Moments Hospice of Green Bay

“It is required that the hospice designates a Registered Nurse member of the IDG to provide coordination of care; ensure continuous assessment of each patient’s and family’s needs; and ensure the implementation of the interdisciplinary plan of care. This standard was not met as evidenced by a review of documents, clinical record review, and interview. Agency Document: The agency’s wound process stated in part, “wound must be measured weekly.” In 4 of 20 (20%) clinical records reviewed, the agency did not ensure that the Registered Nurse (RN) coordinated all care or implemented the plan of care as ordered. CLINICAL RECORD 1/HOME VISIT 4: The patient elected hospice care on 06/19/2024 with diagnoses of end-stage congestive heart failure and diabetes. For the benefit period dated 06/19/2024 through 08/17/2024, a physician’s order dated 06/27/2024 ordered “Insulin Lispro 100u/ml 12 units subcutaneous (subq) three times a day. Hold for Blood Sugar of 120 or lower... update MD if blood sugar is over 400. Lantus insulin sub q 100 units per milliliter (ml) 70 units subcutaneous (subq) at bedtime.” On 07/17/2024, the Lantus insulin was decreased to 40 units BID, and on 08/09/2024, it was increased to 46 units BID. On 08/14/2024, the Lispro was changed to 15 units, three times a day. A clinical record review revealed that no blood sugars were documented in the skilled nursing notes or the Interdisciplinary meeting minutes, which were documented every two weeks. For the benefit period dated 08/18/2024 through 10/16/2024, an updated IDG on 10/07/2024 documented that the patient’s “blood sugars are in the 300s and they are monitored 4 times a day.” There was no documentation of the blood sugars 4 times a day. For the benefit period dated 02/14/2025 through 04/14/2025, the IDG documented that blood sugars had been discontinued. For the benefit period dated 08/13/2025 through 10/11/2025, the physician’s order dated 09/24/2025 ordered to check blood sugars twice a day. During the home visit on 09/25/2025 with the Registered Nurse (RN) [Personnel Record 11], the facility nurse stated they had been checking blood sugars four times a day for insulin dosing, averaging in the 300s, but documented all blood sugars. The coordination of the blood sugar monitoring and oversight was not documented in the hospice clinical record. CLINICAL RECORD 2: The patient elected hospice care on 12/19/2024 with a diagnosis of chronic obstructive pulmonary disease (COPD). For the benefit period 06/07/2025 through 08/05/2025, a wound was documented on the nursing clinical note on 07/21/2025, located on the left leg with wound care orders. A new wound was documented in the nursing clinical note dated 08/06/2024 on the left shin with wound care ordered. A new wound was documented in the nursing clinical note on 09/02/2025, along with wound care orders. Wound measurements were documented on 07/21/2025. A clinical record review revealed that no further measurements were documented until 08/06/2025, after which weekly measurements followed. The wound did resolve without infection. There was no evidence that the IDG coordinated the weekly wound measurements to monitor the wound’s progress. CLINICAL RECORD 11: The hospice benefit of election was 06/17/2025 with a primary diagnosis of Alzheimer’s disease. Benefit period #6 was 06/17/2025 - 08/15/2025. A nursing clinical note on 06/17/2025 documented a wound on the right heel, and wound care was ordered. The wound was measured at this visit, and measurements continued weekly until the weeks of 07/20/2025 - 07/26/2025 and 08/10/2025 - 08/16/2025. The wound resolved by 08/31/2025 without any signs of infection. Nursing coordination should have had weekly wound measurements to monitor the progress of the wound. CLINICAL RECORD 12: The hospice benefit of election was 08/15/2025 benefit period #1 with a primary diagnosis of neoplasm of unspecified part of right bronchus or lung. A secondary diagnosis was dementia. Benefit period #1 was 08/15/2025 - 11/02/2025. The initial plan of care was dated on 08/15/2025, and updated plans of care were provided every two weeks. There was a physician order documented on 08/20/2025 for wound care for a PleurX drain, which the nurse was to assess weekly. These assessments were not documented weekly. There was a drain assessment documented on 08/21/2025 and 09/02/2025, but no further assessments as of review 09/25/2025. During the interview on 09/25/2025, the Administrator, Team Leader, and Alternate Administrator stated that the assessment and measurements were not documented in the clinical record. The quality Director noted this is a current process improvement as it was self-identified. HWIL.21 DHS131.25(4)(a)1 Nursing services shall be provided by or under the supervision of a registered nurse and shall consist of all of the following: regularly assessing the patient’s nursing needs, implementing the plan of care provisions to meet those needs and reevaluating the patient’s nursing needs.”

