospice medication profile did not include oxygen. Clinical Record 14: The patient elected hospice care on 02/01/2024 with a diagnosis of Unspecified Protein-Calorie Malnutrition. The skilled nursing prn (as needed) visit completed on 04/10/2024 read in part “Oxygen Use, continuous: 3L/min.” The hospice medication profile did not include oxygen. During the joint record review and interview on 11/26/2024, the Clinical Supervisor (personnel record 5) confirmed the findings that oxygen was not documented on the medication profiles for clinical records 2, 13, and 14.”

“It is required that the comprehensive assessment includes an initial bereavement assessment of 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 considered in the bereavement plan of care. This standard was not met as evidenced by clinical record review, document review and interview. In 5 of 14 (36%) clinical records reviewed it was revealed that the agency did not ensure that the comprehensive assessment included an initial bereavement assessment of the patient’s family and other individuals’ ability to cope with the patient’s death. Document 1: Agency policy titled, Comprehensive Assessment-Hospice, effective 05/2024, read in part, “2. The comprehensive assessment of the patient is completed by designated members of the IDG, in consultation with the patient’s attending physician, no later than five calendar days after the patient elects the hospice benefit. 3. The hospice nurse coordinates the comprehensive assessment process and ensures that the patient’s physical, emotional, psychosocial, spiritual, and bereavement needs are assessed.” Clinical Record 3: The patient elected hospice care on 10/25/2024 with a diagnosis of Unspecified Severe Protein-Calorie Malnutrition. The clinical record lacked evidence that a bereavement assessment was completed as part of the comprehensive assessment through the date of the review. Clinical Record 5: The patient elected hospice care on 06/17/2024 with a diagnosis of Chronic Obstructive Pulmonary Disease. The clinical record lacked evidence that a bereavement assessment was completed as part of the comprehensive assessment through the date of the review. Clinical Record 6: The patient elected hospice care on 07/08/2024 with a diagnosis of Metabolic Encephalopathy. The clinical record lacked evidence that a bereavement assessment was completed as part of the comprehensive assessment through the date of the review. Clinical Record 7: The patient elected hospice care on 08/09/2024 with a diagnosis of Malignant Neoplasm of the Kidney. The clinical record lacked evidence that a bereavement assessment was completed as part of the comprehensive assessment through the date of the review. Clinical Record 8: The patient elected hospice care on 07/24/2024 with a diagnosis of Malignant Neoplasm of the Lung. The clinical record lacked evidence that a bereavement assessment was completed as part of the comprehensive assessment through the date of the review. During the joint record review and interview on 11/26/2024, the Clinical Supervisor (personnel record 5) confirmed the comprehensive assessment did not include a bereavement assessment through the date of the review for clinical records 3, 5, 6, 7, and 8. Reviewed under Wisconsin licensure standard HWIL.12/DHS 131.21(3)(a).”

“It is required that each patient’s individualized written plan of care reflects patient, and family goals and 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, document review and interview. In 1 of 14 (7%) clinical records reviewed, it was revealed that the agency did not ensure that the patient’s individualized written plan of care reflected patient and family goals and identified planned interventions based on problems identified in the initial and comprehensive assessments. Document 1: Agency policy titled, Plan of Care-Hospice, effective 05/24/2024, read in part, “The plan of care reflects patient and family goals and interventions that are based on the problems identified in the initial, comprehensive and updated assessments.” Clinical Record 8: The patient elected hospice care on 07/24/2024 with a diagnosis of Malignant neoplasm of unsp part of unsp bronchus or lung. The Initial/Comprehensive Assessment completed on 07/24/2024 read in part, “Pt c/o SOB with minimal exertion and occasionally with speech.” The clinical record lacked evidence that the plan of care included patient and family goals and planned interventions for the identified problem of shortness of breath. During the joint record review and interview on 11/26/2024, the Clinical Supervisor (personnel record 5) confirmed that the plan of care did not include goals or interventions related to shortness of breath.”

