Every finding on record at Minnesota Hospice LLC

Based on interview and document review, the agency failed to ensure a care plan was developed for 3 of 3 patients (P14, P20, and P21) reviewed for spiritual support. --- P21's hospice plan of care (POC) dated 7/29/24, indicated P21 had diagnoses of chronic combined systolic congestive and diastolic congestive heart failure, anxiety, depression, and had four as needed chaplain visits every 30 days. Further, the POC indicated P21's recertification for the 3rd benefit period dated 8/1/24, thru 9/29/24, indicated chaplain services would be available per patient request and spiritual concerns were met by chaplain visits. The POC lacked a care plan or interventions for the chaplain that identified P21's individualized spiritual needs during chaplain visits. P21's initial social work assessment dated 12/5/23, indicated P21 regularly attended a Christian evangelical church on Sundays. P21's Chart Entries form indicated P21 saw the chaplain on the following dates: 12/6/23, 12/20/23, 1/10/24, 1/18/24, 2/9/24, 3/22/24, and 6/6/24. P21's chaplain visit note dated 6/6/24, indicated P21 told the chaplain she had one to two months to live, and the chaplain explored with P21 what that meant and P21 was able to respond without fear or anxiety that was displayed in earlier visits and the chaplain concluded the visit with prayer. The visit lacked information whether P21 wanted further chaplain visits. During interview on 9/18/24 at 2:04 p.m., the director of nursing stated P21 and patients should have a care plan for spiritual care if they have as needed visit sets. During interview on 9/18/24 at 3:25 p.m., the administrator stated the social worker (SW) determined spiritual counselor needs of patients and a referral was sent to the director of spiritual care (DOSC) who had been the sole chaplain. The DOSC follows up with the referral within 5 days and determined the kind of problems a person was encountering and what the plan of care would look like. The administrator further stated visit frequencies were documented as part of the transcription process at interdisciplinary group (IDG) and stated he would expect a care plan specific to spiritual care. A policy, IDG Care Planning Process, dated 10/2023, indicated in order to assure that care provided is appropriately planned to meet each patient's specific needs and problems, hospice will utilize data and information gathered during the comprehensive assessment, updates to the comprehensive assessment and reassessments, in the care planning process to provide care that is consistent with the patient and family needs, with patient's needs and goals as a priority. The plan of care specifies the care and services necessary to meet the patient and family-specific needs identified in the comprehensive assessment as such needs related to the terminal illness and related conditions. All care and services furnished to patients and their families follows an individualized written plan of care established by the IDG in collaboration with the attending physician, the patient or representative and the primary caregiver in accordance with the patient's needs. P14's hospice plan of care (POC), dated 8/14/24, indicated P14 was admitted to hospice services on 8/13/24 with a primary diagnosis of malignant neoplasm of lower lobe, left bronchus or lung. P14's POC identified P14 should receive spiritual care services but did not indicate a frequency of visits. P14's POC further lacked a spiritual care care plan. P14's Existing Chart Entries, printed 9/18/24, indicated P14 received a spiritual care visit on 8/14/23, indicating P14 was "open to spiritual support including visits." An additional spiritual care visit was conducted during survey on 9/17/24. P20's POC, dated 2/28/24, indicated P20 was admitted to hospice care on 2/27/24 with a primary diagnosis of primary diagnosis of malignant neoplasm of lower lobe, right bronchus or lung. P20's POC indicated P20 had a spiritual care visit frequency of four visits as needed (PRN) every 30 days, however lacked a spiritual care care plan. P20's POC, dated 5/20/24, indicated P20 entered his second benefit period on 5/27/24. P20's POC indicated P20 had a spiritual care visit frequency of four visits as needed (PRN) every 30 days, however lacked a spiritual care care plan. P20's Existing Chart Entries, printed 9/18, indicated P20 received a spiritual care visit on 3/1/24 indicating P20 had requested "last rights when the time came." A second spiritual care visit was documented on 6/4/24 indicating "Chaplain provided Last Rites." During an interview on 9/18/24 at 12:29 p.m., the director of nursing (DON) stated it would be expected that all disciplines, including spiritual care, have a care plan in place prior to providing visits and confirmed P14 and P20 did not have a spiritual care care plan in place.

