Minnesota Hospice LLC

“Based on interview and document review, the agency failed to ensure a care plan was developed for 3 of 3 patients (P14, P20, and P21) reviewed for spiritual support. P21’s hospice plan of care (POC) dated 7/29/24, indicated P21 had diagnoses of chronic combined systolic congestive and diastolic congestive heart failure, anxiety, depression, and had four as needed chaplain visits every 30 days. Further, the POC indicated P21’s recertification for the 3rd benefit period dated 8/1/24, thru 9/29/24, indicated chaplain services would be available per patient request and spiritual concerns were met by chaplain visits. The POC lacked a care plan or interventions for the chaplain that identified P21’s individualized spiritual needs during chaplain visits. P21’s initial social work assessment dated 12/5/23, indicated P21 regularly attended a Christian evangelical church on Sundays. P21’s Chart Entries form indicated P21 saw the chaplain on the following dates: 12/6/23, 12/20/23, 1/10/24, 1/18/24, 2/9/24, 3/22/24, and 6/6/24. P21’s chaplain visit note dated 6/6/24, indicated P21 told the chaplain she had one to two months to live, and the chaplain explored with P21 what that meant and P21 was able to respond without fear or anxiety that was displayed in earlier visits and the chaplain concluded the visit with prayer. The visit lacked information whether P21 wanted further chaplain visits. During interview on 9/18/24 at 2:04 p.m., the director of nursing stated P21 and patients should have a care plan for spiritual care if they have as needed visit sets. During interview on 9/18/24 at 3:25 p.m., the administrator stated the social worker (SW) determined spiritual counselor needs of patients and a referral was sent to the director of spiritual care (DOSC) who had been the sole chaplain. The DOSC follows up with the referral within 5 days and determined the kind of problems a person was encountering and what the plan of care would look like. The administrator further stated visit frequencies were documented as part of the transcription process at interdisciplinary group (IDG) and stated he would expect a care plan specific to spiritual care. A policy, IDG Care Planning Process, dated 10/2023, indicated in order to assure that care provided is appropriately planned to meet each patient’s specific needs and problems, hospice will utilize data and information gathered during the comprehensive assessment, updates to the comprehensive assessment and reassessments, in the care planning process to provide care that is consistent with the patient and family needs, with patient’s needs and goals as a priority. The plan of care specifies the care and services necessary to meet the patient and family-specific needs identified in the comprehensive assessment as such needs related to the terminal illness and related conditions. All care and services furnished to patients and their families follows an individualized written plan of care established by the IDG in collaboration with the attending physician, the patient or representative and the primary caregiver in accordance with the patient’s needs. P14’s hospice plan of care (POC), dated 8/14/24, indicated P14 was admitted to hospice services on 8/13/24 with a primary diagnosis of malignant neoplasm of lower lobe, left bronchus or lung. P14’s POC identified P14 should receive spiritual care services but did not indicate a frequency of visits. P14’s POC further lacked a spiritual care care plan. P14’s Existing Chart Entries, printed 9/18/24, indicated P14 received a spiritual care visit on 8/14/23, indicating P14 was “open to spiritual support including visits.” An additional spiritual care visit was conducted during survey on 9/17/24. P20’s POC, dated 2/28/24, indicated P20 was admitted to hospice care on 2/27/24 with a primary diagnosis of primary diagnosis of malignant neoplasm of lower lobe, right bronchus or lung. P20’s POC indicated P20 had a spiritual care visit frequency of four visits as needed (PRN) every 30 days, however lacked a spiritual care care plan. P20’s POC, dated 5/20/24, indicated P20 entered his second benefit period on 5/27/24. P20’s POC indicated P20 had a spiritual care visit frequency of four visits as needed (PRN) every 30 days, however lacked a spiritual care care plan. P20’s Existing Chart Entries, printed 9/18, indicated P20 received a spiritual care visit on 3/1/24 indicating P20 had requested “last rights when the time came.” A second spiritual care visit was documented on 6/4/24 indicating “Chaplain provided Last Rites.” During an interview on 9/18/24 at 12:29 p.m., the director of nursing (DON) stated it would be expected that all disciplines, including spiritual care, have a care plan in place prior to providing visits and confirmed P14 and P20 did not have a spiritual care care plan in place.”

