North Memorial Home Hlth Hospc

“Based on interview and document review the facility failed to ensure a current bereavement assessment was completed for 1 of 14 patients (P2) reviewed for comprehensive assessments. Findings include:P2’s current plan of care (POC) dated 7/13/25, indicated P2 admitted to hospice care on 7/13/25, with a primary diagnosis of metastatic prostate cancer. P2’s POC also indicated P2 was only receiving skilled nursing visits. Review of P2’s electronic medical record (EMR) lacked evidence that P2 had a bereavement assessment since his admission to hospice on 7/13/25.During an interview on 9/4/25 at 8:53 a.m., registered nurse (RN)-A stated it was generally understood the social workers completed a bereavement assessment when a patient signed onto hospice services. RN-A stated the social workers had “a few days” to complete. If the social worker was not involved with the start of care, they saw the patient within a few days. RN-A stated if social work was refused by the patient, then spiritual care completed the bereavement assessment. If both social work and spiritual care were refused then it would be the nurse’s responsibility stating, “I would have to ask how that was done.” During an interview on 9/4/25 at 11:25 a.m., the hospice manger stated it was expected that a current bereavement assessment was documented for all patients when they signed onto hospice, even if they were on hospice services prior. The hospice manger stated the hospice agency needed a concrete plan to ensure a bereavement assessment was competed in the situation a patient refused to have social work or spiritual care involved. A facility policy titled Hospice Initial and Comprehensive Assessment, dated 7/3/24, indicated the hospice comprehensive assessment must be completed within 5 calendar days and identify physical, psychosocial, emotional, and spiritual needs including an initial bereavement assessment.”

“Based on observation, interview, and document review, the facility failed to ensure the care plan was followed for 1 of 1 patient (P14) who was not transferred according to the current plan care. Findings include:P14’s Plan of Care dated 8/20/25, indicated P14 was admitted to hospice care on 2/1/25 with a primary diagnosis of Alzheimer’s disease and required a Hoyer lift (a mechanical lift that uses a full-body sling to safely lift and transfer individuals with limited mobility from one surface to another) for transfers.During interview and observation on 9/3/25 at 10:39 a.m., hospice aide (HA)-A stated the “girls” who cared for P14 needed to use a Hoyer lift for transfers, but he was able to pivot transfer (a method for moving a person from one surface to another by using their legs and feet to pivot or spin their body). HA-A proceeded to pivot transfer P14 from his high-backed wheelchair to his bed by lifting P14 up from under his arms. P14 appeared to not be able to bear weight on his legs as they did not fully straighten and remained dangling in the air during the transfer.During an interview on 9/4/25 at 8:53 a.m., registered nurse case manager (RN)-B stated P14 had progressed from using easy stand (a mechanical lift that assist’s a person into a standing position) for transfers to requiring a Hoyer lift due to disease progression. RN-B confirmed P14 should not have been transferred as observed as he cannot bear weight or even fully straighten his legs, stating he required a Hoyer lift with all transfers.During an interview on 9/4/25 at 11:25 a.m., the hospice manager stated it was the expectation that the hospice aides followed the care plan at all times.A facility policy titled Hospice Interdisciplinary Group, Care Planning, and Coordination of Services, dated 7/10/24, indicated “all hospice care and services furnished to patients and their families must follow an individualized written plan of care established by the hospice interdisciplinary group in collaboration with the attending physician, the patient or representative and the primary care giver in accordance with the patient’s needs.””

“Based on interview and document review, the facility failed to ensure ordered services were provided in accordance with the plan of care for 1 of 14 patients reviewed for visit set accuracy. Findings include:P2’s hospice plan of care (POC) dated 7/13/25, indicated P2 was admitted to hospice care on 7/13/25 with a primary diagnosis of metastatic prostate cancer and 1-3 skilled nursing visits every week for eight weeks, dated 7/13/25 - 9/6/25. P2 Electronic Medical Record (EMR) indicated P2 did not receive a skilled nursing visit on the weeks of 8/3/25-8/9/25 and 8/17/25-8/23/25. During an interview on 9/2/25 at 3:20 p.m., hospice IT support, who was conducting chart reviews with the surveyor, confirmed P2 had missed a skilled nursing visit on the weeks of 8/3/25-8/9/25 and 8/17/25-8/23/25, stating the clinician should have filled out a missed visit note. During an interview on 9/4/25 at 8:23 a.m., registered nurse case manager (RN)-C stated P2 was difficult to schedule visits as he lived in a private home with his daughter. RN-C stated he had been accepting skilled nursing visits weekly but was currently only allowing her to come every other week. RN-C stating she was hoping this would change and he would accept her visit weekly, confirming P2’s visit frequency should have been adjusted to meet his needs/choice, or a missed visit should have been put into the EMR. RN-C stated she needed clarification on how to enter a missed visit. During an interview on 9/4/25 at 11:25 a.m., the hospice manager stated it was expected P2’s visit set be adjusted to reflect what was currently happening or for his EMR to contain documentation as to why the visits were missed. A hospice policy titled Hospice Interdisciplinary Group, Care Planning, and Coordination of Services, dated 7/10/24, indicated, “The hospice must develop and maintain a system of communication and integration to: Ensure that the care and services are provided in accordance with the plan of care.””

“Based on interview and record review, the agency failed to ensure registered nurse (RN) supervisory visits were made at least every 14 days for 2 of 14 patients (P7 and P8) patients in the sample who received home health aide (HHA) services. Findings include:P7 was admitted for hospice services on 1/28/25, with diagnoses that included chronic heart failure, atrial fibrillation, chronic obstructive pulmonary disease. The current plan of care indicated P7 received skilled nurse services 1-2 times weekly. The plan of care also indicated the patient received home health aide (HHA) services one time weekly to assist the patient with personal cares. P7’s medical record indicated the registered nurse (RN) had completed a supervisory visit on 8/6/25 and on 8/29/25. The RN had visited P7 on 8/13/25 and 8/20/25, however, there was no supervisory completed between 8/6/25 and 8/29/25. P8 was admitted to hospice services on 3/10/25, with diagnoses of hepatic cirrhosis and dementia. The current plan of care indicated P8 received skilled nurse services 1-3 visits every 2 weeks and HHA 1-2 visits every 2 weeks. P8’s medical record indicated the RN had completed supervisory visits on 7/10/25 and 7/31/25. However, the record failed to indicate supervisory visit was completed between those dates. During an interview on 9/4/25 at 8:53 a.m., RN-A stated supervisory visits were done at least every fourteen days. Supervisory visits were done to ensure HHA visits were going well and to make changes to the plan of care when needed. RN-A stated he would review the patient records to recheck for the missing supervisory visits. At 9:30 a.m., RN-A followed stated P7 had a twenty-three-day period that did not have a supervisory visit completed despite the RN having been there. P8 had a twenty-one-day time period without a supervisory visit completed. P8 had 2 licensed practical nurse (LPN) visits during that time but LPN’s were not allowed to complete supervisory visits of the HHAs. RN-A stated that both patients had HHA visits during the gap in supervisory visits. Provider policy Supervision of HHA (home health aide) services effective 11/5/21, indicated HHA supervisory visits were completed at a minimum of every fourteen days while the customer received hospice services to ensure the services were meeting the customer needs.”