St Croix Hospice

“It is required that the patient’s pain is assessed as part of a comprehensive assessment. Assessment of pain in children and adolescents is conducted with consideration of age and neurocognitive development. The documented assessment of the patient’s pain includes: history of pain and its treatment, both pharmacological and non-pharmacological; use of a standardized pain assessment tool appropriate to the patient’s developmental and cognitive status; characteristics of the pain, including: location, frequency, and intensity; and how pain impacts the patient’s ability to engage in usual activities and function (e.g., appetite, sleeping); and the patient’s/family’s goals for pain management and their satisfaction with the current level of pain control. This standard was not met as evidenced by clinical record review and interview. 3 of 23 (13%) clinical records reviewed revealed that the agency did not ensure that a comprehensive pain assessment was completed upon admission. CLINICAL RECORD 7: The patient’s date of election was 09/02/2025. The RN [registered nurse] Hospice Start of Care visit note dated 09/02/2025 documented in part, “Was the patient screened for pain? Yes ... Pain score (0-10) 0 - Patient has no pain. Was a comprehensive pain assessment done? No...” The coordination admission note stated in part, “Patient was seen at (State) Specialty Hospital (City/State) on 08/04/2025 due to steady abdominal pain that radiated to back... CT scan of abdomen and pelvis performed and revealed a nodular mass in the ascending colon and cecum. Mild adjacent pericolonic inflammatory changes. Suspected carcinoma. Patient was given script for tramadol for pain.” The medication profile reviewed revealed tramadol 50 mg tablet, take 1-2 tablets by mouth every 6 hours for pain, dated 09/02/2025. The record lacked a comprehensive pain assessment that would have included history of pain and its treatment, both pharmacological and non-pharmacological; characteristics of the pain, including: location, frequency, and intensity; how pain impacts the patient’s ability to engage in usual activities and function; and the patient’s/family’s goals for pain management and their satisfaction with the current level of pain control. CLINICAL RECORD 8: The patient’s date of election was 10/16/2025. The RN Hospice Start of Care visit note dated 10/16/2025 documented in part, “Was the patient screened for pain? Yes ... Pain score (0-10) 0 None...Was a comprehensive pain assessment done? No...” The coordination admission note stated in part, “Pain: patient has some mild pain that is being managed with prn (as needed) and scheduled Tylenol.” The medication profile reviewed revealed acetaminophen 325 mg tablet, take 1 tablet every 4 hours as needed for pain or fever, dated 10/16/2025; and acetaminophen 325 mg tablet, take 2 tablets every 8 hours for pain, dated 10/16/2025. The record lacked a comprehensive pain assessment that would have included history of pain and its treatment, both pharmacological and non-pharmacological; characteristics of the pain, including: location, frequency, and intensity; how pain impacts the patient’s ability to engage in usual activities and function; and the patient’s/family’s goals for pain management and their satisfaction with the current level of pain control. CLINICAL RECORD 22: The patient’s date of election was 11/28/2025. The RN Hospice Start of Care visit note dated 11/28/2025 documented in part, “Was the patient screened for pain? Yes ... Pain score (0-10) 0 - Patient has no pain...Was a comprehensive pain assessment done? No...” The coordination admission note stated in part, “Pt (patient) indicates (patient) has no pain at this time. Staff stated (patient) continues with Tylenol 3x a day scheduled for chronic pain. They feel (patient) is comfortable at this time.” The medication profile reviewed revealed acetaminophen 500 mg tablet, 1 tablet three times a day orally for chronic pain, dated 11/28/2025. The record lacked a comprehensive pain assessment that would have included history of pain and its treatment, both pharmacological and non-pharmacological; characteristics of the pain, including: location, frequency, and intensity; how pain impacts the patient’s ability to engage in usual activities and function; and the patient’s/family’s goals for pain management and their satisfaction with the current level of pain control. During a joint clinical record review and interview on 04/17/2026, the Regional Director of Clinical Operations confirmed that the records lacked evidence that comprehensive pain assessments were conducted upon admission.”

