Every finding on record at Allina Health Hospice & Palliative Care

Based on interview and document review, the hospice agency failed to report allegations of abuse to the hospice administrator immediately when a nursing assistant reported to a nurse that she witnessed rough handling and threatening hand gestures during cares, made by a staff member. --- Findings include: P1’s plan of care (POC) for benefit period 5/3/25 through 7/31/25 indicated she was admitted to the residential hospice agency on 5/3/25, with diagnoses of uterine cancer with metastasis (spread) to the bone, liver, lymph nodes and both lungs. P1 required the assistance of one staff for personal cares and transfers, along with the use of a walker. P1 was cognitively intact. A facility document, internal investigation of vulnerable adult incident, indicated nursing assistant (NA)-B’s written statement where she wrote she witnessed NA-A yelling at P1, as she was pushing and pulling on her lower legs, in her room. NA-B wrote P1 told NA-A she was hurting her, but NA-A continued her actions. NA-B wrote she immediately reported these observations to registered nurse (RN)-B. The document also indicated P1 was interviewed in the afternoon on 6/9/25, by RN-C where she explained the rough handling she endured that morning by NA-A. On 8/28/25 at 1:39 p.m., NA-A stated she worked with P1 overnight from 6/8/25 through 6/9/25. She stated she assisted P1 to the bathroom around 7:00 a.m. on 6/9/25. NA-A denied rough patient handling and stated she was attempting to keep P1 from falling. On 8/28/25 at 2:08 p.m., the hospice manager (HM) stated she was made aware of the allegations of abuse on 6/10/25 around 8:00 a.m., related to rough handling of P1 and immediately informed the administrator and medical director at that time. She stated she made the report to the State Agency on 6/10/25 at 11:50 a.m. She stated the supervisor on duty did not report the incident to the State Agency or to anyone in management. She stated it should have been escalated right away. On 8/28/25 at 2:47 p.m., RN-C stated she interviewed P1 on 6/9/25, in the afternoon. She stated P1 was apprehensive about NA-A caring for her, because earlier that day she made her feel vulnerable and felt as though NA-A might punch her. RN-C stated P1 told her NA-A was rough with her, she attacked her, and grabbed her arm very hard. RN-C stated she informed RN-A of the report. On 8/28/25 at 4:00 p.m., RN-A stated she was the supervisor on duty on 6/9/25, but was not informed of the alleged abuse until the afternoon on 6/9/25, by RN-B. She stated she had not had to deal with reports of abuse prior to this incident. She stated she emailed the hospice manager with the concerns.A facility document, Vulnerable Adult Maltreatment: Assessing and Reporting  in Minnesota, dated 8/2025, directed All mandated reporters at Allina Health must make a vulnerable adult report whenever they have reason to believe that a patient or client in Minnesota, who is considered a vulnerable adult, is being or has been maltreated; or they have knowledge that a vulnerable adult has sustained emotional abuse and/or a physical injury that is not reasonably explained. Mandated reporters may fulfill their reporting obligation by reporting following internal reporting procedures.

Based on interview and document review, the hospice failed to immediately investigate and take actions to prevent further potential abuse when a nursing assistant reported rough handling and threatening gestures by a staff member during the care of P1, and the alleged perpetrator (AP) continued to work scheduled shifts. --- Findings include: P1’s plan of care (POC) for benefit period 5/3/25 through 7/31/25 indicated she was admitted to the residential hospice agency on 5/3/25, with diagnoses of uterine cancer with metastasis (spread) to the bone, liver, lymph nodes, and both lungs. P1 required the assistance of one staff for personal cares and transfers, along with the use of a walker. On 8/28/25 at 1:39 p.m., nursing assistant (NA)-A stated she worked with P1 overnight from 6/8/25 through 6/9/25. She stated she assisted P1 to the bathroom around 7:00 a.m. NA-A stated she feared P1 would fall and provided guidance and education. NA-A stated she came back to work on 6/9/25 and worked a double-shift from the afternoon through 6/10/25 morning. She stated she was instructed not to care for P1 but was allowed to care for the other residential hospice patients. On 8/28/25 at 2:08 p.m., the hospice manager (HM) stated the residential hospice redistributed staff so NA-A would not work with P1 for the evening shift into night shift 6/9/25 through 6/10/25. She stated she was made aware of the allegations of abuse on 6/10/25 around 8:00 a.m. She stated RN-A should have escalated the report right away. She stated, “If there are concerns about one patient, there should be concerns about all.”On 8/28/25 at 4:00 p.m., registered nurse (RN)-A stated she was the supervisor on duty on 6/9/25, when the allegations were reported to her that afternoon by RN-B. She stated she emailed HM with the concerns. RN-A stated the decision was made to have NA-A continue with her scheduled shift from the evening of 6/9/25 through the morning of 6/10/25 (a double shift), with the direction other staff (nurses) would provide necessary care for P1. A facility timecard for NA-A indicated she worked 6/8/25 at 7:01 p.m. through 6/9/25 at 7:43 a.m. It also indicated she worked 6/9/25 at 3:01 p.m. through 6/10/25 at 7:34 a.m.A facility document, Vulnerable Adult Maltreatment: Assessing and Reporting in Minnesota, dated 8/2025, directed to immediately investigate all alleged violations involving anyone furnishing services on behalf of home care or hospice. Immediately take action to prevent further potential violations while the alleged violation is being verified. Investigations and/or documentation of all alleged violations must be conducted in accordance with established procedures.

