Every finding on record at Sanford Bemidji Hospice

Based on interview and document review, the agency failed to identify the order or visit frequency for volunteer services for 8 of 8 patients (P5, P6, P7, P10, P11, P12, P13) who had volunteer services ordered. --- P5's plan of care (POC) dated 9/10/23, identified a start of care (SOC) 6/12/23, with diagnoses of lymphocytosis (blood has to many lymphocytes, a type of cell that fights infection), chronic pain syndrome and dementia. The POC identified planned visits for services with visit sets, which included home health aide (HHA) one visit weekly for 13 weeks, medical social work visits two every 30 days for 90 days and 4 visits prn, and skilled nursing visits one weekly for 13 weeks and five visits as needed (prn). P5 had ongoing hospice services for massage therapy one time per week, but failed to indicate the duration of the services. P5's Hospice Volunteer Patient Care Plan dated 6/15/23, identified P5 would receive volunteers weekly for socialization and reading. P5's Hospice Volunteer Visit Reports identified P5 received volunteer visits on 6/15/23, 6/21/23, 6/27/23, 7/5/23, 7/18/23, 7/19/23, 7/25/23, 7/26/23, 8/3/23, 8/8/23, 8/15/23,8/17/23, 8/22/23, 8/29/23, 9/5/23, 9/12/23 and 9/19/23. P5's communication notes identified P5 received massage therapy on 5/19/23, 5/26/23, 6/6/23, 6/21/23, 6/29/23 and 7/4/23. Visits were attempted and refused on 6/3/23, 6/17/23 and 7/11/23, with recommendation made on 7/11/23, to discontinue the massage therapy visits. P5's medical record lacked physician orders to initiate massage therapy visits for P5, despite the therapy visits as a paid staff position and service provided by the agency, nor were orders obtained to discontinue the services on 7/11/23. Interventions for volunteer services and massage therapy were identified on P5's POC under ongoing hospice services, as well as noted changes with volunteer services when they occurred; however, planned visits for volunteer services and massage therapy were not identified on P5's POC visit sets. P6's plan of care POC dated 5/18/23, identified SOC date 5/18/23, with diagnoses of Alzheimer's disease and depression. The POC identified planned visits for services with visit sets, which included chaplain visits every two weeks for 14 weeks and one to four visits prn, HHA one visit weekly for 12 weeks, medical social work visits two every 30 days for 90 days and 4 visits prn, and skilled nursing visits one weekly for 14 weeks and three visits prn. P6's POC update 6/19/23, identified volunteer services would be provided for socialization and music weekly through P6's current benefit period. P6's Hospice Volunteer Patient Care Plan dated 6/19/23, identified P6 would receive weekly volunteer visits for socialization and music therapy. P6's Hospice Volunteer Visit Reports identified P6 had volunteer visits 6/23/23, 7/242/23, 7/31/23, 8/7/23, 8/14/23, 8/21/23, 8/28/23, 9/11/23, 9/18/23, and 9/25/23. Interventions for volunteer services were identified on P6's POC under ongoing hospice services, as well as noted changes with volunteer services when they occurred;however, planned visits for volunteer services were not identified on P6's POC visit sets. P6's medical record lacked physician orders to initiate volunteer services and/or orders for changes to frequency and duration of volunteer visits when they occurred . P7's POC dated 8/2/23, identified a start of care (SOC) 8/2/23, with diagnosis of myelodysplastic syndrome (a group of cancers). The POC identified planned visits for services with visit sets, which included chaplain visits every two weeks for 12 weeks and one to four visits as needed (prn), home health aide (HHA) two visits weekly for 12 weeks, medical social work visits two every 30 days for 90 days and 4 visits prn, and skilled nursing visits one weekly for one week then two visits every week for 12 weeks and five visits prn. Interventions included volunteers to provide companionship and music per patient's request with visit frequency one time per week. P7's Hospice Volunteer Patient Care Plan dated 8/8/23, identified P7 would receive volunteers weekly for socialization and music. P7's Hospice Volunteer Visit Reports identified P7 received volunteer visits on 8/9/23, 8/23/23, 8/30/23, 9/6/23, and 9/13/23. Interventions for volunteer services were identified on P7's POC under ongoing hospice services, as well as noted changes with volunteer services when they occurred, however, planned visits for volunteer services were not identified on P7's POC visit sets. P7's medical record lacked physician orders to initiate volunteer services and/or orders for changes to frequency and duration