Brighton Hospice Madison

“It is required that the hospice provides information on advance directives upon initiation of hospice care. Whether or not the patient has executed an advance directive is documented in a prominent part of the patient’s record. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #9-008 “Advance Directives” stated in part, “Upon receipt of a Do not resuscitate (DNR)/Do not intubate (DNI) order, the DNR/DNI order will be clearly identified in the clinical record. A copy of the DNR order will be kept in the patient’s home. The Case Manager will immediately advise the Clinical Supervisor. The Case Manager will notify other personnel involved in the case within 24 hours and document this notification in the clinical record.” DOCUMENT 3: A review of the complaint log revealed a complaint dated 06/21/2025 from the Director of Nursing (DON) at the skilled nursing facility (SNF) where the patient resided. The complaint stated that the DON was calling about a situation with a patient (Clinical Record 12) who had been rapidly declining, and emergency medical services (EMS) had been called by facility staff. The complaint documented that the DON expressed frustration with the facility staff not knowing that the patient was a DNR. Additionally, the DON reported that they had called the hospice and were told by the on-call nurse that the patient was a full code. The patient was sent to the hospital by EMS per the power of attorney (POA) (the son’s) request. The form’s “Problem Resolved” section was completed by the hospice Administrator documenting, “Followed up with on-call nurse, explained that the patient’s status in the EMR was listed as full code. I followed up with RNCM and notified that if a patient becomes a DNR, the status needs to be changed in the EMR to reflect that.” In 1 of 14 (7%) clinical records reviewed, the hospice did not ensure that the patient’s updated code status was documented in a prominent part of the patient’s record. CLINICAL RECORD 12: The patient elected the hospice benefit on 06/12/2025 and was discharged on 06/21/2025. The Registered Nurse (RN) and Social Worker (SW) visit notes dated 06/12/2025, documented that the patient was a full code. The Chaplain (SC) visit note dated 06/16/2025, documented that the son was “ready to sign a DNR order, notified MSW after visit of this.” A DNR was uploaded to the patient’s documents, revealing that it was signed by the power of attorney (son) on 06/16/2025, and subsequently signed by the Hospice Medical Director on 06/17/2025. The patient’s clinical record face sheet revealed a code status of “FULL CODE” from 06/12/2025 through 06/21/2025 (discharged to hospital). There was no documented evidence that the hospice provided the SNF with a copy of the updated advanced directives, which showed the DNR status. During a joint record review and interview on 09/04/2025, the Senior Director of Clinical Quality agreed that there was no documented evidence that the hospice had updated the face sheet to reflect the DNR status. Additionally, during an interview on 09/04/2025, the Senior Director of Clinical Quality stated, “We need to make some process changes in how this is handled.””

“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 drug profile that contained the patient’s current medications. CLINICAL RECORD 1/HOME VISIT 1: The patient elected hospice care on 07/17/2025, with a diagnosis of peripheral vascular disease. The patient resided in an assisted living facility (ALF). During the home visit with the Registered Nurse (RN) [Personnel Record 6] on 09/03/2025, the hospice medication profile was compared to the ALF medication list. The hospice medication profile documented an active medication, lorazepam 0.5mg oral tablet, take one tablet every hour as needed for anxiety, agitation, restlessness, and nausea, with a start date of 07/18/2025. The ALF medication list did not document the use of lorazepam. There was no evidence that the RN reconciled the medication with the ALF and updated the hospice medication profile to reflect the changes. During the home visit, the RN [Personnel Record 6] stated, “It must have been discontinued. I am not sure why the hospice medication list was not updated.” CLINICAL RECORD 3/HOME VISIT 3: The patient elected hospice care on 07/17/2025, with a diagnosis of peripheral vascular disease. The patient resided in a skilled nursing facility (SNF). During the home visit with the Chaplain (SC) [Personnel Record 7] on 09/03/2025, the hospice medication profile was compared to the SNF medication list. The SNF medication list documented the active medication, polyvinyl alcohol ophthalmic solution 1.4%, instill two drops in both eyes three times a day for infection/dry eyes, with a start date of 05/31/2024. The hospice medication profile did not document polyvinyl alcohol eye drops. The hospice medication profile included an active medication, olanzapine 2.5mg oral tablet, take one tab once a day for anxiety, with a start date of 05/30/2025. The SNF medication list did not document the use of olanzapine. The SNF Director of Nursing reported that olanzapine was discontinued on 06/23/2025, due to a potential moderate to severe interaction with sertraline and tramadol. During a joint record review and interview on 09/03/2025, the Senior Director of Clinical Quality agreed that there was no documented evidence that the medications had been reconciled and updated to the drug profile. DHS_131.20(3)(f) and DHS.131.33(3)(e)”

