Hospice of the Midwest

“Based on interviews, record review, and review of agency policy, the Hospice agency failed to ensure a system of communication between the interdisciplinary group (IDG) and the volunteer coordinators (VC) for two patients (Patients (P)2, P7) in a total sample of 14. This failure placed residents at risk for a decreased quality of life. Findings include: 1. Review of the “Patient Information” tab located in the electronic medical record (EMR) revealed P2 had a “Start of Care (SOC)” date of 02/03/26 for prostate cancer. During a home visit on 06/03/26 at 12:32 PM, P2 and his/her spouse were asked if P7 had been offered volunteer services when he/she had elected the hospice benefit. P2’s spouse stated, “I asked them if someone could come and play cribbage with him/her and they said they would try but we haven’t heard anything more.” During an interview on 06/03/26 at 1:52 PM, Volunteer Coordinator (VC)1 stated that she knew about the request, and had a logbook, but acknowledged that she never called back to let them know they were still on the volunteer list. During a follow-up interview on 06/04/26 at 8:51AM, VC1 stated, “When we get a request [for a volunteer] and if we don’t have an immediate volunteer for that request, we are not matching a volunteer until we have one.” VC1 further stated, “We don’t have anyone out there to play cribbage.” VC1 was asked if she had follow-up with P2 and his/her spouse regarding this. VC1 stated, “No, that is not part of our process.” 2. Review of the “Patient Information” tab located in the EMR revealed P7 had a “SOC” date of 03/16/26 for chronic obstructive lung disease. During a home visit on 06/03/26 at 9:03 AM, P7 stated, “I don’t really remember signing the election of benefits, but I am sure I was asked about having a volunteer, but don’t really remember.” P7 further stated, “I would be open to having a volunteer. I was in the military, and it would be nice to talk with someone.” During the home visit on 06/03/26 at 9:15 AM, Registered Nurse/Case Manager (RN/CM)1 was asked if he had completed the admission for P7. RN/CM1 stated “No, the admission nurse does the admissions. I was not aware of P7’s wish for a volunteer.” During an interview on 06/04/26 at 9:23 AM, VC2 stated, “I was trained that if there was not a volunteer available, we would wait until we had one [to let the patient know].” VC2 was asked if there was any follow-up with P7 regarding this. VC2 stated, “No, there was no follow-up. I thought that was how the process worked.” VC2 was asked if she attended the IDG meetings. VC2 stated, “Yes, I do attend the meetings.” Review of the Hospice agency polity titled, “Interdisciplinary Group Coordination of Care” revised October 2019, revealed, “…The type and scope of services provided by the interdisciplinary group will be based upon comprehensive and ongoing assessments regarding the needs of the patient and family/caregiver…The exact combination of services and the level of care will be unique to each patient and family/caregiver unit and will change as the needs of the patient and family/caregiver evolver over the course of their involvement with hospice…” Refer to L647: Volunteer level of activity for additional information.”

“Based on interviews, document review, and policy review, the Hospice agency failed to have volunteer hours that equaled five (5) percent (%) of total patient care hours. This had the potential to cause all 220 patients currently receiving hospice services to have unmet needs. Findings include: Review of the Hospice agency’s document titled, “2025 Volunteer Cost Savings,” provided by the Director of Clinical Operations (DCO) revealed the agency’s monthly volunteer hour percentages were: 1. Monticello (MNC) branch:January - 0.00%February – 0.00%March – 1.17%April – 0.21%May – 0.65%June – 0.15%July – 0.90%August – 0.68%September – 1.65%October – 8.6%November – 6.45%December – 4.71 % 2. Forest Lake (FLM) branch:January – 0.17%February – 0.37%March – 0.58%April – 0.09%May – 0.12%June – 0.21%July – 0.23%August – 0.07%September – 0.58%October – 0.58%November – 1.14%December – 1.41%3. Woodbury (MSP) parent office:January – 1.83%February – 1.07%March – 1.44%April – 1.24%May – 2.44%June – 1.89%July – 2.76%August – 1.61%September – 5.03%October – 3.14%November – 4.82%December – 1.70% During an initial interview on 06/02/26 at 1:00 PM, Volunteer Coordinators (VC)1 and VC2 stated that they currently have a PIP (performance improvement plan) for not meeting the five percent. “It’s just been hard in this economy to get volunteers.” During a follow-up interview on 06/04/26 at 8:51 AM, VC1 stated, “I am the VC for MNC and Edina (EDI) branches. The EDI branch is the one making the volunteer hours. We developed a PIP in July 2025, and we are currently working on it. In May 2026 we determined that old PIP was inadequate, and we decided to start a new PIP in June 2026. We are looking at making it a bit broader. One of the things we were working on was retention, this is where we struggle. They [volunteers] come on and go off within a month so we are trying to pick quality people who will stay, that is the main thing we are working on right now. In March 2026, I was new and did not have a ton of thorough training, it’s been pretty piecemeal.” During an interview on 06/04/26 at 9:03 AM, The DCO stated, “There have been employee changes that have occurred since July 2025, and we are now onboarding a new person who will be assisting with the PIP. We never quit doing the 2025 PIP and we have a corporate volunteer coordinator and both VC1 and VC2 have been sent to training locally. The DCO was asked why the volunteer hours are so low. The DCO stated, “I really don’t know the answer to this, but we have not stopped working on the PIP.” During an interview on 06/04/26 at 9:23 AM, VC2 stated, “We have been following what we have been doing and are trying to grow our veteran volunteers. When corporate sent us a new blank PIP and had us fill it out in mid-May of this year, we spent a whole day and talked about hurdles and how to make it easier.” VC2 was asked what is holding you up. VC2 stated, “Background stuff. VC1 lost a hand full of people due to the fingerprinting requirement, and I also lost a few people.” Review of the agency policy titled “Volunteer Services” revised 09/01/22 revealed, “The Volunteer Coordinator will track the use of volunteers, the cost savings achieved, and that the hours of volunteer services will exceed 5% of the total patient care hours of paid and contracted hospice personnel...The Volunteer Coordinator will document ongoing efforts to recruit, train, and retain volunteers of all ages and ethnic backgrounds.””