of volunteer visits when they occurred . P10's plan of care (POC) dated 9/3/23, identified SOC date 6/5/23, with diagnoses frontotemporal neurocognitive disorder and dementia with anxiety. The POC identified planned visits for services with visit sets, which included chaplain visits every two weeks for 12 weeks and one to five visits prn, HHA one visit weekly for 13 weeks, medical social work visits two every 30 days for 90 days and 4 visits prn, and skilled nursing visits one weekly for 13 weeks and five visits prn. P10's Hospice Volunteer Patient Care Plan dated 6/6/23, identified P10 would receive weekly volunteer visits for socialization and music therapy. P10's Hospice Volunteer Visit Reports identified P10 had volunteer visits 6/7/23, 6/21/23, 7/12/23, 7/26/23, 9/5/23, 9/12/23, and 9/17/23. Interventions for volunteer services were identified on P10's POC under ongoing hospice services, as well as noted changes with volunteer services when they occurred, however, planned visits for volunteer services were not identified on P10's POC visit sets. P10's medical record lacked physician orders to initiate volunteer services and/or orders for changes to frequency and duration of volunteer visits when they occurred . P11's POC dated 7/19/23, identified a SOC date 7/19/23, with diagnoses of heart and kidney disease, and diabetes. The POC identified planned visits for services with visit sets, which included HHA two visits weekly for 12 weeks, medical social work visits two every 30 days for 90 days and 4 visits prn, and skilled nursing visits two times weekly for 13 weeks and five visits prn. P11's Hospice Volunteer Patient Care Plan dated 7/25/23, identified P11 would receive weekly volunteer visits for socialization and music therapy. P11's Hospice Volunteer Visit Reports identified P11 had volunteer visits 7/28/23, 8/18/23, 8/25/23, 9/1/23, 9/8/23, 9/15/23 and 9/22/23. Interventions for volunteer services were identified on P11's POC under ongoing hospice services, as well as noted changes with volunteer services when they occurred, however, planned visits for volunteer services were not identified on P11's POC visit sets. P11's medical record lacked physician orders to initiate volunteer services and/or orders for changes to frequency and duration of volunteer visits when they occurred . P12's POC dated 7/27/23, identified a SOC date 4/28/23, with diagnoses of heart and kidney disease, diabetes and dementia. The POC identified planned visits for services with visit sets, which included chaplain every two weeks for 12 weeks and three visits prn, HHA two visits weekly for 12 weeks and one visit weekly for one week, medical social work visits two every 30 days for 90 days and 4 visits prn, and skilled nursing visits one weekly for 13 weeks and five visits prn. P12's medical record dated 5/15/23, identified P12 would like volunteers to start two times per month and prn. P12's volunteer visit reports identified P12 received volunteer visits 7/25/23, 8/1/23, 8/8/23, 8/15/23, 8/22/23, and 8/31/23. Interventions for volunteer services were identified on P12's POC under ongoing hospice services, as well as noted changes with volunteer services when they occurred, however, planned visits for volunteer services were not identified on P12's POC visit sets. P12's medical record lacked physician orders to initiate volunteer services and/or orders for changes to frequency and duration of volunteer visits when they occurred . P13's POC dated 8/23/23, identified a SOC date 8/23/23, with diagnoses of abnormal finding in lung field, dysphagia (swallowing disorder) and multiple sclerosis (disease that affects the nervous system). The POC identified planned visits for services with visit sets, which included HHA one time per week for one week and two visits weekly for 12 weeks, medical social work visits two every 30 days for 90 days and 4 visits prn, and skilled nursing visits two times weekly for 13 weeks and five visits prn. P13's social work visit note dated 8/23/23, identified P13 wanted volunteer services. P13's volunteer coordinator note dated 9/12/23, identified P13 would have volunteer visits prn. P13's volunteer visit reports identified P13 received volunteer visits on 9/5/23, 9/12/23, and 9/18/23. Interventions for volunteer services were identified on P13's POC under ongoing hospice services, as well as noted changes with volunteer services when they occurred, however, planned visits for volunteer services were not identified on P13's POC visit sets. P13's medical record lacked physician orders to initiate volunteer services and/or orders for changes to frequency and duration of volunteer visits when they occurred . During interview on 