Every finding on record at Essentia Health St Marys Hospice & Palliative Care Services

Based on interview and record review, the agency failed to inform patients about the scope of services the hospice would provide and limitations of those services for 1 of 3 patients (R1) reviewed for discharge processes. --- Findings include:P1’s plan of care (POC) dated 10/8/25 for benefit period 10/22/25 to 1/19/26, identified a start of care (SOC) of 7/24/25. Diagnoses included decompensated hepatic cirrhosis, depression with anxiety, hepatic encephalopathy, ascites due to alcoholic cirrhosis and alcohol use disorder. Services were ordered for medical social work visits one to five visits every month for one month for social and emotional support needs, skilled nursing visits (SNV) one visit every week for twelve weeks to assist with nutrition, anxiety, pain, infection, and management of medications, and spiritual care visits two to twelve visits every twelve weeks for twelve weeks for grief and spiritual support.P1’s medical record identified the following:-On 10/1/25, a care conference was held regarding substance use and compliance with hospice medications while living in an assisted living home. P1 was invited to attend, however did not attend. The assisted living staff indicated they would discuss their expectations of P1 while living at the facility. Hospice noted P1 called hospice regarding his concern of being kicked out of the assisted living and his desire to continue to reside at the facility. Hospice documented the agency had no determination over P1’s behavior and could only offer supports. The medical record lacked documentation the hospice agency notified P1 of limitation of their services if P1 had a lack of housing.-On 10/6/25, a SNV was made with various assessments. The visit note lacked any review of the 10/1/25 care conference with P1, including any limitations or discontinuation of hospice services if P1 was no longer able to reside at the assisted living.-On 10/9/25, the assisted living called the hospice agency to report behaviors and continued substance use. The hospice agency’s decision was to immediately discharge P1 from hospice services due to P1 was homeless and the agency could not provide hospice services and controlled substances in an unstructured environment without oversight.The medical record lacked evidence P1 was informed of the limitations of hospice services on admission to hospice or during his episode of care.During interview on 10/21/25, at 2:30 p.m. registered nurse (RN)-A stated she had admitted P1 to the hospice agency when P1 was living at temporary housing for homeless people. P1 then transitioned to an assisted living. Hospice attended a care conference with the assisted living facility on 10/1/25, to discuss P1’s drug use and behavior at the facility. P1 chose not to attend the care conference. During that meeting, the assisted living was not specific with what they would need to discharge P1 from the facility and they were willing to work with P1 and wanted to help him. No consequences or ultimatum were given to P1 regarding continued drug use in the assisted living facility. RN-A received a call from the assisted living that P1 had erratic behaviors, making other residents feel unsafe the evening of 10/8/25, and requested a skilled nurse visit to check on him. RN-A made the visit. The assisted living was going to call their supervisors, so RN-A left. Later RN-A received a call from the assisted living that P1 would not be able to stay there. RN-A contacted the hospice agency supervisors to decide what to do and was told to discharge P1 from hospice services. RN-A made a discharge visit on 10/9/25 and told P1 he could go to the homeless shelter and for pain, he was to go to the emergency room. During telephone interview on 10/21/25, at 3:30 p.m. the assisted living director (ALD)-A stated they had multiple conversations with hospice regarding P1’s behaviors and illicit drug use. ALD-A asked hospice for help on 10/9/25, when P1 was acting so erratically and hospice pretty much said to do what we had to do. At no time was it ever discussed hospice was going to discharge P1.During interview on 10/22/25, at 9:00 a.m. RN-A stated to attempt to do daily medication administration for P1 would have put the agency in the position of having to pick up medications and potentially destroy medications if P1 did not show up for daily administration and the agency would not have any place to store medications.  P1 would not have been a candidate to reside in the agency hospice house as certain criteria needed to be met and P1 did not meet the criteria. P1’s hospice physician was updated regularly on his behavior and illicit drug use.When interviewed on 10/22/25, at 12:30 p.m. the hospice medical director (MD)-A stated she had been aware a care conference had been held on 10/1/25 to discuss P1's behavior at the assisted living where he resided. The assisted living facility was the only place willing to take P1 so P1 had no other options if he was evicted and the hospice team was very concerned about that. The hospice team was aware of P1's drug use and behaviors prior to 10/9/25. The hospice agency should have been more on point with P1 regarding the consequences of his behaviors. The agency had to discharge P1 due to his escalating behaviors and staff concerns. The agency could have made it safer for P1 and gave him better options. The agency felt they had to discharge P1 from hospice because the assisted living was going away and the ability to see P1 in a safe setting would be gone. Thinking more about the hospice program and staff safety. The hospice policy Discharge for Cause dated 2/22/24, identified discharge for cause should be the last option for a hospice provider. There should be documented evidence of provider attempts to solve the issue that le to the discharge for cause. The hospice RN or social worker should advise the patient that a discharge for cause was being considered. The hospice interdisciplinary team (IDT) should make a serious effort to resolve the problem/behaviors presented by the patient in the patient's home. The agency's undated Live Discharge Hospice Checklist directed staff to discuss pending discharges with the hospice team at their IDT and with the patient's caregivers and the patient's attending physician. Staff were directed to have the patient or caregiver sign the Medicare Notice of Non-Coverage form at least 10 days prior to discharge. Staff were to document all attempts to contact family to discuss discharge.