The hospice agency failed to report allegations of abuse to the State Agency immediately but not more than 24 hours, when nursing assistant (NA)-A reported she witnessed rough handling and threatening hand gestures made by NA-B toward P1 during care. --- Findings include:P1’s plan of care (POC) for benefit period 5/3/25 through 7/31/25, indicated she was admitted to the residential hospice agency on 5/3/25, with diagnoses of uterine cancer with metastasis (spread) to the bone, liver, lymph nodes and both lungs. P1 required the assistance of one staff for personal cares and transfers, along with the use of a walker. P1 was cognitively intact. A facility document, internal investigation of vulnerable adult incident, indicated nursing assistant (NA)-B’s written statement where she wrote she witnessed NA-A yelling at P1, as she was pushing and pulling on her lower legs, in her room. NA-B wrote P1 told NA-A she was hurting her, but NA-A continued her actions. NA-B wrote she immediately reported these observations to registered nurse (RN)-B. The document also indicated P1 was interviewed in the afternoon on 6/9/25, by RN-C where she explained the rough handling she endured that morning by NA-A. On 8/28/25 at 1:39 p.m., NA-A stated she worked with P1 overnight from 6/8/25 through 6/9/25. She stated she assisted P1 to the bathroom around 7:00 a.m. on 6/9/25. NA-A denied rough patient handling and stated she was attempting to keep P1 from falling. On 8/28/25 at 2:08 p.m., the hospice manager (HM) stated she was made aware of the allegations of abuse on 6/10/25 around 8:00 a.m., related to rough handling of P1 and immediately informed the administrator and medical director at that time. She stated she made the report to the State Agency on 6/10/25 at 11:50 a.m. She stated the supervisor on duty did not report the incident to the State Agency or to anyone in management. She stated it should have been escalated right away. On 8/28/25 at 2:47 p.m., RN-C stated she interviewed P1 on 6/9/25, in the afternoon. She stated P1 was apprehensive about NA-A caring for her, because earlier that day she made her feel vulnerable and felt as though NA-A might punch her. RN-C stated P1 told her NA-A was rough with her, she attacked her and grabbed her arm very hard. RN-C stated she informed RN-A of the report. On 8/28/25 at 4:00 p.m., RN-A stated she was the supervisor on duty on 6/9/25, but was not informed of the alleged abuse until the afternoon on 6/9/25, by RN-B. She stated she had not had to deal with reports of abuse prior to this incident. She stated she emailed the hospice manager with the concerns.A facility document, Vulnerable Adult Maltreatment: Assessing and Reporting  in Minnesota, dated 8/2025, directed all mandated reporters at Allina Health must make a vulnerable adult report whenever they have reason to believe that a patient or client in Minnesota, who is considered a vulnerable adult, is being or has been maltreated; or they have knowledge that a vulnerable adult has sustained emotional abuse and/or a physical injury that is not reasonably explained. Mandated reporters may fulfill their reporting obligation by reporting following internal reporting procedures. All mandated reports will be submitted via on-line format to Minnesota Adult Abuse Reporting Center (MAARC).

Based on a review of available documentation and staff interview, the facility failed to inspect the fire sprinkler system per NFPA 101 (2012 edition), Life Safety Code, section 9.7.5, and NFPA 25 (2011 edition), Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, section 5.1.1.2. This deficient finding could have a widespread impact on the residents within the facility. --- Findings include: On 12/06/2023 between 10:30 AM and 12:30 PM, it was revealed by a review of available documentation that at the time of the survey the facility could not provide documentation showing that a quarterly sprinkler inspection had been completed during the second quarter of 2023 or the fourth quarter of 2022. An interview with the Hospice Clinical Manager verified this deficient finding at the time of discovery.

