Every finding on record at Essentia Health Hospice West

Based on observation, interview, and document review, the agency failed to ensure medications were reconciled and/or set up as ordered for 2 of 3 clients (P3, P5) whose medications were reviewed during home visits. --- Findings include:P3's plan of care (POC) dated 11/29/25 to 2/26/26, identified a start of care (SOC) date 11/29/25. Skilled nurse visits (SNV) were ordered one time per week for 12 weeks for various assessments and evaluation of general condition, end of life process, symptom control, mobility, nutrition, respiratory, home safety and management of home medications. Diagnoses included coronary artery disease, vascular dementia and recurrent urinary tract infection. During a home visit on 1/7/26, at 11:00 a.m. P3 was seated in a recliner in her living room sleeping. Family member (FM)-D brought all P3's medication bottles and stated he administered P3 medications to her every am. FM-D stated P3 had not taken Vitamin D3 for quite some time. FM-D could not remember when P3 had stopped the medication but stated it was quite some time ago, prior to her starting hospice services. Review of P3's undated Active Medication list printed 1/6/26, identified several prescribed and over the counter medications for P3. Cholecalciferol (vitamin D3) was listed for P3 to take 50 micrograms (MCG) by mouth (po) daily with start date 8/21/25. Review of P3's POC updated 12/31/25, identified a Medication section which listed P3's prescriptions and patient reported medications. Cholecalciferol (vitamin D3) was listed for P3 to take 50 micrograms (MCG) by mouth (po) daily with start date 8/21/25. When interviewed on 1/8/26, at 10:19 a.m. the hospice manager (HM)-A stated if P3 was no longer taking vitamin D3, her primary nurse should have notified P3's provider and if provider was in agreement, completed an order to stop the medication and update the medication list. P5's POC dated 12/31/25, identified a SOC date 7/24/25. P5 had orders for skilled nurse visits (SNV) one time per week for 13 weeks for various assessments and evaluation of general condition, end of life process, symptom control, mobility, nutrition, respiratory, home safety and management of home medications.  Diagnoses included Alzheimer's disease, weight loss, and rectal neoplasm.During a home visit 1/7/26, at 9:30 a.m. P5 was seated at the dining room table along with FM-B. FM-E was working in the kitchen and stated he administered P5's medications every morning. FM-E brought out P5's medication bottles and stated they gave P5 children's acetaminophen two times per day, to help her relax. FM-E stated P5 had been taking the children's acetaminophen for a couple of months. They thought it helped a little to calm and relax P5. Review of P5's undated Active Medications list printed 1/6/26, identified several prescribed and over the counter medications. The list lacked documentation of the over-the-counter medication children's acetaminophen that P5's family reported as an active medication. P5's POC updated on 10/22/25, identified a Medication section which listed P5's prescriptions and patient reported medications. The list lacked documentation of the over-the-counter medication children's acetaminophen that P5's family reported as an active medication. During interview on 1/7/26, at 10:25 a.m. registered nurse (RN)-A stated she had noticed P5's medication list did not list acetaminophen and that would be a medication that should be supplied by the agency for symptom control. RN-A stated she was not P5's primary nurse so was not sure why the medication was not listed on her medication lists. RN-A planned to return to the office and get the medication list updated and ordered. RN-A did not know why the medication list had not been updated. Medications were reviewed every nurse visit, and the medication should have been updated to reflect P5's current medications. When interviewed on 1/8/26, at 10:20 a.m. the hospice manager stated P5 medication list should have included the acetaminophen the family reported and hospice should have been supplying the medication to P5 as it was to manage symptoms related to her disease process. The agency nurses were supposed to review a patient's medications at every visit. The family may have reported the information to the nurse and the nurse forgot to update the medication list. The agency had ordered the acetaminophen now and updated P5's medication list. The agency policy Medication Management dated 7/18/25, identified upon admission, the RN would obtain a drug profile from the patient for all medications taken at home. The RN would reconcile current medication orders with the patient, care giver or facility staff during all routine visits and as needed. Any discrepancies or errors identified would require a discussion with the hospice provider for resolution. Resulting changes or clarifications would be documented in the electronic health record.

