St Croix Hospice

“Based on a home observation visit, staff interview, clinical record reviews and agency policy review, the hospice failed to ensure the Plans of Care (POC) for 5 of 6 sampled patients included all physician orders and all medical equipment and supplies necessary to meet identified patient needs (Patients #1, #2, #3, #4 and #6). Failure to include all physician orders and all medical equipment and supplies the patient used on the POC placed patients at risk of unanticipated decline or injury and of needs not met. Findings include: 4. Patient #1 had a hospice admission date of 12/5/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 12/5/25 to 3/4/26, identified the patient had a diagnosis of Alzheimer’s disease and used the following medical equipment and supplies: cleanser foam, no rinse, adult briefs, medium exam gloves, lip balm, mouthwash, barrier ointment, shampoo cap, oral swabs and body cleanser. b. During a home observation visit on 12/29/25 at 1:15 PM with Staff C, RN, the surveyor observed the patient to be sitting in a wheelchair with a wheelchair cushion and then observed staff to transfer the patient from the wheelchair to the bed utilizing a gait belt. The surveyor also observed a bedside table, toilet safety frame and shower chair in the patient’s room/bathroom. Staff C stated the patient has utilized the medical supplies and equipment since admission. The hospice failed to include all medical supplies and equipment utilized by the patient on the plan of care including wheelchair, wheelchair cushion, gait belt, bedside table, toilet safety frame and shower chair. 5. Patient #6 had a hospice admission date of 9/25/25, a death date of 12/1/25 and received hospice services while residing in an assisted living facility. Clinical record review revealed: a. The POC, dated 9/25/25 to 12/23/25, identified the patient had diagnoses of other specified disorders of the brain, altered mental status and dementia and identified the patient used the following medical supplies and equipment: foam cleanser, fit right protective underwear, lip balm, body cleanser, oral swabs and scented wipes. b. The skilled nurse visit note, dated 11/24/25, completed by Staff C, RN identified the patient utilizes a gel/foam mattress. c. The IDG meeting notes, dated 11/26/25, failed to identify the gel/foam mattress utilized by the patient. The hospice failed to include all medical supplies and equipment utilized by the patient on the plan of care, including gel/foam mattress. The above findings were reviewed with the Administrator and Clinical Manager. According to the hospice policy, titled The Plan of Care, dated December 2018, the plan of care will contain, but will not be limited to the following: durable medical equipment and medical supplies necessary to meet patient needs, drugs and treatments, and physician (or other authorized licensed independent practitioner) orders. 1.Patient #2 had a hospice admission date of 11/14/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 11/14/25 to 2/11/26, identified the patient had a diagnosis of cerebral atherosclerosis and included an order for oxygen therapy. The physician order written as follows: oxygen gas for inhalation, 1 to 5 liter for anxiety/shortness of breath, via nasal cannula/face mask, tracheostomy for continuous, at bedtime or as needed for anxiety or shortness of breath. The hospice failed to ensure the order was specific to the patient’s individual needs. b. The interdisciplinary group (IDG) meeting notes, dated 11/25/25, failed to identify patient specific orders for oxygen utilized by the patient. The hospice failed to include patient specific orders for oxygen utilized by the patient. 2. Patient #3 had a hospice admission date of 12/12/25 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 12/12/25 to 3/11/26, identified the patient had a diagnosis of lung cancer and included the following medical equipment and supplies: foam cleanser, no rinse, nail clipper, hydraguard, adult briefs, extra protective underwear, exam glove, remedy lotion, mouthwash, moisturizing oral gel, body cleansing cloth, shampoo cap, skin cream, silicone barrier cream with zinc oxide, total body cleanser, oral dentips, under pad, washbasin and aloe touch wipes. b. The skilled nurse note, dated 12/13/25, included documentation Staff F, Registered Nurse (RN) supplied a medication planner and set up the patient’s medications. c. The IDG meeting note, dated 12/23/25, failed to identify a medication planner as medical equipment and supplies utilized by the patient. The hospice failed to include all medical equipment and supplies utilized by the patient. 3. Patient #4 had a hospice admission date of 12/6/25 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 12/6/25 to 3/5/26, identified the patient had a diagnosis of acute on chronic heart disease and included orders for skilled nurse services, medications and treatments. The POC included identification of medical equipment and supplies used by the patient including an oxygen concentrator, oxygen tubing and oxymask size 7. The POC failed to include physician orders for the specific use of oxygen for the patient. b. The skilled nurse visit note at start of care, dated 12/6/25, documented the patient used oxygen from 2 to 4 liters per minute. c. The IDG meeting notes, dated 12/9/25 and 12/23/25, failed to identify physician orders for oxygen therapy utilized by the patient. The hospice failed to include all physician orders including oxygen therapy utilized by the patient.”