Based on observation and staff interview, the facility failed to install corridor doors per NFPA 101 (2012 edition), Life Safety Code, section 19.3.6.3.5, and CFR 483.90 paragraph (a)(1)(ii). This deficient finding could have an isolated impact on the residents within the facility. --- Findings include: On 12/06/2023 between 10:30 AM and 12:30 PM, it was revealed by observation that the doors to the paper closet across from the Hospice Clinical Manager's office had roller latches installed on them. An interview with the Hospice Clinical Manager verified this deficient finding at the time of discovery.

Based on a review of available documentation and staff interview, the facility failed to inspect fire dampers per NFPA 101 (2012 edition), Life Safety Code, section 8.5.5.4.2, and NFPA 105 (2010 edition), Standard for Smoke Door Assemblies and Other Opening Protectives, section 6.5.2, 6.5.11, and 6.5.12. This deficient finding could have a widespread impact on the residents within the facility. --- Findings include: On 12/06/2023 between 10:30 AM and 12:30 PM, it was revealed by a review of available documentation that at the time of the survey the facility could not provide documentation showing that the dampers in the facility had been inspected within the last four years. An interview with the Hospice Clinical Manager verified this deficient finding at the time of discovery.

Based on a review of available documentation and staff interview, the facility failed to conduct fire drills per NFPA 101 (2012 edition), Life Safety Code sections 19.7.1.6. This deficient finding could have a widespread impact on the residents within the facility. --- Findings include: On 12/06/2023 between 10:30 AM and 12:30 PM, it was revealed by a review of available documentation that at the time of the survey the facility could not provide documentation showing that a fire drill had been conducted during the first shift during the first quarter of 2023. An interview with the Hospice Clinical Manager verified this deficient finding at the time of discovery.

Based on a review of available documentation and staff interview, the facility failed to inspect fire doors per NFPA 101 (2012 edition), Life Safety Code section 8.3.3.1, and NFPA 80 (2010 edition), Standard for Fire Doors and Other Opening Protectives, section 5.2.1. This deficient finding could have a widespread impact on the residents within the facility. --- Findings include: On 12/06/2023 between 10:30 AM and 12:30 PM, it was revealed by a review of available documentation that the fire door inspection report that the facility provided did not list each door that was tested along with what was inspected. An interview with the Hospice Clinical Manager verified this deficient finding at the time of discovery.

Based on a review of available documentation and staff interview, the facility failed to test the Emergency Power Supply System (EPSS) per NFPA 99 (2012 edition), Health Care Facilities Code, section 6.4.4.1.1.3, and NFPA 110 (2010 edition), Standard for Emergency and Standby Power Systems, section 8.4.9, 8.4.9.1, 8.4.9.2, and 8.4.9.5.3. This deficient finding could have a widespread impact on the residents within the facility. --- Findings include: On 12/06/2023 between 10:30 AM and 12:30 PM, it was revealed by a review of available documentation that at the time of the survey the facility could not provide documentation showing that they have had a four-hour load bank test completed on the generator within the last 36 months. An interview with the Hospice Clinical Manager verified this deficient finding at the time of discovery.

Based on observation, interview and record review the agency failed to ensure that a comprehensive medication assessment was completed for 1 of 1 patients (P19) reviewed for skilled nurse visit in a facility. --- P19's interdisciplinary team (IDT) update dated 11/22/23, identified P19 was admitted to hospice services on 9/5/23, and terminal diagnosis of chronic kidney disease with chronic heart failure. P19's plan of care (POC) goals included P19 would have safe and accurate medication administration and the POC interventions which included review of medication list for accuracy. During a home visit conducted with registered nurse (RN)-D clinical supervisor on 12/5/23 at 10:00 a.m., for P19 in an assisted living facility (ALF), P19's Active Medication form was compared to the ALF's medication Order Report. RN-D verified the following findings. Review of P19's hospice Active Medication list dated 12/4/23, identified the following:-aspirin chewable tablet 81 milligrams (mg) (nonsteroidal anti-inflammatory drug, uses include prevention of blood clots) chew one tablet by mouth once a day -loratadine (Claritin) (antihistamine-to treat allergies) 10 mg take one tablet by mouth once daily. -omeprazole (Prilosec) (proton pump inhibitor-to