“Based on interview, and document review, the agency failed to ensure a detailed statement for the frequency of spiritual care visits to meet specific family and patient needs for P14 and failed to adjust routine skilled nursing visit sets after frequent use of as needed (PRN) visits for P10, and P11. P11’s hospice plan of care (POC) dated 6/8/24, indicated P11 had a diagnosis of cirrhosis of the liver, and required routine skilled nursing visits once a week along with 6 as needed (PRN) skilled nursing visits every 7 days. P11’s local coverage determination (LCD) summary identified P11 had nonalcoholic cirrhosis of the liver, heart failure, repeated falls, and esophageal varices with bleeding and other anemia. The PRN visit sets lacked information what the PRN visit was for. P11’s hospice POC dated 9/3/24, indicated P11 required 1 skilled nursing visit weekly and 6 PRN visits every 7 days. P11’s Existing Chart Entries form indicated P11 had skilled nursing visits on the following dates: For the week 6/2/24, to 6/8/24, P11 was seen once on 6/7/24. For the week 6/9/24, to 6/15/24, P11 was seen on 6/10/24, and 6/14/24. For the week 6/16/24, to 6/22/24, P11 was seen on 6/18/24, and 6/21/24. For the week 6/23/24, to 6/29/24, P11 was seen on 6/25/24, 6/26/24, and 6/28/24. For the week 6/30/24, to 7/6/24, P11 was seen on 7/1/24, and 7/3/24. For the week 7/7/24, to 7/13/24, P11 was seen on 7/8/24, and 7/10/24. For the week 7/14/24, to 7/20/24, P11 was seen on 7/16/24. For the week 7/21/24, to 7/27/24, P11 was seen on 7/22/24. For the week of 7/28/24, to 8/3/24, P11 was seen on 8/2/24. For the week 8/4/24, to 8/10/24, P11 was seen on 8/5/24. For the week 8/11/24, to 8/17/24, P11 was seen on 8/13/24, and 8/16/24. For the week 8/18/14, to 8/24/24, P11 was seen on 8/19/24, 8/21/24, and 8/23/24. For the week 8/25/24, to 8/31/24, P11 was seen on 8/26/24, and 8/28/24. For the week 9/1/24, to 9/7/24, P11 was seen on 9/5/24. For the week 9/8/24, to 9/14/24, P11 was seen on 9/10/24, 9/13/24, and 9/14/24. For the week 9/15/24, to 9/21/24, P11 was seen on 9/15/24, 9/17/24, 9/17/24, 9/18/24, 9/19/24. During interview on 9/18/24 at 12:24 p.m., the director of nursing (DON) stated she expected visit frequencies increased if staff were utilizing multiple PRN visits and verified P11’s visit set indicated skilled nursing visits one time a week. A policy, Minnesota Hospice-Nursing Services, Visits, Missed Visits, dated 5/30/24, indicated all hospice patients will receive a routine nursing visit at a minimum of one-time weekly Sunday through Saturday, unless the patient refuses. A policy, IDG Care Planning Process, dated 10/2023, indicated an individualized written plan of care is developed for each patient. The POC reflects patient and family goals and interventions based on the problems identified in the initial, comprehensive and updated comprehensive assessments. The POC is written to include all services necessary for the palliation and management of the terminal illness and related conditions, including a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. Visit ranges may be used: the plan the plan of care includes a range of visits and PRN orders for visit frequencies to ensure the most appropriate level of service is provided to the patient. A range is acceptable as long as it continues to meet the identified needs of the patient/family. Visit ranges with small intervals are acceptable e.g. 1-3 visits/week; 2-4 visits/week, but ranges that include “0” as frequency are not allowed, if the patient requires frequent use of PRN visits, the plan of care will be updated to include the need for additional visits. P10’s hospice POC, dated 9/2/24, indicated R10 was admitted to hospice services on 8/30/24 with a primary diagnosis of Parkinson’s Disease. The POC indicated P10 had a physician order for Skilled Nursing visits one time per week and six visits every seven days as needed (PRN), however lacked indication of what the PRN visits were for. P10’s Physican/Provider Orders, printed 9/18/24, indicated an order, dated 9/3/24, for wound care for the hospice RN to perform two times per week. P10’s Existing Chart Entries, printed 9/18/24, indicated P10 received Skilled Nursing visits on the following dates; For the week of 9/1/24 through 9/7/24, P10 was seen by skilled nursing on 9/3/24 and 9/5/24, with 9/5/24 listed as a PRN visit. For the week of 9/8/24 through 9/14/24, P10 was seen by skilled nursing on 9/9/24 and 9/13/24, with 9/13/24 listed as a PRN visit. P14’s POC, dated 8/14/24, indicated P14 was admitted to hospice services on 8/13/24 with a primary diagnosis of malignant neoplasm of lower lobe, left bronchus or lung. The POC lacked a spiritual care visit frequency or visit set, indicating “chaplain [spiritual care] visits per patient request.” P14’s Existing Chart Entries, printed 9/18/24, indicated P14 received a spiritual care visit on 8/14/23, indicating P14 was “open to spiritual support including visits.” During an interview on 9/18/24 at 12:29 p.m., the director of nursing (DON) stated she would expect the visit frequencies to match the individual needs of each patient, including wound care needs. The DON further stated she would expect a visit frequency for spiritual care visits. During an interview on 9/18/24 at 3:25 p.m., the administrator also confirmed he would expect visit frequency or visit set for spiritual care visits prior to visit being completed, confirming “per patient request” was not a visit set.”