“It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as: hand hygiene This standard was not met, as evidenced by observation, document review, and interview. Agency policy #7-009 “Hand Hygiene” (reviewed 02/14/2024), read in part, “1. Wet hands and apply the soap and rub hands together vigorously; avoid use of hot water because repeated exposure to hot water may increase risk of dermatitis. 2. Wash hands for at least 20 seconds covering all surfaces of the hands and fingers. 3. Rinse with warm water and dry the hands with a disposable towel from the fingers toward the forearm. 4. Use a dry disposable towel to turn off faucet.” In 1 of 4 (25%) home visits observed, the agency did not ensure that hand hygiene was performed correctly when indicated. Home Visit 2/Clinical Record 2: The patient elected hospice care on 09/12/2024. During the home visit with the Licensed Practical Nurse (LPN) [Personnel Record 7] on 09/24/2024, the LPN turned the faucet on, washed their hands with dish soap, rinsed their hands, turned the faucet off with their right hand, and used a paper towel to dry their hands. The LPN did not use a dry disposable towel to turn off the faucet per the agency policy. In an interview on 09/24/2024, the Manager of Accreditation confirmed that the LPN did not use a disposable towel to turn off the faucet after washing their hands per the policy.”

“It is required that the hospice provides nursing care under the supervision of a registered nurse. This standard was not met as evidenced by clinical record review, document review, and interview. In 2 of 18 (11%) clinical records reviewed of patients that received Licensed Practical Nurse (LPN) visits, the agency did not ensure that a Registered Nurse (RN) provided supervision of the LPN nursing services per agency policy. Agency policy #1-031 “Responsibilities/Supervision of Clinical Services” (reviewed 02/14/2024), read in part, “A monthly patient visit will be completed by a registered nurse to supervised licensed practical/vocational nursing services.” Clinical Record 11: The patient elected hospice care on 04/05/2024. The plan of care dated 07/04/2024 through 10/01/2024 ordered skilled nursing twice (2) weekly beginning 07/04/2024. A Licensed Practical Nursing (LPN) supervisory visit was completed on 07/22/2024. LPN visits were completed 07/25/2024, 08/02/2024, 08/30/2024, 09/13/2024, 09/17/2024, and 09/19/2024. A clinical record review revealed no evidence that the LPN supervisory visit was completed monthly in August per agency policy. Clinical Record 15: The patient elected hospice care on 10/08/2023. The plan of care dated 01/06/2024 through 04/04/2024 ordered skilled nursing twice (2) weekly beginning 01/07/2024. LPN visits were completed on 01/10/2024, 01/12/2024, 01/30/2024, 02/08/2024, 02/23/2024, and 03/14/2024. A LPN supervisory visit was completed on 03/20/2024. A clinical record review revealed no evidence that the LPN supervisory visit was completed monthly in February per agency policy. In a joint record review and interview on 09/25/2024, the Manager of Accreditation confirmed that monthly LPN supervisory visits were not completed per agency policy.”