Based on interview, and document review, the agency failed to ensure a detailed statement for the frequency of spiritual care visits to meet specific family and patient needs for P14 and failed to adjust routine skilled nursing visit sets after frequent use of as needed (PRN) visits for P10, and P11. --- P11's hospice plan of care (POC) dated 6/8/24, indicated P11 had a diagnosis of cirrhosis of the liver, and required routine skilled nursing visits once a week along with 6 as needed (PRN) skilled nursing visits every 7 days. P11's local coverage determination (LCD) summary identified P11 had nonalcoholic cirrhosis of the liver, heart failure, repeated falls, and esophageal varices with bleeding and other anemia. The PRN visit sets lacked information what the PRN visit was for. P11's hospice POC dated 9/3/24, indicated P11 required 1 skilled nursing visit weekly and 6 PRN visits every 7 days. P11's Existing Chart Entries form indicated P11 had skilled nursing visits on the following dates: For the week 6/2/24, to 6/8/24, P11 was seen once on 6/7/24. For the week 6/9/24, to 6/15/24, P11 was seen on 6/10/24, and 6/14/24. For the week 6/16/24, to 6/22/24, P11 was seen on 6/18/24, and 6/21/24. For the week 6/23/24, to 6/29/24, P11 was seen on 6/25/24, 6/26/24, and 6/28/24. For the week 6/30/24, to 7/6/24, P11 was seen on 7/1/24, and 7/3/24. For the week 7/7/24, to 7/13/24, P11 was seen on 7/8/24, and 7/10/24. For the week 7/14/24, to 7/20/24, P11 was seen on 7/16/24. For the week 7/21/24, to 7/27/24, P11 was seen on 7/22/24. For the week of 7/28/24, to 8/3/24, P11 was seen on 8/2/24. For the week 8/4/24, to 8/10/24, P11 was seen on 8/5/24. For the week 8/11/24, to 8/17/24, P11 was seen on 8/13/24, and 8/16/24. For the week 8/18/14, to 8/24/24, P11 was seen on 8/19/24, 8/21/24, and 8/23/24. For the week 8/25/24, to 8/31/24, P11 was seen on 8/26/24, and 8/28/24. For the week 9/1/24, to 9/7/24, P11 was seen on 9/5/24. For the week 9/8/24, to 9/14/24, P11 was seen on 9/10/24, 9/13/24, and 9/14/24. For the week 9/15/24, to 9/21/24, P11 was seen on 9/15/24, 9/17/24, 9/17/24, 9/18/24, 9/19/24. During interview on 9/18/24 at 12:24 p.m., the director of nursing (DON) stated she expected visit frequencies increased if staff were utilizing multiple PRN visits and verified P11's visit set indicated skilled nursing visits one time a week. A policy, Minnesota Hospice-Nursing Services, Visits, Missed Visits, dated 5/30/24, indicated all hospice patients will receive a routine nursing visit at a minimum of one-time weekly Sunday through Saturday, unless the patient refuses. A policy, IDG Care Planning Process, dated 10/2023, indicated an individualized written plan of care is developed for each patient. The POC reflects patient and family goals and interventions based on the problems identified in the initial, comprehensive and updated comprehensive assessments. The POC is written to include all services necessary for the palliation and management of the terminal illness and related conditions, including a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. Visit ranges may be used: the plan the plan of care includes a range of visits and PRN orders for visit frequencies to ensure the most appropriate level of service is provided to the patient. A range is acceptable as long as it continues to meet the identified needs of the patient/family. Visit ranges with small intervals are acceptable e.g. 1-3 visits/week; 2-4 visits/week, but ranges that include "0" as frequency are not allowed, if the patient requires frequent use of PRN visits, the plan of care will be updated to include the need for additional visits. P10's hospice POC, dated 9/2/24, indicated R10 was admitted to hospice services on 8/30/24 with a primary diagnosis of Parkinson's Disease. The POC indicated P10 had a physician order for Skilled Nursing visits one time per week and six visits every seven days as needed (PRN), however lacked indication of what the PRN visits were for. P10's Physican/Provider Orders, printed 9/18/24, indicated an order, dated 9/3/24, for wound care for the hospice RN to perform two times per week. P10's Existing Chart Entries, printed 9/18/24, indicated P10 received Skilled Nursing visits on the following dates; For the week of 9/1/24 