Based on interview and document review the facility failed to bathing refusals were communicated to update the plan of care for 1 of 6 patients (P5) reviewed that received services from a hospice aide. --- Findings include:P5's plan of care (POC) dated 12/31/25, identified a start of care (SOC) date 7/24/25. P5 orders included skilled nurse visits (SNV) one time per week for 13 weeks to assess and evaluate general condition, symptoms related diagnoses and end of life care, response to medications and treatment, supervise and evaluate home health aide services every 14 days. A hospice aide was ordered one time per week for 13 weeks to assist P5 with ambulation, personal care and bathing. Diagnoses included Alzheimer's disease, weight loss, and rectal neoplasm.During a home visit on 1/9/26, at 9:30 a.m. family member (FM)-B stated P5 had a hospice aide (HA)-A that came one time per week to assist P5 with a bath. FM-B stated P5 had not had a shower or bath for a few weeks. P5 could be belligerent and resistive with care due to Alzheimer's. HA-A had difficulty getting P5 to take a bath or shower and was only able to complete the task if P5's other family member (FM)-C was present. FM-B stated for some reason FM-C was able to divert P5's attention and persuade her to let HA-A bathe her. FM-C and HA-A were able to complete bathing if doing it together. P5's medical record identified the following:On 12/1/25, 12/8/25, 12/15/25, 12/22/25, and 12/29/25, hospice aide visits were completed. Documentation for the five HA visits identified P5 refused to allow the hospice aide to assist with a bath. The aide visits notes lacked documentation if P5's nurse had been notified of the inability to assist P5 with her bath. On 12/19/25 through 12/31/25, three skilled nursing visits were completed and identified hospice aide (HA) supervision and the POC had been reviewed with P5's caregiver. HA supervision identified staff were providing services in accordance with the plan of care and demonstrated competency with assigned tasks. The supervision lacked documentation of P5's refusal to complete the assigned bathing task.During interview on 1/8/26, at 10:19 a.m. the hospice manager (HM)-A stated she would expect the aide to communicate with the patient's primary nurse each time P5 refused care. She planned to make sure the aide was correctly documenting and reporting to the primary nurse as well as educate both the primary nurse and the hospice aide. The agency policy Hospice Aide Services dated 8/22/25, identified aide services would be assigned on an intermittent basis when personal care was needed. Hospice aides must report changes in the patient's medical, nursing and social needs to the registered nurse as the changes relate to the plan of care. The aides were also to complete appropriate records in compliance with hospice's policies and procedures. The aide would report any changes in the patient's status and needs to the case manager and collaborate how to address the patient needs. The hospice RN was to supervise the aide no less frequently then every 14 days to assess the quality of care and services provided by the hospice aide to ensure that the services ordered met the patient's needs.

