Moments Hospice of Sheboygan

“Based on record review, interview, and agency policy review, the agency failed to ensure that the initial comprehensive assessment was completed by the interdisciplinary group (IDG) members within five days of a hospice admission for three of 14 patients reviewed (Patient (P) P2, P10, and P12). Failure to complete the initial comprehensive assessment within five days had the potential for new patients to have physical, psychosocial, spiritual, or financial needs not addressed in a timely manner.Findings include: 1. Review of P2’s “Patient Information Record” revealed an admission date of 11/06/25, and the social work (SW) assessment, located in the “Clinical Progress Notes,” in the electronic medical record (EMR) was not completed until 11/12/25. No additional documentation was noted in the EMR that explained the delay in assessment. 2. Review of P10’s “Patient Information Record” revealed P10’s admission date was 12/23/25; however, the initial chaplain assessment, located in the “Clinical Progress Notes” in the EMR, was not completed until 12/29/25. Review of P10’s “Clinical Coordination Note” by the chaplain, dated 12/29/25, stated “patient request.” No further documentation was noted in P10’s EMR that indicated what that statement meant. 3. Review of P12’s “Patient Information Record” revealed P12’s admission date was 10/16/25; however, the initial SW assessment, located in the “Clinical Progress Notes” in the EMR was not completed until 10/24/25. No additional documentation was noted in the EMR that explained the delay in assessment.During an interview on 04/30/25 at 10:00 AM, the Administrator confirmed that the initial SW and chaplain assessments were not completed within five days of the hospice admission for P2, P10, and P12.During an interview on 04/30/26 at 1:50 PM, the SW stated it was seven calendar days to complete the initial SW assessment and not five days. The Administrator was present during the interview and informed the SW that it was five calendar days for completion of initial assessments.During an interview on 04/30/26 at 2:30 PM, the Chaplain stated that due to the Christmas holidays, the initial assessment for P10 was not completed until 12/29/25. The Chaplain was unable to state if there was any additional documentation in the EMR that explained the late initial assessment.Review of the undated hospice agency policy titled, “The Plan of Care” revealed, “. . . The Hospice core team shall develop an integrated plan of care, based on initial assessments, for the new patient within 5 days of admission . . .””

“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 13 (8%) clinical records reviewed, the agency did not ensure that all problems identified in the initial and updated comprehensive assessment had planned interventions in the patient’s individualized written plan of care. Clinical Record 5: The clinical record revealed a physician’s order dated 04/18/2024 that read in part, “Clopidogrel 75mg tablet daily by mouth.” The plan of care dated 04/18/2024-07/16/2024 lacked interventions related to the patient being at risk for bleeding. In an interview on 10/16/2024, the Executive Director reviewed the clinical record and stated, “There are no interventions for the patient being a bleeding risk.” Applicable State Regulations: DHS 131.21(3)(b).”

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. 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 and interview. In 1 of 11 (9%) clinical records with aide services provided reviewed, the agency did not ensure that all written patient care instructions were included in the aide care plan. Clinical Record 9: The patient elected hospice care on 02/23/2024. On 02/23/2024, the physician ordered wound care with a wound dressing to a wound on the patient’s abdomen. On 02/23/2024, the physician ordered: “HHA 3x per week.” The HA care plan dated 02/23/2024 assigned the HA the relevant task of a “Bed bath at every visit.” The HA care plan did not provide the HA with instructions addressing the abdominal dressing during the bed bath should the dressing become wet or dislodged. During an interview on 10/16/2024, the Executive Director reviewed the record and stated, “There are no wound instructions on the aide care plan.” Applicable State Regulations: DHS 131.26(2)(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 physician orders. This standard was not met as evidenced by clinical record review and interview. In 1 of 13 (8%) clinical records reviewed, the agency did not ensure that all physician’s orders were included in the patient’s clinical record. Clinical Record 13: The plan of care dated 01/15/2024-03/13/2024 read in part, “Change Foley catheter per MD orders.” The record lacked a specific physician’s order for the frequency of Foley catheter changes. In an interview on 10/16/2024, the Executive Director reviewed the clinical record and stated, “There is not an order for how often the Foley catheter needs to be changed.””

“It is required that drugs and biologicals are labeled and stored in accordance with state law and regulation, as well as accepted standards of practice. At a minimum, labels include the patient’s full name, generic, trade, or brand name of the medication, as well as amount dispensed, directions for use, including route, rate, frequency, and method of administration; prescriber’s name, expiration date, and cautionary instructions. This standard was not met as evidenced by interview and observation. A tour and observation of the agency’s supply room revealed that the agency did not ensure that all drugs and biologicals were checked for current expiration dates. A review of all supplies in the agency’s supply room was conducted on 10/18/2024. The supply room contained two bottles of antifungal powder with an expiration date of 07/2024 and one box of adhesive remover wipes with an expiration date of 03/02/2024. In a review of the supply room on 10/18/2024, the Executive Director confirmed the finding that the adhesive remover wipes and antifungal powder were expired. Review of the agency’s supply room revealed that the agency did not ensure that all drugs and biologicals were checked for current expiration dates.”

“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, interview, and observation. In 1 of 5 (20%) clinical records reviewed, the agency did not ensure that the written plan of care identified planned interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 3/Home Visit 2: The patient elected the hospice benefit on 10/20/23. The initial comprehensive assessment completed by the Registered Nurse (RN) on 10/20/2023, documented in the narrative note “Left hand severely contracted.” The RN visit note dated 11/16/23 documented, “Left hand constricted with rolled up fabric in it to keep skin off.” During the home visit on 11/20/23, the patient was observed gripping a roll of gauze tightly in their left hand. The patient’s caregiver/spouse expressed concern about contracture stating, “It is difficult to clean because it causes them a lot of pain to open hand.” The plan of care for benefit period 2, dated 10/20/23 through 1/17/24, did not include documentation of problems, goals or interventions to address the care of the patient’s left-hand contracture. During an interview conducted on 11/21/23, the Alternate Clinical Director confirmed the plan of care did not include problems, goals or interventions to address the care of the patient’s left-hand contracture.”