through 9/7/24, P10 was seen by skilled nursing on 9/3/24 and 9/5/24, with 9/5/24 listed as a PRN visit. For the week of 9/8/24 through 9/14/24, P10 was seen by skilled nursing on 9/9/24 and 9/13/24, with 9/13/24 listed as a PRN visit. P14's POC, dated 8/14/24, indicated P14 was admitted to hospice services on 8/13/24 with a primary diagnosis of malignant neoplasm of lower lobe, left bronchus or lung. The POC lacked a spiritual care visit frequency or visit set, indicating "chaplain [spiritual care] visits per patient request." P14's Existing Chart Entries, printed 9/18/24, indicated P14 received a spiritual care visit on 8/14/23, indicating P14 was "open to spiritual support including visits." During an interview on 9/18/24 at 12:29 p.m., the director of nursing (DON) stated she would expect the visit frequencies to match the individual needs of each patient, including wound care needs. The DON further stated she would expect a visit frequency for spiritual care visits. During an interview on 9/18/24 at 3:25 p.m., the administrator also confirmed he would expect visit frequency or visit set for spiritual care visits prior to visit being completed, confirming "per patient request" was not a visit set.

Based on interview and document review, the agency failed to ensure services were provided in accordance with the plan of care for P1, P5, and P9, and P10. --- P5's hospice plan of care (POC) dated 8/26/24, indicated P5 enrolled into hospice in the first benefit period on 8/23/24, had a diagnosis of heart failure and required three hospice aide visits weekly. Under physician orders in the POC dated 8/23/24, indicated P5 required a hospice aide twice a week starting on week two. P5's Existing Chart Entries form indicated the hospice aide visited on the following dates: From 8/25/24, to 8/31/24, P5 was seen by the hospice aide on 8/30/24. From 9/1/24, to 9/7/24, P5 was seen by the hospice aide on 9/3/24, 9/4/24, and 9/5/24. From 9/8/24, to 9/14/24, P5 was seen by the hospice aide on 9/9/24, and 9/11/24. P5's Missed Visit form indicated on 9/13/24, the hospice aide visit was missed and under comments, indicated the nursing assistant was not available. P9 P9's hospice POC dated 8/19/24, indicated P9 enrolled into hospice on 8/16/24, in the first benefit period with a diagnosis of Alzheimer's disease and required hospice aide visits twice weekly beginning week two. P9 Existing Chart Entries form indicated the hospice aide visited on the following dates: 8/18/24, to 8/24/24, P9 was seen by the hospice aide on 8/21/24, and 8/23/24. 8/25/24, to 8/31/24, P9 was seen by the hospice aide on 8/26/24, and 8/29/24. 9/1/24, to 9/7/24, P9 was seen by the hospice aide on 9/5/24. 9/8/24, to 9/14/24, P9 was seen by the hospice aide on 9/9/24, and 9/12/24. P9's Missed Visit form dated 9/2/24, indicated the hospice aide visit was missed due to holiday scheduling for the Labor Day holiday. During interview on 9/18/24 at 12:24 p.m., the director of nursing (DON) stated nurses post admission visits and complete an evaluation to determine a patient's needs. The DON further stated visit frequencies were located on the POC and if a visit was missed, a missed visit was documented in the patient's record. The DON verified P5 should have had another aide visit made. A policy, Nursing Services, Visits, Missed Visits, dated 5/30/24, indicated all hospice patients will receive a routine nursing visit at a minimum of one-time weekly Sunday through Saturday, unless the patient refuses. Missed visits include patient refusal, emergency situations, staffing, schedule discrepancies and other. Missed visits will be attempted to be made up in the same Medicare week. When a missed visit occurs a missed visit entry will be made in the patient's chart. All missed visits will be reported to the physician and a physician order will be obtained and the plan of care updated. Missed visits will be tracked weekly by the director and reported to compliance. P1's hospice plan of care (POC), dated 8/2/24, indicated R1 was admitted to hospice services on 8/1/24 with a primary diagnosis of hypertensive heart disease with heart failure. The POC indicated P1 had a physician order for two hospice aide visits per week. P1's Existing Chart Entries form, printed 