Every finding on record at Winona Area Hospice Services

Based on interview and document review, the hospice agency failed to ensure spiritual care providers had appropriate care plans in place, to include patient problems, interventions and goals, and were a part of the interdisciplinary plan of care for 3 of 3 patients (P1, P13, P14) reviewed who were receiving spiritual care support. --- Findings include:P1P1’s Plan of Care, dated 1/19/26 – 4/18/26, indicated P1 was admitted to hospice care on 1/19/26 with a primary diagnosis of Alzheimer’s Disease. The plan of care lacked involvement from spiritual care to include problems, interventions and goals of care. The plan of care also lacked individualized visit sets, indicating 10 Chaplain visits as needed for the certification period of 1/29/26 – 4/18/26.P1’s Visit Management list, dated 1/19/26 – 4/18/26, indicated P1 received one Chaplain visit since admission on 2/3/26.P1’s Chaplain Visit Note, dated 2/3/26, indicated, “Chaplain will continue to visit to foster relationship of care.”P13P13’s Plan of Care, dated 2/6/26 – 4/6/26, indicated P13 was admitted to hospice care on 6/11/25 with a primary diagnosis of nonrheumatic aortic (valve) stenosis. The plan of care lacked involvement from spiritual care to include problems, interventions and goals of care. The plan of care also lacked individualized visit sets, indicating 7 Chaplain visits as needed for the certification period of 2/6/26 – 4/6/26.P13’s Visit Management list, dated 2/6/26 – 4/6/26, indicated P13 received three Chaplain visits since admission on 8/11/25 (initial visit), 10/31/25 and 2/3/26.P13’s most recent Chaplain Visit Note, dated 2/3/26, indicated, “Chaplain will continue to support [P13] until EOL [end of life].”P14P14’s Plan of Care, dated 2/7/26 – 4/7/26, indicated P14 was admitted to hospice care on 6/12/25 with a primary diagnosis of chronic combined systolic and diastolic heart failure. The plan of care lacked involvement from spiritual care to include problems, interventions and goals of care. The plan of care also lacked individualized visit sets, indicating 10 Chaplain visits as needed for the certification period of 2/7/26 – 4/7/26.P14’s Visit Management list, dated 2/7/26 – 4/7/26, indicated P14 received seven Chaplain visits since admission on 6/16/25 (initial visit), 8/11/25, 9/19/25, 10/27/25, 11/17/25, 12/16/25, and 1/12/26.P14’s most recent Chaplain Visit Note, dated 1/12/26, indicated, “Chaplain will continue with regular visits to support [P14].”During an interview on 3/4/26 at 11:40 a.m., the chaplain stated she does not put in a spiritual care plan as patients’ needs were evolving and had one concern one time, and another concern a different time.During an interview on 3/4/36 at 9:00 a.m., the hospice manager stated it would be expected for the chaplain to be a part of the plan of care.A facility policy titled Assessment-Comprehensive Assessment, dated 7/2025, indicated, "each member of the interdisciplinary group provides input into the Care Plan within the scope of his/her practice."