treat excessive stomach acid) 20 mg, take one tablet by mouth once daily Review of P19's facility Order Report dated 12/5/23, identified aspirin, loratadine and omeprazole were not included in P19's medications. On 12/5/23 at 10:45 a.m., medications were reviewed with RN-D and assisted living director of nursing (DON). DON confirmed P19 did not receive the three medications listed above. DON stated P19's omeprazole and aspirin were discontinued prior to hospice admission, and loratadine was listed on the facility's standing orders as an as needed medication (PRN). During a follow up interview on 12/5/23 at 10:56 a.m., RN-D confirmed the above findings. RN-B stated the agency's usual practice was to review and assure accuracy of patient's medications during skilled nursing visits, as well as during interdisciplinary (IDT) meetings. RN-D indicated medication reconciliation was important to assure medications were accurate, so the hospice team and physicians were aware of what medications the patients were currently receiving. During interview on 12/6/23 at 11:56 a.m., quality and compliance manager (QCM)-A indicated the expectation was medications were reviewed with every nurse visit, for safety and appropriate patient treatment. The agency policy titled Medication Procurement, Administration, and Documentation dated 2/10/22, identified a medication record of all drugs taken by the patient was kept in the clinical record, Beyond Now. The policy also identified medication profiles were reviewed for accuracy of medication entry, duplicate therapy, and drug interactions by the pharmacist during IDT meetings. The policy failed to identify a process to assure hospice current medication orders were reconciled with facility medication orders to assure they were accurate. The agency policy titled Medication Reconciliation, dated 2/24/22, was to ensure a continuum of communication of patient medications from time of referral through death/discharge and all staff had access to an accurate medication plan at every point of care. The policy instructed staff at time of admission to verify current medications by obtaining medication history, and to compare this medication list to mediation list received ensuring the accuracy of all elements of the patients medication history. The policy further instructed staff to clarify any discrepancies between the patient's stated list of medications, and what the patient reports taking by calling the prescriber to reconcile the discrepancy. The policy instructed staff for a day-to-day process, to review medications and their administration ongoing as necessary. The policy instructed the medication list to be kept current and updated.

Based on interview and document review, the agency failed to ensure an individualized plan of care for 1 of 2 patients (P4) reviewed for oxygen. --- P4's Interdisciplinary team (IDT) update dated 11/22/23, indicated P4 enrolled into hospice on 9/27/23 and had the following diagnoses: secondary malignant neoplasm of the brain, left lung, right lung, and bone. The IDT update lacked a care plan that addressed P4's respiratory and oxygen use status. Further, the update indicated durable medical equipment as of 11/21/23, included a hospital bed, but lacked information regarding oxygen. P4's Active Medications form dated 12/4/23, lacked information P4 was using oxygen. P4's comprehensive nurse visit note dated 11/29/23, indicated P4 was in bed and was using oxygen at 2 liters per nasal cannula because of difficulty breathing and the oxygen was effective. Additionally, the note indicated P4's lungs were clear and used oxygen for the first time on 11/29/23. P4's comprehensive nurse visit note dated 12/4/23, indicated P4 had wheezing to his lungs and used supplemental oxygen at 2 liters per minute as needed and had required oxygen one time. P4's Active Medications form dated 12/4/23, lacked information P4 was using oxygen as needed. During interview on 12/4/23, at 2:08 p.m. registered nurse manager (RN)-C verified the active medication form lacked an order for as needed oxygen and the electronic medical record (EMR) was reviewed and lacked a care plan that addressed oxygen use and respiratory status. During interview on 12/6/23, at 12:05 p.m., RN quality and compliance manager (QACM)-A stated she would have to look at the hospice standing orders regarding the oxygen but expected oxygen to be care planned. No additional information was provided. A policy, Care Planning Process for Hospice indicated the care plan is based upon the initial and comprehensive assessments; is individualized, interdisciplinary and focused on outcomes. All patients have a documented care plan that is based on the assessed needs of the patient and updated as often as necessary but no later than every 14 days. Updates will reflect progress towards desired outcomes and response to care.