“It is required that the hospice’s policies and procedures define a system of communication and integration that sustains coordination of services and provides documentation of exchange of information. Sharing of information occurs between all disciplines providing care and services in all settings and is ongoing whether or not the care and services are provided directly or under arrangement. This standard was not met as evidenced by clinical record review, document review and interview. In 3 of 14 (21%) clinical records reviewed it was revealed that the agency did not ensure that information was shared between all disciplines providing care and services. Document 1: Policy Coordination of Care-Hospice effective date 05/2024 read in part “An assigned hospice RN coordinates the patient’s plan of care and facilitates the ongoing sharing of information with the attending physician, contracted facilities, vendors, other members of the IDG and non-hospice healthcare providers furnishing services unrelated to the terminal illness.” Clinical Record 1: The patient elected hospice care on 02/19/2024 with a diagnosis of Alzheimer’s Disease. A care coordination note dated 11/07/2024 read in part “Call from [Facility] states pt sustained an abrasion to the RLE anterior, approx 2 cm long, 0.1cm wide. Nurse advising keeping the area clean and dry and open to air with monitoring. This RN agreed. Nurse states pt sustained abrasion when trying to move wheelchair with feet. This RN advised care team will be notified.” A Skilled Nursing visit was completed on 11/08/2024. The clinical record lacked evidence that care was coordinated with the attending physician. Clinical Record 2: The patient elected hospice care on 02/22/2024 with a diagnosis of Acute on chronic combined systolic heart failure. Missed visits were completed on 10/24/2024 (volunteer) and 10/25/2024 (skilled nursing). The visit notes read in part “Physician Notified: No”. The clinical record lacked evidence that coordination occurred between disciplines and that the missing visit was communicated to the physician. Clinical Record 5: The patient elected hospice care on 06/17/2024 with a diagnosis of Chronic Obstructive Pulmonary Disease. A care coordination note dated 10/27/2024 read in part “Facility nurse calling from [Facility] reporting that patients BP was 197/81 this morning. Nurse is requesting a prn medication like hydralazine for elevated BP so can be given as needed.” The skilled nursing visit completed on 10/28/2024 did not include documentation of follow-up related to elevated blood pressure. The clinical record lacked evidence that the registered nurse coordinated with the physician or that new orders were obtained. During the joint record review and interview on 11/26/2024, the Clinical Supervisor (Personnel Record 5) confirmed that the clinical record lacked evidence that the registered nurse coordinated with the physician regarding changes in condition and missed visits.”

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. and written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review, document review and interview. In 4 of 14 (29%) clinical records reviewed it was revealed that the agency did not ensure that the registered nurse provided the aide with written care instructions that were patient-specific and not generic. Document 1: Policy Aide Duties and Assignments-Hospice effective 05/2024 read in part “1. The hospice RN responsible for supervising the hospice aide prepares written instructions that are patient-specific and not generic. Clinical Record 1: The patient elected hospice care on 02/19/2024 with a diagnosis of Alzheimer’s Disease. The recertification plan of care effective 10/19/2024 included orders for hospice aide visits twice weekly beginning 10/19/2024. The hospice aide care plan effective 10/19/2024 included the assigned tasks of bed bath twice weekly and shower twice weekly. The hospice aide plan of care did not include specific instructions from the registered nurse delineating when the patient was to receive a shower or a bed bath. Clinical Record 2: The patient elected hospice care on 02/22/2024 with a diagnosis of Acute on chronic combined systolic heart failure. The recertification plan of care effective 10/16/2024 included orders for hospice aide visits twice weekly beginning 10/16/2024. The hospice aide care plan effective 10/16/2024 included the assigned tasks of bed bath twice weekly and shower twice weekly. The hospice aide plan of care did not include specific instructions from the