Based on interview and document review, the hospice agency failed to ensure spiritual care providers had appropriate visit set orders for 4 of 4 patients (P1, P11, P13, P14) reviewed who were receiving spiritual care support. --- Findings include:P1P1's Plan of Care, dated 1/19/26 – 4/18/26, indicated P1 was admitted to hospice care on 1/19/26 with a primary diagnosis of Alzheimer’s Disease. P1’s Visit Management list, dated 1/19/26 – 4/18/26, indicated P1 received one Chaplain visit since admission on 2/3/26.P1’s Chaplain Visit Note, dated 2/3/26, indicated, “Chaplain will continue to visit to foster relationship of care.”P1’s Discipline Orders, dated 1/19/26 – 4/18/26, indicated 10 as needed Chaplain visits for spiritual support. The orders lacked any scheduled visit sets for Chaplain care.P11P11’s Plan of Care, dated 12/23/25 – 3/22/26, indicated P11 was admitted to hospice care on 12/23/25 with a primary diagnosis of senile degeneration of the brain.P11’s Visit Management list, dated 12/23/25 – 3/4/25, indicated P11 received one Chaplain since admission on 12/30/25.P11’s Medical Social Worker Visit Note, dated 12/23/25, indicated P11, “will be utilizing the Chaplain at St. Anne’s for spiritual care needs but appreciative to know hospice also has a Chaplain available.”P11’s Discipline Orders, dated 12/23/25 – 3/22/26, indicated five as needed Chaplain visits for spiritual support. The orders lacked any scheduled visit sets for Chaplain care.P13P13’s Plan of Care, dated 2/6/26 – 4/6/26, indicated P13 was admitted to hospice care on 6/11/25 with a primary diagnosis of nonrheumatic aortic (valve) stenosis. P13’s Visit Management list, dated 2/6/26 – 4/6/26, indicated P13 received three Chaplain visits since admission on 8/11/25 (initial visit), 10/31/25 and 2/3/26.P13’s most recent Chaplain Visit Note, dated 2/3/26, indicated, “Chaplain will continue to support [P13] until EOL [end of life].”P13’s Discipline Orders, dated 2/6/26 – 4/6/26, indicated seven as needed Chaplain visits for spiritual support. The orders lacked any scheduled visit sets for Chaplain care.P14P14’s Plan of Care, dated 2/7/26 – 4/7/26, indicated P14 was admitted to hospice care on 6/12/25 with a primary diagnosis of chronic combined systolic and diastolic heart failure.P14’s Visit Management list, dated 2/7/26 – 4/7/26, indicated P14 received seven Chaplain visits since admission on 6/16/25 (initial visit), 8/11/25, 9/19/25, 10/27/25, 11/17/25, 12/16/25, and 1/12/26.P14’s most recent Chaplain Visit Note, dated 1/12/26, indicated, “Chaplain will continue with regular visits to support [P14].”P14’s Discipline Orders, dated 2/7/26 – 4/7/26, indicated ten as needed Chaplain visits for spiritual support. The orders lacked any scheduled visit sets for Chaplain care.During an interview on 3/4/26 at 11:40 a.m., the chaplain stated every patient she worked with received as needed visits only for flexibility, stating patient needs change throughout their hospice stay. The Chaplain stated she never scheduled visits nor put in a spiritual care plan as patients’ needs were evolving and had one concern one time, and another concern a different time.During an interview on 3/4/36 at 9:00 a.m., the hospice manager stated it would be expected for the chaplain to be a part of the plan of care, to include visit sets.A facility policy titled Assessment-Comprehensive Assessment, dated 7/2025, indicated, "each member of the interdisciplinary group (IDG) provides input into the Care Plan within the scope of his/her practice." The policy further stated the IDG must reassess the patient's response to care on a regular basis. The policy did not speak to visit sets specifically.