Based on interview and document review, the agency failed to ensure services were provided in accordance with the plan of care for 6 of 20 patients (P2, P15, P19, P14, P16, P13) reviewed for services planned. --- P13's hospice plan of care (POC) dated 11/1/23, indicated p13 was enrolled in the 5th benefit period 11/1/23, through 12/30/23, and required a home health aide once between 11/1/23, and 11/4/23, and then twice weekly from 11/5/23, to 12/30/23. P13's home health aide visit contacts in the electronic medical record (EMR) indicated P13 had a home health aide visit on the following dates: 11/7/23, 11/10/23, 11/16/23, 11/21/23, 12/5/23, P13's EMR indicated four missed visits from the following time frames which lacked documentation why the visits were missed: 11/12/23, through 11/18/23, 11/19/23, through 11/25/23, 11/26/23, through 12/2/23, 11/26/23, through 12/2/23, During interview on 12/5/23 at 2:36 p.m., registered nurse (RN)-C verified there were four uncompleted home health aide visits and stated the home health aide should have documented why the visits were missed and further stated she expected documentation to be completed within 24 hours and expected the aide to complete visits according to the orders. P16's interdisciplinary team (IDT) update dated 11/29/23, indicated P16 enrolled in hospice 5/31/23, and had the following diagnosis: other symptoms and signs involving cognitive functions following cerebral infarction (stroke). Additionally, the update indicated P16 was in a facility and required 1 to 2 skilled nursing visits every 6 days for 6 days from 11/27/23, to 12/2/23, from 12/3/23, to 1/25/24, 1 to 2 visits every week for 8 weeks. P16's skilled nurse visit orders indicated from 9/3/23, to 11/25/23, P6 required one to 2 visits every week for 12 weeks. P16's skilled nurse visit contacts in the electronic medical record indicated P16 had a skilled nurse visit on the following dates: 9/7/23, 9/11/23, 9/13/23, 9/18/23, 9/22/23, 9/28/23, 10/5/23, 10/12/23, 10/17/23, 10/26/23, 11/8/23, 11/26/23. P16 lacked skilled nurse visits during the week of 10/29/23, through 11/4/23, 11/12/23, through 11/18/23, and 11/19/23, through 11/25/23. P16's skilled nurse missed visit note dated 11/2/23, indicated the following, "Missed visit this date". The note was signed on 12/4/23 and lacked information why the visit was missed. P16's hospice skilled nurse phone call note dated 11/22/23, indicated a communication note and under the heading, "Relationship to patient" indicated, "Caregiver". Under the heading, "Communication Details" indicated, "No visit needed today, no refills needed". The note lacked information why the visit was not needed other than P16 did not require any medication refills. P16's skilled nurse missed visit note dated 12/1/23, indicated the following, "Missed visit this day". The note was signed on 12/4/23, and lacked information why the visit was missed. A policy, Care Planning Process for Hospice dated 4/21/21, indicated the care plan addresses care provided to the patient and the patient's family, and the manner in which hospice will provide care and services. P14s Interdisciplinary Team note, dated 11/29/23, indicated P14 was enrolled in his first benefit period 10/19/23 through 1/16/24 and required a skilled nursing visit one to two times weekly and 1 to ten times as needed for symptom management. P14s skilled nursing visits in the electronic medical record (EMR) indicated P14 had a skilled nursing visit on the following dates: 10/19/23 10/23/23 11/6/23 11/20/23 12/4/23 During an interview on 12/6/23 at 1:00 p.m., clinical manager and registered nurse (RN)-H confirmed that P14 was missing three skilled nursing visits, stating the nurse needed to ";put in a few missing visits." P2's Plan of Care (POC) dated 11/5/23, identified P2 was admitted to hospice services on 8/7/23, with a terminal diagnosis of neurocognitive disorder with Lewy bodies (form of dementia characterized by buildup of protein masses in the brain). P2's planned visits included home health aide (HHA) visits: two visit every week for 12 weeks, and one to three visits as needed. Review of P2's electronic record from 9/1/23 to 12/4/23, identified the following: -9/4/23, HHA missed visit, communication notes: due to holiday-9/8/23, HHA failed visit, communication notes: failed visit-9/20/23, HHA missed visit, communication notes: missed visit-9/25/23, HHA missed visit, communication notes: missed visit-10/4/23, HHA missed visit, no communication note.-11/23/23, HHA missed visit, communication notes: missed visit due to Thanksgiving During interview on 12/4/23, at 12:52 p.m. registered nurse (RN)-H clinical manager confirmed above findings. RN-H indicated expectations were to document reasons for missed visit and reschedule if able. P15P15's Plan Of Care (POC) dated 10/26/23, identified P15 was admitted to hospice services on 7/28/23, with terminal diagnosis of bronchiectasis (lung condition with abnormal damage and widening of airways). P15's planned visits included medical social work (MSW) visits one to three visits every 30 days for 60 days and one to seven visits as needed. Review of P2's electronic record from 9/1/23 to 12/4/23, identified no MSW visits were completed in September. During interview on 12/6/23, at 8:41 a.m. manager of interdisciplinary team (IDT) group (MIDT)-A confirmed the above findings. MIDT-A indicated expectations were to complete the visit, document reason of missed visit, and alter frequency of visits as needed. P19 P19's Plan of Care (POC) dated 11/22/23, identified P19 was admitted to hospice services on 9/5/23, with terminal diagosis of chronic kidney disease with chronic heart failure. P19's planned visits included spiritual care visits one to three visits every 30 days for 86 days. Review of P19's electronic record from 9/5/23 to 12/4/23, identified no spiritual care visits were made between 10/12/23 to 12/2/23. P19's record lacked documentation for reason of missed spiritual care visit. During interview on 12/5/23 at 2:38 p.m., MIDT-A confirmed the above findings. MIDT-A indicated the spiritual care visit should have been completed or missed visit documentation should have been completed to indicate the reason of the missed visit. During interview on 12/6/23 at 11:56 a.m., quality and compliance manager (QCM)-A indicated the agency was aware of a trend in missed visits, and they would be completing a performance improvement project (PIP) in 2024 related to missed visits. QCM-A indicated she would expect the visits to be made, and staff to explore options for other staff to complete the visits if scheduled staff were unable to make the visit. QCM-A indicated if a visit could not be made, then a brief explanation of the reason for the missed visit should be documented. The agency policy titled Care Planning Process for Hospice dated 4/21/21, identified the care plan addressed care provided to the patient and the patient's family, and the manner in which hospice would provide care/services. The care plan was based upon the initial and comprehensive assessments, was individualized, interdisciplinary, and focused on outcomes. The policy identified the plan of care would include services to be provided to the patient/family.