9/18/24, indicated R1 received hospice aide visits on the following dates: For the week of 8/4/24 through 8/10/24, P1 was seen by the hospice aide on 8/5/24 and 8/7/24. For the week of 8/11/24 through 8/17/24, P1 was seen by the hospice aide on 8/12/24 and 8/14/24. For the week of 8/18/24 through 8/24/24, P1 was seen by the hospice aide on 8/19/24 and 8/21/24. For the week of 8/25/24 through 8/31/24, P1 was seen by the hospice aide on 8/26/24 and 8/28/24. For the week of 9/1/24 through 9/7/24, P1 was seen by the hospice aide on 9/4/24. For the week of 9/8/24 through 9/14/24, P1 was seen by the hospice aide on 9/9/24 and 9/11/24. P1's Missed Visits form, printed 9/18/24, indicated the hospice aide missed a visit on 9/2/24 due to "Holiday Scheduling" indicating the office was closed for Labor Day. P10's hospice POC, dated 9/2/24, indicated R10 was admitted to hospice services on 8/30/24 with a primary diagnosis of Parkinson's Disease. The POC indicated P10 had a physician order for two hospice aide visits per week starting the week of 9/1/24. P10's Existing Chart Entries form, printed 9/18/24, indicated R1 received hospice aide visits on the following dates: For the week of 9/1/24 through 9/7/24, P10 was seen by the hospice aide on 9/4/24. For the week of 9/8/24 through 9/14/24, P10 was seen by the hospice aide on 9/9/24 and 9/11/24. P10's Missed Visits form, printed 9/18/24, indicated the hospice aide missed a visit on 9/2/24 due to "Holiday Scheduling" indicating the office was closed for Labor Day. During an interview on 9/18/24 at 12:29 p.m., the director of nursing (DON) confirmed both P1 and P10 had a missed hospice aide the week of 9/1/24 through 9/7/24 and she would expect that the hospice aide made a second visit for both P1 and P10.

Based on interview and document review the facility failed to ensure their emergency preparedness plan (EPP) addressed the use of volunteers in an emergency including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This had the potential to affect all 40 patients the hospice served. Findings include: During review of the EPP dated 2/2021, the policies and procedures did not include the use of volunteers in an emergency, or other emergency staffing strategies that utilized volunteers to address surge needs in an emergency. During interview on 10/26/21, at 10:00 a.m. assistant director of hospice services stated the EPP did not contain a policy or procedure that addressed the training of and use of volunteers during an emergency or other emergency staffing strategies that involved the use of volunteers. During interview on 10/28/21, at 8:10 a.m. director of hospice services confirmed the EPP did not contain a policy or procedure that addressed the training of and use of volunteers during an emergency or other emergency staffing strategies that involved the use of volunteers.

Based on interview and document review, the hospice failed to develop an abuse prevention policy which provided clear directions for staff to report all allegations involving mistreatment, neglect, abuse, injuries of unknown origin and misappropriation of patient property to the administrator immediately, directions to complete a thorough investigation of alleged abuse, and lacked a procedure to ensure protection of the vulnerable adult during the investigative process. This had the potential to impact all 40 patients who were currently served by hospice. Findings include: A policy on investigating allegations of abuse or maltreatment was requested but not received. During an interview on 10/27/21, at 1:20 p.m. the Director of Hospice Services stated she was not aware of any facility policy regarding investigating allegations of abuse or maltreatment or how to protect the vulnerable adult in situation of actual or perceived abuse. During an interview on 10/27/21, at 3:14 p.m. social worker (SW)-A stated she was not aware of a policy or procedure which instructed staff to report allegations of abuse to the Director of Hospice Services immediately, provided instruction on investigating allegations of abuse, or how to ensure the vulnerable adult is protected during the investigation. SW-A stated she would report any allegation of abuse or maltreatment to the Director of Hospice Services immediately.