“It is required that each patient’s individualized written plan of care: includes all services necessary for the palliation and management of the terminal illness, including the following: drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) clinical records reviewed, the agency did not ensure that the patient’s plan of care included treatments to meet the patient’s needs. CLINICAL RECORD 3: The patient elected hospice care on 09/17/2025. The initial comprehensive visit dated 09/17/2025 documented an indwelling 18 French (Fr) catheter with a 10 cc balloon, last changed on 07/18/2025, for urinary retention. The SN assessment visit note dated 09/28/2025 documented that an 18 Fr 10cc indwelling catheter was in place. The plan of care documented an intervention for the patient/caregiver to verbalize adequate knowledge to manage an indwelling catheter. A clinical record review revealed that the plan of care did not include orders for the care and maintenance of the catheter, if it were to fall out or become plugged, or for any change or irrigation. During the interview with the administrator and the nurse/case manager on 02/24/2026, it was stated that the patient was imminent and that the family did not want the catheter changed, but agreed that this had not been documented.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: the initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes including the care and services provided. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) clinical records reviewed, the agency did not ensure that the patient’s record contained correct clinical information. CLINICAL RECORD 3: The patient elected hospice care on 09/17/2025. The initial comprehensive visit dated 09/17/2025 documented an indwelling 18 French (Fr) catheter with a 10 cc balloon, last changed on 07/18/2025, for urinary retention. The Skilled Nursing (SN) clinical note dated 09/24/2025 documented that the patient was incontinent and did not have a catheter. The SN assessment visit note dated 09/27/2025 documented a 16 Fr indwelling catheter. A review of the clinical records revealed no SN visit notes documenting whether the catheter was ever removed or reinserted. The SN assessment visit note dated 09/28/2025 documented that an 18 Fr 10cc indwelling catheter was in place. During an interview on 02/24/2026, the Executive Director and the SN stated that it was a missed click on the device, and the patient had the catheter the entire time, and that the family requested that it not be changed as the patient was imminent.”

“It is required that each patient’s individualized written plan of care reflects patient and family goals; and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 2 of 20 (10%) clinical records reviewed, the agency did not ensure that the patient’s plan of care included interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 14: The patient elected the hospice benefit on 11/03/2024. The initial nursing comprehensive assessment dated 11/03/2024 documented, “Patient is a diabetic and receives insulin.” The plan of care dated 11/03/2024 through 01/01/2025 did not include documentation of interventions related to the management of the patient’s diabetes. Clinical Record 17: The patient elected the hospice benefit on 10/17/2023. The initial nursing comprehensive assessment dated 10/17/2023 documented, “Patient is a diabetic and receives insulin.” The plan of care dated 10/17/2023 through 01/14/2024 did not include documentation of interventions related to the management of the patient’s diabetes. On 01/16/2025, the Director of Clinical Operations reviewed the records and confirmed that the plans of care did not include interventions related to diabetes management.”

“It is required that the hospice provides nursing care under the supervision of a registered nurse. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #1-031.1 “Responsibilities/Supervision of Clinical Services” (dated 10/2019) stated in part, “A monthly patient visit will be completed by a registered nurse to supervise licensed practical/vocational nursing services.” In 3 of 20 (15%) clinical records reviewed, the agency did not ensure that Licensed Practical Nurses (LPN) were supervised by a Registered Nurse (RN) at least monthly per the agency policy. Clinical Record 1: The patient elected the hospice benefit on 04/19/2024. The plans of care dated 07/18/2024 through 10/16/2024 and 10/17/2024 through 12/14/2024 ordered skilled nursing (SN) “SN 2x/week.” A clinical record review revealed skilled nursing visits performed by a LPN dated 10/06/2024, 11/06/2024, 11/17/2024, and 12/01/2024. The first LPN supervisory visit was dated 12/03/2024, with 33 days outstanding. Clinical Record 7: The patient elected the hospice benefit on 06/06/2024. The plan of care dated 06/06/2024 through 09/03/2024 ordered skilled nursing (SN) “SN 2x/week.” A clinical record review revealed a skilled nursing visit performed by a LPN dated 06/25/2024. No LPN supervisory visits were documented. Clinical Record 20: The patient elected the hospice benefit on 03/14/2024. The plan of care dated 03/14/2024 through 06/12/2024 ordered skilled nursing (SN) “SN 2x/week.” A clinical record review revealed a skilled nursing visit performed by a LPN dated 03/22/2024. The first LPN supervisory visit was dated 05/08/2024, with 38 days outstanding. On 01/15/2025, the Director of Clinical Operations reviewed the records and confirmed the LPN supervisory visits were completed less frequently than monthly.”