Based on interview and document review, the agency failed to ensure a registered nurse (RN) provided a supervisory visit of home health aide services at least every 14 days for 2 of 19 patients (P16, P15 ) reviewed for home health aide supervisory visits. --- P16's interdisciplinary team (IDT) update dated 11/29/23, indicated P16 enrolled in hospice 5/31/23, and had the following diagnosis: other symptoms and signs involving cognitive functions following cerebral infarction (stroke). Additionally, the update indicated P16 was in a facility and required 1 to 2 skilled nursing visits every 6 days for 6 days from 11/27/23 to 12/2/23, from 12/3/23 to 1/25/24 1 to 2 visits every week for 8 weeks. P16's skilled nurse visit orders indicated from 9/3/23 to 11/25/23, P6 required one to 2 visits every week for 12 weeks. P16's skilled nurse visit contacts in the electronic medical record indicated P16 had a skilled nurse visit on the following dates: 9/7/23, 9/11/23, 9/13/23, 9/18/23, 9/22/23, 9/28/23, 10/5/23, 10/12/23, 10/17/23, 10/26/23, 11/8/23, 11/26/23. P16 lacked skilled nurse visits during the week of 10/29/23, through 11/4/23, 11/12/23 through 11/18/23, and 11/19/23 through 11/25/23. P16's skilled nurse missed visit note dated 11/2/23, indicated the following, "Missed visit this date". The note was signed on 12/4/23 and lacked information why the visit was missed. P16's hospice skilled nurse phone call note dated 11/22/23, indicated a communication note and under the heading, "Relationship to patient" indicated, "Caregiver". Under the heading, "Communication Details" indicated, "No visit needed today, no refills needed". P16's skilled nurse missed visit note dated 12/1/23, indicated the following, "Missed visit this day". The note was signed on 12/4/23 and lacked information why the visit was missed. P16's hospice recertification skilled nurse visit note dated 10/26/23, indicated P16 had a home health aide supervisory visit completed by the registered nurse (RN). P16's hospice routine visit notes dated 11/8/23, and 11/16/23, were conducted by a licensed practical nurse (LPN) and therefore a home health aide supervisory visit was not conducted. P16's skilled nurse comprehensive visit note dated 12/4/23, indicated the RN also conducted a home health supervisory visit. During interview on 12/5/23 at 3:22 p.m., RN-C verified P16 had a home health aide supervisory visit conducted on 10/26/23, and not again until 12/4/23, and stated she expected home health aide supervisory visits to be conducted every 14 days. During interview on 12/6/23 at 11:59 a.m., the RN quality and compliance manager (QACM) stated it was important to supervise the home health aides because it was a regulatory requirement, and it helped support the home health aide and the family to assure services are appropriate and ensure the family does not have concerns. A policy was requested but was not received. P15's Plan of Care (POC) dated 10/26/23, identified P15 was admitted to hospice services on 7/28/23, with terminal diagnosis of bronchiectasis (lung condition with abnormal damage and widening of airways). P15's planned visits included home health aide visits, one visit every week and one to three visits as needed. P15s POC planned visits also included skilled nursing visits one to two visits every two weeks for eight weeks and one to ten visits as needed. P15's skilled nurse comprehensive visit note dated 11/3/23, indicated the RN also conducted a home health supervisory visit. P15's skilled nurse comprehensive visit note dated 11/15/23, indicated the RN had not conducted a home health supervisory visit. P15s visit notes identified respite stay at Wedum (hospice residential house) 11/15-11/20. P15s Home Health Aide Supervisory Documentation, care provided as assigned by HHA was documented as: N/A (not applicable). P15's skilled nurse comprehensive visit note dated 12/1/23, indicated the RN had not conducted a home health supervisory visit. P15s Home Health Aide Supervisory Documentation, care provided as assigned by HHA, was documented as: N/A and Type of Supervision as: indirect. HHA name was identified. No other supervision documentation noted, including patient/patient care giver (PCG) response to care given, HHA care plan reviewed, or comments. P15s medical record lacked a HHA supervisory visit completed from 11/4/23, to 12/6/23, 32 days since last supervisory visit was completed. During interview on 12/6/23 at 8:31 a.m., registered nurse clinical manager (CM)-A confirmed P15s last home health aide