Based on observation, interview and document review, the hospice agency failed to ensure infection control practices were followed with proper bag technique when visiting patients and following enhanced barrier precautions for a patient residing in a skilled nursing facility on enhanced barrier precautions for catheter. This had the potential to affect 2 of 4 (P11, P14) residents reviewed and followed for home visits. --- Findings include:P11P11’s Plan of Care, dated 12/23/25 – 3/22/26, indicated P11 was admitted to hospice care on 12/23/25 with a primary diagnosis of senile degeneration of the brain.On 3/3/26 at 8:33 a.m., hospice aide (HA)-A was observed to enter P11’s room. Hanging on the wall outside P11’s room was a sign indicating staff were to utilize Enhanced Barrier Precautions (EBP), to include required personal protective equipment (PPE) of a gown and gloves with any high contact patient care. HA-A donned gloves and proceeded to give P11 a full bed bath to include catheter care and peri care.  After the observation HA-A stated she was “not exactly sure what [the sign was] referring to” stating she assumed it meant to have gloves on when providing care. A facility aide entered P11’s room with a gown and gloves on to assist with a transfer, stating P11 was on EBP due to her foley catheter.P14P14’s Plan of Care, dated 2/7/26 – 4/7/26, indicated P14 was admitted to hospice care on 6/12/25 with a primary diagnosis of chronic combined systolic and diastolic heart failure.During observation on 3/3/26 at 2:35 p.m., registered nurse case manager (RNCM)-A was visiting P14 in her private apartment, her work bag was lying near a kitchen chair, directly on the ground. RNCM-A moved her bag closer to the P11 and then placed a barrier on the ground under her bag. RNCM did not perform hand hygiene directly prior to entering her clean bag for supplies. RNCM-A placed her stethoscope, blood pressure cuff and INR machine directly on P11’s coffee table and couch without a barrier underneath. RNCM-A was also observed removing an oximeter directly from her jacket pocket and placing it on P11’s finger. RCNM-A then placed the oximeter and blood pressure cuff directly back into her bag without cleaning the instruments.During an interview on 3/4/26 at 9:35 a.m., the hospice manager stated all staff were educated on proper bag technique and it was an expectation that a barrier be used under bags and all equipment during patient visits. The hospice manager stated hospice staff had not had specific education on EBP, but it would be excepted that staff follow any transmission-based precaution for hospice patients in facilities.A facility policy titled Infection Control Program, dated 1/2026, indicated the hospice agency follows steps to prevent and control the risk of infection for caregivers, patients and families by maintaining compliance with standard precautions and the appropriate use of PPE. The policy further states caregivers will ensure all supplies and equipment used will be clean and disinfected.

Based on interview and document review the agency failed to complete a comprehensive medication review for 1 of 4 patients (P13) whose medications were reviewed. --- P13's hospice plan of care (POC) dated 5/3/23, identified P13 had a diagnosis of cerebrovascular disease unspecified, was seen by nursing once a week and medications included: Colace sodium 100 mg oral capsule; take one capsule orally every other day. lisinopril 5 mg oral tablet; take one tablet orally once a day. The hospice POC medication list lacked medication orders for azithromycin 250 mg tablets daily for 5 days for an eye infection. The hospice POC medication list lacked medication orders for Zeasorb-AF POW 2% apply topically to the groin after cleaning and drying well every morning until healed and alert the nurse when healed to change to as needed for intertrigo. P13's hospice medication profile dated 7/18/23, indicated P13 had the following medications orders: Colace sodium 100 mg oral capsule; take one capsule orally every other day. lisinopril 5 mg oral tablet; take one tablet orally once a day. The hospice medication profile lacked medication orders for azithromycin 250 mg tablets daily for 5 days for an eye infection. The hospice medication profile lacked medication orders for Zeasorb-AF POW 2% apply topically to the groin after cleaning and drying well every morning until healed and alert the nurse when healed to change to as needed for intertrigo. P13's assisted living facility (ALF) medication orders dated 7/18/23, identified P13 had the following medications ordered: docusate sodium capsule (generic for Colace) 100 mg take one capsule by mouth everyday contrary to the hospice POC and medication profile that identified Colace sodium 100 mg oral capsule; take one capsule every other day. azithromycin 250 mg tablet take one tablet orally once daily for 5 days for an eye infection with a start date of 7/14/23 and an end date of 7/19/23. Zeasorb-AF POW 2% apply topically to the groin after cleaning and drying well every morning until healed and alert the nurse when healed to change to as needed for intertrigo. The ALF medication orders lacked an order for lisinopril 5 mg orally once a day. P13's nursing visit note dated 7/18/23 at 2:00 p.m., indicated hydrocortisone cream daily was ordered for seven days due to redness and itching around P13's left eye. During interview on 7/19/23 at 2:16 p.m., hospice registered nurse (RN)-A stated it had been a month since she looked at the ALF medication list and was not aware P13 was taking an antibiotic adding she had just started a cream for P13 and would review the ALF medication list. During interview on 7/20/23 at 9:00 a.m., the hospice director stated medications should be reviewed regularly for dosing and would have to reference the policy regarding frequency of medication review. Hospice director reviewed the policy and stated medications should be reconciled at every visit. A policy, Patient Medication Profile dated July 2023, indicated the medications would be maintained and up to date on all patients receiving hospice services and the RN would monitor for effectiveness of drugs, side effects, duplications, and any interactions (potential or actual) and involve the medical director and or pharmacist as needed for further assistance. The policy further indicated the patient medication list was updated with changes at the visit.

