Every finding on record at Millennium Hospice, Inc

Based on administrative record review and interview of the agency Volunteer program, the agency failed to achieve a 5% cost savings for Volunteer activities. This failed practice had the potential to prevent the agency from providing assistance and support to the 42 patients and families currently on service. --- Review of the Volunteer program activity log for 2025 showed a year end average of 0.9 % cost savings with 2 months >5%. The current cost savings log for January 2026 showed no cost savings.During an interview on 04/28/26 at 3:15PM, Staff B stated the Volunteer program did not meet the required hours.

Based on record review and interview, the hospice failed to ensure: 1. Hospice nursing services were provided in accordance with the plan of care for two (Patients #3 and #5) of 14 patients; 2. Hospice aide services were provided in accordance with the plan of care for two (Patients #4 and #12) of 14 patients and; 3. Medication administration by nursing services were provided for one (Patient #7) of 14 patients. --- Findings: Patient #3 A review of the plan of care dated 05/09/23 to 07/07/23 and plan of care updates dated 05/19/23 and 06/02/23 ordered hospice nursing visits at a frequency of two visit per week. Documentation showed hospice nursing visits during the week of 06/03/23 to 06/09/23 one visit on 06/05/23 (one visit missed). Documentation showed no patient or family refusal of visits and no changes in the ordered frequency for the hospice nurse. Patient #4 A review of the plan of care dated 05/15/23 to 07/13/23 and plan of care updates dated 05/19/23 and 06/02/23 ordered hospice aide visits at a frequency of three visits per week. Documentation showed hospice aide visits during the week of 05/15/23 to 05/20/23 on 05/15/23, 05/17/23, 05/19/23 and 05/20/23 (three visits ordered, four visits conducted); 05/21/23 to 05/27/23 on 05/21/23, 05/22/23, 05/23/23, 05/24/23, 05/25/23, 05/26/23 and 05/27/23 (three visits ordered, seven visits conducted); 05/28/23 to 06/03/23 on 05/28/23, 05/29/23, 05/30/23, 05/31/23, 06/01/23, 06/02/23 and 06/03/23 (three visits ordered, seven visits conducted); and 06/04/23 to 06/10/23 on 06/04/23, 06/05/23, 06/07/23, 06/09/23 and on 06/10/23, (three visits ordered, five visits conducted). Documentation showed no changes in the ordered frequency for hospice aide services. On 06/15/23 at 2:15 p.m., Staff B stated: 1. The nurse aide at the assisted living facility checks on the patient on days the hospice aide is not there and documents the contact on the hospice agencys aide visit form and; 2. The assisted living facility nurse aide does not work for the hospice agency and should not use the hospice agencys documentation forms. Patient #5 A review of the plan of care dated 04/09/23 to 06/07/23 and plan of care updates dated 04/20/23, 05/05/23, 05/19/23 and 06/02/23 ordered hospice nursing visits at a frequency of two visit per week. Documentation showed hospice nursing visits during the week of 04/16/23 to 04/22/23 one visit on 04/19/23 (one visit missed). Documentation showed no patient or family refusal of visits and no changes in the ordered frequency for the hospice nurse. Patient #7 A review of the plan of care dated 04/06/23 to 06/14/23 and plan of care updates dated 04/07/23, 04/20/23, 05/05/23, 05/19/23 and 06/02/23 ordered SN to administer medication fentanyl patch (pain medication) topically to the skin weekly. SN visits during the week of 05/28/23 to 06/03/23 showed visits on 05/30/23 and 06/02/23. Documentation showed no medication administration of the fentanyl patch, no patient or family refusal of the medication administration and no changes in the ordered medication. Patient #12 A review of the plan of care dated 01/03/23 to 04/01/23 and plan of care updates dated 01/13/23 ordered hospice aide visits at a frequency of two visits per week. Documentation showed hospice aide visits during the week of 01/03/23 to 01/07/23 (two visits ordered, two visit missed). Documentation showed no patient or family refusal of visits and no changes in the ordered frequency for the hospice aide. On 06/15/23 at 2:30 p.m., Staff B stated: 1. The hospice nursing visit frequencies for patients #3 and #5 were not followed as ordered; 2. The hospice aide visit frequencies for patients #4 and #12 were not followed as ordered and; 3. The documentation showed no fentanyl medication administration for patient #7 during the SN visits on 05/30/23 and 06/02/23.

Based on record review and interview, the hospice failed to ensure an initial psychosocial assessment was conducted by medical social work for one (Patient #10) of 14 patients. --- Findings: Patient #10 A review of the clinical record showed an election of the hospice benefit on 04/19/23 with completion of the initial psychosocial on 05/08/23 (18 days after the initial comprehensive assessment). Documentation showed a declined medical social work visit on 04/28/23 (nine days after the initial comprehensive assessment) with no other contact attempts by the Medical Social Worker until 05/08/23. On 06/15/21 at 2:25 p.m., Staff B stated the Social Worker had not attempted patient contact or completed the initial psychosocial assessment for patient #10 within the five day timeframe required to complete the initial comprehensive assessment.