Every finding on record at Caringedge Hospice of Hermantown, LLC

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed it was revealed that the agency did not ensure that the hospice interdisciplinary group completed the initial comprehensive assessment no later than five calendar days after the election of hospice care. CLINICAL RECORD 2: The patient elected the hospice benefit on 01/29/2024. The initial social work assessment was dated 02/08/2024, 10 days later and 5 days outstanding. The record lacked documentation of a physician's order or missed visit note to explain why the initial social work assessment was late. During an interview on 04/10/2025, the Administrator reviewed the record, confirmed the finding that the social work assessment was completed later than five calendar days after the election of hospice care, and stated "There are no notes explaining why the social work assessment was late".

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 and interview. In 1 of 14 (7%) clinical records reviewed it was revealed that the agency did not ensure that all problems identified in the initial and updated comprehensive assessments had interventions in the patient's individualized written plan of care. CLINICAL RECORD 10: The patient elected the hospice benefit on 10/29/2024. A physician's order dated 12/03/2024 read in part "Give Miralax 17 grams orally daily as needed for constipation". The plan of care dated 01/27/2025-04/26/2025 lacked documentation of individualized interventions related to constipation. During a joint record review on 04/11/2025, the Administrator confirmed the above finding that the patient's plan of care did not include individualized interventions for constipation.

It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient's attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and associated conditions. This standard was not met as evidenced by a review of clinical records. 3 of 11 (27%) records reviewed revealed that problems were not added to the plan of care for needs identified in the comprehensive assessment. Record #25149 was reviewed and identified the patient elected the hospice benefit on 3/29/2022 with a primary hospice diagnosis of Chronic Diastolic Heart Failure. The initial RN assessment stated in part, "She has dyspnea at rest and angina," and "Patient experiences moderate shortness of breath with activity." The dyspnea screening also identified the patient was short of breath and identified the use of opiates for treatment. There was no respiratory problem identified on the plan of care. Record #54439 was reviewed and identified the patient elected the hospice benefit on 1/8/2021 with a primary hospice diagnosis of Cerebrovascular Disease. The MD wrote the Certificate of Terminal Illness on 5/3/2022, stating, "patient continues to have dyspnea at rest and is disabling with any exertion." There is no respiratory problem identified on the plan of care. Record #95377 was reviewed and identified the patient elected the hospice benefit on 3/23/2022 with a primary hospice diagnosis of Prostate Cancer. An order was written on 3/23/2022 to continue Physical Therapy and Occupational Therapy services. No frequencies or problem was identified, which supported the need for services in the care plan for Physical Therapy and Occupational therapy. The Administrator and Director of Nursing were interviewed on 6/21/2022. They both agreed that these problems were missing from the plan of care. They had no additional information to provide.

It is required that a hospice aide provides services as ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. 1 of 11 (9%) records reviewed revealed that aide services were not provided consistent with the plan of care. Record #38506 was reviewed and identified the patient elected the hospice benefit on 2/15/2022 with a primary diagnosis of Liver Cancer. The updated plan of care/IDG note completed on 6/16/2022 identified the visit frequency for the hospice aide at 3x a week. The most recent Hospice Aide Plan of Care completed on 5/16/2022 had a visit frequency of 2x a week. Documentation of visits completed by the hospice aide indicate visit frequency of 2x a week. The Director of Nursing was interviewed on 6/21/2022 and agreed that the plan of care was not updated with the appropriate frequency. She had no additional information to provide.

It is required that a written agreement with another organization or individual to furnish hospice care or services includes: the scope of services to be provided, how Interdisciplinary Group (IDG) management oversight and coordination is provided, how communication with the IDG and hospice administration occurs, care provided only upon authorization of the hospice, care provided in a safe and effective manner and by qualified personnel that meet the human resources requirements of the hospice and care delivered in accordance with patient’s plan of care. The hospice retains administrative and financial management responsibility, as well as the oversight of staff and the quality of care and services provided under arrangement. This standard was not met as evidenced by document review and interview. The hospice failed to secure a written agreement for therapy services. Policy Number 8-018 Revised November 2021 Written Agreement for Contracted Services stated in part "Senior Management will be responsible or the availability of qualified care and services to meet the needs of the patients served...contracted services will be defined by a written agreement before individuals from that source will be permitted to provide services on behalf of the organization. PROCEDURE 1. The written agreement between the organization and the contract service/individual will define the nature and scope of services. 3. The written agreement will stipulate the following: A. Service to be provided. B. Contractor is required to perform work in accordance with the primary organizations applicable policies and procedures. C. The Interdisciplinary Group will maintain oversight and coordination of care. D. Care will be provided upon authorization of hospice and will be provided in a safe and effective manor by qualified personnel." In an interview with the Administrator on 6/21/2022 she agreed that there was no formal written agreement with the therapy services who are utilized to perform Physical Therapy, Occupational Therapy and Speech Therapy (PT/OT/ST). She believed that a written agreement was not necessary because the therapy services are owned by the same parent company. She had no additional information to provide.

It is required that the hospice obtains a criminal background check on all hospice employees who have direct patient contact or access to patient records. Hospice contracts require that all contracted employees who have direct patient contact or access to patient records obtain criminal background checks. This standard was not met as evidenced by personnel record review and interview. 1 of 11 (9%) records reviewed revealed that background checks were not in the personnel record. Record #71002 was reviewed and identified that the date of hire for the employee was 12/1/2020. The agency could not provide evidence of a completed background check on the employee. The Administrator was interviewed on 6/22/2022 and agreed that they could not locate the employee's background check results. She stated that the employee completed the appropriate forms, but they were not able to find the results of the search. She had no additional information to provide.