North Woods Home Nursing & Hospice

“Based on record review and interview, the agency failed to conduct annual exercises to test the effectiveness of the emergency plan, resulting in the potential for poor patient outcomes due to an unprepared staff response in the event of an actual emergency. Findings include: The agencys Emergency Preparedness (EP) binder was reviewed on 7/10/24. Upon review of the information, it was noted the agency performed a testing drill in 2022 and 2 in 2024, but there was no record of a testing drill being performed in 2023. The Administrator (Staff A) was interviewed on 7/10/24 at 1:00 PM regarding a drill for 2023. Staff A reviewed the binder and agreed there was no record of a drill performed in 2023. Staff A stated he used the pandemic as the emergency drill for 2023, but admitted it was not documented and acknowledged the findings.”

“Based on record review and interview, the hospice failed to ensure all members of the interdisciplinary group were involved in completing the comprehensive assessment of the patient no later than 5 calendar days after the election of the hospice benefit in 5 (P-1, P-4, P-6, P-9, P-12) of 14 sample records reviewed resulting in unidentified and unmet spiritual and/or psychosocial needs of the patient and family. Findings include: Agency policy titled “;IDG Functioning-Hospice”; Revised 8/2023, was reviewed on 7/10/23. On page 1., it stated “;Policy: The Hospice program of North Woods Home Care and Hospice will have a designated Interdisciplinary group (IDG) care team to oversee all Hospice patients... 1. North Woods Home Care and Hospice designates an IDG... team will include at least the following individuals: a doctor... a registered nurse, a social worker and a pastor or counselor. P-12: This 78-year-old was admitted to the agency on 6/11/24 with a terminal diagnosis of Emphysema (lung disease causing decreased amount of oxygen in the blood). The medical record was reviewed on 7/10/24. The election of hospice benefit was signed on 6/11/24. A live discharge was completed on 7/5/24 due to the patient leaving the service area. There was no comprehensive assessment made by the Medical Social Worker (MSW) while the patient was on hospice service with the agency (25 days). There was no evidence in the medical record that MSW services were refused by the patient or family. These findings were reviewed and acknowledged by the Administrator (Staff A) and the Director of Nursing (Staff B) during interview on 7/10/24 at 3:10 p.m. During interview, Staff A stated that their staff MSW (Staff E) had gone on maternity leave 10 weeks earlier and would be returning in 2 weeks from the date of this survey. Staff A stated that another MSW had been seeing patients after Staff E went on leave however, the MSW had left (quit) the agency in the first week of June 2024 and during the time of this patients admission and service, there was no MSW to see patients. P-6: This 73-year-old patient was admitted to this hospice agency on 2/15/24 with the terminal diagnoses of malignant neoplasm of the right lung (cancer) and chronic obstructive pulmonary disease (COPD). During record review on 7/9/24, it was noted the chaplain visit scheduled for 2/16/24 stated “;Chaplain Pt Refused/Not Home”. It was unclear if the patient refused or if they were not home and the chaplain should reschedule their visit to complete the comprehensive assessment. No other visits were made by the chaplain. The Director of Nursing (Staff B) was queried during an interview on 7/10/24 at 2:00 PM if there was further documentation regarding whether the patient was not home or refused chaplain services. Staff B stated there should be additional information within the note to state whether the patient still needed chaplain services, however, she admitted there were no further details for this patient and acknowledged the findings. P-9: This 94-year-old patient was admitted to this hospice agency on 6/3/24 with the terminal diagnoses of Alzheimers disease and dementia. During record review on 7/10/24, it was noted there was no evaluation completed by the chaplain or social worker to complete the comprehensive assessment. During the interview on 7/10/24 at 2:00 PM, Staff B was also asked about the chaplain and social work evaluations for P-9. Staff B stated she is not sure why the chaplain did not see this patient as