“It is required that each patient’s individualized written plan of care: 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 and interview. In 1 of 20 (5%) clinical records reviewed, the agency did not ensure that the plan of care included individualized interventions based on problems identified in the comprehensive assessment. CLINICAL RECORD 1: The patient elected hospice care on 06/19/2024 with diagnoses of end-stage congestive heart failure and diabetes. On 06/27/2024, the physician ordered Insulin “Lispro 100u/ml 12 units subcutaneous (subq) three times a day. Hold for Blood Sugar of 120 or lower... update MD if blood sugar is over 400. Lantus insulin sub q 100 units per milliliter (ml) 70 units subcutaneous (subq) at bedtime.” On 07/17/2024, the Lantus insulin was decreased to 40 units BID, and on 08/09/2024, it was increased to 46 units BID. On 08/14/2024, the Lispro was changed to 15 units, three times a day. The initial plan of care, dated 06/19/2024, for the benefit period dated 06/19/2024 through 08/17/2024, was updated every two weeks. The plan of care did not document interventions or goals for diabetes. The updated interdisciplinary group (IDG) meeting on 10/07/2024 documented that the patient’s “blood sugars are in the 300s and they are monitored 4 times a day.” The plans of care for the benefit period dated 08/18/2024 through 10/16/2024 did not include documentation of interventions for the diabetes. As of review on 09/24/2025, the plan of care did not include documentation of diabetic interventions or interventions for the blood glucose monitoring. During an interview on 09/25/2025, the Administrator stated that the plan of care did not document the interventions.”

“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, observation, and interview. In 2 of 20 (10%) clinical records reviewed, the agency did not ensure that the medications on the plan of care were accurate for what the patient was taking or being given in the facility. CLINICAL RECORD 12: The patient elected hospice care on 08/15/2025 with diagnoses of neoplasm of unspecified part of right bronchus or lung and dementia. The initial plan of care, dated 08/15/2025, and the updated plans every two weeks did not document specific interventions for the PleurX drain placed on the right side on 08/12/2025. The plan of care documented the interventions: “observation and assessment of respiratory status and instruction for performing inhalation therapy and care of equipment,” but did not document interventions for draining, site care, or dressing changes related to the Plurex drain. There were orders documented for the care of the PleurX drain, written 08/19/2025, and from the referral source. The interventions were not documented on the plan of care. During an interview on 09/25/2025, the Administrator stated that the plan of care did not document the interventions for the PleurX drain. CLINICAL RECORD 2: The patient elected hospice care on 12/19/2024 with the diagnosis of chronic obstructive pulmonary disease (COPD). The patient resided in an assisted living facility (ALF). During the home visit with the Chaplain (SC) [Personnel Record 8] on 09/25/2025, the patient’s ALF medication profile was reviewed and included: vitamin D3 2000 international units (IU), one (1) capsule every day (ordered 02/21/2025), and clopidogrel 75mg every day (ordered 01/02/2025). The hospice plans of care for the benefit period dated 12/19/2024 through 3/08/2025 did not document vitamin D3 and clopidogrel.”

“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 {reviewed 9/07/2022} stated in part, “Hand decontamination using an alcohol based hand rub should be performed: Before having direct contact with patients. After contact with a patient’s intact skin.” In 1 of 4 (25%) observations during home visits, the agency did not ensure that all clinicians followed hand hygiene according to the agency policy. HOME VISIT 4: During observed visit on 09/25/2025 with staff, [Personnel Record 8], [Clinical Record 2]. The chaplain was seated near the patient during the visit and removed his phone from his pocket to sing with the patient. He held the patient’s hand while talking, then returned the phone to his lap. He continued to visit with the patient, holding her hand, picked up his phone to read a passage, and then held her hand to pray with the patient. There was no hand sanitization during these transitions. The phone was returned to a pocket, and that was not cleansed. Hands were cleansed after leaving the patient’s room. During the interview with the Administrator, who stated that hand hygiene will have to be reviewed. The chaplain’s interview said that he should have cleaned his phone and hands because he was nervous.”

