The Mdh Hospice

“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; [and] documented in the patient record, including the time spent. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical records reviewed with orders for a volunteer revealed that the agency did not ensure that volunteer services were provided to the patient. CLINICAL RECORD 1/ HOME VISIT 1: The patient elected the hospice benefit on 06/12/2026. The plan of care dated 06/12/2026 included orders that stated, “Volunteer 1 wk 12; Beginning during week of 06/15/2026.” During the home visit on 06/30/2026, the RN explained to the patient that a volunteer would start visiting this week. As of 06/30/2026, the clinical record did not have documented evidence of any volunteer visits and no documented missed visits. The Administrator confirmed in an interview that there were no missed visit documentation or revised orders and that the volunteer did not start as ordered. The Administrator confirmed in an interview that there were no missed visit documentation or revised orders and that the volunteer did not start as ordered.”

“It is required that the hospice obtain a criminal background check on all hospice employees who have direct patient contact or access to patient records. Hospice contracts require that all contracted employees who have direct patient contact or access to patient records obtain criminal background checks. Criminal background checks are obtained in accordance with state requirements. This standard was not met as evidenced by document review, interview, and personnel record review. In 1 of 2 (50%) contract for Medical Director and Alternate Medical Director reviewed, it was revealed that the agency did not ensure that the contract included the requirement for criminal background checks. Medical Director Agreement: The Medical Director Agreement, executed March 11, 2022, did not include language requiring the Medical Director or the Alternate Medical Director to complete a background check. Addendum to the Medical Director contract, executed August 9, 2023, included the requirement to complete a face-to-face visit but no background check requirements. Review of the Medical Director’s personnel file did not include background checks. In an interview with the administrator and the Human Resources staff, they confirmed that the files and contract did not include a requirement for a background check.”

“Based on document review and interview, it was determined that for 2 of 19 (Pt #13 and Pt #16) patients, the facility failed to ensure that care coordination for social work was completed per patient Plan of Care. Findings include:1. A review of the record for Pt #13 indicated the Plan of Care for the initial certification period of 4/24/2025 to 6/22/2025, documented the need for social work to see the patient once per month, for three months, with 2 additional PRN (as needed) visits. The record indicated an initial visit and assessment by the social worker was completed on 4/28/2025. No additional documentation was present in the record indicating the additional required visits were completed. There were no physician orders present indicating a change in the order for social work during this certification period.2. A review of the record for Pt #16 indicated the Plan of Care for the initial certification period of 7/18/2025 to 10/15/2025, documented the need for social work to see the patient once per month, for three months, with 2 additional PRN (as needed) visits. The record indicated an initial visit and assessment by the social worker was completed on 7/21/2025. No additional documentation was present in the record indicating the additional required visits were completed. There were no physician orders present indicating a change in the order for social work during this certification period. 3. The Policy titled “Hospice Plan of Care”, effective 9/17/2025, states “All hospice services furnished to patient and their families must follow the written Plan of Care.” 4. An interview was conducted on 9/18/2025 at approximately 11:50 AM, with the Director of Home Health and Hospice, (E#5). During discussion regarding the absence of documentation of the ordered social work visits, E #5 agreed the documentation was not there and noted this was due to the visits not being completed. E #5 stated she is “currently short one social worker” and has been working diligently to hire another, to ensure the patients are receiving their needed and ordered services. E #5 stated the current social worker is working “extremely hard to try to keep up, and works long hours” on a daily basis, but also noted she is having trouble doing so. E #5 stated she has been “working with the State to get an exception to the one-year rule” regarding social work experience, and has a “new grad (graduate)” candidate that is currently awaiting licensure, that she is planning to hire.”