Bristol Hospice Green Bay

“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. Agency policy #1-014 “Comprehensive Assessment” (reviewed 05/2020) stated in part, “During the comprehensive patient assessment... Review of current and related past medications, including prescription over-the-counter medications, supplements, herbal remedies, alternative treatments, allergy history, and other medication information.” Agency policy #2-004 “Medication Profile” (reviewed 09/2024) stated in part, “The medication profiles will be updated for each change to reflect current medications, and new and/or discontinued medications. A drug regimen review will be performed at the time of initial and comprehensive assessment, when updates to the comprehensive assessments are performed, when care is resumed after a patient has been placed on hold, and with the addition of new medication.” In 2 of 19 (11%) clinical records reviewed, the agency did not ensure that the comprehensive assessment included a drug profile that contained the patient’s current prescription and OTC drugs. Clinical Record 16: The patient elected hospice care on 09/26/2024 with a diagnosis of chronic obstructive pulmonary disease (COPD). The comprehensive nursing assessment completed by the skilled nurse (SN) on 09/26/2024 documented, “She is requiring use of supplemental oxygen at 2l/min.” The interdisciplinary group (IDG) meeting log dated 09/27/2024 documented “supplemental oxygen at 2l/m.” The hospice medication profile did not document the oxygen noted in the clinical note or the IDG meeting log. Clinical Record 18: The patient elected hospice care on 04/27/2024 with a diagnosis of hypertensive heart disease with heart failure. The SN visit note dated 07/31/2024 documented, “O2 Flow Rate-2LPM via NC, discussed using oxygen when he’s up and moving around.” The IDG meeting log dated 08/02/2024 documented, “Looking very SOB. I asked if he’d put his oxygen on so I could maybe get an oxygen saturation reading on him.” The hospice medication profile did not document the oxygen noted in the clinical note or the IDG meeting log. During a joint record review and interview on 02/27/2025, the Executive Director/Administrator confirmed that oxygen was not documented on the medication profiles for clinical records 16 and 18.”

“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. Agency policy #9-017, “The Plan of Care” (reviewed 09/2024), stated in part, “A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. This plan will focus on identified problems, goals, and interventions.” In 5 of 19 (26%) clinical records reviewed, the agency did not ensure that the patient’s plan of care reflected patient and family goals and identified planned interventions based on problems identified in the initial and comprehensive assessments. Clinical Record 5: The patient elected hospice care on 05/17/2024 with the diagnoses of hypertensive heart and chronic kidney disease with heart failure. The comprehensive assessment completed by the skilled nurse (SN) on 05/17/2024 documented, “She has had 2 falls since March r/t her wanting to keep her independence, MAHC 10 score of 6.” The plan of care dated 05/17/2024 through 08/14/2024 and the IDT (Interdisciplinary Team) meeting logs dated 05/24/2024 through the review date did not include planned interventions and patient and family goals for the patient’s identified fall risk. Clinical Record 9: The patient elected hospice care on 10/26/2024 with a diagnosis of Alzheimer’s disease with late-onset. The on-call/as-needed SN visit dated 01/30/2025, due to a change in the patient’s respiratory status, documented, “Lung sounds revealed slight inspiratory wheezes in the left upper lobe and right lower lobe. Continuing patient education on coughing and deep breathing exercises to promote lung expansion and prevent respiratory infections.” The plan of care dated 01/24/2025 through 04/23/2025 and the IDT meeting logs dated 01/31/2025 and 02/14/2025 did not include planned interventions and patient and family goals for the patient’s identified respiratory change in condition. Clinical Record 11: The patient elected hospice care on 11/15/2024 with a diagnosis of malignant neoplasm of the ascending colon. The on-call/as-needed SN visits dated 12/08/2024, 01/08/2025, and 02/06/2025 documented follow-up to patient falls. The plan of care dated 11/15/2024 through 02/12/2025 and the IDT meeting logs dated 12/31/2024 through 02/18/2025 (last IDT meeting) did not include planned interventions and patient and family goals for the patient’s identified problem with falls. Clinical Record 13: The patient elected hospice care on 01/12/2025 with a diagnosis of emphysema. The comprehensive assessment completed by the SN on 01/12/2025 documented, “Patient struggles with pain in her neck, back, and legs, stating it is continuous and sharp. She experiences pain with fevers and SOB, rated 9/10.” The plan of care dated 01/12/2025 through 03/12/2025 and the IDT meeting logs dated 01/21/2025 and 02/18/2025 did not document patient and family goals for the identified pain problem. Clinical Record 15: The patient elected hospice care on 05/10/2024 with a diagnosis of hypertensive heart and chronic kidney disease with heart failure. The comprehensive assessment completed by the SN on 05/10/2024 documented, “Patient c/o dull, right-sided, abdominal pain r/t tumor rated 6/10.” The plan of care dated 05/10/2024 through 08/07/2024 and the IDT meeting logs dated 05/24/2024 and 07/05/2024 did not document patient and family goals for the identified pain problem. During a joint record review and an interview on 02/27/2025, the Executive Director/Administrator confirmed that clinical record 5 did not include patient and family goals and planned interventions for fall risk, clinical record 9 did not document patient and family goals and planned interventions for respiratory problems, clinical record 11 did not document patient and family goals and planned interventions for fall risk, clinical record 13 did not document patient and family goals for pain, and clinical record 15 did not document patient and family goals for pain.”