“It is required that the hospice provides nursing care under the supervision of a Registered Nurse. This standard was not met as evidenced by clinical record review, document review, and interview. In 4 of 4 (100%) clinical records reviewed, where an LPN (Licensed Practical Nurse) provided care, the agency did not ensure that documentation of supervision followed the agency’s policy. Agency policy #1-031 “Responsibilities/Supervision of Clinical Services” [reviewed 09/08/2022] stated in part, “A monthly patient visit will be completed by a registered nurse to supervise licensed practical/vocational nursing services. “ CLINICAL RECORD 2: The patient elected the hospice benefit on 12/19/2024 with a primary diagnosis of chronic obstructive pulmonary disease. During the benefit period dated 08/06/2025 through 10/04/2025, the LPN documented a visit on 08/19/2025 to provide wound care. No LPN supervision was documented as of the review on 09/24/2025, with 36 days outstanding. CLINICAL RECORD 7: The patient elected the hospice benefit on 12/10/2024 with a primary diagnosis of unspecified protein-calorie malnutrition. During the benefit period dated 08/07/2025 through 10/05/2025, the LPN documented visits on 08/16/2025 and 08/17/2025 to provide daily wound care. No LPN supervision was documented as of the review on 09/23/2025, with 38 days outstanding. CLINICAL RECORD 11: The patient elected the hospice benefit on 06/17/2025 with a primary diagnosis of Alzheimer’s Disease. During the benefit period dated 06/17/2025 through 08/15/2025, the LPN documented a visit on 07/30/2025 to provide wound care. No LPN supervision was documented as of the review on 09/24/2025, with 56 days outstanding. CLINICAL RECORD 12: The patient elected the hospice benefit on 08/15/2025 with a primary diagnosis of lung cancer. During the benefit period dated 08/15/2025 through 11/02/2025, the LPN documented a visit on 08/16/2025 to provide wound care. No LPN supervision was documented as of the review on 09/24/2025, with 39 days outstanding. During an interview on 09/25/2025, the team leader and the Administrator stated that the LPN is quite new to the agency, and they will have to educate them on the supervision documentation. HWIL.21 DHS131.25(4)(a)2 Nursing services shall be provided by or under the supervision of a registered nurse and shall consist of all of the following: Supervising and teaching other nursing personnel, including licensed practical nurses, nurse aides.”