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 6 of 17 (35%) clinical records reviewed of patients who received Hospice Aide Services (HA), the agency did not ensure that all written patient care instructions were included in the aide care plan. Clinical Record 1: The patient elected the hospice benefit on 04/19/2024. On 12/31/2024, the physician ordered wound care with a wound dressing to a wound on the patient’s sacrum. The plan of care dated 12/15/2024 through 02/13/2025 ordered: “Aide 2x/week.” The HA aide care plan dated 12/14/2024 assigned the HA the relevant task of “Shower at every visit.” The HA care plan did not include instructions addressing the wound dressing on the sacrum should it become dislodged or wet during the shower. Clinical Record 2: The patient elected the hospice benefit on 05/02/2024. On 12/31/2024, the physician ordered wound care with a wound dressing to a wound on the patient’s right leg. The plan of care dated 12/28/2024 through 02/25/2025 ordered: “Aide 1x/week.” The HA care plan dated 05/02/2024 assigned the HA the relevant task of “Shower at every visit.” The HA care plan did not include instructions addressing the wound dressing on the right leg should it become dislodged or wet during the shower. Clinical Record 4: The patient elected the hospice benefit on 07/30/2023. On 09/24/2024, the physician ordered wound care with a wound dressing to a wound on the patient’s left heel. The plan of care dated 09/23/2024 through 11/21/2024 ordered: “Aide 2x/week.” The HA care plan dated 08/16/2024 assigned the HA the relevant task of “Shower at every visit.” The HA care plan did not include instructions addressing the wound dressing on the left heel should it become dislodged or wet during the shower. Clinical Record 6: The patient elected the hospice benefit on 09/17/2024. The plan of care dated 09/17/2024 through 11/08/2024 ordered: “Insert indwelling urinary catheter per physician order 22 French (FR) with 10ml balloon” and “Aide 2x/week.” The HA care plan dated 09/18/2024 did not include instructions addressing the care and maintenance of the Foley catheter during personal care. Clinical Record 9: The patient elected the hospice benefit on 08/27/2024. On 01/07/2025, the physician ordered wound care with a wound dressing to a wound on the patient’s right heel. The plan of care dated 11/25/2024 through 02/22/2025 ordered: “Aide 2x/week.” The initial HA care plan dated 08/28/2024 assigned the HA the relevant task of “Shower at every visit.” The HA care plan was not updated to include instructions addressing the wound dressing on the right heel should it become dislodged or wet during the shower until 01/14/2025. Clinical Record 14: The patient elected the hospice benefit on 11/03/2024. On 11/08/2024, the physician ordered wound care with a wound dressing to a wound on the patient’s coccyx. The plan of care dated 11/03/2024 through 01/01/2025 ordered: “Aide 2x/week.” The HA care plan dated 11/03/2024 assigned the HA the relevant task of “Shower at every visit.” The HA care plan was not updated to include instructions addressing the wound dressing on the coccyx should it become dislodged or wet during the shower. In an interview and a joint record review on 01/14/2025, the Director of Clinical Operations confirmed the findings, stating, “There are no wound dressing or Foley catheter care instructions on the aide care plans.””

“It is required that hospice aides are supervised by a registered nurse who makes 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; and ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 2 of 17 (12%) clinical records reviewed of patients who received Hospice Aide (HA) services, the agency did not ensure that the HA was supervised by a Registered Nurse (RN) no less frequently than every 14 days. Clinical Record 1: The patient elected the hospice benefit on 04/19/2024. The plans of care dated 04/19/2024 through 07/17/2024 and 07/18/2024 through 10/16/2024 ordered: “Aide 2x/week.” A clinical record review revealed a HA supervisory visit dated 06/28/2024. The next HA supervisory visit was dated 07/18/2024, with 20 days outstanding. Clinical Record 20: The patient elected the hospice benefit on 03/14/2024. The plan of care dated 03/14/2024 through 06/12/2024 ordered “Aide 2x/week.” A clinical record review revealed a HA supervisory visit dated 04/30/2024. The next HA supervisory visit was dated 05/17/2024, with 17 days outstanding. On 01/15/2025, the Director of Clinical Operations reviewed the records and confirmed that aide supervisory visits were completed less frequently than every 14 days.”