Based on interview and document review the agency failed to update the comprehensive assessment and plan of care to reflect changes in patient progress and goals that had occurred since initial admission assessments for 1 of 3 patients (P1) reviewed for discharge. --- Findings include:P1’s plan of care (POC) dated 10/8/25 for benefit period 10/22/25 to 1/19/26, identified a start of care (SOC) of 7/24/25. Diagnoses included decompensated hepatic cirrhosis, depression with anxiety, hepatic encephalopathy, ascites due to alcoholic cirrhosis and alcohol use disorder. Services were ordered for medical social work visits one to five visits every month for one month for social and emotional support needs, skilled nursing visits (SNV) one visit every week for twelve weeks to assist with nutrition, anxiety, pain, infection, and management of medications, and spiritual care visits two to twelve visits every twelve weeks for twelve weeks for grief and spiritual support.P1's medical record identified the following:On 8/25/25, a social work (SW) note dated 8/25/25, identified the housing staff where P1 resided, reported P1 was disruptive in the house and there was suspicion of methamphetamine use. The housing agency notified SW-A P1 would need to find other housing.On 8/27/25, P1's POC identified a problem for future care placement with the SW plan to assist P1 in applying for medical assistance for long term care placement and assistance to coordinate a search for home or placement at an assisted living or skilled nursing facility with start date 7/24/25. The POC lacked identification and approaches for P1's inappropriate behaviors. The POC lacked an assessment of P1's behavior or documentation the hospice's interdisciplinary team (IDT) were aware of P1's behavior or had discussed implications of the behaviors to the hospice POC and treatment goals. On 9/30/25, a note identified assisted living staff reported P1 was found smoking a drug pipe in his room under his covers.  A skilled nurse visit (SNV) was completed. Registered nurse (RN)-A observed a glass pipe lying on floor of P1’s room. P1 was sleepy and minimally responsive. The assisted living staff reported frustration over P1’s behavior.On 10/1/25, a note identified a care conference was held regarding inappropriate behavior, suspected substance uses and compliance with hospice medications while living in an assisted living home. P1 was invited to attend, however declined the invitation. The assisted living planned to talk with P1 to discuss their expectations of P1 while living at the facility. Hospice noted P1 had called hospice regarding his concern of being kicked out of the assisted living and his desire to continue to reside at the facility.  Hospice documented the agency had no determination over P1’s behavior and could only offer supports. P1's POC dated 10/8/25, lacked documentation of the above concerns or new interventions or approaches to address these concerns. 10/8/25, lacked any assessment of inappropriate behaviors, illicit drug use with potential interactions with hospice medications and treatments. The POC also lacked approaches and goals related to P1’s suspected illicit drug use, disruptive behaviors, and potential of eviction from his home related to his actions and behaviors. In addition, the POC failed to identify a plan to address P1's lack of housing if he should be evicted from the assisted living, he currently resided in. During interview on 10/21/25 at 2:35 p.m. registered nurse (RN)-A stated she did remember a glass pipe on the floor of P1's room at the assisted living during one of her skilled nurse visits (SNV). The facility requested a care conference on 10/1/25, to discuss P1's drug use. P1 refused to attend and went to stay with his significant other as he was worried, he would be evicted from the assisted living. The assisted living was willing to try and work with P1, however, no consequences or plan was developed if P1 continued drug use. RN-A was aware P1 was using illicit drugs but felt like as a hospice that was not something hospice assessed as that was more on the assisted living to deal with. RN-A stated hospice was there more as a support and could not control what happened at the assisted living. RN-A stated it was hard to have a coherent discussion with P1 due to his erratic behaviors. RN-A was not sure if was related to his drug use or elevated ammonia levels. Whenever there was any drug abuse or things like that, RN-A called her supervisor as well as several conversations with the hospice physician. The assisted living did a full assessment of P1 and accepted him and the hospice social worker was also working with the community mental health worker. During telephone interview on 10/21/25, at 4:12 p.m. the social worker (SW)-A stated she had assisted P1 to find a place to live and the assisted living had accepted him and so he moved over there. There were challenges during P1's time at the assisted living. SW-A would get updated and follow up when needed. At one point, the facility held a care conference. They were very frustrated at that point and so we all met together to talk it through. The assisted living stated they would follow up with P1 about his drug use and behavior, and if he turned in all his drugs and paraphernalia he would be allowed to stay there. Hospice medications were discussed, and the use of illicit drugs would not be good, but the assisted living facility was responsible to manage his drug use and behavior, not hospice. The hospice agency was just there as a support. The agency was dependent on what the assisted living decided but had discussed if P1 was evicted, hospice would have to discharge him. If P1 did not have housing, it would be a huge problem to have the hospice medications on the street. So, the agency discharge was dependent on the assisted living discharge. The agency would not have discharged P1 if the assisted living had kept him there. During interview on 10/22/25, at 12:30 p.m. the hospice physician (MD)-A stated she was aware a care conference had been held with the assisted living to discuss P1's behaviors and drug use. P1 had no other housing options and that concerned the hospice staff. P1's drug and alcohol use would affect hospice medications and treatment. The agency's policy Initial, Comprehensive and Ongoing Assessments dated 8/28/24, identified an update of the comprehensive assessment must be accomplished by the hospice interdisciplinary team (IDT) and must consider changes that had taken place since the initial assessment. It must include information on the patent's progress toward desired outcomes and well as a re-assessment of the patient's response to care. Reassessments may include physiological response to care and service, changes in condition, diagnosis, prognosis, changes in patient's care environment or support systems, psychosocial patient needs, spiritual needs and safety/home environment.  Based on the re-assessments, the plan of care, including problems, needs, goals, and outcomes would be reviewed and revised.