“It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The hospice documents the cost savings achieved through volunteers. Documentation includes the identification of each position that is occupied by a volunteer, the work time spent by volunteers occupying those positions, estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions noted in Item 1, and for the durations noted in Item 2. This standard was not met as evidenced by document review and interview. Upon reviewing the volunteer program, the documentation showed volunteer hours of 467.92 and direct patient care hours of 45,608.29, resulting in a combined volunteer-to-patient-care ratio of 1.03% for 2025. The agency had a Performance Improvement Project (Document 1) identified and initiated on 01/01/2025. The project contained quarterly data for each branch through Quarter 1, January 2026. Agency Performance Improvement Project: Volunteer Cost Savings, dated 01/01/2025, documented: Date Identified: 01/01/2025. Revaluation Date: 03/30/2026. List of indicators: (State) Branches not at or above 5% cost savings. Measurable goals for each indicator: Successful achieved 5% cost savings; volunteer recruitment growth; improvement in volunteer service hours. Root Cause Analysis: 04/2020-12/31/2023, PHE-1135 Volunteer Services Waiver in place; Waiver lifted on 01/2024. Metric Scores/Location(s) as Applicable: The following Branches in (State); Pre-Intervention Score: Q4-2024: 0.46%. Remeasurement Scores are sectioned out by Branch and quarter. The PIP remeasurement data: Q2-April 2025: Parent (P): 0.49%, ADS1: 0.79%, ADS2: 0%; Q3-July 2025: P:0.94%, ADS1: 1.85%, 0.71%; Q4-October 2025: P: 1.13%, ADS1: 1.30%, ADS2: 0.65%; Q1-January 2026: P: 1.02%, ADS1: 0.80%, ADS2: 0.92%. Task Related to Desirable Outcome: RVC’s (Regional Volunteer Coordinators) to re-evaluate and enhance recruitment strategy; enhance the recruitment network with the community; and engage with current volunteers to maximize volunteer activity. All tasks were assigned to team members. All tasks had a start date of 01/15/2025 and a revaluation date of 03/30/2026. During a joint document review and interview on 04/15/2026, the Director of Human Resources Operations and the previous Manager of Volunteer Services (Corporate) provided an overview of the Volunteer Program. This position was in the process of being transitioned to the current Manager of Volunteer Services (Personnel Record 13). The discussion covered recruitment and retention efforts, as well as recent attempts to recruit more volunteers and processes for retaining them. During a joint document review and interview on 04/16/2026, the Regional Volunteer Coordinator discussed efforts to increase the number of volunteers and volunteer hours at the parent and two alternate delivery sites. During a joint document review and interview on 04/16/2026, the Regional Director of Clinical Operations discussed the Performance Improvement Project that began in January 2025 and the progress of interventions aimed at improving volunteer hours. A discussion was held regarding the volume of direct patient care hours, including multiple monthly visits for Music Therapy and Massage Therapy, and the volume of end-of-life visits, which resulted in a higher total number of direct patient care hours and a lower percentage for the volunteer hours. Upon reviewing the volunteer program, the documentation showed volunteer hours of 467.92 and direct patient care hours of 45,608.29, resulting in a combined volunteer-to-patient-care ratio of 1.03% for 2025. The agency had a Performance Improvement Project (Document 1) identified and initiated on 01/01/2025. The project contained quarterly data for each Branch through Quarter 1, January 2026.”

