Every finding on record at Moments Hospice of Mankato, LLC

It is required that the hospice designates a Registered Nurse member of the IDG to provide coordination of care; ensure continuous assessment of each patient’s and family’s needs; and ensure the implementation of the interdisciplinary plan of care. This standard was not met as evidenced by clinical record review, and interview. 2 of 3 (67%) clinical records reviewed of patients receiving wound care revealed the hospice did not ensure that the Registered Nurse (RN) coordinated all care and implemented the plan of care as ordered by measuring wounds as ordered and/or per protocol. Review of the Performance Improvement Plan (PIP) - "Wound" initiated on 11/24/2025 revealed the PIP documented that some patients are not getting measurements per protocol. CLINICAL RECORD 4: The patient elected hospice care on 06/11/2025 with a diagnosis of chronic pulmonary disease (COPD). The patient resided in a Skilled Nursing Facility (SNF). The physician's wound care orders for Wound #1 (Med Prox Pretibial Rt, Surgical dated 06/11/2025, 06/12/2025, 07/12/2025, 08/21/2025, 09/10/2025, and 12/26/2025) ordered the hospice nurse to measure the wound weekly. The wound measurements for Wound #1 on 06/11/2025 were 1.0x0.3x0cm. There were no weekly wound measurements documented for Wound #1 for the weeks between 06/15/2025-07/19/2025. The wound measurements for Wound #1 on 07/25/2025 were 1.1x0.6x0.8cm. There were no weekly wound measurements documented for Wound #1 for the weeks between 07/27/2025-08/30/2025. The wound measurements for Wound #1 on 09/03/2025 were 9.9x1.2x0cm. The IDG (Interdisciplinary Group) meeting note on 08/19/2025 documented, "Patient is noted to be increasingly confused about time and situation. Patient has cellulitis and started on a week of Keflex." There were no weekly wound measurements documented for Wound #1 for the weeks between 12/07/2025-12/20/2025. The wound measurements for Wound #1 on 12/26/2025 were 1.42x0.58x0.3cm. There were no weekly wound measurements documented for Wound #1 for the week of 12/28/2025. The wound measurements for Wound #1 on 01/09/2026 were 1.71x0.34x1.2cm. There were no weekly wound measurements documented for Wound #1 for the weeks between 01/11/2026-1/24/2026. The wound measurements for Wound #1 on 01/30/2026 were 4x1x0.5cm. CLINICAL RECORD 10: The patient elected hospice care on 10/14/2025 with a diagnosis of Hypertensive Heart Disease without Heart Failure. The patient resided in a Skilled Nursing Facility. The physician's wound care orders for Wound #2 (Mid Plantar Rt PU, ST 3) dated 10/21/2025 ordered the hospice nurse to complete wound care weekly and, on 01/13/2026, ordered hospice to measure the wound weekly. The wound measurements for Wound #2 on 10/21/2025 were 1.5x1.5.0.4cm. There were no weekly wound measurements documented for Wound #2 for the weeks between 10/26/2025-11/08/2026. The wound measurements for Wound #2 on 11/11/2025 were 1.5x1.5.0.5cm. There were no weekly wound measurements documented for Wound #2 for the weeks between 11/16/2025-12/6/2025. The wound measurements for Wound #2 on 12/09/2025 were 2x2x0.2cm. There were no weekly wound measurements documented for Wound #2 for the weeks between 12/14/2025-01/03/2026. The wound measurements for Wound #2 on 01/07/2026 were 1x1x0.2cm. There were no weekly wound measurements documented for Wound #2 for the weeks between 01/11/2026-1/24/2026. The wound measurements for Wound #2 on 01/29/2026 were 1x5x1.5x0.3cm. During a joint record review and interview on 01/30/2026, the Administrator agreed that there was no documented evidence that the wounds were being measured weekly during the identified gaps. Additionally, during the interview, the Administrator stated, "We have a PIP for this and recently rolled out education, it's an open PIP we are working on. Our protocol is to assess and measure weekly." During the joint record review and interview on 01/30/2026, the Team Director agreed that there was no documented evidence that the wounds were being measured weekly during the identified gaps.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as: Hand hygiene; Use of gloves, mask, eye protection, or face shield depending on anticipated exposure; Safe handling of equipment in the patient’s care environment if it is likely to have been contaminated with body fluids; Safe handling of soiled items in the patient’s care environment; Other requirements of applicable state and federal law and regulation. This standard was not met as evidenced by document review, interview and observation. In 1 of 5 (20%) home visit observations, the agency did not ensure that staff performed hand hygiene when indicated in accordance with the agency's policy. Agency Policy, titled "Hand Hygiene", stated in part, "Hand decontamination using an alcohol-based hand rub should be performed: After contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings; When moving from a contaminated body site to a clean body site during patient care; After removing gloves." HOME VISIT 4: The patient elected hospice care on 10/14/2025 with a diagnosis of Hypertensive Heart Disease without Heart Failure. The patient resided in a Skilled Nursing Facility. During the observed home visit with the Registered Nurse (RN - Personnel Record 12) and the Team Director (Personnel Record 6) on 01/29/2026, the RN donned gloves, removed the soiled wound dressing, changed gloves, measured the wound (mid-plantar right foot), donned new gloves, picked up the clean dressing pad and passed it to the facility nurse (assisting with the wound care), held the foot, and donned new gloves. The RN did not perform hand hygiene after removing gloves between glove changes or after contact with wound dressings in accordance with agency policy. During an interview with the Team Director on 01/30/2026, the Team Director agreed that the RN did not follow the hand hygiene policy.