Based on interview and document review, the agency failed to obtained physician order to discharge from hospice services for 1 of 3 patients (P1) reviewed for discharge. --- Findings include:P1’s plan of care (POC) dated 10/8/25 for benefit period 10/22/25 to 1/19/26, identified a start of care (SOC) of 7/24/25. Diagnoses included decompensated hepatic cirrhosis, depression with anxiety, hepatic encephalopathy, ascites due to alcoholic cirrhosis and alcohol use disorder. Services were ordered for medical social work visits one to five visits every month for one month for social and emotional support needs, skilled nursing visits (SNV) one visit every week for twelve weeks to assist with nutrition, anxiety, pain, infection, and management of medications, and spiritual care visits two to twelve visits every twelve weeks for twelve weeks for grief and spiritual support.P1's medical record identified the following:-On 10/9/25, the assisted living called hospice agency to report behaviors and continued substance use. The hospice agency’s decision was to discharge P1 from hospice services due to P1 was homeless and the agency could not provide hospice services and controlled substances in an unstructured environment without oversight.The medical record lacked evidence physician orders for discharging P1 from hospice was obtained, along with medication orders.During interview on 10/21/25, at 2:35 p.m. registered nurse (RN)-A stated she had discharged P1 for cause on 10/9/25. RN-A stated she did not know if the assisted living had given P1 his routine medications, but she instructed them not to send his controlled substance medications with him. RN-A notified the pharmacy that P1 had been discharged from hospice. RN-A stated she just assumed an order had been placed to cover the discharge as it was discussed in multiple meetings with the physician throughout the day. RN-A had done all her discharge paperwork and documentations; however, the hospice physician had not documented any discharge orders in the medical record. When interviewed on 10/22/25, at 12:30 p.m. the hospice physician (MD)-A stated she had not completed a discharge statement at the time of P1's discharge and had just completed it yesterday 10/21/25, after survey entrance. The agency did not normally do a discharge statement when a client was discharged for cause, but she did complete one yesterday for clarification. Normally MD-A would get the discharge orders from the nurse to sign and then MD-A put a note in the medical record as a summary. During interview on 10/22/25, at 2:30 p.m. program manager (PM)-A stated P1 did not have a formal discharge order in his chart. The agency's normal practice was to complete a discharge order for the hospice physician to sign as part of the client's medical record. The discharging nurse was in communication with MD-A and had received orders ok to discharge from hospice services, however, had not formally documented the orders in P1's medical record as she should have done. The agency's policy Patient No Longer Terminally Ill Live Discharge dated 3/26/25, identified the hospice physician would sign a discharge order, notify the attending physician of the plan for discharge and write a progress note documenting the reason for discharge.

Observed in Record Review. In 1 of 2 Live discharge records, it was noted the organization failed to ensure that the patient was informed in advance about the expected outcomes of care and services. For example, in RRDC#1 the patient was discharged from hospice services due to patient no longer terminally ill. The Notification of Medicare Non-Coverage (NOMNC) was provided however, it was issued on the same day the patient was discharged. This finding was discussed and validated by the Hospice management team.

Observed in Record Review. In 23 of 23 patient records reviewed, the organization failed to ensure that the written plan of care was developed in accordance with the patient's identified goals with defined timeframes for achieving those goals. For example, in all patient records reviewed (RRHV#1,RRHV#2,RRHV#3,RRHV#4,RRHV#5,RRHV#6, RRNHV#1, RRNHV#2, RRNHV#3, RRNHV#4,RRNHV#5,RRNHV#6,RRNHV#7,RRNHV#8,RRNHV#9, RRNHV#10,RRNHV#11,RRNHV#12,RRDC#1,RRDC#2, HOSInpnt#1,HOSInpnt#2, HOSInpnt#3) some of the goals documented in the plan of care such as: the patient will have an absence of falls while on the hospice program; patient will have effective breathing pattern, hygiene will be maintained, and the patient's family will demonstrate correct use and understanding of home medications planner were not measurable and all time frame listed as throughout the hospice encounter was too general. This finding was discussed and validated by the hospice management team.