“It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #1-031 “Responsibilities/Supervision of Clinical Services” (reviewed 02/14/2024), read in part, “Hospice aide supervisory visits will be conducted on-site at least every two (2) weeks by a hospice registered nurse.” In 6 of 17 (35%) clinical records reviewed of patients that received Hospice Aide (HA) services, the agency did not ensure that a Registered Nurse (RN) made an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the HA. Clinical Record 5: The patient elected hospice care on 06/02/2024. The recertification plan of care effective 08/01/2024 through 09/29/2024 ordered HA services twice (2) weekly beginning 08/01/2024 and five (5) times a week beginning 08/05/2024. The HA provided visits from 08/01/2024 through 08/27/2024 as ordered. The HA supervisory visit was completed on 08/27/2024, with 26 days outstanding. A clinical record review revealed no evidence that HA supervisory visits were completed every 14 days per agency policy. Clinical Record 7: The patient elected hospice care on 05/09/2024. The recertification plan of care effective 07/27/2024 through 09/24/2024 ordered HA services twice (2) weekly beginning 07/28/2024. The HA visits were provided beginning 07/30/2024 as ordered. A clinical record review revealed no evidence that HA supervisory visits were completed every 14 days per agency policy through the date of the record review on 09/24/2024, with 56 days outstanding. Clinical Record 10: The patient elected hospice care on 07/11/2023. The recertification plan of care update effective 09/03/2024 through 11/01/2024 ordered HA services twice (2) weekly beginning 09/03/2024. The HA visits were provided beginning 09/05/2024 as ordered. A clinical record review revealed no evidence that HA supervisory visits were completed every 14 days per agency policy through the date of the record review on 09/24/2024, with 19 days outstanding. Clinical Record 11: The patient elected hospice care on 04/05/2024. The recertification plan of care update effective 07/04/2024 through 10/01/2024 ordered HA services twice (2) weekly beginning 07/04/2024. The HA visits were provided beginning 07/05/2024 as ordered. The HA supervisory visit was completed on 07/22/2024, with 17 days outstanding. A clinical record review revealed no evidence that HA supervisory visits were completed every 14 days per agency policy. Clinical Record 12: The patient elected hospice care on 05/01/2024. The recertification plan of care update effective 07/30/2024 through 10/27/2024 ordered HA services twice (2) weekly beginning 07/30/2024. The HA visits were provided beginning 07/30/2024 as ordered. The HA supervisory visit was completed on 08/19/2024, with 20 days outstanding. A clinical record review revealed no evidence that HA supervisory visits were completed every 14 days per agency policy. Clinical Record 13: The patient elected hospice care on 08/01/2023. The recertification plan of care update effective 07/26/2024 through 09/23/2024 ordered HA services twice (2) weekly beginning 07/28/2024. The HA visits were provided beginning 07/30/2024 as ordered. The HA supervisory visits were completed on 08/17/2024 and 09/16/2024, with 18 and 30 days outstanding, respectively. A clinical record review revealed no evidence that HA supervisory visits were completed every 14 days per agency policy. In a joint record review and interview on 09/25/2024, the Manager of Accreditation confirmed that HA supervisory visits were not completed every 14 days per agency policy for clinical records 5, 7, 10, 11, 12, and 13.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record contains at a minimum: physician orders. This standard was not met as evidenced by clinical record review, document review, and interview. Agency Policy #2-002 “Verification of Physician Orders” Effective Date: December 2018 read in part “Orders will be obtained from a licensed physician (or other authorized independent practitioner) for care and services to be provided to hospice patients.” In 1 of 19 (5%) clinical records reviewed, the agency did not ensure the clinical record contained the patient’s physician’s orders. Clinical Record 1: The patient elected hospice care on 03/27/2024 and resided in a facility. The facility called the hospice after hours on 09/21/2024 to report a change in condition. An “On-Call Triage Note” dated 09/21/2024 documented, “PT has a skin tear to left hand that she placed steri strips on.” A clinical record review revealed no evidence of a physician order for the wound care provided by the facility. In a joint record review and interview on 09/24/2024, the Manager of Accreditation confirmed that the clinical record lacked evidence that the record included physician orders for the wound care provided by the facility.”