It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services provided to patients/families are in a defined role and under the supervision of a designated hospice employee. Volunteer services are noted in the plan of care; documented in the patient record, including the time spent. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed of patients who accepted volunteer services, the agency did not ensure that the plans of care included volunteer services. CLINICAL RECORD 4: The patient elected hospice care on 06/11/2025 with a diagnosis of chronic pulmonary disease (COPD). The patient resided in a Skilled Nursing Facility (SNF). Volunteer visits were documented on 09/08/2025, 11/21/2025, and 12/10/2025. The plans of care reviewed for the period between 06/11/2025 through 02/27/2026 did not include volunteer services, a volunteer visit frequency, or assigned tasks for volunteer services. The volunteer visit note on 09/08/2025 documented, "Comforted the patient while she slept. The patient remained asleep during the visit." The volunteer visit note on 11/21/2025 documented, "I visited the patient in her room while she was asleep and comforted her. The patient woke up briefly but was mainly asleep and nonverbal during the visit." The volunteer visit note on 12/10/2025 documented, "I visited the patient in her room while she was asleep and rubbed her arm to keep her company without waking her up. The patient remained asleep and appeared comfortable during the visit." It was unclear who requested the volunteer visits, the frequency of visits, or the tasks assigned. There was no documented evidence that the clinical record included a plan of care for volunteer services. CLINICAL RECORD 14: The patient elected hospice care on 03/21/2024 with a diagnosis of Alzheimer's Disease with late onset. The patient resided in an Assisted Living Facility (ALF). Volunteer visits were documented on 11/25/2025 and 12/23/2025. The plans of care reviewed for the period between between 11/01/2025-01/27/2026 did not include volunteer services, a volunteer visit frequency, or assigned tasks for volunteer services. The volunteer visit note on 11/26/2025 documented, "Made turkey crafts." The volunteer visit note on 12/23/2025 documented, "Made Christmas crafts." It was unclear who requested the volunteer visits, the frequency of visits, or the tasks assigned. There was no documented evidence that the clinical record included a plan of care for volunteer services. During an interview on 01/29/2026, the Administrator stated, "We went through it yesterday and I provided education so she knows what needs to be done now." During a joint record review and interview on 01/28/2026, the Volunteer Coordinator agreed there was no documented evidence of a plan of care for volunteer services. During a joint record review and interview on 01/29/2026, the Volunteer Coordinator stated, "I didn't know to put in frequency orders or plan of care before. I just assigned a volunteer and they went out."

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The hospice documents the cost savings achieved through volunteers. Documentation includes: the identification of each position that is occupied by a volunteer; the work time spent by volunteers occupying those positions; estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions noted in Item 1 and for the durations noted in Item 2. This standard was not met as evidenced by document review and interview. A review of the Hospice Volunteer Requirement report for 2024 and 2025 revealed the hospice did not ensure that volunteers provided day-to-day administrative and/or direct patient care services at a minimum of 5% of the total patient care hours of all paid hospice employees and contract staff. The "Hospice Volunteer Requirement" reports dated 01/01/2024 through 12/31/2024 and 01/01/2025 through 12/31/2025 were reviewed with the Volunteer Coordinator on 01/28/2026. The Volunteer Coordinator confirmed the 2024 report findings, that volunteers provided day-to-day administrative and/or direct patient care services at 2.20% of the total patient care hours of all paid hospice employees and contract staff. The Volunteer Coordinator also confirmed the 2025 report findings, that volunteers provided day-to-day administrative and/or direct patient care services at 0.95% of the total patient care hours of all paid hospice employees and contract staff. During an interview on 01/30/2026, the Administrator agreed that the hospice did not meet the 5% requirement for 2024 and 2025. Additionally, during the interview, the Administrator stated, "We offer volunteers on admission but need to get better at offering it throughout. Management has changed here and there is a different focus now. We have a PIP we are working on for volunteer services." During an interview on 01/28/2026, the Volunteer Coordinator agreed that the hospice didn't meet the 5% requirement for 2024 and 2025. Additionally, during the interview, the Volunteer Coordinator stated, "We are trying to recruit more volunteers and get more patients to accept volunteers." A review of the Hospice Volunteer Requirement report for 2024 and 2025 revealed the hospice did not ensure that volunteers provided day-to-day administrative and/or direct patient care services at a minimum of 5% of the total patient care hours of all paid hospice employees and contract staff.

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 5 (20%) clinical records reviewed, the hospice failed to ensure that all members of the interdisciplinary group completed an initial comprehensive assessment within five days. Clinical Record 3: The patient was admitted on 1/19/23. Medical Social Worker's (MSW) initial comprehensive assessment was on 1/27/23. There was no note in the chart as to why the visit was late. In a joint record review with the Administrator, she agreed that the documentation was missing.