Observed in Document Review. During the Volunteer employee competence session, it was noted that the organization did not have written policies and procedures describing its methods to perform assessment of Volunteer employee competence. This observation was reviewed with the Volunteer Coordinator and the Vice President of Quality.

Observed in Tracer Visit. In 1 of 3 In-patient facility hospice visit, it was noted the organization had failed to follow procedures for the control and accountability of all medications within the hospice facility. For example, during the inpatient hospice visit (HOSInpt#2), the clinical nurse described the process for counting controlled drugs, which involves both incoming and outgoing staff verifying the count and signing the paper medication log. However, a review of the documentation revealed multiple instances in February and March where clinician signatures were missing. There was no documentation provided to explain the absence of these signatures. This finding was confirmed and validated by the hospice team who were present during the visit.

Observed in Building Tour. In the Spa room, the two fire sprinkler heads do not provide coverage for the full room. The distance from the two fire sprinkler heads to the far wall is over 13 feet in length. This was verified by the facilities team. The surveyor discussed the Life Safety deficiency with the organization, and it was determined that the following ILSMs will be implemented until the deficiency has been resolved and according to the organization's ILSM policy:

Based on interview and document review, the agency failed to ensure patient participation was included in the development of the patient's code status for 1 of 3 patients (P1) reviewed for advance directives. --- P1's plan of care (POC) 6/23/23 through 7/4/23, identified P1's start of hospice care was 6/23/23, with a terminal diagnosis of diffuse large B-cell lymphoma of intra-abdominal lymph nodes. Registered nurse (RN)-A's hospice admission note indicated hospice consent paperwork and code status/ Provider Orders for Scope of Treatment (POST) were reviewed and signed by family. The patient's family member signed a POST to conduct cardiopulmonary resuscitation (CPR) on hospice admission and a POST was noted in the patient skilled nursing facility chart dated a month prior as do not resuscitate (DNR). The note indicated follow up was needed for pain and symptoms as well as code status. P1's POST prepared by RN-B on P1's hospice admission on 6/23/23, directed staff, if the patient had no pulse and was not breathing to attempt resuscitation/CPR and full treatment with primary goal of prolonging life by all medically effective means as well as defined trial period of artificial nutrition by tube. The form was signed by P1's family member (FM)-C and signed and dated by the nurse who prepared the form on 6/23/23. The hospice medical director signed the order on 6/27/23. P1's Emergency Care Do Not Resuscitate Order identified the form was a legal document that was used to provide specific care instructions for health care providers responding to emergency calls. If the form was completed, emergency personnel should limit care as outlined. The form identified providers would not perform chest compressions, insert advanced airways, administer cardiac resuscitation drugs, provide ventilator assistance or defibrillate. The form was also completed by FM-C and signed on P1's hospice admission 6/23/23. The hospice medical director signed the order on 6/27/23. P1's primary physician (MD)-A visit note dated 6/22/23, indicated MD-A discussed treatment options and prognosis with P1 during the visit. P1 made the decision to elect hospice care and forgo further aggressive treatment. A hospice referral was placed. Code status was identified as DNR and comfort care. P1's skilled nurse visit notes 6/24/23 and 6/26/23, indicated P1 was answering questions related to pain status, comfort level and respiratory status appropriately, however advanced directives or code status were not discussed. P1's Nurse Practioner (NP) visit note dated 6/27/23, indicated P1 was conversing and answering questions appropriately. P1 stated he was at peace with his decision to receive hospice care. The NP note indicated P1's code status was DNR. P1's communication note dated 7/1/23 at 3:25 p.m. indicated the hospice agency received telephone notification P1 had been found with absence of pulse and respirations at 2:25 p.m. The agency notified FM-C of P1's death. RN-C noted P1 had a POST on file that indicated CPR was desired. The hospice provider was notified, who then instructed to initiate CPR. The skilled nursing facility (SNF) was notified and activated the emergency medical system (EMS) and initiated CPR. When EMS arrived, P1 was declared deceased with time of death 3:28. During telephone interview on 9/12/23, at 10:15 a.m. the director of nursing (DON) of the SNF where P1 resided stated she and the facility dietician met with P1 in April 2023, to discuss his significant continued weight loss and to discuss the option of a feeding tube placement. P1 clearly stated to them that he did not want a feeding tube placed, nor any other life saving measures. P1 indicated he felt when it was his time to go, it was his time to go. So P1 filled out a POST at that time which directed DNR and no artificial nutrition. P1's primary physician made his monthly nursing home rounds soon after and discussed this with P1 as well to make sure he had a clear understanding of the code status and advanced directives. P1 stated clearly that he did not want his heart restarted. He was in remission with his cancer but continued to lose weight. When his last lab results came in it was clear his cancer came back and so he was referred to hospice. He was alert and responsive at the time of his hospice admission. P1 did not become unresponsive until the day he passed away. The SNF received the hospice admission paperwork but never received a hospice POST, so had assumed P1's code status remained the same as what he had signed in April and was in the SNF chart. The hospice agency had contacted P1's FM-C prior to his admission visit here and had all the admission paperwork signed before his admission assessment was done at the SNF. During a telephone interview on 9/12/23, at 10:30 a.m. MD-A stated he was aware there had been some confusion related to P1's code status. P1 was alert and orientated and MD-A had even dictated during his monthly rounding visit 6/22/23, P1 was a DNR code status. After P1 expired, MD-A discussed the issue with the hospice agency and was told FM-C wanted a full code but he did not feel that should have superseded P1's wishes. He definitely felt P1 had the capacity to make his own decisions when he visited with him on rounds on 6/22/23. MD-A was told the hospice agency was investigating the issue. During interview on 9/12/23, at 2:40 p.m. RN-A stated he admitted P1 to hospice on 6/23/23, but another nurse obtained the signed admission paperwork from FM-C earlier that day. RN-A was not involved with any of the consent forms. Usually the referral nurse decided who would be responsible for signing the admission paperwork and he was told to just do the admission and another nurse would take care of all the consent forms. P1 was sleeping when he arrived at the SNF and he had tried to wake him up a little but he was pretty sleepy. He had noted the SNF had a DNR code status and the hospice paperwork indicated a full code. He had not spoken with the SNF staff regarding the code status but had passed it on to the hospice team to follow up. When interviewed on 9/12/23, at 4:00 p.m. the nursing supervisor (NS)-B stated the referral nurse did a chart review and conducted an assessment for eligibility on the phone with either the patient, family member or facility staff. The referral nurse set up the admission appointment with whoever they deemed was appropriate to sign the consent forms. If a patient chooses to be a full code, the agency would notify the primary physician and it would be brought up daily at the team huddle. The case manager, social worker and physician would be responsible for following up with the patient or decision-maker. RN-A notified the team of the conflicting code status orders. FM-C signed the hospice admission paperwork because the admission note indicated P1 was drowsy and lethargic. P1's case manager and assigned social worker were aware of the issue and were following up with FM-C. It was discussed with FM-C that full code was in direct conflict with P1's previous signed code status and hospice philosophy and risk and benefits related to full code status were discussed, however, the conversation had not been documented. When a hospice patient was a full code it was expected the hospice team would be discussing the plan daily and following up with interventions. The agency's policy Admission Consent Forms dated 6/16/23, indicated DNR Emergency Care Do Not Resuscitate Order would have patient or health care agent signature and date and a copy of the signed form needs to be placed in the paper chart if a patient resides in a SNF. If a patient or health care agent selected CPR on a POST form, a goal of care conversation needed to be held. The agency Hospice Referral Process dated 5/10/23, indicated the referral nurse would determine if admission consent forms could be signed via Adobe Sign prior to admission or if they needed to be completed in person at time of admission. If the patient was unable to sign their own consent forms, they would verify the patient's health care agent would be present to sign forms at the time of admission. A policy to determine decision-making capacity to sign hospice consent forms of a new hospice admission was requested, however, was not received.

