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.”