Every finding on record at Osf Bay De Noc Hospice

Based on record review and interview, the agency failed to ensure the comprehensive assessment included an initial bereavement assessment to assess the needs of the patient’s family and other individuals who are involved in the care of the patient in 3 (P-2, P-11, and P-13) of 14 records reviewed resulting in the potential lack of bereavement support for individuals that may be affected upon the patient's death.  Findings include: --- Patient #11 (P-11) was admitted to the hospice agency on 3/25/25 with a terminal diagnosis of prostate cancer. The medical record was reviewed on 7/11/25. During review of the start of care assessment completed by the registered nurse (RN) on 3/25/25, it was noted that the RN entered a “Survivor Risk Assessment” (assessment of risk faced by a person who will be surviving the death of the individual on hospice, and which gives a score for risk concerning mental health; financial; spiritual; and other concerns); The total score entered by the RN for the Survivor Risk Assessment completed was “0” indicating there was no risk related to topics assessed for the individual undergoing the assessment; The RN failed to include a name, relationship, or any additional comments related to the individual who was assessed for survivor risk; The RN documented that P-11 lived with a daughter and a granddaughter. It was unclear in the documentation who the RN provided the Survivor Risk Assessment for.During further review of the record, it was noted that the initial medical social worker (MSW) evaluation was held until 7/10/25 and showed documentation of the only bereavement risk assessment in the medical record using a “Bereavement Risk Assessment Tool” for the P-11’s daughter (over 3 months later). There were no additional bereavement risk assessments for any other person (including the granddaughter living in the home) noted in the medical record.On 7/11/25, the Administrator (Adm-1) reviewed this finding during interview at 11:05 a.m. Adm-1 agreed that it was unclear who the Survivor Risk Assessment was completed for at the start of care and acknowledged that the RN should have documented the individual being assessed for incorporation into the plan of care.  Patient #2 (P-2) was admitted to this hospice agency on 6/25/24 with the terminal diagnosis of hypertensive heart disease with heart failure. During record review on 7/9/25, an initial bereavement assessment was not found in the record.During an interview with the administrator (Adm-1) on 7/9/25 at 11:15 AM, Adm-1 was asked who completed the initial bereavement assessment and where it could be found in the record. Adm-1 stated the social worker completed the initial bereavement assessment and it would be found in the social work evaluation, or a separate bereavement counselor note. Adm-1 then confirmed she could not find one in the record for P-2.During a joint home visit with P-2 and the social worker (MSW-1) on 7/9/25 at 1:30 PM, P-2 talked about her daughter who visited 3 times a week and another daughter and son-in-law who came to visit over the weekend. P-2 indicated she had 5 children – 2 boys and 3 girls.During an interview with MSW-1 on 7/11/25 at 10:15 AM, MSW-1 was asked why an initial bereavement assessment was not completed for this patient after learning of several children who were involved in her care. MSW-1 stated the nurse completed a risk assessment upon admission and did not identify anyone in need, so he was not referred to complete an initial bereavement assessment. Upon review of the skilled nursing “Hospice Part 2 Admission” dated 6/28/24, it was noted “Total Score = 0" was documented under the “Survivor Risk Assessment” section. The documentation did not indicate who was specifically assessed; however, it was noted the daughter who visited 3 times a week was identified as the “Psychosocial Caregiver.” In addition, it was documented this daughter was “cooperative, involved, overwhelmed, supportive.” [sic] MSW-1 was unable to give a reason why this person or any of the other children weren't assessed, other than it was not referred to him after the nursing assessment.Adm-1 was present during the interview with MSW-1 on 7/11/25 at 10:15 AM and acknowledged the findings.Patient #13 (P-13) was admitted to this hospice agency on 6/24/25 with the terminal diagnosis of malignant neoplasm of the left kidney (kidney cancer). During record review on 7/10/25, it was noted the social work evaluation dated 6/25/25 identified a wife and daughter under the “Psychosocial Caregiver” section. Additionally, a section titled “Bereavement Risk Assessment Tool” assessed P-13’s wife, however, there was no indication the daughter was assessed. During the interview with Adm-1 on 7/11/25 at 10:15 AM, Adm-1 was asked if more than one individual could be assessed by the agency during the initial bereavement assessment. Adm-1 stated the assessment should be done on any individual identified with a bereavement risk and acknowledged the daughter was not assessed in this case. Adm-1 was unable to provide a reason for this at the time of interview and acknowledged the findings.

Based on record review, policy review, and interview, the agency failed to provide a completed volunteer plan of care for each patient receiving volunteer services that included the patient's name, contact information, family/caregivers, interests, duties the volunteer is responsible to provide, safety precautions, functional limitations, and frequency and duration of services for 10 of 10 records reviewed in which volunteer services were provided. Findings included: Policy #8472645: "Volunteers," dated 8/19/2020. The policy states, Trained Volunteers are available to offer support and services to patients/families admitted to OSF Hospice. On 7/12/2022 @ 12:30p.m., during an interview, the Volunteer Coordinator (VC-I) was asked to provide 10 Volunteer records for review. VC-I provided 10 random Volunteer Records for review. A review of the 10 individual volunteer records, revealed that none of the 10 records included a Volunteer Plan of Care that included the name of the volunteer, the name of the patient, contact information, family members or caregivers, the patient's interests, services/duties the volunteer is responsible to provide, safety precautions, functional limitations, and frequency and duration of services that would be provided to the patient for any of the patients to which the volunteers had been assigned. During an interview on 7/12/22 at 1:30 p.m. with the Volunteer Coordinator (VC-I), VC-I was aked to provide the Volunteer Plan of Care for each of the 10 records. VC-I stated, "we don't have any plans of care for volunteer services, we just tell the volunteer what activities and services the patient is interested in receiving and help schedule the visits. I did not know that a Volunteer Plan of Care was required." These findings were reviewed and acknowledged with the Volunteer Coordinator and Administrator during an interview on 7/13/2022 at 4:00 p.m. The Volunteer Coordinator stated, I am new in this position, and did not know about the requirement for a Volunteer Plan of Care. The Administrator confirmed that the agency had never included a Volunteer Plan of Care for their volunteers or patients.