supervisory visit was conducted on 11/3/23, and stated she expected home health aide supervisory visits to be conducted every 14 days. P15's Plan of Care (POC) dated 10/26/23, identified P15 was admitted to hospice services on 7/28/23, with terminal diagnosis of bronchiectasis (lung condition with abnormal damage and widening of airways). P15's planned visits included home health aide visits, one visit every week and one to three visits as needed. P15s POC planned visits also included skilled nursing visits one to two visits every two weeks for eight weeks and one to ten visits as needed. P15's skilled nurse comprehensive visit note dated 11/3/23, indicated the RN also conducted a home health supervisory visit. P15's skilled nurse comprehensive visit note dated 11/15/23, indicated the RN had not conducted a home health supervisory visit. P15s visit notes identified respite stay at Wedum (hospice residential house) 11/15-11/20. P15s Home Health Aide Supervisory Documentation, care provided as assigned by HHA was documented as: N/A (not applicable). P15's skilled nurse comprehensive visit note dated 12/1/23, indicated the RN had not conducted a home health supervisory visit. P15s Home Health Aide Supervisory Documentation, care provided as assigned by HHA, was documented as: N/A and Type of Supervision as: indirect. HHA name was identified. No other supervision documentation noted, including patient/patient care giver (PCG) response to care given, HHA care plan reviewed, or comments. P15s medical record lacked a HHA supervisory visit completed from 11/4/23, to 12/6/23, 32 days since last supervisory visit was completed. During interview on 12/6/23 at 8:31 a.m., registered nurse clinical manager (CM)-A confirmed P15s last home health aide supervisory visit was conducted on 11/3/23, and stated she expected home health aide supervisory visits to be conducted every 14 days. P16's interdisciplinary team (IDT) update dated 11/29/23, indicated P16 enrolled in hospice 5/31/23, and had the following diagnosis: other symptoms and signs involving cognitive functions following cerebral infarction (stroke). Additionally, the update indicated P16 was in a facility and required 1 to 2 skilled nursing visits every 6 days for 6 days from 11/27/23 to 12/2/23, from 12/3/23 to 1/25/24 1 to 2 visits every week for 8 weeks. P16's skilled nurse visit orders indicated from 9/3/23 to 11/25/23, P6 required one to 2 visits every week for 12 weeks. P16's skilled nurse visit contacts in the electronic medical record indicated P16 had a skilled nurse visit on the following dates: 9/7/23, 9/11/23, 9/13/23, 9/18/23, 9/22/23, 9/28/23, 10/5/23, 10/12/23, 10/17/23, 10/26/23, 11/8/23, 11/26/23. P16 lacked skilled nurse visits during the week of 10/29/23, through 11/4/23, 11/12/23 through 11/18/23, and 11/19/23 through 11/25/23. P16's skilled nurse missed visit note dated 11/2/23, indicated the following, "Missed visit this date". The note was signed on 12/4/23 and lacked information why the visit was missed. P16's hospice skilled nurse phone call note dated 11/22/23, indicated a communication note and under the heading, "Relationship to patient" indicated, "Caregiver". Under the heading, "Communication Details" indicated, "No visit needed today, no refills needed". P16's skilled nurse missed visit note dated 12/1/23, indicated the following, "Missed visit this day". The note was signed on 12/4/23 and lacked information why the visit was missed. P16's hospice recertification skilled nurse visit note dated 10/26/23, indicated P16 had a home health aide supervisory visit completed by the registered nurse (RN). P16's hospice routine visit notes dated 11/8/23, and 11/16/23, were conducted by a licensed practical nurse (LPN) and therefore a home health aide supervisory visit was not conducted. P16's skilled nurse comprehensive visit note dated 12/4/23, indicated the RN also conducted a home health supervisory visit. During interview on 12/5/23 at 3:22 p.m., RN-C verified P16 had a home health aide supervisory visit conducted on 10/26/23, and not again until 12/4/23, and stated she expected home health aide supervisory visits to be conducted every 14 days. During interview on 12/6/23 at 11:59 a.m., the RN quality and compliance manager (QACM) stated it was important to supervise the home health aides because it was a regulatory requirement, and it helped support the home health aide and the family to assure services are appropriate and ensure the family does not have concerns. A policy was requested but was not received.