Based on observation, interview and document review, the agency failed to ensure the registered nurse ensured care planned interventions were being completed by nursing assistants as part of the supervisory visits for 1 of 6 patients (P5) whose hospice aide services were reviewed. --- Findings include:P5's plan of care (POC) dated 12/31/25, identified a start of care (SOC) date 7/24/25. P5 orders included skilled nurse visits (SNV) one time per week for 13 weeks to assess and evaluate general condition, symptoms related diagnoses and end of life care, response to medications and treatment, supervise and evaluate home health aide services every 14 days. A hospice aide was ordered one time per week for 13 weeks to assist P5 with ambulation, personal care and bathing. Diagnoses included Alzheimer's disease, weight loss, and rectal neoplasm.During a home visit on 1/9/26, at 9:30 a.m. family member (FM)-B stated P5 had a hospice aide (HA)-A that came one time per week to assist P5 with a bath. FM-B stated P5 had not had a shower or bath for a few weeks. P5 could be belligerent and resistive with care due to Alzheimer's. HA-A had difficulty getting P5 to take a bath or shower and was only able to complete the task if P5's other family member FM-C was present. FM-B stated for some reason FM-C was able to divert P5's attention and persuade her to let HA-A bathe her. FM-C and HA-A were able to complete bathing if doing it together.P5's medical record identified the following:On 12/1/25, 12/8/25, 12/15/25, 12/22/25, and 12/29/25, hospice aide visits were completed. Documentation for the five HA visits identified P5 had refused to allow the hospice aide to assist with a bath. The aide visits notes lacked documentation if P5's nurse had been notified of the inability to assist P5 with her bath. On 12/19/25 through 12/31/25, three skilled nurse visits were completed and identified hospice aide (HA) supervision and the POC had been reviewed with P5's caregiver. HA supervision identified staff were providing services in accordance with the plan of care and demonstrated competency with assigned tasks. HA supervision identified staff were providing services in accordance with the plan of care and demonstrated competency with assigned tasks. The supervision lacked documentation of P5's refusal to complete the assigned bathing task.During interview on 1/8/26, at 10:19 a.m. the hospice manager (HM)-A stated if P5 was refusing hospice aide assistance with a bath it should be documented in P5's medical record and care planned with interventions for the aide to accomplish her tasks. HM-A would expect the aide to communicate with the patient's primary nurse each time P5 refused care. It may be the aide was not documenting the refusals correctly on her forms and the supervising nurse was not aware of P5's refusals. She planned to make sure the aide was correctly documenting and reporting to the primary nurse as well as educate both the primary nurse and the hospice aide. The agency policy Hospice Aide Services dated 8/22/25, identified aide services would be assigned on an intermittent basis when personal care was needed. The activity would be assigned and supervised by a registered nurse (RN). Hospice aides must report changes in the patient's medical, nursing and social needs to the registered nurse as the changes relate to the plan of care. The aides were also to complete appropriate records in compliance with hospice's policies and procedures. The aide would report any changes in the patient's status and needs to the case manager and collaborate how to address the patient needs. The hospice RN was to supervise the aide no less frequently then every 14 days to assess the quality of care and services provided by the hospice aide to ensure that the services ordered met the patient's needs.

Based on interview and document review, the agency failed to ensure volunteers provided administrative or direct patient care services to patients to equal a minimum of 5 percent of the total patent care hours of all paid hospice employees and contract staff. This had the potential to affect all hospice patients. --- Findings include:Review of the agency Volunteer list identified they had two volunteers.The agency's FY 2025 Volunteer Hours log from January 2025 to December 2025, identified a monthly calculation of patient hours, volunteer hours and included the percentage of volunteer hours worked. The log identified total of 119.5 hours of volunteer time and 3166.47 hours of total staff hours. The identified total cost savings was 3.77% for the year.  During interview on 1/8/26, at 9:00 a.m. the volunteer coordinator stated the agency currently had one active volunteer who provided spiritual support to patients, as the other volunteer was currently out on leave. The agency did not currently have any volunteers that provided respite, patient care, or administrative duties. The agency was currently trying to recruit volunteers through the use of brochures, and they had reached out to local churches. During the holidays the hospice manager did a radio interview and promoted volunteer services. During interview on 1/8/26, at 10:19 a.m. the hospice manager stated the agency's main volunteer had been out on medical leave since June 2025. The agency's current volunteer only performed spiritual support and duties. The agency did not currently have an active volunteer that provided general volunteer tasks such as patient, or respite care or administrative duties. The agency was not able to meet the 5% required and that was something they planned to work on. The agency policy Hospice Volunteer Services dated 7/12/25, identified hospice volunteers must provide day to day administrative and/or direct patient care services in an amount that, at a minimum, equaled 5 % of the total patient care hours of all paid hospice employees and contract staff.