there was no documentation regarding this. Staff B stated social work did not evaluate the patient because they dont have a social worker working at this time. Staff B acknowledged the findings. P-1: The patient was admitted to Hospice on 6/27/24 with terminal diagnosis of dementia, congestive heart failure, and chronic kidney disease. During record review on 7/9/24, it was noted that there was no evidence of a social work assessment performed by MSW (Master of Social Work) services between the dates of 6/27/24 and 7/9/24. There was no documented reason why the required core service of MSW was not furnished. No evidence was found in the medical record the MSW services were declined or delayed. This finding was reviewed and acknowledged by the Administrator (Staff A) during an interview on 7/9/24 at 1:40 PM. Staff A acknowledged MSW needs were being temporarily filled by skilled nursing staff. However, review of RN staff personnel files on 7/10/24, found no evidence of that any of the RNs had certification that met MSW requirements to provide services. P-4: The patient was admitted to Hospice on 6/4/24 with the terminal diagnosis of chronic obstructive pulmonary disease and congestive heart failure. During record review, on 7/10/24, it was noted that there was no evidence of a social work assessment performed by MSW services between the dates of 6/4/24 and 7/10/24. This finding was reviewed and acknowledged by the Administrator (Staff A) during an interview on 7/10/24 at 2:15 PM. Staff A had acknowledged the day prior that MSW needs were being temporarily filled by skilled nursing staff (see above). The Hospice agency failed to adhere to its policy “;IDG Functioning-Hospice” referenced below.”

“Based on record review and interview, the Hospice failed to ensure the initial Bereavement Risk Assessment was comprehensive and included relevant patient family members noted during clinical record review to determine factors that may impact the family’s ability to cope with the patient’s impending death for 6 (P-2, P-5, P-6, P-7, P-9 and P-13) of 14 records reviewed from a total sample of 14 records. This deficient practice has the potential to negatively affect the loss/grief issues for all 110 patients/family members serviced within the past 12 months. Findings include: P-13: This 96-year-old was admitted to the agency on 11/2/23 with a terminal diagnosis of acute diastolic (congestive) heart failure (progressive disease which affects the pumping action of the heart muscle). The medical record was reviewed on 7/9/24. The comprehensive assessment was completed by the registered nurse on 11/2/23 and included an initial bereavement assessment for the primary caregiver (one of the patients sons). It was noted that the patient had a second son who was listed as an “;emergency contact” and was mentioned in skilled nursing documentation regarding the day-to-day care of the patient (notes dated 2/26/24; 1/30/24; 3/5/24). There was no evidence of a comprehensive bereavement assessment for the second son who was noted to be involved/supportive for the patient. This finding was reviewed and acknowledged by the Administrator (Staff A) and the Director of Nursing (Staff B) during interview on 7/10/24 at 3:10 p.m. P-2: The patient was admitted to hospice on 10/29/2023 with terminal diagnosis of malignant neoplasm of prostate (cancer), acute kidney failure, and diabetes-type 2. On 7/9/24, review of the initial start of care assessment performed by skilled nursing on 10/29/23, documented on pg. 9 of 20 under “Bereavement-Bereavement Status” the following individual(s) concerning the bereavement assessment (BA): “Wife” with a score of 20 (low risk is 13-22). No other individuals were identified in the medical record from admission to date of survey review on 7/9/24. However, further review of clinical notes revealed other emotionally significant family members not included in the BA. On 11/2/23, visit note(s) by MSW (Master of Social Work) services documented, “They (patient and wife) have two daughters that both live very close. One is close emotionally to (Patient) and spends a lot of time with him...”