Essentia Health St Mary’s 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 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 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.”