Based on interview and document review the agency failed to ensure allegations of abuse were immediately reported to the administrator for 1 of 5 patients (P31) reviewed for vulnerable adult investigations. --- P31's Plan Of Care (POC) dated 3/30/23, identified R31 was admitted to hospice services on 7/7/22. Diagnoses included: end stage renal disease, diabetes mellitus, and hemiplegia (weakness or paralysis on one side of body) of the right side. The agency form Current Summary Safety, Security, Patient Behavior Event dated 5/19/23, identified on 5/19/23, family member (FM)-B admitted to home health aide (HHA)-C and writer (unidentified) she hit P31, while demonstrating a slap to the cheek. No marks were observed on P31's face during bed bath. FM-B stated she was upset with P31 because P31 did not take his medications. Dried bowel movement was noted in P31's brief. About 4 weeks prior FM-B mentioned the same type of scenario, being upset with P31, because P31 had called FM-B names, so FM-B slapped P31 in the face. P31 did verbalize to staff FM-A hit P31 and no marks were noted at that time. P31 appeared safe at that time and FM-A appeared to have remorse so no report was filed for the previous incident. The form lacked identification the first allegation was reported to the administrator. During interview on 7/19/23 at 2:34 p.m., social work supervisor (SWS)-A confirmed the above findings of both allegations of abuse and confirmed no report was made regarding the first allegation of abuse to the administrator. During interview on 7/19/23 at 3:29 p.m., hospice director (HD)-A confirmed the findings of both allegations of abuse for P31. HD-A stated his expectation was for staff to complete an incident report, which would be reviewed by the agency's risk management team for all allegations of abuse. HD-A indicated both allegations of abuse should have been reported immediately to the administrator. The agency's policy Reporting Of Suspected Vulnerable Adult (VA) Maltreatment dated 4/21/22, identified immediately after learning about suspected vulnerable maltreatment staff were to contact their supervisor or leadership team or on call leader to consult the situation. The employee would also complete a Patient Safety Event Report. The agency policy Vulnerable Adult Policy dated 9/24/19, identified its purpose as assuring patient safety by assisting staff to recognize, respond and report maltreatment of a vulnerable adult. The policy included the definition of abuse as conduct that could produce physical pain, injury or emotional distress, and examples which included hitting and slapping. The policy further identified any employee who witnessed or suspected maltreatment reported the event to their supervisor. The supervisor reported the event through his/her appropriate entity chain of command. A Patient Safety Event Report would be completed by the end of the shift.