“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 documented in the patient record, including the time spent. This standard was not met as evidenced by clinical record review and interview. In 5 of 5 (100%) clinical records reviewed of patients who accepted volunteer services, the agency did not ensure that volunteer services were noted in the plan of care. CLINICAL RECORD 2: The patient elected hospice care on 12/19/2024 with a diagnosis of chronic pulmonary disease (COPD). The patient resided in an assisted living facility (ALF)/memory care unit. The volunteer request was documented on 04/05/2025. Volunteer visits were documented on 04/05/2025, 04/15/2025 05/27/2025 06/28/2025, 07/20/2025, 08/19/2025 and 08/21/2025. The plans of care for the benefit periods dated 3/9/2025 through 6/6/2025, 06/07/2025 through 08/05/2025, and 08/06/2025 through 10/04/2025 did not document the frequency or the tasks of volunteer services. A clinical record review revealed volunteer visit notes documenting that the volunteer was sitting with the patient and talking. IDG (interdisciplinary meeting) documentation dated 06/18/2025 and 09/17/2025 documented volunteer “per patient needs, and by request.” It was unclear who requested and how this was coordinated. During an interview on 09/24/2025, the Volunteer Coordinator (VC) stated that the family and caregiver determine the frequency, but this was not clearly documented in the record. The VC stated that most families text their information. The VC reported that the volunteer service to be provided was companionship, but the request form did not clearly document this. CLINICAL RECORD 4: The patient elected hospice care on 09/04/2024 with a diagnosis of congestive heart failure (CHF). The patient resided in an ALF/memory care unit. The volunteer request was made on 10/31/2024 for pet therapy with a frequency of “per patient/staff/caregiver request.” A clinical record review revealed no documentation of who requested the volunteer services or how the frequency of services was coordinated. The volunteer documented visits on 11/07/2024, 11/14/2024, 06/01/2025, 06/14/2025, 06/19/2025, and 07/24/2025. There was no documentation of volunteer services provided for the period of 12/2024 through 05/2025. During an interview on 09/24/2025, the Volunteer Coordinator (VC) stated that the frequency was determined with caregivers and volunteers, but agreed the clinical record did not document this clearly. The VC stated that they did not have documentation for why the visits were not provided for several months and that they will work with the Administrator regarding documentation. CLINICAL RECORD 6: The patient elected hospice care on 09/17/2024 with a diagnosis of amyotrophic lateral sclerosis (ALS). The patient resided in a skilled nursing facility (SNF). The initial nursing comprehensive assessment, dated 09/17/2024, documented that the patient wanted a volunteer. On 09/18/2024, a volunteer request was completed, documenting the need for a volunteer for pet therapy and initiating recruitment. The interdisciplinary meetings (IDG), with updated plans of care dated 09/23/2024 and scheduled every two weeks as of the review on 09/25/2025, did not document the status of the volunteer request or the patient’s desires. During an interview on 09/24/2025, the team leader and VC stated that they would verify with the patient that they still wanted a volunteer. The VC stated that the patient’s location had made placement of pet therapy difficult. The VC reported that they attended all IDGs and said that updates related to volunteers had not been documented but would be in the future. CLINICAL RECORD 12: The patient elected hospice care on 08/15/2025 with a diagnosis of lung cancer. The patient resided in an ALF and had an active power of attorney (POA). The volunteer request was made on 08/15/2025. The request note documented that the frequency was to be determined by the patient, staff, or caregiver. It was documented that the patient was forgetful and that the patient’s daughter made the decisions. There were volunteer visits dated 09/10/2025 and 09/17/2025. The volunteer notes detailed companionship. The plan of care did not clearly document the frequency or the task to be provided. During an interview on 09/24/2025, the VC stated that the referral note contained the plan but lacked the task details. CLINICAL RECORD 14: The patient elected hospice care on 06/25/2025 with a diagnosis of congestive heart failure (CHF). The volunteer request was made on 08/07/2025. The referral documented the frequency of requests per patient, staff, and caregiver, but was not specific. There were volunteer visits dated 08/25/2025 and then 09/11/2025. The 09/11/2025 visit note documented that the volunteer would visit monthly after speaking with the patient. The frequency for volunteers was not clearly documented in the clinical record. During an interview on 09/24/2025, the VC stated that they believed they could determine the frequency and did not need to define it, but they would meet with the administrator to work on the process.”

“It is required that hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF or ICF/IID representatives. The hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met as evidenced by clinical record review, observation, and interview. In 1 of 5 (20%) clinical records reviewed of patients residing in a skilled nursing facility (SNF), the agency did not ensure that the plan of care identified the care and services needed by the patient and who was responsible for performing the agreed-upon functions. CLINICAL RECORD 1/Home Visit 4: The patient elected hospice care on 06/19/2024 with diagnoses of end-stage congestive heart failure and diabetes. On 06/27/2024, the physician ordered Insulin “Lispro 100u/ml 12 units subcutaneous (subq) three times a day. Hold for Blood Sugar of 120 or lower... update MD if blood sugar is over 400. Lantus insulin sub q 100 units per milliliter (ml) 70 units subcutaneous (subq) at bedtime.” On 07/17/2024, the Lantus insulin was decreased to 40 units BID, and on 08/09/2024, it was increased to 46 units BID. On 08/14/2024, the Lispro was changed to 15 units, three times a day. The initial plan of care, dated 06/19/2024, for the benefit period dated 06/19/2024 - 08/17/2024, was updated every two weeks. The plan of care did not include documentation of who would be doing the blood sugar monitoring and who would do the reporting. The updated interdisciplinary group (IDG) meeting on 10/07/2024 documented that the patient’s “blood sugars are in the 300s and they are monitored 4 times a day.” The plans of care for the benefit period dated 08/18/2024 through 10/16/2024 did not include documentation of who would monitor the blood sugars. During the home visit with the Registered Nurse (RN) [Personnel Record 11], on 09/25/2025, it was revealed that the facility was monitoring blood sugars four times a day throughout the entire year. During an interview on 09/24/2025, the Administrator stated that the plan of care should have specified who was responsible for monitoring blood sugar.”