. The patient died on 11/28/23 and review of 3 of 3 bereavement follow-ups (12/6/23, 1/5/24, and 3/28/24) had no acknowledgement of the emotionally close daughter identified above. This finding was reviewed and acknowledged by the Administrator (Staff A) and Director of Nursing (Staff B) during an interview on 7/11/24 at 8:50 AM. P-5: The patient was admitted to hospice on 9/20/23 with terminal diagnoses of squamous cell carcinoma (skin cancer). On 7/10/24, review of the initial start of care assessment performed by skilled nursing on 9/20/23, documented on pg. 9 of 20 under “Bereavement-Bereavement Status” a bereavement risk score of 20 (low) but failed to identify who the score pertained to. No other individuals were identified in the medical record from admission to date of survey (7/10/24) concerning a bereavement risk assessment. Additional record review noted P-5 had a total of 3 entries (all sons) listed under “;Personal Contacts”. (Son-A) was listed first, (Son-B) listed second, was P-5s Power of Attorney, and the third contact (Son-C) was listed under “;Primary Caregiver”. The patient died on 11/7/23, and review of 2 of 2 bereavement follow-ups (11/14/23, and 12/8/24) had no specific identification of who the bereavement follow-up was directed towards. This finding was reviewed and acknowledged by the Administrator (Staff A) and Director of Nursing (Staff B) during an interview on 7/11/24 at 8:55 AM. Both noted that better documentation was needed to clarify the specific details concerning bereavement assessment and follow-up. The agency failed to adhere to its policy referenced below. Agency Policy: “Bereavement Program Description” (Revised 08/23) stated, “Our program has been designed in a way which will provide continuous support during all phases of the grief/bereavement process for both the patient and family/caregiver. Assess individual and family caregiver coping skills, support systems and stress levels to determine which type(s) of bereavement services to offer. Bereavement is an ongoing process which begins immediately with admission... and may continue many months after a person has died.” P-6: This 73-year-old patient was admitted to this hospice agency on 2/15/24 with the terminal diagnoses of malignant neoplasm of the right lung (cancer) and chronic obstructive pulmonary disease (COPD). During record review on 7/9/24, it was noted the start of care dated 2/15/24 identified 1 daughter (who lived locally) under the initial bereavement assessment. Upon further record review, it was noted the patient has another daughter who lives further away that was not identified and assessed. P-7: This 88-year-old patient was admitted to this hospice agency on 2/7/24 with the terminal diagnoses of malignant neoplasm of the prostate (cancer) with metastases to the lung and bone. During record review on 7/9/24, it was noted the start of care dated 2/7/24 identified a daughter who is also the patients DPOA (durable power of attorney) under the initial bereavement assessment. Upon further review of the record, it was determined another daughter was identified on the start of care under patient “;support system” and in the demographic section under “;emergency contact”, however, she was not identified for an initial bereavement assessment. P-9: This 94-year-old patient was admitted to this hospice agency on 6/3/24 with the terminal diagnoses of Alzheimers disease and dementia. During record review on 7/10/24, it was noted the start of care dated 6/3/24 identified the patients daughter (who lives out of the country) under the initial bereavement assessment. Upon further review of the record, it was noted the start of care also identified another individual as a caregiver and local family friend under patient “;support system” and in the demographic section “;emergency contact”, however, she was not identified for an initial bereavement assessment. The Director of Nursing (Staff B) was interviewed on 7/10/24 at 2:00 PM regarding the process for the initial bereavement assessment. Staff B reported that individuals that needed assessment were identified by the nurse at the start of care and the assessment should be included in that note. Staff B also stated that additional individuals can be assessed later as they are identified, however, she reported this is not documented in a central location and may just be mentioned in a treatment note. When asked about the above situations, Staff B was unable to find later assessments of the other identified individuals and agreed there should have been initial assessments done on each of them. Staff B acknowledged the findings.”