Based on interview and document review, the facility failed to immediately report allegations of abuse to the state agency for 1 of 5 patients (P31) reviewed for vulnerable adult investigations. --- P31's Plan Of Care (POC) dated 3/30/23, identified R31 was admitted to hospice services on 7/7/22. Diagnoses included: end stage renal disease, diabetes mellitus, and hemiplegia (weakness or paralysis on one side of body) of the right side. The agency form Current Summary Safety, Security, Patient Behavior Event dated 5/19/23, identified on 5/19/23, family member (FM)-B admitted to home health aide (HHA)-C and writer (unidentified) she hit P31, while demonstrating a slap to the cheek. No marks were observed on P31's face during bed bath. FM-B stated she was upset with P31 because P31 did not take his medications. Dried bowel movement was noted in P31's brief. About 4 weeks prior FM-B mentioned the same type of scenario, being upset with P31, because P31 had called FM-B names, so FM-B slapped P31 in the face. P31 did verbalize to staff FM-A hit P31 and no marks were noted at that time. P31 appeared safe at that time and FM-A appeared to have remorse so no report was filed for the previous incident. The was no evidence the incident(s) were reported to the state agency. During interview on 7/19/23 at 2:34 p.m., social work supervisor (SWS)-A confirmed the above findings of both allegations of abuse and confirmed no reports were filed with the state agency. During interview on 7/19/23 at 3:29 p.m., hospice director (HD)-A confirmed the findings of both allegations of abuse for P31. HD-A stated his expectation was for staff to complete an incident report, which would be reviewed by the agency's risk management team, and P31's allegation of abuse should have been reported to the state agency During a phone interview on 7/19/23 at 4:10 p.m., medical director (MD)-A indicated he had been aware of the above allegations and indicated the agency interdisciplinary team (IDT) had reviewed the allegations for P31's safety. MD-A confirmed a report should have been made to state agency right away regarding P31's allegations of abuse. The agency's policy Reporting Of Suspected Vulnerable Adult (VA) Maltreatment dated 4/21/22, identified immediately after learning about suspected vulnerable maltreatment staff were to contact their supervisor or leadership team or on call leader to consult the situation. The policy then identified the leadership, and an employee would consult the situation and come to a decision regarding the necessity of a VA report as soon as possible (ASAP), following the Vulnerable Adult Act, Essentia Health policy. If determined necessary, the report would be filed by the employee within 24 hours of learning about the suspected vulnerable adult. The employee would also complete a Patient Safety Event Report. The agency policy Vulnerable Adult Policy dated 9/24/19, identified its purpose as assuring patient safety by assisting staff to recognize, respond and report maltreatment of a vulnerable adult. The policy included the definition of abuse as conduct that could produce physical pain, injury or emotional distress, and examples which included hitting and slapping. The policy further identified suspected maltreatment of a VA must be reported immediately in compliance with the Vulnerable Adult Act and this policy and procedure. All known or suspected incidents of abuse must be reported. The policy also instructed staff to complete a Patient Safety Report by the end of the shift.

Based on interview and document review, the agency failed to ensure a complete comprehensive assessment with the interdisciplinary group within 5 days for 2 of 18 patients (P7, P13) reviewed for comprehensive assessments. --- P7's Plan of Care (POC) dated 7/20/23, identified P7 was admitted to hospice services on 6/21/23. P7 had diagnoses included: glioblastoma multiforme (a cancerous tumor which developed in the brain), seizure disorder, and malignant neoplasm (cancer) of breast. P7's Missed Visit Documentation form dated 6/30/23, identified P7 was admitted to hospice on 6/21/23, and was not assigned to a team by the system and did not show up on the medical social worker (MSW) census report which resulted in a missed visit. The form also identified MSW was out of office due to holiday and MSW reached out to patient's family on 7/6/23. P7's MSW assessment dated 7/6/23, identified P7's initial social worker assessment was completed 15 days after admission. P13's POC dated 7/18/23, identified P13 was admitted to hospice services on 8/9/21. Diagnoses included: bladder cancer with metastasis (the development of secondary malignant growths at a distance from a primary site of cancer) and hypertension. P13's Missed Visit Documentation form dated 8/16/21, identified no social worker was available to complete the initial social worker assessment. P13's assessment was completed 8/16. P13's MSW Hospice Phone Assessment dated 8/16/21, identified P13's initial social worker assessment was completed 7 days after admission. During interview on 7/19/23, at 3:55 p.m. hospice director (HD)-A indicated he was not aware P7 or P13's initial SW assessments were completed late. HD-A indicated his expectation was for initial assessments to be completed per guidelines. The agency policy Initial Comprehensive And Ongoing Assessments dated 12/3/21, identified the hospice must conduct and document in writing a patient-specific assessment that identified the patient's need for hospice care and services, and the patient's need for physical, psychosocial, emotional, and spiritual care. The policy identified the registered nurse would complete an initial assessment within forty-eight hours after the election of hospice care and the interdisciplinary group, in consultation with the individual's attending physician, must complete the comprehensive assessment no later than 5 calendar days after the election of hospice care.