Based on observation, interview, and record review, the agency failed to ensure hand hygiene, proper handling of linens, and use of a barrier between the floor and staffs supply bag for 1 of 4 patients (P13) observed for cares. --- P13s hospice plan of care indicated a diagnosis of cerebrovascular disease and had a home health aide (HHA) for a tub or whirlpool bath. P13s medication list from the assisted living facility indicated P13 had the following medication order: 7/14/23, azithromycin (an antibiotic medication) 250 milligram (MG) daily for five days for an eye infection and had an end date of 7/19/23. During interview and observation on 7/18/23, between 3:37 p.m. and 3:39 p.m., HHA-A set her supply bag down on the floor in P13s room without a barrier between the bag and the floor. Family member (FM)-A stated P13 had an eye infection and was taking an oral antibiotic. During observation on 7/18/23 between 3:47 p.m. and 3:52 p.m., HHA-A brought P13 to a communal whirlpool bathroom and set the supply bag down on the tile floor without placing a barrier between the bag and the floor. P13 had an area of redness to surrounding skin to P13s left eye. During observation on 7/18/23 at 4:17 p.m., HHA-A donned gloves, applied lotion to P13s legs and back and donned socks and a new incontinence pad. At 4:23 p.m., HHA-A assisted P13 to stand and assisted in drying P13s buttocks, pulled up the incontinence brief, adjusted clothes, and assisted P13 to sit down in the wheelchair. HHA-A picked up P13s soiled clothes from the stationary chair in the whirlpool bathroom and placed them on the shower chair with P13s used towels from the whirlpool bath. At 4:27 p.m., HHA-A applied a gait belt around P13 and removed her gloves but did not perform hand hygiene and pushed P13 to the day room and at 4:29 p.m. transferred P13 to a chair in the day room. At 4:32 p.m., HHA-A went back into the whirlpool bathroom and cleaned the tub. HHA-A stated staff used the whirlpool room as a bathroom because the room also had a toilet. At 4:36 p.m., HHA-A took P13s unbagged clothing items that were on the shower chair in the whirlpool room and carried the items in her arms out of the whirlpool bathroom, down the hall to P13s room. At times, the items were touching HHA-As shirt. During interview on 7/18/23 at 4:43 p.m., HHA-A stated her supply bag contained an I-Pad, gloves, gait belt and supplies that were used for patients in their home. HHA-A stated she was instructed to use a barrier to set her bag on and was getting back into the habit of bringing her bag into patients homes following the public health emergency. HHA-A stated she should have put P13s clothing items in a bag and added she forgot to sanitize her hands after removing her gloves. During interview on 7/20/23 at 8:56 a.m., the hospice director stated staff were trained to keep items away from their body, expected staff to wash hands after use of gloves, and use barriers between surfaces and their supply bags. The hospice director further stated these actions were important to prevent the transmission of infection. A policy, Infection Control Program dated April 2022, indicated infection control was the responsibility of all personnel and the agency follows steps to prevent and control the risk of infection for staff, patients and families including maintaining compliance with hand washing and personal hygiene, use of standard precautions when providing patient care. Additionally, the policy indicated staff would abide by policy when transporting any equipment/supplies or specimens in their vehicles and in their bag. A policy, Bag Technique dated July 2023, indicated bags were not set on the floor and if there was no hard, clean, non-porous space available, put down newspapers to set the bag on.