“Based on interview and document review, the agency failed to ensure services were provided in accordance with the plan of care for P1, P5, and P9, and P10. P5’s hospice plan of care (POC) dated 8/26/24, indicated P5 enrolled into hospice in the first benefit period on 8/23/24, had a diagnosis of heart failure and required three hospice aide visits weekly. Under physician orders in the POC dated 8/23/24, indicated P5 required a hospice aide twice a week starting on week two. P5’s Existing Chart Entries form indicated the hospice aide visited on the following dates: From 8/25/24, to 8/31/24, P5 was seen by the hospice aide on 8/30/24. From 9/1/24, to 9/7/24, P5 was seen by the hospice aide on 9/3/24, 9/4/24, and 9/5/24. From 9/8/24, to 9/14/24, P5 was seen by the hospice aide on 9/9/24, and 9/11/24. P5’s Missed Visit form indicated on 9/13/24, the hospice aide visit was missed and under comments, indicated the nursing assistant was not available. P9 P9’s hospice POC dated 8/19/24, indicated P9 enrolled into hospice on 8/16/24, in the first benefit period with a diagnosis of Alzheimer’s disease and required hospice aide visits twice weekly beginning week two. P9 Existing Chart Entries form indicated the hospice aide visited on the following dates: 8/18/24, to 8/24/24, P9 was seen by the hospice aide on 8/21/24, and 8/23/24. 8/25/24, to 8/31/24, P9 was seen by the hospice aide on 8/26/24, and 8/29/24. 9/1/24, to 9/7/24, P9 was seen by the hospice aide on 9/5/24. 9/8/24, to 9/14/24, P9 was seen by the hospice aide on 9/9/24, and 9/12/24. P9’s Missed Visit form dated 9/2/24, indicated the hospice aide visit was missed due to holiday scheduling for the Labor Day holiday. During interview on 9/18/24 at 12:24 p.m., the director of nursing (DON) stated nurses post admission visits and complete an evaluation to determine a patient’s needs. The DON further stated visit frequencies were located on the POC and if a visit was missed, a missed visit was documented in the patient’s record. The DON verified P5 should have had another aide visit made. A policy, Nursing Services, Visits, Missed Visits, dated 5/30/24, indicated all hospice patients will receive a routine nursing visit at a minimum of one-time weekly Sunday through Saturday, unless the patient refuses. Missed visits include patient refusal, emergency situations, staffing, schedule discrepancies and other. Missed visits will be attempted to be made up in the same Medicare week. When a missed visit occurs a missed visit entry will be made in the patient’s chart. All missed visits will be reported to the physician and a physician order will be obtained and the plan of care updated. Missed visits will be tracked weekly by the director and reported to compliance. P1’s hospice plan of care (POC), dated 8/2/24, indicated R1 was admitted to hospice services on 8/1/24 with a primary diagnosis of hypertensive heart disease with heart failure. The POC indicated P1 had a physician order for two hospice aide visits per week. P1’s Existing Chart Entries form, printed 9/18/24, indicated R1 received hospice aide visits on the following dates: For the week of 8/4/24 through 8/10/24, P1 was seen by the hospice aide on 8/5/24 and 8/7/24. For the week of 8/11/24 through 8/17/24, P1 was seen by the hospice aide on 8/12/24 and 8/14/24. For the week of 8/18/24 through 8/24/24, P1 was seen by the hospice aide on 8/19/24 and 8/21/24. For the week of 8/25/24 through 8/31/24, P1 was seen by the hospice aide on 8/26/24 and 8/28/24. For the week of 9/1/24 through 9/7/24, P1 was seen by the hospice aide on 9/4/24. For the week of 9/8/24 through 9/14/24, P1 was seen by the hospice aide on 9/9/24 and 9/11/24. P1’s Missed Visits form, printed 9/18/24, indicated the hospice aide missed a visit on 9/2/24 due to “Holiday Scheduling” indicating the office was closed for Labor Day. P10’s hospice POC, dated 9/2/24, indicated R10 was admitted to hospice services on 8/30/24 with a primary diagnosis of Parkinson’s Disease. The POC indicated P10 had a physician order for two hospice aide visits per week starting the week of 9/1/24. P10’s Existing Chart Entries form, printed 9/18/24, indicated R1 received hospice aide visits on the following dates: For the week of 9/1/24 through 9/7/24, P10 was seen by the hospice aide on 9/4/24. For the week of 9/8/24 through 9/14/24, P10 was seen by the hospice aide on 9/9/24 and 9/11/24. P10’s Missed Visits form, printed 9/18/24, indicated the hospice aide missed a visit on 9/2/24 due to “Holiday Scheduling” indicating the office was closed for Labor Day. During an interview on 9/18/24 at 12:29 p.m., the director of nursing (DON) confirmed both P1 and P10 had a missed hospice aide the week of 9/1/24 through 9/7/24 and she would expect that the hospice aide made a second visit for both P1 and P10.”