registered nurse delineating when the patient was to receive a shower or a bed bath. Clinical Record 3: The patient elected hospice care on 10/25/2024 with a diagnosis of Unspecified Severe Protein-Calorie Malnutrition. The initial plan of care effective 10/25/2024 included orders for hospice aide visits twice weekly beginning 10/27/2024. The hospice aide care plan effective 10/27/2024 included the assigned tasks of bed bath twice weekly and shower twice weekly. The hospice aide plan of care did not include specific instructions from the registered nurse delineating when the patient was to receive a shower or a bed bath. Clinical Record 6: The patient elected hospice care on 07/08/2024 with a diagnosis of Unspecified Metabolic Encephalopathy. The recertification plan of care effective 10/06/2024 included orders for hospice aide visits twice weekly beginning 10/06/2024. The hospice aide care plan effective 10/06/2024 included the assigned tasks of bed bath twice weekly and shower twice weekly. The hospice aide plan of care did not include specific instructions from the registered nurse delineating when the patient was to receive a shower or a bed bath. During the joint record review and interview on 11/26/2024, the Clinical Supervisor (personnel record 5) confirmed the hospice aide plans of care did not reflect specific instructions from the registered nurse delineating when the patient was to receive a shower or a bed bath.”

“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 to ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. This standard was not met as evidenced by clinical record review, document review and interview. In 5 of 14 (36%) clinical records reviewed of patients that received Hospice Aide (HA) services, the agency did not ensure that a Registered Nurse (RN) made 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 HA. Document 1: Policy Hospice Aide Supervision-Hospice effective date 05/2024 read in part “1. A registered nurse makes an on-site visit to the patient’s home no less frequently than every 14 days to ensure that the services ordered by the IDG and provided by the hospice aide is meeting the patient’s need. 6. The supervisory visits are documented in the patient’s clinical record every two weeks and include notations regarding the aide’s competency, whether the aide is following the patient’s plan of care and is satisfactory to the patient/family.” Clinical Record 1: The patient elected hospice care on 02/19/2024 with a diagnosis of Alzheimer’s Disease. The recertification plan of care dated 10/16/2024 through 12/14/2024 ordered HA services twice (2) weekly beginning 10/16/2024. The HA visits were provided beginning 10/18/2024 as ordered. The HA supervisory visits were provided on 10/31/2024 and 11/15/2024, with 1 day outstanding. Clinical Record 2: The patient elected hospice care on 02/22/2024 with a diagnosis of Acute on chronic combined systolic heart failure. The recertification plan of care dated 08/20/2024 through 10/18/2024 ordered HA services twice (2) weekly beginning 08/20/2024. The HA visits were provided beginning 08/22/2024 as ordered. The HA supervisory visits were provided on 09/05/2024 and 09/20/2024, with 1 day outstanding. Clinical Record 11: The initial plan of care effective 02/21/2024 and recertification plan of care effective 05/21/2024 included orders for HA services twice (2) weekly beginning 02/21/2024. The hospice aide visits were provided as ordered beginning 02/21/2024. A hospice aide supervisory visit was completed on 05/20/2024, with 99 days outstanding. Clinical Record 13: The patient elected hospice care on 01/04/2024 with a diagnosis of Unspecified protein-calorie malnutrition. The initial plan of care dated 01/04/2024 through 01/31/2024 ordered HA services twice (2) weekly beginning 01/04/2024. The HA visits were provided beginning 01/11/2024 as ordered. The HA supervisory visit was provided on 01/31/2024, with 6 days outstanding. Clinical Record 14: The patient elected hospice care on 02/01/2024 with a diagnosis of Unspecified protein-calorie malnutrition. The initial plan of care dated 02/01/2024 through 04/12/2024 ordered HA services twice (2) weekly beginning 02/01/2024. The HA visits were provided beginning 02/07/2024 as ordered. The HA supervisory visits were provided on 03/18/2024, with 40 days outstanding, and 04/11/2024, with 24 days outstanding. In a joint record review and interview on 11/26/2024, the Clinical Supervisor (personnel record 5) confirmed that HA supervisory visits were not completed every 14 days per agency policy. Reviewed under Wisconsin licensure standard HWIL.21/DHS 131.25(4)(a).”