“Based on home observations, staff and family interviews, record reviews, and policy review, the agency failed to maintain and develop a system of communication and integration in accordance with the hospices own policy to ensure the interdisciplinary group maintains responsibility for directing coordination and supervising the care and services provided for 1 of 4 sampled patients. (Patient #3) Failure of the interdisciplinary team to collaborate and communicate effectively increased the risk that patients did not receive services to meet assessed needs. Findings include: In the policy titled Interdisciplinary Group Coordination of Care, dated 2/20/2024, the hospice interdisciplinary group will retain professional management responsibilities/ for the provision of services, including inpatient care, and will insure that services are furnished in a safe and effective manner. The hospice agency will utilize a case management system to guide an interdisciplinary group to provide comprehensive, coordinated health care to patients and families/caregivers serviced by the hospice. The Registered Nurse Case manager will be responsible for the coordination of services with the interdisciplinary group from referral to discharge and know the scope of care which can be provided by the different members of the interdisciplinary team. Patient #3 had a start of care date of 8/19/24. Interview 10/8/24 at 3:35 pm, Staff A, Manager of Clinical Services with the Cedar Falls Branch, stated, on 9/24/24, the agency became aware at approximately 4:00PM, that Staff B, Registered Nurse (RN) Case Manager did not complete a scheduled visit for patient #3 on 9/23/24. Staff A reported that she received a call from Staff C, Home Health Aide, who reported the family member of Patient #3 was concerned that Patient #3 did not receive the scheduled skilled nurse visit on 9/23/24. Staff A reported she called and spoke with the family member of Patient #3. Patient #3’s family member stated the nurse did not make the visit on 9/23/24, based on the private caregivers report. Staff A reported the family did not want Staff B, RN back into the home. Staff A, reported she called Staff B, RN, immediately after speaking with Patient #3’s family member. Staff A reported initially Staff B stated she made the visit, but then Staff B RN, recanted and stated she was confused and she had not made the visit. Staff A reported the family of Patient #3 was offered an additional skilled nurse visit on 9/24/24, but the visit was declined. Staff A reported the next scheduled skilled nursing visit, 9/26/24, was completed by Staff D, Licensed Practical Nurse (LPN), who identified a new pressure area that was red and non blanchable to Patient #3s right hip. Staff F, Nurse Practitioner was notified at the time of the LPN visit and order obtained for mepilex (foam) dressing to be placed over the area. Staff A acknowledged a Registered Nurse did not complete an assessment following the missed visit on 9/23/24, until 10/1/24. Staff A reported that Staff E, RN, noted a second pressure area to the left hip on 10/1/24 and noted the pressure area on the right hip was open with minimal drainage. Staff E, notified Staff F, Nurse Practitioner, and received order to cover area with mepilex, change two times per week and as needed. Staff A reported on 10/1/24, agency offered daily nursing visits for Patient #3 family member, until the skin areas healed, the family member declined. Record review indicated no Registered Nurse (RN) completed a comprehensive assessment on 9/24/24. Patient #3’s record review identified the agency did not have a RN complete an assessment visit until 10/1/24. Interview 10/9/24 at 8:23 AM, with Staff C, Home Health Aide (HHA), stated when Staff C placed a call to Patient #3’s family member for an update, following her visit on 9/24/24, the family member reported she was concerned, the RN did not make the scheduled visit on 9/23/24. Staff C, HHA reported she called Staff A, Manager of Clinical Services and reported Patient 3’s family member’s concern. Interview 10/9/24 at 10 AM, with Staff B, RN Case Manager, reported she made a mistake and became confused on dates, and indicated the visit scheduled for 9/23/24 for Patient #3 was not missed on purpose. Staff B reported when she realized the visit was missed, she did document a missed visit and notified the physician via fax on 9/24/24. Interview 10/09/24 at 10:AM, with Staff F, Nurse Practitioner (NP) stated on 9/26/24, the missed RN visit and the stage 1 pressure area to the right hip was reported to her during the visit by Staff D, LPN, and again on 10/1/24, when Staff E, RN notified Staff F, NP, of a second pressure area over the left hip. Staff F reported on 10/1/24, Patient 3’s family was offered daily nursing visits for monitoring of skin breakdown, until skin areas could heal and the family declined. Interview 10/9/24 at 3:00 PM, with Patient #3s family