“Based on record review and interview, the agency failed to ensure the interdisciplinary group (IDG) included all necessary, qualified individuals who practice in the following professional roles: a Doctor of Medicine or osteopathy, a registered nurse, a social worker (or marriage and family therapist or mental health counselor), and a pastoral or other counselor. This deficiency has the potential for poor patient outcomes and unmet care needs for all 11 patients currently being served by this agency. Findings include: **Policy titled “;IDG Functioning – Hospice” (revised 8/23) stated “;...The team will include at last the following individuals: a doctor of medicine or osteopath, a register nurse, a social worker and a pastor or counselor.” During the entrance interview on 7/8/24 at 1:30 PM, the Administrator (Staff A) was asked about the members of the IDG. Staff A was able to name individuals for the roles of the doctor, RN, and pastoral counselor, however, Staff A reported the agency does not have a social worker actively working at this time. Staff A stated the regular social worker (Staff E) went on maternity leave at the end of April and is scheduled to return in late July (after 12 weeks). Staff A stated they had another social worker trained to fill in, however, that person left the position in the beginning of June and there has not been anyone else to fill that role. According to review of the records, the social workers last day was 6/4/24, so the agency had not had a working social worker for 34 days when the survey began. Staff E isn’t scheduled to return until 7/21/24. According to IDG meeting records, there was no social worker present for the meetings held on 6/18/24 and 7/2/24. When asked how the agency was dealing with social work need that have come up during this time, Staff A sated the RN and other disciplines have worked together to address any issues, however, he acknowledged the findings.”

“Based on record review and interview, the agency failed to maintain documentation to demonstrate 75 total hours of aide training prior to testing along with documentation that the content, training, and instructors met the requirements of the regulation in 1 (Staff D) of 4 aide personnel files reviewed, resulting in the potential for untrained individuals performing patient care duties. Findings include: **Policy titled “;Home Health Aide Skills Evaluation and Proof of Competency” (revised 2/23) stated: “;Skilled Home Health Aides hired by North Woods Home Care and Hospice should have: 1 1) A nurse aide training and competency evaluation program approved by the state (CNA (Certified Nursing Assistant) License) as meeting the requirements of 483.151 through 484.154, and is currently listed in good standing on the state nurse aide registry and has not had a 24 month consecutive period with no compensation; or 2 2) Completed training totally a minimum of 75 hours, at least 16 of which will be devoted to supervise practice training. This practical training will follow a minimum of 16 hours classroom training. Additionally each Home Health Aide, prior to rendering service, must successfully pass the written Home Health Aide Skills Assessment Test....” [sic} During review of the aide personnel files on 7/10/24, it was noted that there was no state CNA certification number for Staff D (home health aide). The Administrator (Staff A) reported Staff D did not complete the state certification during an interview on 7/10/24 at 2:30 PM. Staff A stated Staff D was trained and tested by the office according to the regulation and agency policy before he started as administrator. Staff A was asked for documentation regarding the training program, qualified instructors and proof of hours. Staff A was able to provide 2 booklets of testing/observations of Staff D with documentation that she passed; however, he was unable to find proof of the hours of training that occurred prior to testing. Staff A stated he called Staff D to ask if she had a record of her training hours, however, he was unable to provide the documentation by the conclusion of the survey. Staff A acknowledged the findings.”

“Based on record review and interview, the hospice failed to ensure the registered nurse (RN) made an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide in 3 (P-6, P-10, and P-12) of 9 sample records reviewed for which home hospice aide services were utilized, potentially resulting in inadequate or unmet services in relationship to the needs of the patient and/or family. P-10: This 69-year-old was admitted to the agency on 8/29/23 with a terminal diagnosis of lung cancer. The medical record was reviewed on 7/10/24. During review, it was noted that the plan of care (POC) dated for the certification period of 6/24/24 through 8/22/24 included orders for hospice aide services at a frequency of 3 times per week. The hospice aide made 8 visits in 17 days (6/24/24 through 7/10/24). There were no hospice aide supervisory visits documented by the RN during that period. On 7/10/24 at 3:00 p.m., the Director of Nursing (Staff