Based on interview and document review, the agency failed to complete an initial bereavement risk assessment for 1 of 18 patients (P11) reviewed for bereavement assessments. --- P11's plan of care 6/27/23 to 9/24/23, identified a start of care date 6/27/23. The hospice Certificate of Terminal illness identified a primary diagnosis of Alzheimer's dementia. P11's initial nursing assessment dated 6/27/23, identified a primary caregiver (PC)-A and documented P11 had family members who were involved in her care. The initial nursing assessment contained assessments on P11's physical condition, spiritual, psychosocial and emotional needs, but did not include a bereavement assessment to include all family members needs were met. P11's initial social worker (SW) assessment dated 6/29/23, identified a telephone call to PC-A, collaboration with staff, interpersonal and well being review. The social worker did not complete a bereavement assessment at this visit. P11's initial IDG meeting was completed 7/6/23, and under social work identified to continue to provide psychosocial support monthly and as indicated. Anticipatory grief support available through social work as indicated. When interviewed on 7/21/23, at 1:10 p.m. SW-H indicated it was an oversight the bereavement risk assessment was not completed and she would do the assessment during her next visit. During interviewed on 7/20/23, at 11:45 p.m. the social services supervisor (SS)-E stated the SW was responsible to complete the anticipatory grievement assessment and provide support if indicated. Bereavement assessments were to assess the patient on coping with what is coming and upcoming death. Also to assess caregiver and family members on how they are coping with the anticipated loss. If the SW was unable to interview the patient then they were to call a family member for the bereavement information. During interviewed on 7/20/23, at 1:30 p.m. the clinical manager (CM)-B stated the bereavement assessment should include an assessment of the family members. The agency policy Initial Comprehensive and Ongoing Assessments dated 12/3/21, indicated the interdisciplinary group must complete the comprehensive assessment no later than five calendar days after the election of hospice. An initial bereavement assessment of the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment must be incorporated into the plan of care and considered in the bereavement plan of care.

Based on observation, interview and document review, the agency failed to ensure all prescribed medications were part of the plan of care (POC) for 1 of 6 patients (P18) whose medications were reviewed during a home visit. --- P18's plan of care (POC) 7/13/23 to 7/28/23, identified a start of care (SOC) 12/28/22. Diagnosis included mixed Alzheimer's and vascular dementia. Skilled nurse visits were ordered one time weekly and five as needed for symptom management for various assessments and teaching, including management of home medications. P18's POC identified a family member (FM)-A set up his medications. Interventions included for the skilled nurse to review medication boxes at each visit, assist with set up as needed, reconcile any medications and to verify FM-A med setup. The most recent outcome listed the patient and caregiver would follow prescribed medication therapy and schedule and verbalize understanding of purpose and side effects of medications. Prescribed and patient reported medications were listed including donepezil (used to treat confusion in Alzheimer's disease) 10 milligrams (mg) by mouth (po) at bedtime for fourteen days. During a home visit on 7/18/23, at 10:30 a.m. FM-A reviewed the medication set up for P18's medications. FM-A indicated P18 no longer was taking donepezil. He had stopped the medication a couple of weeks ago. When interviewed on 7/18/23, at 11:00 a.m. registered nurse (RN)-A stated P18 had been seen by a different nurse in the past weeks as she had been on leave. FM-A must not have notified the nurse of the discontinued medication and so the POC had not been updated. Medication review should be done at every visit and was important so the nurse could watch for side effects or concerns when medication changes were made. During interview on 7/19/23, at 10:00 a.m. clinical manager (CM)-B stated nurses were expected to review patient medications at every visit. The agency policy medication management dated 7/18/23, indicated the hospice RN would reconcile current medication orders with the patient, caregiver, or facility staff during routine visits and as needed. The RN would educate the patient, caregiver or facility staff on any patient medication changes and request verbal read back to verify understanding. The RN would provide the patient an updated copy of the patient's medication list each time any prescription was changed throughout the hospice episode.