member stated, Patient #3 is a centurion, and resided in the home alone monitored by live cameras approximately every 2 hours. The family member reported she and a private caregiver provided cares for Patient #3 for the last three years. She reported Patient #3 was bedbound and fatigued easily, sleeping about 16 out of 24 hours a day. The family member reported the private caregiver came Monday through Friday in the morning about 8:00 AM to get Patient #3 out of bed, complete a sponge bath, change the incontinency briefs, prepare a meal and help Patient #3 back to bed, placing a cup with water or juice by the bedside and filling a bowl with snacks. The family member reported the hospice agency agreed to send a nurse twice a week on Monday and Thursday and a home health aide on Tuesday and Friday to complete the same routine at about 3pm, and the family provided cares on the weekend. The family member reported, hospice staff agreed to call or text her after every visit to give an update on Patient #3. On Monday, 9/23/24, she realized at 11:30 PM, no communication from the hospice agency had been received. The family member stated she checked the camera and noted Patient #3 was sleeping, and waited for the private caregiver to arrive the next day at 9 am for a report. The family member stated she placed a call to the on call nurse, Staff G, RN on Sunday, 9/29/24 to report a new reddened area over the right hip. Stated Staff G instructed her to put a foam dressing over that area as well, and stated she would pass the information on to Staff E, RN Case Manager. Clinical record revealed the following. a. The Plan of Care (POC), dated 8/19/24 to 11/16/24 diagnoses of senile degeneration of brain, malignant neoplasm of rectum and urinary incontinence. The POC included physician orders for skilled nurse visits 2x a week. The skilled nurse visit included assess medication response, provide instructions related to prevention/management of skin breakdown. b. Clinical record review revealed a missed visit notification on 9/24/24. c. The Interdisciplinary Group Note (IDG) dated 9/25/24, noted the missed visit and identified concerns that Patient #3 was completely bedbound and unable to transfer out of bed without max assist. IDG documentation noted the IDG team was concerned that Patient #3 needed 24-hour care in the home and documented the agency would be providing resources. d. The skilled nurse visit dated 9/26/24 by Staff D, LPN identified a stage 1 pressure ulcer measuring 1 cm x 1cm, non blanchable, over the right hip. The Nurse Practitioner (NP) was notified of the stage 1 pressure ulcer by the LPN and a physician order obtained to apply Mepilex (foam dressing) over the area, change 2x week and as needed and continue to monitor until healed. e. Care coordination note, dated 9/29/24, revealed the family member of Patient #3 placed a call to Staff G, RN Triage Nurse to report a newly identified red area on the right hip and asked if Mepilex could be applied to that area also. Staff G, RN instructed Patient #3’s family member to cover that area with Mepilex and noted it was passed on to the RN Case Manager, Staff E, to update. The documentation lacked a physicians order for Mepilex to area reported by family member. f. A skilled nursing visit completed by Staff E, RN Case Manager on 10/1/24, identified a new stage 1 pressure area over the left hip measuring 5.4 cm x 4cm, non blanchable. Staff F, NP was notified and a new physicians order obtained to cover the area with Mepilex and continue to monitor. Staff E, also documented a deterioration to the stage 1 pressure ulcer to the right hip and documented the area as dark red and open with minimal drainage. Documentation revealed the third wound area to the right hip , was a 3cm by 3cm bruise, non blanchable with Mepilex foam dressing. The clinical record lacked a physicians order noted for the third wound on the right hip to be covered by Mepilex dressing. Documentation from Staff E, RN noted a wound care nurse would be notified to assist in recommendations for Patient #3. The clinical record lacked any documentation of assessment of wounds by a wound care nurse. g. The IDG note dated, 10/9/24, lacked discussion of the call family member placed to Staff G , RN triage nurse on 9/29/24, for new reddened area over the right hip, and no order in the IDG notes for Mepilex to be applied to third wound located on right hip. h. Clinical progress note, dated 10/9/24, Staff F, NP, identified Patient #3 was bedbound and completely dependent, for all personal care needs. Staff F, NP, documented a skin assessment and identified all three areas as stage 1 pressure ulcers, two areas on the right hip, and one area on the left hip. Physician orders to continue Mepilex to all three areas. The IDG team failed to maintain responsibility for coordinating and supervising the care and services provided to meet the individualized needs of the patient.”