Every finding on record at St. Joseph's Area Health Services

Observed in Record Review. In 6 of 14 active hospice patient records reviewed, it was noted the organization had failed to ensure that the plan of care includes all services needed for the palliation and management of the terminal illness and related conditions, including the drugs necessary to meet the needs of the patient. For example, in review of HosRRHV#2. HosRRHV#4, HosRRNHV#1, HosRRNHV#4, and HosRRNHV#8, there were 2 PRN pain medications, Acetaminophen 325 mg 2 tablets orally as needed for pain and Morphine 5 mg oral suspension every 6 hours PRN for pain, however. the order did not specify the pain level at which each medication should be administered. Additionally, in HosRRNHV#7, two (2) PRN pain medication Lyrica 50 mg q HS PRN for pain and Morphine Concentrate PRN did not specify the pain level at which each medication should be administered. This finding was discussed and validated by the Hospice Director.

Observed in Record Review. In 1 of 4 active patient records with hospice aide services,, it was noted the organization had failed to ensure that the written patient care instructions for a hospice aide must be prepared by a registered nurse who is responsible for the supervision of a hospice aide. For example, in record of HosRRHV#1, the patient was on continuous oxygen at 3 LPM via nasal cannula, however, the hospice aide care plan did not address whether the oxygen could be removed for the bath. This finding was discussed and validated by the Hospice Director.

Observed in Record Review. In 3 of 14 active hospice patient records reviewed,, it was noted the organization failed to ensure that the medical director, physician member of the interdisciplinary team, or physician designee reviews the clinical information for each hospice patient and provides written certification that the patient’s life expectancy is six months or less if the illness runs its normal course and had addressed the several factors including the current medication orders. For example in HosRRNHV#2, the Certificate of Terminal Illness (CTI) dated 08/07/2025 still had not signed by MD and the narrative documentation did not consistently contain the current medication status as required. The section where they supposed to document medication status was left blank. Also noted in HosRRNHV#4, and HosRRNHV#9, wherein the CTI narrative documentation did not include the current medication status as required. The section where they supposed to document medication status was left blank. This finding was discussed with and validated by the Hospice Director.

Observed in Record Review. In 14 of 14 active hospice patient records reviewed, , it was noted that the organization failed to ensure that all documentation entries were appropriately authenticated. For example, in review of records HosRRHV#1, HosRRHV#2, HosRRHV#3, HosRRHV#4, HosRRNHV#1, HosRRNHV#2, HosRRNHV#3, HosRRNHV#4, HosRRNHV#5, HosRRNHV#6, HosRRNHV#7, HosRRNHV#8, HosRRNHV#9, and HosRRNHV#10 - the paper-format Hospice Management Order Set was not properly authenticated, as it did not include the credential of the individual who signed the clinical document. This finding was discussed and validated by the hospice Director.

Observed in Record Review. In 1 of 14 active hospice patient records,, it was noted the organization failed to ensure that the clinical record must be accurate. For example in HosRRNHV#7, the two (2) Skilled nursing notes dated (08/11 and 08/04), stated that the patient had no oxygen in the home, which contradicts prior assessments, the hospice plan of care, and medication profile indicating the patient has been receiving home oxygen therapy. This finding was discussed and validated by the Hospice Director.

Observed in Patient Home. In 3 of 3 home visits conducted, the hospice did not provide the patient with written information about its policies on advance directives. While reviewing home folders at HV#1, HV#2 and HV#3 the surveyor found that information from the state of Minnesota was provided, but the policy was not. This was reviewed with the Hospice Director.

Observed in Record Review. In 11 of 11 patient records reviewed, the hospice did not develop plans of care that were based on patients’ goals and the time frames, settings, and services required to meet those goals. During review of every record. it was found that most goals were not measurable and did not include targeted completion dates. This was reviewed with the Hospice Director.

Observed in Record Review. In the record of HV#1 there was an order for oxygen at two liters per minute as needed for shortness of breath. The nurse documented that the patient was using oxygen continuously, but there was no order for this change. This was reviewed with the Hospice Director.

Observed in Record Review. In 11 of 11 patient records reviewed, it was noted that the interdisciplinary group narrative by every discipline for the past two weeks was the same and did not address new patient needs or decline. And plans for the following two weeks were ambiguous. This was reviewed with the Hospice Director.

Observed in Patient Home. In 2 of 3 home visits conducted, staff failed to perform hand hygiene consistent with the Hand Hygiene policy and CDC guidelines. At HV#1 an aide used a patient's clean hand towel to dry hands and turn off the faucet, but then dried her hands again. At HV#2 a social worker washed her hands with soap and water, touched the faucet to adjust the water temperature but did not start the process over. In addition, she used her forearm to turn off the faucet. This was reviewed with the Hospice Director.

Observed in Competency Session. During the HR competence session, it was learned that staff have competence assessed annually but volunteers do not. This was confirmed by the Hospice Director. Observed in Competency Session. During the HR competence session, it was learned that competence is not assessed for volunteers as part of the on-boarding process. This was confirmed by the Hospice Director. Observed in Competency Session. During the HR competence session, it was learned that there was no policy and procedure that defined competencies for volunteers and how and when they are to be assessed. This was confirmed by the Hospice Director.

Observed in Patient Home. In 3 of 3 home visits conducted, there was no evidence that patients and caregivers were provided information on the hospice’s policy for the management and disposal of controlled medications in the home folders, nor was there documentation of this in patient records. This was reviewed with the Hospice Director.