9/27/23, at 8:49 a.m. the volunteer coordinator (VC) stated she was unable to go into the patient POC and input visit sets and had never been instructed to obtain physician orders for volunteer visits. When a patient had a change in their volunteer services she notified the hospice team or completed a communication note to the team. When interviewed on 9/27/23, at 9:00 a.m. the hospice manager (HM) stated the volunteer enters data into a patient's POC using a different process that does not allow input of visit sets for planned visits. Volunteer services were discussed at the patient's interdisciplinary team (IDT) meetings and the physician signed each IDT note. The agency did not obtain physician orders to initiate volunteers or when there was a change in volunteer services. Volunteer orders were not obtained when the services were initiated or changed in between the every two week IDT meetings. The physician would be updated on the initiation or change when the next IDT meeting was held. The agency policy Plan of Care dated 4/18/23, identified the hospice POC plans the patient's care, treatment and services based on the individual patient needs identified by the hospice interdisciplinary team's comprehensive assessments. Diagnostic and therapeutic orders would be obtained from the attending physician. The agency policy Provider Orders and Notifications dated 4/21/23, identified all treatments and care must be ordered, dated and signed by the provider. When services were provided on the basis of a providers orders, a nurse must document orders in the patient's medical record and sign, date and time the order. Following the completion of a SOC, the provider must be contacted and a verbal order obtained in order to continue services.

Based on observation, interview and document review, the agency failed to ensure all prescribed medications were part of the plan of care (POC) for 1 of 4 patients (P13) whose medications were reviewed during a home visit. --- P13's POC dated 8/23/23, identified a SOC date 8/23/23, with diagnoses of abnormal finding in lung field, dysphagia (swallowing disorder) and multiple sclerosis (disease that affects the nervous system). The POC identified planned visits for services, which included HHA one time per week for one week and two visits weekly for 12 weeks, medical social work visits two every 30 days for 90 days and 4 visits prn, and skilled nursing visits two times weekly for 13 weeks and five visits prn. Interventions for skilled nurse visits (SNV) included various assessments and education, including to educate patient and caregiver on medication management, dose, route, frequency, storage, new/changed medications, classifications food/drug interactions and potential complications. Prescribed and patient reported medications were listed on the POC, including Seroquel (an antipsychotic medication to treat schizophrenia, bipolar disorder and depression) 25 milligram (mg) tablet-give one half a tablet (12.5 mg) by mouth every night at bedtime. During a home visit on 9/26/23, at 1:00 p.m. family member (FM)-A reviewed the medication set up for P13's medications. FM-A was getting a whole Seroquel 25 mg tablet because the tablet was so small, FM-A was unable to cut the tablet in half. FM-A did not give P13 the medication every night and P13 only had the medication three nights since his return home from the hospital on 8/23/23. When interviewed on 9/27/23, at 2:45 p.m. registered nurse (RN)-A stated she talked with FM-A yesterday and discovered she was only administering Seroquel on an as needed (prn) basis and FM-A was unable to split the pill in half as directed, so was giving P13 the whole tablet. RN-A usually went through a patient's medications with the family and inquired if refills were needed but she did not read and review each medication bottle with the family or patient. It was a misunderstanding and P13's physician had been notified with new orders received. During interview on 9/27/23, at 11:50 a.m., with the administrator and hospice manager, the administrator stated the agency's practice was to complete a medication review with every visit and update the provider if any discrepancies were noted. The agency policy Medication Management dated 10/19/22, identified a medication profile was completed with current medications, including over-the-counter medications, identifying contraindications and potential interactions. The policy directed staff to ensure patients had a current medication list at each medication reconciliation. Throughout and upon completion of an episode of care, the patient and/or caregiver would be educated regarding the importance of managing medication information.

