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F0849
D

Failure to Ensure Hospice Collaboration and Documentation

Muskego, Wisconsin Survey Completed on 06-16-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure proper collaboration and communication with hospice providers for three residents receiving hospice services. For each of these residents, the current hospice plan of care, visit notes, and schedules of hospice providers were not consistently available to facility staff. In addition, the facility did not designate a staff member to coordinate the plan of care with the hospice provider, and in some cases, did not develop a facility hospice care plan at all. These deficiencies were identified through interviews and record reviews, which revealed gaps in documentation, lack of clear processes for communication, and inconsistent maintenance of hospice records. One resident with multiple diagnoses, including dementia, atrial fibrillation, diabetes, and colon cancer, was receiving hospice care, but the facility's records lacked up-to-date hospice communication notes and schedules after a certain date. The hospice binder contained some documentation, but there were missing notes for recent hospice visits, and staff interviews indicated uncertainty about who was responsible for ensuring hospice notes were provided and uploaded into the medical record. There was also no clear designation of a hospice liaison among facility staff, and the process for communication with hospice was inconsistent. Another resident with Alzheimer's disease and other conditions was also on hospice, but the hospice binder contained no communication notes after a certain date, and the interdisciplinary team form was not filled out. Staff interviews revealed that hospice visit forms were sometimes uploaded into the medical record, but not consistently, and there was no designated hospice liaison. The process for documenting and communicating hospice care was unclear, and schedules for hospice visits were not consistently provided. These findings were consistent across multiple residents, indicating a systemic issue with hospice collaboration and documentation within the facility.

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