Based on record review and interview, the facility failed to ensure a plan of care was completed to meet the individualized patient and family needs for 1 of 13 patients (P6) when admitted to the hospice facility. Findings include: Patient 6 was admitted to the hospice agency on 8/13/21, with a primary diagnosis of acute respiratory failure with hypercapnia. P6 had been discharged from hospice services on 8/12/21, and admitted to a hospital for a large postoperative hematoma that led to hemorrhagic shock. The admitting registered nurse indicated P6 was readmitted with a JP drain (Jackson- Pratt drain system that collects bodily fluids from surgical sites) on 8/13/21, and also had a new onset of nausea, and increase in pain. The medical record indicated an initial nursing assessment was completed on 8/13/21, however the medical record lacked a current plan of care after readmission to hospice services to address the new concerns. On 10/29/21, at 12:30 p.m. the assistant director of hospice services verified a new plan of care had not been developed for P6 after admission. At 3:30 p.m. the Director of Hospice verified a plan of care was not developed when P6 was readmitted to hospice services. The IDG: Care Planning Process policy last revised 2014, indicated the hospice will utilize data/information gathered during the comprehensive assessment in the care planning process to provide are that is consistent with the patient and family needs.

Based on interview and record review the agency failed to ensure a comprehensive discharge summary was completed for 2 of 2 patients reviewed for hospice discharge (P14 and P15) who revoked hospice benefits or was discharged from hospice services. Findings include: P14's hospice services were terminated on 6/2/21, and the record lacked a discharge summary that included a summary of the patient's treatments, symptoms, pain management and physician's orders. P14's physician order, dated 6/2/21, indicated " P14 no longer meets hospice eligibility. Discharge effective today 6/2/2021, family has switched attending physician." P14's nursing note dated 6/2/21, stated P14 was discharged from hospice with service ending on 6/2/21 and P14 would transferring care to his primary provider. During interview on 10/27/21, at 4:05 p.m. director of hospice services (DHS) stated a written discharge summary that included a summary of the patient's treatments, symptoms, pain management and physician's orders had not been provided to the physician that assumed care for P14 following discharge. P15's hospice services were terminated on 12/23/20, and the record lacked a discharge summary that included a summary of the patient's treatments, symptoms, pain management and physician's orders. P15's physician order, dated 12/23/21, indicated "OK to discharge P15 per family request due to condition improvement. Discharge effective 12/23/2020. P15's nursing note dated 12/23/20, indicated P15 revoked his hospice benefit and wished to be discharged from hospice care. P15's Hospice Revocation Form dated 12/23/20, indicated P15's revoked his election for the Hospice Medicare Benefit on 12/23/20. During interview on 10/27/21, at 4:05 p.m. director of hospice services (DHS) stated a written discharge summary that included a summary of the patient's treatments, symptoms, pain management and physician's orders had not been provided to the physician that assumed care for P14 following discharge. Agency policy titled Discharge Summary, undated, stated "If a patient revokes the election of Hospice care, or is discharged from Hospice, Hospice will forward tot he patient's physician, a copy of: The hospice discharge summary, the patients record if requested. The hospice discharge summary will include: A summary of the patient's stay including treatments, symptoms and pain management, the patients current plan of care, the patient's latest physician orders, any other documentation that will assist in post-discharge continuity of care or that is requested by the attending physician of receiving facility, the date and reason for discharge, any instructions given to the patient and family, patient identifying information, patient's physician, hospice diagnosis, significant health history, discharge orders, instruction, medication profile and allergies, if discharge is other than patient's death, a brief description of services provided and ongoing needs that cannot be met, status of patient at time of discharge, presence of advance directives, end of life decisions, any third party revocation or termination.