Based on interview and document review the agency failed to update patient's plan of care (POC) to reflect all services provided for the palliation and management of terminal illness and related condition for 1 of 10 patients (P4) who received scheduled volunteer service for spiritual support. --- P4's plan of care (POC) dated 8/16/23, identified a hospice start of care (SOC) date of 12/6/22, in his fourth benefit period. Multiple myeloma was identified as the terminal diagnoses for hospice care. Problems identified included coping and emotional distress, need for cultural, religious and spiritual support and need for emotional and social support. Interventions included to assist P4 and family with spiritual/cultural customs and decisions related to end of life as deemed important to P4, with a goal P4 would have a sense of well being and adjustment. Services ordered included skilled nurse visits and medical social work visits. P4's medical record identified P4 received visits from the hospice agency's spiritual care volunteer two times through June 2023, four visits through July 2023 and one visit in August 2023. P4's visit orders identified an order for spiritual care visits was received on 6/19/23, to provide volunteer spiritual care visits one time per month for one month, two times per month for one month and three visits as needed. P4's POC lacked documentation spiritual visits were being provided to P4, as well as interventions and goals that were anticipated to meet P4 need for spiritual support. During interview on 8/23/23 at 1:20 p.m. the hospice manager stated the agency had a care plan for volunteers that staff were to add to patient's POC when they initiated the spiritual care volunteer. It was important to have all services a patient received on their care plan so everyone knew what care was being delivered to patients, as well as having interventions and goals listed. It was expected to have all care and services a patient was receiving to be on their POC. The agency policy Interdisciplinary Group, Care Planning and Coordination of Services dated 7/21/23, indicated the contents of the written plan of care would reflect the patient and family goals and interventions based on the problems identified during the initial comprehensive and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of terminal illness and related conditions.

Based on interview and document review, the agency failed to ensure the medical director or physician designee reviewed or provided written certification with all required components, to certify the hospice patient's life expectancy was 6 months or less for 1of 10 patients (P10) reviewed in the sample. --- P10's plan of care (POC) dated 8/2/23, identified a hospice start of care (SOC) 3/28/23, in his second benefit period. P10's terminal diagnoses was identified as end stage heart failure. Services included skilled nursing, social work, home health aide and spiritual care volunteer. P10's initial Certificate of Terminal Illness dated 3/28/23, identified his first benefit period with a terminal diagnoses of end stage heart failure. The certification identified a face to face visit was conducted with the hospice medical director on 3/2/23, and P10's life expectancy was six months or less if the terminal disease ran it's normal course. The certification lacked physician narrative attestation related to any comorbidities, subjective and objective medical findings, current medication and treatment orders or information about the medical management of any patient conditions unrelated to the terminal illness. During interview on 8/23/23, at 1:20 p.m. the hospice manager stated the agency had been going through a transition with formats of some of their medical forms in February and P10's certification of terminal illness was missed and was not fully completed. All certifications were being completed as required since. The agency's policy Admission Criteria dated 7/26/23, indicated the hospice medical director would review the referral assessment documentation and determine the patient had a life expectancy of six months or less and sign the patients Certification of Terminal Illness order.

Based on interview and document review, the agency failed to ensure a comprehensive discharge summary of the patients stay was completed for 1 of 2 patients (P11) reviewed, who were discharged from hospice services. --- P11's plan of care (POC) identified a start of care (SOC) 1/18/23, in her second benefit period. Terminal diagnoses was identified as severe protein-calorie malnutrition. P11's discharge summary form dated 4/17/23, identified P11 was discharged from the agency on 4/17/23, due to no longer terminally ill, health status stabilized and no longer requiring hospice services. P11's spouse would continue to care for her P11's discharge summary identified all diagnoses and current medication orders. P11's medical record lacked a completed discharge summary that included a summary of P11's stay, including services received, treatments, symptoms, pain management, and other pertinent information needed to provide care for P11. During interview on 8/23/23, at 1:20 p.m. the hospice manager stated a patient's discharge summary needed to include documentation of the patient's plan of care. The agency policy Hospice Revocation dated 6/28/23, indicated a discharge summary that included a summary of the patient's stay, including symptoms, treatment and pain management interventions, the patient's current plan of care, and the latest physician orders.