Based on interview and document review the agency failed to ensure all contracted staff were fully vaccinated with COVID-19 vaccine, had a qualifying exemption, or temporary delay as recommended by the CDC prior to staff providing any care, treatment, or other services for the agency and/or its patients for 1 of 2 hospice contracted durable medical equipment (DME)-A companies this had the potential to affect all patients who received services from the hospice agency. Findings include: The Center for Medicare and Medicaid Services (CMS) QSO memo 22-07, revised 4/5/22, identified on November 5, 2021, CMS established requirements regarding COVID-19 vaccine immunization of staff among Medicare-and Medicaid-certified providers and suppliers. The Provider-Specific Guidance, Attachment C: Hospice, stated the hospice must develop and implement policies and procedures to ensure that all staff were fully vaccinated for COVID-19. The Hospice attachment further identified; Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following hospice staff, who provide any care, treatment, or other services for the hospice and/or its patients. The hospice staff identified, included individuals who provide care, treatment, or other services for the hospice and/or its patients, under contract or by other arrangement. The undated, untitled DME-A vaccination status log, which included staff names, departments worked, and vaccination status or exemptions, identified all staffs' exemption status as non-applicable (N/A) for those who had received booster or fully vaccinated, and no, for those listed as unreported or unvaccinated. The departments listed included: delivery, Clinical / Respiratory, customer service, and operations. The form's column titled COVID Vaccination Status identified: -10 staff-booster -10 staff- fully vaccinated -10 staff-unreported -10-staff-unvaccinated On 4/13/22, at 2:21 p.m. during a phone interview, Administrator confirmed the information provided by one DME-A, identified 20 staff were listed as unreported, or unvaccinated on the company's COVID-19 immunization staff tracking log. Administrator indicated if contracted DME-A staff entered a skilled nursing facility they were tested/screened for COVID-19, but they were not tested/screened prior to entering patients' homes. Administrator stated they had begun to work with a new, second DME-B, but the original DME-A still had contact with their patients while unvaccinated. On 4/13/22, at 2:36 p.m. during a phone interview, DME-A vice president (DVP)-A confirmed all 40 staff listed on the COVID-19 vaccination log provided made deliveries to patients or had patient contacts. DVP-A confirmed that 20 of the 40 staff listed, did not have proof of vaccination and they had no exemptions. DVP-A stated their company policy did not require their staff to be vaccinated for COVID-19. DVP-A indicated the hospice agency was very clear on their standards and expectations of their staff to be vaccinated for COVID-19, and had sent DME-A their policies on it, but DVP-A confirmed DME-A could not justify only having vaccinated staff to make their deliveries. On 4/14/22, at 8:58 a.m. during a follow up interview, Administrator confirmed they had not received any documentation from DME-B, so was unable to provide proof of COVID-19 vaccination of contracted DME-B staff. Administrator indicated the hospice agency's process to assure their employees and contracted staff were vaccinated was done at their corporate level, but was unsure who was responsible. On 4/14/22, at 11:36 a.m. during a phone interview Vice President of Supply Chain (VPSC)-A indicated when they wrote their policy for COVID-19 vaccinations, they provided all their independent contractors with them, and expected them to follow their company policy on vaccinations. VPSC-A indicated the agency staff could just ask contracted staff and confirm with them to assure they were vaccinated and following their procedures, but he had not. The agency and system wide policy titled COVID-19 Immunization Program, dated 8/21, identified the agency was committed to a standardized COVID-19 immunization program that followed guidance from the Centers for Disease Control (CDC) and the Minnesota Department of Health (MDH) for the prevention and control of COVID-19. The policy identified it was applicable to all health care workers, which included: employees, medical staff, licensed independent practitioners, contracted Allina clinical personnel, students and volunteers...The agency policy specified contractors or vendors who failed to comply with the vaccination requirements would not be permitted to do business on their premises until they were in compliance with this policy.