“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. Agency policy #1-037 “Hospice Aide Supervisory Visits” (reviewed 11/ 2021 stated in part, “The frequency of supervisory visits will be based upon the needs of the patient after the plan of care is established. They must be conducted no less frequently than every 14 days.” In 2 of 18 (11%) clinical records reviewed of patients who 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. Clinical Record 11: The patient elected hospice care on 11/15/2024 with a diagnosis of malignant neoplasm of the ascending colon. The plan of care dated 11/15/2024 through 02/12/2025 ordered HA services twice (2) weekly beginning 11/19/2024. The HA visits were provided as ordered, beginning 11/19/2024. The HA supervisory visit was provided on 12/18/2024, with 15 days outstanding. Clinical Record 15: The patient elected hospice care on 05/10/2024 with the diagnoses of hypertensive heart and chronic kidney disease with heart failure. The plan of care dated 05/10/2024 through 08/07/2024 ordered HA services twice (2) weekly beginning 05/13/2024. The HA visits were provided as ordered, beginning 05/15/2024. The HA supervisory visit was provided on 06/21/2024, with 23 days outstanding. In a joint record review and interview on 02/22/2025, the Executive Director/Administrator confirmed that, per agency policy, HA supervisory visits were not completed every 14 days.”

“It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services are: noted in the plan of care. This standard was not met, as evidenced by clinical record review, document review, and interview. Agency policy #9-024 “Volunteer Services” (review 01/2023) stated in part, “To ensure that qualified volunteers provide appropriate services in accordance with the plan of care and hospice program needs. The Volunteer Coordinator will arrange for volunteers to provide volunteer support to patient and family/caregiver in accordance with the plan of care.” In 1 of 2 (50%) clinical records reviewed of patients with identified volunteer needs who accepted volunteer services, the agency did not ensure that volunteer services were provided and noted in the plan of care based on the patient’s needs as identified in the comprehensive assessment. Clinical Record 6: The patient elected hospice care on 11/05/2024 with a diagnosis of senile degeneration of the brain. The comprehensive assessment completed by the skilled nurse on 11/05/2024 documented, “HCA Accepted Hospice Clergy, Accepted MSW, Accepted Volunteer Accepted for companionship.” A clinical record review revealed no evidence that the volunteer services were provided, a follow-up assessment was completed, or a care plan was initiated to address volunteer needs. During the joint record review and interview on 02/27/2025, the Executive Director/Administrator confirmed that the clinical record did not include evidence that volunteer services were implemented based on needs identified in the comprehensive assessment.”

“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. Agency policy #9-024 Volunteer Services review date: January 2023 read in part “The Volunteer Coordinator will track the use of volunteers, the cost savings achieved, and that the hours of volunteer services will meet or exceed 5% of the total patient care hours of paid and contracted hospice personnel.” The hospice agency did not ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The “Volunteer Coordinator” report for 02/25/2024 through 02/25/2025 was reviewed with the Executive Director on 02/28/2025. The Executive Director confirmed that 3% of volunteers provided day-to-day administrative and/or direct patient care services from 02/25/2024 through 02/25/2025, less than the required 5%. During an interview on 02/27/2025, the Executive Director/Administrator confirmed that volunteer utilization was below the 5% requirement for 02/25/2024-02/25/2025 and stated, in part, “Our volunteer coordinator is focusing on recruitment.” During an interview on 02/28/2025, the Volunteer Coordinator confirmed that volunteer utilization was below the requirement of 5% for 02/25/2024-02/25/2025 and stated in part, “The focus is recruitment. I have two (2) active volunteers, and I’m in the process of onboarding four (4) additional volunteers.” The hospice agency did not ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff.”