Based on interview and document review, the agency failed to ensure services were provided in accordance with the plan of care (POC) for 1 of 18 patients (P15) reviewed for services planned. --- P15's Plan of Care Update (POCU) dated 7/12/23, identified P15 was admitted to hospice services on 12/8/22. Diagnoses included: late effects cerebrovascular disease (condition that affects the blood vessels and arteries that supply the brain), vascular dementia, depression, and hypertension. P15's planned visits as of 7/12/23, included volunteer visits-1 visit every week for 9 weeks dated 6/4/23 to 8/4/23. P15's missed visit documentation identified P15 had a volunteer visit missed 7/2/23 to 7/8/23, but lacked reason. P15's medical record lacked volunteer visit documentation or reason for missed visits 6/4/23, to 7/1/23. During interview on 7/19/23 at 1:18 p.m., volunteer director (VD)-A confirmed the above findings. VD-A indicated the volunteer had not started at the time the planned visits began, and the volunteer visits were not completed for over a month due to a scheduling issue. VD-A indicated the patient was aware, but the medical director was not notified and P15's POC was not updated. During interview on 7/19/23 at 3:59 p.m. hospice director (HD)-A stated that if volunteer visits for P15 were not able to be completed, he would expect P15's POC would have been updated and it was documented very clearly the reason. HD-A stated that is why the agency had interdisciplinary meetings. The undated agency policy Interdisciplinary Group, Care Planning, and Coordination of Services, identified the POC must specify the hospice care and services necessary to meet the patient and family specific needs. The undated agency policy Missed Visits identified visits must be ordered in a "visit set" in remote client, which became a part of the patient's POC. The policy instructed if a visit was missed, the staff member would attempt to complete the visit another day within the visit set frequency. Documentation would include why the visit was missed, when the visit would be rescheduled, time of attempted visit, communication made to the patient/caregiver and notification of the hospice physician.

Based on interview and document review, the agency failed to conduct baseline Tuberculosis (TB) health screening, that included screening for symptoms of TB, an assessment of TB history and a two step tuberculin skin test (TST) or single Interferon Gamma Release Assay (IGRA), to identify potential TB symptoms which was an accepted standard of practice for TB screening according to the Center for Disease Control (CDC) for 5 of 5 volunteers (V-A, V-B, V-C, V-D. V-E) reviewed in the sample. --- Volunteer (V)-A completed the orientation program 2/6/23. The volunteer's personnel file lacked documentation of TB symptom screen, assessment of TB history or testing for the presence of TB infection as required. Volunteer (V)-B completed the orientation program 5/23/23. The volunteer's personnel file lacked documentation of TB symptom screen, assessment of TB history or testing for the presence of TB infection as required. Volunteer (V)-C completed the orientation program 9/15/21. The volunteer's personnel file lacked documentation of TB symptom screen, assessment of TB history or testing for the presence of TB infection as required. Volunteer (V)-D completed the orientation program 6/7/22. The volunteer's personnel file lacked documentation of TB symptom screen, assessment of TB history or testing for the presence of TB infection as required. Volunteer (V)-E completed the orientation program 1/2/21. The volunteer's personnel file lacked documentation of TB symptom screen, assessment of TB history or testing for the presence of TB infection as required. When interviewed on 7/18/23,at 4:25 p.m. the volunteer director (VD) stated the agency had never screened or tested volunteers for TB. The subject had been under discussion with management but a final decision if TB screening and testing was needed for their volunteers had not been made. During interview on 7/20/23, at 3:45 p.m. the hospice director (HD) stated the agency followed the Essentia Health systems TB policy. The agency's TB Risk Assessment Worksheet dated 7/1/23, indicated the agency was a low risk health setting. The agency Employee Tuberculosis Screening policy dated 6/14/23, indicated a new employee must bring any records of prior TB testing to their appointment with employee health. Employee health would review the employee's TB health screening questionnaire for any TB symptoms or past exposures. If an employee had indicated any current TB symptoms or history of exposure to TB, a negative TB test or chest xray would be required. The Regulations for Tuberculosis Control in Minnesota Health Care Settings dated July 2013, identified all health care settings in Minnesota should have an up to date TB infection control program that included a team responsible for TB infection control, a facility TB risk assessment, written TB infection control procedures and health care worker education. Volunteers were included in the list of staff who should be considered health care workers and be included in the agency's TB screening program. Baseline TB screening was required for all health care workers and consisted of three components: to assess for current symptoms of TB, TB history and testing for the presence of infection either by administering a two step tuberculin skin test (TST) or single Interferon Gamma Release Assay (IGRA).

Based on observation, interview and document review, the agency failed to ensure hair nets were worn when preparing resident meals, to prevent the spread of food born illness. This had the potential to affect all 7 patients who resided in the agency's residential hospice house. --- During home visit to the agency's residential hospice on 7/18/23, at 8:30 a.m. cook (CK)-F was observed putting away food items in the kitchen. CK-A had very short hair and beard and was wearing a baseball cap. Hospice aide (HA)-A entered the kitchen preparation area to obtain breakfast and liquids for a patient. HA-A had shoulder length hair that was not covered by a hair net or restrained in any way. HA-A obtained the meal and left the kitchen area. When interviewed on 7/18/23, at 9:00 a.m. CK-F verified some of the dietary staff had longer hair but were not required to wear hair nets. It would be important to wear hair nets with longer hair so hair did not end up in the food. During interview on 7/18/23, at 9:15 a.m. the clinical manager (CM)-A stated none of the dietary staff wore hair nets. Hair nets had not been required for the dietary staff in the residential hospice kitchen. The January 2023, State Food Safety Resources identified hair could have several types of pathogens on it, including Staphylococcus bacteria. The main goal of hair restraints was to hold any dislodged hair in place so it would not fall into food or onto equipment. The agency policy Food Preparation and storage dated 5/31/21, indicated all food service workers were required to wear hair restraints such as hairnets, bonnets, caps, or visors with hairnets and beard protection as appropriate.