“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. Sharing of information occurs and is ongoing with other non-hospice healthcare providers providing services unrelated to the terminal illness and related conditions. This standard was not met as evidenced by clinical record review, document review, interview, and observation. Agency policy #9-008 “Advance Directives” stated in part, “Upon receipt of a Do not resuscitate (DNR)/Do not intubate (DNI) order, the DNR/DNI order will be clearly identified in the clinical record. A copy of the DNR order will be kept in the patient’s home. The Case Manager will immediately advise the Clinical Supervisor. The Case Manager will notify other personnel involved in the case within 24 hours and document this notification in the clinical record.” In 1 of 1 (100%) home visits observed of a patient residing in an assisted living facility (ALF), the hospice did not ensure that a copy of the patient’s DNR order was provided to the ALF where the patient resided. HOME VISIT 1/CLINICAL RECORD 1: The patient elected hospice care on 07/17/2025, with a diagnosis of peripheral vascular disease. The patient resided in an assisted living facility (ALF). During the home visit with the Registered Nurse (RN) [Personnel Record 6] on 09/03/2025, a review of the patient’s ALF face sheet revealed that the patient was listed as a FULL CODE. A review of the hospice clinical record revealed the patient’s face sheet, which listed the patient’s code status as “DNR,” and an uploaded document dated 07/18/2025, indicating the same. The ALF staff were unable to locate the patient’s DNR order. The ALF staff confirmed the patient’s ALF face sheet and chart listed the patient as a FULL CODE. There was no evidence that the hospice provided the ALF with a copy of the updated advanced directives, which showed the patient’s DNR status. There was no documented evidence of the DNR order in the patient’s room. During the home visit, the Registered Nurse stated, “This is important, and we are going to get this updated right away. I am going to request a copy be sent over immediately.” During a joint record review and interview on 09/04/2025, the Senior Director of Clinical Quality agreed that there was no documented evidence that the hospice provided the ALF with a copy of the patient’s DNR orders. Additionally, during an interview on 09/04/2025, the Senior Director of Clinical Quality stated, “We need to make some process changes in how this is handled.””

“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 agency did not ensure that hospice volunteers provided day-to-day administrative or direct patient care services in an amount of at least five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The hospice documents the cost savings achieved through volunteers. A review of the Cost Savings Report revealed that hospice volunteers provided administrative or direct patient care services for the period 09/01/2024 through 08/31/2025, which was 1.66%. During a joint record review and interview on 09/04/2025, the Volunteer Coordinator agreed that there was no documented evidence that the agency had met the 5% minimum for cost savings. During a joint record review and interview on 09/04/2025, the Administrator agreed with the finding, stating, “We had some challenges with recruitment when we didn’t have a local Volunteer Coordinator for a period of time. We have one now that started a few months ago. We started a PIP on May 1, 2025, and are working on it.” A review of the Cost Savings Report revealed the hospice did not ensure that the cost savings achieved through volunteers was at least 5%.”

“It is required that the designated IDG member provides the SNF/NF or ICF/IID with the following information for each patient/resident: hospice election form and any advance directives. This standard was not met as evidenced by clinical record review, document review and interview. Agency policy #9-008 “Advance Directives” stated in part, “Upon receipt of a Do not resuscitate (DNR)/Do not intubate (DNI) order, the DNR/DNI order will be clearly identified in the clinical record. A copy of the DNR order will be kept in the patient’s home. The Case Manager will immediately advise the Clinical Supervisor. The Case Manager will notify other personnel involved in the case within 24 hours and document this notification in the clinical record.” DOCUMENT 3: A review of the complaint log revealed a complaint dated 06/21/2025 from the Director of Nursing (DON) at the skilled nursing facility (SNF) where the patient resided. The complaint stated that the DON was calling about a situation with a patient (Clinical Record 12) who had been rapidly declining, and emergency medical services (EMS) had been called by facility staff. The complaint documented that the DON expressed frustration with the facility staff not knowing that the patient was a DNR. Additionally, the DON reported that they had called the hospice and were told by the on-call nurse that the patient was a full code. The patient was sent to the hospital by EMS per the power of attorney (POA), the son’s request. In 1 of 3 (33%) clinical records reviewed of patients residing in a skilled nursing facility (SNF), the hospice did not ensure that the SNF was provided with the patient’s advanced directives, which indicated the patient’s DNR status. CLINICAL RECORD 12: The patient elected the hospice benefit on 06/12/2025 and was discharged on 06/21/2025. The Registered Nurse (RN) and Social Worker (SW) visit notes dated 06/12/2025, documented that the patient was a full code. The Chaplain (SC) visit note dated 06/16/2025, documented that the son was “ready to sign a DNR order, notified MSW after visit of this.” A DNR was uploaded to the patient’s documents, revealing that it was signed by the power of attorney (son) on 06/16/2025, and subsequently signed by the Hospice Medical Director on 06/17/2025. The patient’s clinical record face sheet revealed a code status of “FULL CODE” from 06/12/2025 through 06/21/2025 (discharged to hospital). There was no documented evidence that the hospice provided the SNF with a copy of the patient’s updated advanced directives, which showed the DNR status. During a joint record review and interview on 09/04/2025, the Senior Director of Clinical Quality agreed that there was no documented evidence that the hospice provided the SNF with a copy of the updated advanced directives, which reflected the patient’s DNR status. Additionally, during an interview on 09/04/2025, the Senior Director of Clinical Quality stated, “We need to make some process changes in how this is handled.” During a joint record review and interview on 09/03/2025, the Administrator agreed that there was no documented evidence that the hospice provided the SNF with a copy of the updated advanced directives showing the DNR status. Additionally, during an interview on 09/03/2025, the Administrator stated, “The nurse cannot remember if she sent it.””