Based on interview and document review, the agency failed to ensure services were provided in accordance with the plan of care (POC) for 5 of 7 patients (P5, P6, P7, P10, P11) reviewed for volunteer services planned. --- P5's plan of care (POC) dated 9/10/23, identified a start of care (SOC) 6/12/23, with diagnoses of lymphocytosis (blood has to many lymphocytes, a type of cell that fights infection), chronic pain syndrome and dementia. The POC identified planned visits for services with visit sets, which included home health aide (HHA) one visit weekly for 13 weeks, medical social work visits two every 30 days for 90 days and 4 visits prn, and skilled nursing visits one weekly for 13 weeks and five visits as needed (prn). P5's Hospice Volunteer Patient Care Plan dated 6/15/23, identified P5 would receive volunteers weekly for socialization and reading. P5's Hospice Volunteer Visit Reports identified P5 received volunteer visits on 6/15/23, 6/21/23, 6/27/23, 7/5/23, 7/18/23, 7/19/23, 7/25/23, 7/26/23, 8/3/23, 8/8/23, 8/15/23,8/17/23, 8/22/23, 8/29/23, 9/5/23, 9/12/23 and 9/19/23. P5's medical record lacked documentation of the reason for missed visit and physician notification for the missed visit the week of 7/9/23. P6's plan of care POC dated 5/18/23, identified SOC date 5/18/23, with diagnoses of Alzheimer's disease and depression. The POC identified planned visits for services with visit sets, which included chaplain visits every two weeks for 14 weeks and one to four visits prn, HHA one visit weekly for 12 weeks, medical social work visits two every 30 days for 90 days and 4 visits prn, and skilled nursing visits one weekly for 14 weeks and three visits prn. P6's POC update 6/19/23, identified volunteer services would be provided for socialization and music weekly through P6's current benefit period. P6's Hospice Volunteer Patient Care Plan dated 6/19/23, identified P6 would receive weekly volunteer visits for socialization and music therapy. P6's Hospice Volunteer Visit Reports identified P6 had volunteer visits 6/23/23, 7/24/23, 7/31/23, 8/7/23, 8/14/23, 8/21/23, 8/28/23, 9/11/23, 9/18/23, and 9/25/23. P6's medical record lacked documentation or the reason for missed visit and physician notification of the missed visits for the weeks between 6/25/23 to 7/23/23, and the week of 9/3/23. P7's POC dated 8/2/23, identified a start of care (SOC) 8/2/23, with diagnosis of myelodysplastic syndrome (a group of cancers). The POC identified planned visits for services with visit sets, which included chaplain visits every two weeks for 12 weeks and one to four visits as needed (prn), home health aide (HHA) two visits weekly for 12 weeks, medical social work visits two every 30 days for 90 days and 4 visits prn, and skilled nursing visits one weekly for one week then two visits every week for 12 weeks and five visits prn. Interventions included volunteers to provide companionship and music per patient's request with visit frequency one time per week. P7's Hospice Volunteer Patient Care Plan dated 8/8/23, identified P7 would receive volunteers weekly for socialization and music. P7's Hospice Volunteer Visit Reports identified P7 received volunteer visits on 8/9/23, 8/23/23, 8/30/23, 9/6/23, and 9/13/23. P7's medical record lacked documentation of the reason for missed visit and physician notification of the missed visits for the weeks of 8/13/23, 8/27/23 and 9/17/23. P10's plan of care (POC) dated 9/3/23, identified SOC date 6/5/23, with diagnoses frontotemporal neurocognitive disorder and dementia with anxiety. The POC identified planned visits for services with visit sets, which included chaplain visits every two weeks for 12 weeks and one to five visits prn, HHA one visit weekly for 13 weeks, medical social work visits two every 30 days for 90 days and 4 visits prn, and skilled nursing visits one weekly for 13 weeks and five visits prn. P10's Hospice Volunteer Patient Care Plan dated 6/6/23, identified P10 would receive weekly volunteer visits for socialization and music therapy. P10's Hospice Volunteer Visit Reports identified P10 had volunteer visits 6/7/23, 6/21/23, 7/12/23, 7/26/23, 9/5/23, 9/12/23, and 9/17/23. P10's medical record lacked documentation of the reason for missed visits and physician notification of the missed visits for the weeks of 6/11/23, 6/25/23, 7/2/23, 7/16/23, 7/30/23, 8/6/23, 8/13/23, 8/20/23, and 8/27/23. P11's POC dated 7/19/23, identified a SOC date 7/19/23, with diagnoses of heart and kidney disease, and diabetes. The POC identified planned visits for services with visit sets, which included HHA two visits weekly for 12 weeks, medical social work visits two every 30 days for 90 days and 4 visits prn, and skilled nursing visits two times weekly for 13 weeks and five visits prn. P11's Hospice Volunteer Patient Care Plan dated 7/25/23, identified P11 would receive weekly volunteer visits for socialization and music therapy. P11's Hospice Volunteer Visit Reports identified P11 had volunteer visits 7/28/23, 8/18/23, 8/25/23, 9/1/23, 9/8/23, 9/15/23 and 9/22/23. P11's medical record lacked documentation of the reason for missed visits and physician notification of the missed visits for the weeks of 7/30/23 and 8/6/23. During interview on 9/27/23, at 8:49 a.m. the volunteer coordinator (VC) verified the above findings. VC stated some of the patients had refused visits or were sleeping or unavailable on scheduled volunteer days. VC notified the team of missed or refused visits via communication notes or verbal report to the hospice manager. VC indicated she did discuss volunteer visits at each patient's interdisciplinary team meeting, in which the physician also attended. She had never been instructed to document physician notification of missed visits. When interviewed on 9/27/23, at 9:00 a.m. the hospice manager (HM) stated the volunteer enters data into a patient's POC using a different process. Volunteer services and missed visits were discussed at the patient's interdisciplinary team (IDT) meetings and the physician signed each IDT note. Physician notification of missed volunteer visits were not documented individually in the patient charts. The agency policy Provider Orders and Notifications dated 4/21/23, identified the provider must be notified of any missed visits and documentation in the medical record must reflect the notification.