B) was queried to when the last RN supervisory visit had been completed in this patients home and Staff B stated that it was last completed during the previous certification period (4/25/24 through 6/23/24) and was done on 6/10/24 (20 days and 12 hospice aide visits prior to this review). P-12: This 78-year-old was admitted to the agency on 6/11/24 with a terminal diagnosis of Emphysema (lung disease causing decreased amount of oxygen in the blood). The medical record was reviewed on 7/10/24. The POC dated for the certification period of 6/11/24 through 9/8/24 included orders for hospice aide services at a frequency of 2 times per week for 12 weeks. The patient was discharged on 7/5/24 (25 days later) due to moving out of the service area. During the certification period, the hospice aide made 6 visits in 15 days. There were no hospice aide supervisory visits documented by the RN in the record. These findings were reviewed and acknowledged by the Administrator (Staff A) and the Director of Nursing (Staff B) during interview on 7/10/24 at 3:10 p.m. P-6: This 73-year-old patient was admitted to this hospice agency on 2/15/24 with the terminal diagnoses of malignant neoplasm of the right lung (cancer) and chronic obstructive pulmonary disease (COPD). During record review on 7/9/24, it was noted there was an aide supervision note completed by the registered nurse (RN) on 5/28/24. The next aide supervision noted was not completed until 6/19/24 – 22 days after the last aide supervision note. Upon further review of the record on 7/10/24, it was noted there was not another aide supervision noted completed yet – 21 days after the last supervision note. The Director of Nursing (Staff B) was interviewed regarding this finding on 7/11/24 at 2:00. Staff B stated the agency has somebody to audit this, but that person just got back from maternity leave and may not be caught up yet. Staff B acknowledged the findings.”

“Based on record review and interview, the agency failed to ensure volunteers provided day-to-day administrative and/or direct patient care services at a minimum of 5 percent of the total patient care hours of all paid employees and contract staff, resulting in the lack of cost-savings for the agency. Findings include: During an interview regarding volunteer services on 7/9/24 at 1:30 PM, the Administrator (Staff A) was asked to provide documentation of the hours of service provided by the paid staff and volunteers. Staff A provided monthly values for total patient care hours compared to total volunteer hours. Upon review of the year-to-date totals (through June 2024), it was noted: Total patient care hours = 1252.2 Total volunteer hours = 39.5 1252.2/39.5 = 3.15% volunteer usage Staff A agreed the agency is not meeting the 5% threshold and acknowledged the findings at the time of the interview.”

“Based on observation, interview, and record review, it was determined the hospice agency failed to ensure that durable medical equipment (DME) was properly maintained concerning expiration dates and prior use in 1 (Escanaba) of 3 branch sites observed, out of a total of 3 branch sites visited. Findings include: On 7/9/2024, an on-site visit was conducted at the Hospice’s branch site located in Escanaba, 55 miles away from the parent site. During inspection of the agency’s premises, a request was made to inspect DME used for patient care. The office clerk directed the surveyor to the back office where clinicians utilize DME supplies out of two supply closets. During inspection, it was observed that both supply closets contained DME supplies that were significantly past the manufacture’s expiration dates listed on the package containers. Examples include: 1) Central Line Dressing Change Kit with an expiration date of 09/2018, 2) Urinary leg bag with straps had expired on 05/2014, 3) “Promogran” matrix wound dressing with an expiration date of 01/2018, 4) Xero form Petrolatum wound packing gauze that expired on 02/28/2021. There were at least 15 other examples not listed above. In addition, a discharged patient’s ostomy bag (DME used to reroute bodily waste to the outside of the body) with patient and physician identifiers listed, was observed in with the other DME supplies intended for current patient use. This ostomy bag was dispensed to the patient on 09/28/2020. The findings above were reviewed and acknowledged by the agency’s Administrator (Staff A) during an interview on 7/9/24 at 3:15 PM. Staff A stated there was no procedure in place to ensure DME supplies were not expired or repurposed for use in either of the DME supply closets. The facility failed to adhere to its policy referenced below. Agency Policy: “Hospice Equipment and Supply Management” (Revised 8/23) stated, “Equipment and supply services must be provided in a manner consistent with accepted safe practices. It is (Agency) practice to not accept all DME that is being offered as a donation. Each office has a minimal supply of DME that has been purchased and assessed for safety. This is the only DME we should be maintaining in the offices.””