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: physician orders. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 14 (14%) clinical records reviewed, it was revealed that the agency did not ensure the patient’s clinical record contained physician orders for care and services provided. Document 1: Agency policy titled, Contents of Clinical Record, effective 05/2024, read in part, “Each patient’s clinical record includes, at a minimum, k. signed physician orders.” Policy titled, Physician Orders-Hospice, effective 05/2024, read in part, “3. Some of the reasons orders are obtained from physicians include, but are not limited to: a. new medication, change in medication or discontinuance of medication; b. change in visit frequency if not within the range specified in the patient’s plan of care; c. care, treatment and services; d. dressing changes/wound care; and/or e. added disciplines or services or equipment to meet the needs of the patient. Documentation of receipt of verbal orders and of written orders sent to the physician for signature is maintained in the patient’s clinical record.” Clinical Record 1: The patient elected hospice care on 02/19/2024 with a diagnosis of Alzheimer’s Disease. A care coordination note completed on 11/07/2024 read in part “Call from Willowcrest states pt sustained an abrasion to the RLE anterior, approx 2 cm long, 0.1cm wide. Nurse advising keeping the area clean and dry and open to air with monitoring. This RN agreed. Nurse states pt sustained abrasion when trying to move wheelchair with feet. This RN advised care team will be notified.” The follow-up skilled nursing visit was completed on 11/08/2024 and did not include an assessment or treatment of the abrasion. The clinical record lacked evidence that a physician order was obtained for the care of the abrasion. Clinical Record 14: The patient elected hospice care on 02/01/2024 with a diagnosis of Unspecified Protein-Calorie Malnutrition. The skilled nursing prn (as needed) visit completed on 04/10/2024 read in part “Oxygen Use, continuous: 3L/min.” The clinical record lacked evidence that a physician order was obtained for oxygen. During the joint record review and interview on 11/26/2024, the Clinical Supervisor (personnel record 5) confirmed that the clinical records did not include physician orders for the care for the wound for clinical record 1, or oxygen for clinical record 14.”

“It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the following: a summary of the patient’s hospice stay, including treatments, symptoms, and pain management; the patient’s current plan of care; the patient’s latest physician orders; and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 2 (100%) clinical records reviewed of patients that were discharged from the hospice agency, it was revealed that the agency did not ensure that the discharge summary included a copy of the patient’s current plan of care and the current drug profile. Document 1: Agency policy titled, Discharge from Hospice Program-Hospice, effective 05/2024, read in part, “When the patient is discharged from hospice, the hospice provides a copy of the clinical record (if requested) and the hospice discharge summary to the patient’s attending physician. The discharge summary is filed in the clinical record and includes d. a copy of the patient’s current plan of care, including the drug profile.” Clinical Record 11: The patient elected hospice care on 02/21/2024 with a diagnosis of Hepatic Encephalopathy. The patient was transferred to another hospice on 08/27/2024 due to moving out of the service area. The clinical record lacked evidence that the discharge summary sent to the receiving facility included a copy of the patient’s current plan of care and drug profile. Clinical Record 12: The patient elected hospice care on 07/31/2024 with a diagnosis of Chronic Obstructive Pulmonary Disease. The patient revoked the hospice benefit on 08/29/2024 to seek aggressive treatment. The clinical record lacked evidence that the discharge summary sent to the attending physician included a copy of the patient’s current plan of care and drug profile. During the joint record review and interview on 11/26/2024, the Clinical Supervisor (personnel record 5) confirmed the hospice discharge summaries sent to the receiving facility and the physician did not include a copy of the current plan of care or drug profile and stated in part “I didn’t know that needed to be sent as well.””