Based on interview and document review, the agency failed to ensure chaplain services were provided for 1 of 14 patients (P11) reviewed for assessed services. --- P11's POC dated 7/19/23, identified a SOC date 7/19/23, with diagnoses of heart and kidney disease, and diabetes. The POC identified planned visits for services, which included HHA two visits weekly for 12 weeks, medical social work visits two every 30 days for 90 days and 4 visits prn, and skilled nursing visits two times weekly for 13 weeks and five visits prn. P11's medical social work (MSW) visit and initial assessment dated 7/19/23, identified P11 attended the Baptist and Methodist churches in the past and would like to have the hospice chaplain visit since P11 was not connected with a church at the present time. P11's MSW note dated 9/6/23, identified P11 notified licensed social worker (LSW)-A the chaplain called him and planned to visit with P11 soon. P11's chaplain visit note dated 9/18/23, identified the visit was an initial visit and P11 would like to have visits one to two times per month. P11 had losses in his life and the goal would be to build trust with P11 and his family in order to discuss their losses and to provide spiritual resources to them. Visits would be planned once every two weeks. During interview on 9/27/23 at 2:30 p.m., the hospice administrator stated the referral for chaplain services were not made following the initial assessment on 7/19/23. The need to notify the chaplain of the need for an assessment had gotten missed and as a result, chaplain visits were delayed. It was the agency's practice for referrals to be communicated as soon as the patient requested a service. The agency's Plan of Care policy dated 4/18/23, identified employees would use the data obtained during the initial and ongoing assessments and develop a list of patient problems, and needs with corresponding goals and interventions and anticipated target dates for reaching their goals. The agency's Admission Criteria and Process policy dated 7/19/23, indicated during the initial assessment visit, employees would assess the patient's eligibility and decide or confirm level of services required.

Based on interview and document review, the agency failed to ensure a registered nurse (RN) provided a supervisory visit of hospice aide services at least every 14 days for 1 of 14 patients (P10) whose records were reviewed. --- P10's plan of care (POC) dated 9/3/23, identified SOC date 6/5/23, with diagnoses frontotemporal neurocognitive disorder and dementia with anxiety. The POC included planned visits for services with visit sets for HHA one visit weekly for 13 weeks, and skilled nursing visits one weekly for 13 weeks and five visits prn. P10's physician orders identified HHA orders 6/5/23 to 9/2/23, one visit every week for 13 weeks to assist with activities of daily living and a shower. P10's skilled nurse visit notes identified HHA supervision was completed on 7/13/23, 8/21/23, 8/30/23 and 9/18/23. Skilled visit notes for visits completed between 7/14/23 to 8/21/23, and 8/31/23 to 9/18/23, failed to document HHA supervision had been completed every 14 days as required. During interview on 9/27/23 at 2:30 p.m., the hospice manager stated nurses were expected to complete HHA supervision every 14 days with their visits. The agency Home health Aide Supervision and Delegation of Duties policy dated 4/26/23, identified when a HHA provided services to a patient, skilled personnel must make a supervisory visit to the patient's home at least every 14 days. The supervisory visit was to assess the relationships, determine if goals were being met or revise the aide care plan if needed.